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HomeMy WebLinkAbout0621DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -33 BOX 7 No oil :oil A I r1ro rr 61 IN - ti mJ kom I J6 i� �'6 f �. . T . ffill me , - ' „ :� -. i . , 00621 1) 1:7 PRUCE • R. FOLEY Public Health Director DEPARTMENT OF 1 Geneva Road Brewster, New York 1il : �• 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 Date: --zz7`O To: 5155Y Vca• Z-a ©SSA From: Gene D. Reed Putnam County Department of Health ZFor your information For your review As discussed Fax #: 7 7 a °d3 5-5 No. Pages (Including cover sheet) ZPlease respond Attached as requested Please call Notes/Messages Pr--WS cG T)L f—:: PS ON 61 2.0 ZOO t D /; p BtjLL, OEE T r&o4.� 77 ®.4D #7'2SE pit! In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. T, SENDING CONFIRMATION DATE • MAY -16 -2002 THU 22:57 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 919147730355 PAGES : 4/4 START TIME : MAY -16 22:54 ELAPSED TIME : 02'45" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a, BRUCi R FOL6Y LORMA MOI.INARI R.N., M.S.N. P.Wk M41M Dft r A ,con ftbW NedM M—w DAea- of Poew San. — DEPARTMENT OF HEALTH 1 Geneva Road Bmwftr, New Yak 10509 GaAesvw�Ml aa.sta pes)77a.6130 Pa p1f)Zri -791( Nw.mt gr.Yn p65)ZK -665! V"C (Ns)271.1r7& Fa(115)21 -6015 >r&ra' henoaal (165)271 -6014 14a Wd (94S)2754M Fc(U P111•&M1 FAX COVER SHEET Date: ate To: 5155V 77n ca 6255001 Faxµ, 773 —o35S From: {app;P. D—A Putnam County Department of Ho" For your informatlou _-, For your review As disauwed No. Pages it (Including cover &beet) Ple:ue respond Attached as requested _ Plastic can w lam♦ iii In the !vent of transmissiontreMttion difficulties, please contact this office at (845) $70^6130 e3t.1261. BFCUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., 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 Date: e A- d To: - 1 SrZ 25�%o Fax #: `7 -2 3 No. Pages (Including cover sheet) From: Gene D. Reed Putnam.County Department of Health _For your information Please respond For your review As discussed Notes/Messages .1 4— 0 j Attached Attached as requested Please call _34:P9 /`3O W In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. MAY -10 -2002 12:52 PM HARRY W NICHOLS BRUCE R. FOLEY Public Nealih•.Dlreclar -- ATTENTION: 914 279 4567 P.03 LORE'CCA MOLWARI RN., M.S.N. Associate Publk Health Dlreetor Dlreatar of , Pallent Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 REQUEST—FOR FIELD TES'TM ® ADAM STIEBELI NG ENE REED A{1 iJormation below must beIdIX completed prior to any acheduting. DATE: ENGINEER OR FIMI: t `�1"i r.+ t�5 PHONE C REASON: DEEPS: PERCS: PUMP TEST: o ROA.D /STREET: V�oLF_ ` on TOWN- _ _ � �5 Q� TAX MAP✓rt: !• `1, SUBDIVISION: LOT#" 0W,NER; L Al YES NO o proposed SSTS•within the drainage basin of West Branch or B.oyds Corner reservoirs. IMN Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. Proposed SSTS within 200 feet of a watercourse or a DEC wetland.. Proposed SSTS design flow greater than 1000 gallons /da,)rl r 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 m to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable tirne for field testing with the PCDOHC, the Design Professional and NYCOEP. If a project has been determined to be Delegated based on the Above-response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. roR COUNTY usE ohLY r (MLDTEST) MI. ern Q 3" .Solo on i est 0 w� ' I T (D a AV) TOM OP 1 12531 �+ 64 0. 0 1 0 1 311 e 1 own 164 40 M Q"''lip ff May Corn , S a L o i 12563 T -1 Pond R` 164 aines Corners OES ond ttieY MS \\ I ( Areal ae 8 g96 1. e0 4� 1.56 AC. LI 21of 91 III X ., �'a~ .a 13 i ; 43 \rSj. y e I 1y16aC eao,,AAn AL • '/ j // .�` os� ejas� AL -- �, • 76.11 AC. CAL. I °a 38- D a� , r.� \. �• \ /0" S 1,40 AL 1 7gq• '6'� !� !, a�o.00 1305 2 3.0 7 �R�UTF 15 21.44C. a i s 1.49 pROUTE36s.6 .p4 23. I I 23. i r lexa4s _ . - lexe.4s 28 az o .1.8 1.56 x Z6 93-9r- AC.? �\ . A AC. F. AC. n.o6• . lyx9.o6' s 41 s 1 45 •1 N w • s � g 350.00 \. l \ ' 466.04 403. 9 10.41 AC. N CAL. t 36 23165 § 243.46 6 ffi 32.98 AC. 9 396 �3' ` 8.33 A 37 +�� RpAp A o AL 27 27 `J" A ' e C 3,95 AC. 1 47 104,47 AC. 1 • 104,47 AC. CAL. 199.99 CAL `^ 46 2.50 AC. CAL. 7.74•�C. O CAL. X 196.26 3� 7 s ACry 1326.05 I CAL y I x46.05 N i � AL a kr '• ,x.1949 48 /3.41 AC. 31 26.05 AC. i CAL. n 75.96 AC. X34 , 569.75 i JL ,e 50 szs.67 a � e 42. 32 32 33 18.16 AC. CALJ AL 32.68 AC. CAL, 3.1T MC. 455p3 * �' 32,68 AC. CAL. s 1.64 At 52 AL 61x61 296.46 • ( AL 32.18 AC. ' 0 AL 614.70 549.2 % ti Jv !i t i? 960.14 419.95 415.95 24.6 a 30 I l S ;z 13.40 \ AL / _ _P /0 34-3' _ _ _P /0 34 -3 -63 AC.. /0 34 5 27 _P /0 34-5 -1 -- - -- ---- - - -�0- '5 - - - -- �- -- -- i' P/0 34 -5-28 _ a 4� %�RRFp3:A26A$ iPUI6D AREAS -.. r ............. •. ..� 6111iR$XI h4 1141p1s ^6W�eeo.0 a „7,�A,�s �,RE AND 3 4 P R P L I M I N it SENDING CONFIRMATION DATE : JUN -26 -2002 WED 23:51 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 919147730355 PAGES 4/4 START TIME JUN -26 23:48 ELAPSED TIME : 0215211 MODE ECM RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... BRUCE B. FOt-EY * * LORMA MOLWARI R.N., M.B.N. Num Haam D"dw A—um Pre!¢ 17-0 Dbrcw Dkeuw of Pm6mr 3rnka DEPARTMENT OF HEALTH 1 OOM" Bead Btewlter, New Yedc 10509 EaAmam41 Width (Mf)37t -6170 Fu(SO)VII-Ml NmhE Ovaes (MS)171 -M61 trlC (us)"S.6676 Ylw (343)771 -6063 FAtV l%ftM&als (145)776 -6016 ProJre1 (943)2716017 11.040771.6641 FAX CORK 5p8rCT Date: To: SKSY IDcc i L Fu M: �O3yS No. Page+ (Including cover shect) From: C ne D- An6d /Paattnam Coanty Department of HeaM 1 ✓ For your information % rieue respond For your review Attached as requested _ As discussed Please call Notra/1 mages jzF, r' T ON %Z-3,947 / i 3 0 7rfs7 idll aii BAa �.szrr>tr vP ffi�i �''Ie�NL071� /nsi5p/ T6�ST �1t,E-fli Tn the 6vmt of tranemlaslon/reeeption dif icultinl please contact this office at (845) 278 -6130 ewL 2261. z/0 & PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner AL- %elzNegTT Address gry- t/ozj ycl! Located at (Street) 1c, _ -pdAl b Tax Map 2 3 Block 2 Lot (indicate nearest cross street) Municipality &�tr:E e2Z,A! Watershed. hLW6 �3;eye. SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test -7 f 3 ©f a ! NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 2 i :��- �s 0 23% - 2Gjz 10 3 4 5 2 1 1,'31 - : f o l 3 ® � 2 - �2 ��` lam. I3'a 2 ZiV;Z- — a,3 9- 3 c: _CJti 2 3%0' / I .,, / 3 � s33- -3C, 0.3l 3CID. .2 2 —2..% Yoe /7, 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO._ F, HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is observed — ®" 11,0% AI Indicate level to which water level rises after being encountered Deep hole observations made by: 4�Z 7z eb�7 D , �, _ �, Date 7 v 2 Design Professional Name: Address: Signature: Design Professional's Seal Sheet % of�_ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT NAMF: / C. 7'� 7zMOTi TPI: N /,!¢ ATE RF44; 130LGrT 80,: Street Town State Zip . PERSON IN CHARGE OR TNTF.RVTFWFT):/�l'ZZ� A >�GI�LS fir. i)atP: Name and Title TYPE OF FACILITY ; > iZp po S C--7p FINDINGS: -71a Signature and Title $FPORT RFC''FTVP.T) TAY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: ss 2- Z 2-3 - a6 ;!— z— zl z o- - �. 3 �/1 a-2- - 2 3 Yellow By i duce I� S. , a o., gel coa�►�, 6®e.� 1 PUTNAM COUNTY DEPARTMENT OF..HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET.- SUBSURFACE. SEWAGg.T119ATMENT SYSTEM F5 Owner - N 77 Address Located at (Street) 'Pelvj> 11� , Tax Map � _ 3 Block Lot (indicate nearest cross street) Municipality Watershed C.4-S SOIL. PERCOLATION TEST DATA:. Date- of Pre-soaking Date' of Percolation 'rest N(nS: 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 .... ...... e . ......... -A "J"T Ime t . . . . . . . . . . . ri. lao 3 .4 5 133— A,' 3- Noe 2 00 3 4 5 2 3 4 5 N(nS: 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' . 2.51' 3:5- 4.0' 4.5' 5.5` 60' 'b5 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. l3 HOLE NO. c'_° P3" 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: Signature: Design Protessional's'Seal . AA 2 D r� Si F'la E AFL NAP .3 r, �OryP, 4, ml�lffl -7 r� C�B,r 7 r r� r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project n gzyg ;� County Pc-176 tgt f Site Location -By L C ZV, # a 3 — �2- — 3 Building construction begun Extent Is property within NYC Watershed ? ................. Yes , a No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. � Hilly 0 Rolling a Steep slope EdGentle slope F--] Flat 2. 3. 4. 5. 6. 7 8. 9. Evidence of wetlands Q Low area subject to flooding Drainage ditches a Rock outcrops Bodies of water Property lines or corners evident ....................... ............................... Yes Do water courses exist on or adjoin the property? y? ..... dYes Will these affect the design of the sewage system facilities? ... Do watershed regulations apply in this development ? ....................... Yes Will extensive grading be necessary? ................. ............................... 0 Yes Will extensive fill be necessary for SSTS? ......... ............................... 0 Yes Do filled areas exist within the SSTS area? ........ ............................... F--] Yes If yes, what is the condition of the fill? No No No F7 No �No qo No SECTION C. SOIL OBSE VATIONS 10. Appearance of soil: Sand 0 Gravel Loam PBackhoe Clay Hardpan Mixture 11. Observed from: 0 Borings � Bank cut excavations 12. Soil borings /excavations observed by 4 , P -P, Gr 14, V , on ZD o 2 13. Depth to groundwater on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas ...... ............................... F Ye F No 16. Soil percolation tests made by h� (Ael� Azle HgeL S P. F, on 17. Soil percolation tests witnessed by a, ` CC l5 c -q P Ga L?_ on SECTION D (on back) Form ST -1 P� k SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? F] Y s No 19. Will groundwater or surface drainage require special consideration? ..................... Yes 0 Zo 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? .....................:... 0 Yes 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 30 Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ............................... 0 Yes � No 23. Additional comments 24. Site observer /inspector and title �,�`j� 25. Date(s) of observation(s)inspection(s) 7 Z3,V /0.2 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. s 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 \\ P. AM COUNTY DEPARTMENT OF HEALTH VISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P 2-1 " 4 2 Located at *q bo1 of qba kpp Owner /Applicant Name K WMA HII WW Drr Formerly. Town or Village PA _F�eg& H Tax Map Block Lot tt Subdivision Name Subd. Lot # Mailing Address i � "� i �� Ll'� ; 1''�� Zip 105-11 Date Construction Permit Issued by PCHD Separate Sewerage S s� built by WUljkf1 (VO Address �8 �( L Ad N ��Q��� Consisting of 11-60 Gallon Septic Tank and A (M - X14014 Other Requirements: Water Supply: Public Supply From Address- or: ')( Private Supply Drilled by C %-1 '�•f l Mli Address Building Type 9"E ;D 1 1611 Li✓ Has erosion control been completed? �E� Number of Bedrooms A- Has garbage grinder been installed? 'R 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 Cou}ity Department of Health. Date: Q'� I 01) Certified by \ fit+ P.E. _K_ R.A. r (I esi�Professiional Address �- ®� `�� 1�.��Jh, j AIL. fU 3 fj� 0I License # '50M 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 aRod* ject to modification or change when, in the judgment of the Public Health Director, such revocation, cation o ange is necessary. M,, h l0 By: Q/ vr� Title: � /'�" Date: t White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 " . . p��z� . . . ; . ` . � l^~ a Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 VAY 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 Date: To: ? "n Attention: POW rc \* . Gentlemen: We enclose ( ) copies of B/W Prints Specifications Reproducibles Memorandum Job No.: Project th 11 i 1 j/LC(4Lf)2-on f rv-fp Reports Copy of letter Tracings Description: Revision/Date No. _ Cc MkAp OFT el) to((;F�A' y } l S vF- C S r Jp rl)Di Sent Via: Our Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to Very ly y urs, H : Nichols Jr., PE. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 1914) 245-2800 Albert H. Padovani, Director LAB #: 93.301937 CLIENT #: 56745 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ McDERMOTT, DIANA & WIL 489 BULLET HOLE RD PATTERSON, NY 12563 SAMPLING SITE: 489 BULLET HOLE RD : PATTERSON, NY COL'D BY: WILLIAM McDERMOTT ' NOTES...: KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 07/15/03 MF T. COLIFORM 07/15/03 LEAD (IMS) 07/15/03 NITRATE NITROG 07/15/03 NITRITE NITROG 07/15/03 IRON (Fe) 07/15/03 MANGANESE (Mn) 07/15/03 SODIUM (Na) 07/15/03 pH 07/15/03 HARDNESS,TOTAL 07/15/03 ALKALINITY (AS 07/15/03 TURBIDITY (TUR DATE/TIME TAKEN: DATE/TIME REC'D: REPORT DATE: 07/14/03 10:00 07/15/03 09:30 07/31/03 PHONE: (845)-878-0042 SAMPLE TYPE..: POTABLE PRESERVATIVESt NONE TEMPERATURE..: < 4C COLlFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD ABSENT /100 ML ABSENT 1008 <1 ppb 0-15 ppb 9101 0.39 MG 0... 0 - 10 9139 <0.01 MG /L N/A 9146 <0.060 MG/L 0-0.3 mg/1 2037 <0.010 MG/L 0-0.3 mg/l 2037 4.38 MG/L N/A 6.7 UNITS 6.5-8.5 9043 66.0 MG /L N/A 56.0 MG /L N/A 1.5 NTU 0-5 NT COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water- undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium tha.t for people on a codt-011"po more than modera�e'/ �`'� t � �y -e �r�� e' is suggested. 24 are proscribed. Suggested guidelines state sodium restricted diet,the water should 20 mg/L of Sodium. For those on . � diet, a maximum of 270 mg/L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.301937 CLIENT #: 56745 NON STAT PROC PAGE 2 ------------- ~ -------- ----- --------------------------------------� McDERMGTT, DIANA & WIL 489 BULLET HOLE RD PATTERSON, NY 12563 SAMPLING SITE: 489 BULLET HOLE RD : PATTERSON, NY COL'D BY: WILLIAM McDERMOTT NOTES...: KIT TAP ~~~~~~-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE/TIME TAKEN: 07/14/03 10:00 DATE/TIME REC'D: 07/15/03 09:30 REPORT DATE: 07/31/03 PHONE: (845)-878-0042 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: NF ~~~~~~~~~~~~~~~~~~~~~~~~~~~'~~~'~~~~~~~~~ RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH lS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESlUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER' HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2-MG/L) SUBMITTED BY: ELAP* 10323 -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 3 .. K L bMMtf-r r %� Owner or Purchaser of Building. Tax Map ­Block Lot VJ� LAA�m WT6WOVf Building Constructed by TownNillage 1 0_ Location - Street Building Type Subdivision Name Subdivision Lot I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to= whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing'the system. 1 8 a � Dated: Month W1 Day °] Year_ Signature: Title: General Contractor (Owner) - Signatures Corporation Name (if corporation) Address:. T.0 �_ Ok q ff ujo, State Oil Zip IO'N Corporation Namt (if corporation) Address: �� � � 041pl p-U r J1 State J Zip 10 Form GS -97 Jun 13 03 07:41a TOWN OF PRTTERSO JUW-06 -2003 0238 PM PiRRRY W NICHOLS 4'kt SAUCE R FOLBY LORMA MOLD"-R.N., M.S.N. Ir!!tr NtoliA Dfrtsta •Ammral Phil ' 6001 .10&VCw .. . D6venr 4f pok" SWaW DEPARTMNT OF HEALTH I Qaays -Mad tlrewsw. Nny York 10"9 isANMUd ROM (914271 .6130 1w P14) 371 -MI . M�Nty ear (1!6)111 • bs11 . wtc ply) tp • 6A1 •►lol (9t�) s7i •f011 ... .. - . iu11'18ano�i�'a14)11!•f01� MOW) (P{4)31141e1 FU014) 1r•W6 845- 878 -2019 p.2 914 279 4567 P.02 OWNERS NAME:, TAX MAP MUMSF.>Z; Vii ADDRESS. TOWN: AUTHORIUD T0WN.9FFICL41, ...... (SIPAture) DAA t'E: G The Putnam County Department of Health will not issue a Cei'tilkate of Construction Compliance unless the above form b completed, Le., a legal E911 address.is assigned by an authorized town of ivial. This farm is to be submitted with the application for a Certificate of Construction Compliance. Q. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES •, FINAL SITE INSPECTION Date: f ®3 Inspected by: G, ggG-r> Street Location ti6L fT ®G,� Owner _ A ?c-7>_r- lorY Town Permit # P- p 9 - o a TM #- 2.3 - 2 - 33 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 ... ............................... II. Sewage System a. Septic tank size - 1,000 ....... ..l 2 .........other............ 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 & trenche e. Junction Box - properly set ....... ............................... 6. Trenches 1. Length required 5- 7 / Length installed S ?/ 2. Distance to watercourse measured -4- 1 ® a Ft......... . 3. Installed according to plan .............................. . 4. Slope of trench acceptable 1/16 - 1 /32 " /foot.........t 5. 10 ft. from property line - 20 ft.- foundations......... 6. Depth of trench <30 inches from surface ................ 7. Room allowed for expansion, 100 % ....................... 8. Size of gravel 3/4 - 11 /9-" diameter clean ................... 9. Depth of gravel in trench 12" minimum ....... :.......... 10. Pipe ends capped .................... ............................... g. Pump or Dose 1. Size of pump chamber .............. ............................... 2. Overflow tank .. ............................... - ................... 3. Alarm, visual/ audio ........:................ I...................... 4. Pump easily accessible, manhole to grade ............... 5. First box baffled ...................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle......... III. House/Buildhig a. House located per approved plans...... b. Number of bedrooms. ..... ... f........... IV. Well vev� �unc��1 r%v5e 4� T Well located as per approved plans . ......:........................ b. Distance from STS area measured pa ft......... c. Casing. 18" above grade .............. ............... ................. d. Surface drainage around well acceptable ...................... V. Overall Workmanship . a. Boxes properly grouted ............... ............................... b. All pipes partially backfilled ......... ................. ............... c. All pipes flush with inside of box . ............................... d. Backfill material contains stones <4" diameter ............. e. Curtain drain & standpipes installed according to plan f. Curtain drain outfall protected & dir.to exist watercou g. Footing drains discharge away from STS area ............. h. Surface water protection adequate ........:...................... i. Erosion control provided ............. ............................... Rev. 12/02 APR -29 -2003 10:49 AM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DrVIMON.OF ENVIRONMENTAL HEALTH SERVICES For: pill Date: AgAi L.?'1 �� — Trenches 1 PCHD Construction Permit # P- Z 9.0 Z Located: A Ifs CILLil' .NoL% avAl (T) (•V) svi¢.s60 , Owner /Applicant Name: WsQtAm he34 -a a , TIM Z 3 Block Z _ Lot -&I— Formerly: Is'systea-fill completed ?" _ Subdivision Name: Subdivision Lot # 1s system complete? is Is system constructed as per plans? 1416 Is well drilled? Is well located as per plans? Are erosion control measures in place? :Xt$ -- Date: "- Date: Agin L 24 %43 Date: I certify that the syst*(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 Putaam County Department of Health. Daie: Av iL Zlt CertiSed.by: E RA 4D=s'professional Address :...205Q WL A—i 22 .�.jQkQ1 Lic. # , 56124 ..._ Comments:. FoR: a ADAM R(rn m a (NAME) Form FIZZ -99 O LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services May 1, 2003 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 .Harry Nichols, PE Patterson.Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection - McDermott 489 Bullet Hole Road, (T) Patterson TM# 23 -2 -33 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The pipe from the septic tank to the system must be replaced with SDR -35 and can not have 90° bends. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide 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 May 12, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — McDermott 489 Bullet Hole Road, (T) Patterson TM# 23 -2 -33 The above referenced separate sewage treatment system can be backfilled. There are no further comments to be addressed. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR: cj Sincerely, C�p Gene D. Reed Environmental Health Engineering Aide r ON 6 /$ e� ` b ` L1 ' lslX� a 6\ / oz If a �r�bY 2 s o ,g2 Q" .cuv s.e.aoaw m PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # - Located at coor7village 9 A F- (z-SQ ! V Subdivision name Date Subdivision Approved Subd. Lot # � Owner /Applicant Name Tax Map Block 2— Lot 3 Renewal Revision Date of Previous Approval Mailing Address C' � da (; 0K A- CK(�TM � Lu=s—( 0 Zip 101;0 Amount of Fee Enclosed C) C), Apo Building Type 9ESNbENC�-- Lot AreaS,N% No. of Bedrooms Design Flow GPD goo Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of � 2-SO gallon septic tank and e L t\ RS, TEEN C " U Other Requirements: To be constructed by Address Water Supply: Public Supply From Address _ or: - -vl Private,Supply Drilled by T M) Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment s,, stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date License # 1D (Q � 2-4 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 w en )onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pprov r discharge of domestic sanitary sewage only. ` By: Title: Date: �'� ` a Z- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 H "4. Jl- T TT i Geneva Road .,,(845) 278 -6130 f r Brewster NY 10509 - 0 1 i i BEDROOM 3. 1 J' -0" x 10' -0" ! BEDROOM t .'I BATH J1 01 WALK I�.. CLOSET L ~ ' _ _. — •• �� MASTER BEDROOM BEDROOM 2 OPEN N 17'-0 ; t6'•8" 13' O' >r 15.•8•• •PUTNAM COUNTS I, EPAET1,4ENT.OF HEALTH 'H USE PLANS.APPR19QVEI) I' i^ EEU,11(301�1 COUNT ONL'Y, SECOND FL 11,1l___, j.;.^ 4828 = .•1344SF ,,.. f�.I_•,.,;.._ A: ''::.; t. ^.da. TO THESE HOUSE i PLANS PSI i'i' J'` PC,"'Oil F _ • .. r � , l )(' : ,.�. SIGNAT RE IT DATE \ KITCHEN OINING HOOM >b MORNING FIOOM ~ 1 J' 0" x 12'.0 L-. (S° apl ,(G LIVING MOOu 1 J'.0'• sa 1 s'`0" FIRST FLOOn r �D 0q°Xv ow -t � IN • OrEN • � ' A19OVE I FAUILY n00W 13' 0•' a 1?' 0" FOYEM <• 4R2R = 1'�aacF PUT`IANI COUNTY DEPART,NfE \T OF HEALTH _ DMSION OF ENNIRON�IEN"TAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT' NA1,E OF OWNER: STREET LOCATION: REVIEWED BY: RAM, GR, AS, SRD ATE: TAX hLAP =: (CONFll:4%MD) 1' N pOCUl1ENTS Y N (REQUIRED DETAILS ON PLANS CO\'T'D) . ' PERi4IIT APJ�LICATION (HOUSE SEWER-'W' FT. 4 "0'; TYPE PIPE CAST IRON . jR'ELL PERhIIT OR PWS LETTER vUNO BENDS; DIA\ BENDS a5' W /CLEANOUT- PC -97 RENEWALS LETTER OF AUTHORIZATION SITE NOTE (NO CHANGE) DESIGN DATA SHEET (DDS) FILL SYSTEMS VCORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE L�(USHORT EAF FILL SPECS! FILL NOTES 1 -5 (�j PLANS -THREE SETS FILL PROFILE & DIMENSIONS -) UHOUSE PLANS -TWO SETS ILL ri EXPANSION AREA U(_)VAR]ANCE REQUEST FILL GREATER MN 2 FEET SUy3DMSTON (U - CLAY BARRIER EGALSUBDMSION (U FILL CERTIFICATION NOTE. U SUBDIVISION APPROVAL CHECRtD LU DEPT$ GAUGES U PERT RATE (U VOL ON PLAN FOR R.O.B., UNCLASSIFIED & I \1PERVIO JS U FILL REQUIRED DEPTH SEPARATION DISTANCE FROM TOE OF SI;OPE (U URTAIN DRAIN REQUIRED GENERAL (�LULF TRENCH PROVIDED 6OU MAX. ULOCATED N NYC WATERSHED Ui L JPAgA,LEL TO CONTOURS . (� . - PLANS SURIITTTED •TO DEP - UUI �• /o�XPA\SION PROVIDED ELEGATED TO PCHD ((U�(UDETAIL/Dt;S? FREE CRUSHED STONE OR WASHED. 'GRAVEL. (� ._EP APPROVAL, IF REQ'D. ('ULUGEOTEXTILE COYER DEEP TEST HO"LES'OBSERVED N S 0\ PLAN = FROl1 SSl`S S. .. PERCS'TO BE WITNESSED ' . - SEPARk:T ON DISTAL C3 TQ P.L. DRIVEWAY, LARGE TREES,TOP OF FILL C. . EX- APPROVAL SSDS AD7, LOTS- 4LU20' 70 FOU\'D?►TION WALLS " WZ TLANDS �I'OW,N/DE'C.PERbITT;REQ'D ?) �(U100' TO'WELL, 200' IN.DLOD,150' TO PITS DATA-ON DDS:PLANS. &:PERTN�t SANE 100' TO STREA -M, WATERCOURSE LAKE Inc ez na ( PRE 1969 NEIGHBOR-NOTIFICATION �", (' P �U50' TO CATCH BASIN, 35' STORtiIDTtAL\, PIPED WATER (�LETTERBI/ZBA :. (�JLU10' TO WATERLINE (pits -20') 100 YR FLOOD ELEVATION W/1200' L.&_)50; I \'TEPNITTTENT DRAINAGE-COURSE . SOIL TESTING LOTS>10 YEARS OLD 0_)200' /500' RESERVOIR, ET.C. _ 150- GALLEY SYST &MS. REOUIREI,�DETAILS ON PLANS (�(U10'.I ILYTO LEDGE OUTCROP - SEWAGE SYSTEM PLAN - (NORTH ARROW) , SEPTIC TANK SSDS HYDRAULIC PROFILE L�LU10' FRO`I FOUNDATIO�i; 50' TO WELL ' GRAVITY FLOW WELT, _)CO NSTF�U I9�`l.NQ'IES 1- 15_ DISIENSIONS TO•PROPERTY LVE.S ' --. -- LUDESIGN DATA: PERC & DEEP RESULTS LULOCATIOY OF SERVICE CO:INTECTIO\ C ZLU2' C0xNTOURS EXISTING & PROPOSED qL JMPi 15' TO PROPERTY LINE WDRIVEWAY SLOPE FOOTING /GUTTEIt/CURTAIi IDRAINS r 1$LOPE LY SSTS AREA S20% USDA SOILTYPE BOUNDARIES `--' ) 4 ' (TITLE BLOCK; OWNERS NAME ADDRESS (JLJREGRADED TO 15 %, IF REQUIRED DOSE/PUNIP SYST MS (� Thl,' , PE/RA; NAME, ADDRESS, PHONES WL—WUMPNOTES DATE OF DRAWING/REVISION C/O DOSE 751/6 OF PIPE V0LUhIE/D0SE VOLUME VOTED C (UDATUM REFERENCE DETAIL FOR FORCE npi, (PIPE TYP , ETC.) Ui C_)LOCATION OF WATERCOURSES, PONDS PR AND D -BOX SHOWY & DETAILED LAKES ,WETLANDS WITHIN 200' OF.P.L Ljl DAY STORAGE ABOVE ALARh1 (�CUPROPOSED FINISH FLQORAND CURTAT WRAW BASEMENT ELEVATIONS C jt!nSTANDPIPES 5' BOTH SIDES DETAIL WVELLS 8c SSDS'S W/IN 200' OF SSTS U o o o ��R OPERT Y METES &BOUND$ �I5 ML`I to CDS = >5 /o, 20-4 /o, 25.3 /o, ROSION CONTROL FOR HOUSE WELL & _-OLJX MIii to CD DISCHARGE /100'tivith 182 cons day discharge SSTS, EROSION CONTROL NOTE ' hILY to NON - PERFORATED PIPE COMMENTS: (Itusif EET)09101 /00 BRUCE R. FOLEY Public Health Director TO: PROJECT: DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., 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 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 DEPARTMENT OF ENGINEERING AND DESIGN. REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED TOWN: C SE PV DATE SUB'D APPROVAL: NOTICE OF COMPLETE APPLICATION DATE: e � Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 27911003 September 3, 2002 Fax (845) 2794567 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS William McDermott Bullet Hole Road Town of Patterson, T.M.# 23 -2 -33 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSTS," dated 8/9/02. 2. "Application for Approval of Plans for a Wastewater Disposal System." 3. "Construction Permit for Sewage Disposal System," dated 8/9/02. 4. Copies of Certified Mailings are enclosed. 5. "Design Data Sheet." 6. "Letter of Authorization." 7. "Short EAF," dated 8/9/02. 8. Two (2) copies of Residence Floor Plan(s) for bedroom count only. 9. Review Fee in the amount of $300.00. / If there are any questions concerning the enclosed, please call. Very truly yours, H W. Nic ols Jr., P.E. HWN:JM jmm 02 -051.00 14.16 -4 (9M) —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 \niLt_1R 1 MC�E2r� ©�� 2. PROJECT NAME — — Pc�oPos�� ss�s 3. PROJECT LOCATION: �� �� Municipality \ ` { 1 V County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 6. IS ACTION: . _P,Ryp�POSED �!!J New ❑ Expansion C3 Modlficatlon /alteration 6. DESCRIBE PROJECT BRIEFLY: N E W RE.S \bENCL I S S1 S. 7. AMOUNT OF LAND AFFECTED:.; . �y`� Initially t� acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? ZYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? C'J Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: ����L� FAMILy • 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE` R LOCAL)? C 1 Yes ❑ No If yes, list agency(s) and permitlapprovals con► >je\)(_7\uJ PE�'� F U� SEv�AGE TAE A�m�^/� sys =`=M 11. DOES ANY ECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? El Yes If yes,' list agency name and permlt/approval 7No 12. AS A RESULT OF ROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes N0 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ' � L ".5 A 6'� N Applicant/sponsor me: �" ' �+ `\, ` a� , Date: Signature: b� 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 i IDYTTl®T A AX f "���T1sTTQT Tnl�lo A DTT��1�'1®TT (lY,� LYL� A >t .Tyx ,,. Subdivision Lot # Filed Map # Date Filed— Gentlemen: This letter is to authorize H A tux a duly licensed Professional Engineer or Registered Architect to._apply. for the. requiredn.;;_. wastewater treatment and/or water supply permit(s) to serve the above-noted property m' accordance with the standards, rules or regulations as promulgated by the Public Health Director of the 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 p s I�io w • icle 145 and/or. 147 of the Education. Law; t-e Public Health Law, and the Putna 'sfta* ode. r Countersigned: P.E., R.A., # CFO o. 4 �(��2 RQFES5t4ss,z�� / Mailing Address 2 So (<L7 , 22_ State Zip AQ5 Q� Telephone: $ LA State Ny Zip . I U Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR. APPROVAL OF PLANS FOR -- A WASTEWATER TREATMENT SYSTEM' 1. Name and address of applicant.: U p1 M N\ CbF P._MOT1 2. Name of project: S o p Q •� �16 S S-�-S 3. Location TN: �` P 1 -1. ., b 4. Design Professional: MMI `4, N'001S)Z4k.5. Address: 20;0 C-00 7-E 22 6. Drainage Basin: 7. —Type of-Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision_- . Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ......:................ ............................... Type I _.... Exempt... Type II Unlisted 9. Is a Draft Environmental Impact Statement DEIS) required? p . 10. Has DEIS been completed and found acceptable by Lead A g enc y? ............ ,,. N U 11_. Name of Lead Agency fv lh 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 authorities? N 0 Date granted.: 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? - 17. Waters index number (surface) .......................:...............,.... ................�.,.,::........ 18. Is project located near a public water supply system? ....... ............................... IV 19. If yes, name of water supply Distance to Wa er: supply 20: Is project site near a public sewage collection or treatment system? ::.....'..::..:. 21. Name of sewage system Distance to sewage system 22... Date test holes observed f ; D / QZ 23. Name of Health Inspector (SE N 24. Project design flow (gallons per day) .................................. ............................... o 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.:: N-6- 26. Has SPDES Application been submitted to local DEC office? .............. 1V / _._ Form -K -97 z 27. Is any portion of this project located within a designated Town or State wetland? N ...- ...... N 28. Wetlands ID Number ........................................................... ............................... i 29. Is Wetlands Permit required? .............................................. ............................... 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 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ............ .............. 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? .................................. .............................Iv 35. Are any sewage treatment areas in excess of 15% slope? . ............................... �J 36. Tax Map ID Number ............... ............................... .......... Map2 --.- -Block `2_ Lot h 37. Approved plans are to be returned to ..... Applicant _� Design Professional MOTE: 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 nQ re ire DEP approval of the SSTS prior to final approval by the Department. Projects within the watered also require DEP review and approval of other aspects of a project, such as stormwater plans..orTe G- �ri&,n of impervious surfaces, and the project applicant should obtain the appropriate forms for suchmtivg t from DEP and submit those forms to DEP for review and approval. �- e If the application is signed by a person other than the applicant shown in Item l.,the an'mlic must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with%is �rovislon may be grounds for the rejection of any submission. 1 I hereby affirm, ender penalty of perjury, that information provided-,on this form is true to the best of my knowledge and belief. False statements made hereirf are punishable as a Class A misdemeanor pursuant to Seetign 210.45 of the PenoLgw. SIGNATURES & OFFICIAL TITLES: Mailing Address: PUTNAM COUNTY DEPARTMENT OF-HEALTH.,.,. OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM e.0. 60Y, A- Owner WILL-1AM mo,_,F P-M C) T Address CRo Tog _FA 11Sj fly ros19 Locdted at (St(Street) GULI-ET INOL_E ?-OAI� .-Tax Map Block Lot (indicate nearest cross street) Municipality. �'ATTEQS*0l�f Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking -7 29 f 0 Date of Percolation Test -7/_t6/02_ Hole No..: ...,Ryn.NQ T 4.4 is too El' e Time 4DS (M Depth to' Water ": round From G_ d (Inch Surface ei) Start Stop - ,,:;!,Wa er .:��Levvl ro 11 D )"In 'Inges �-.Percolation Rate Miii/I `h- ac V,�o •(5 2-2 23'12- 20 %/,2 21 -W; 2Z4 3 '2� Z_ 4 V 2:\O) 22 2AYA '2/A:--.-. 22- 2 /A- '/Ar .2. -.,CiL 2, z -.3 _730 2-2- .-- 2-3-1 '1 X .27�3'� 4 5 2 3 4 5 NOTES; L. - Tests.to be repeated at same depth until approximately equal perc rates are obtained at each percolation test hole. (i•e. s I 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, 2.51 W . ... ... 3.0 F- ZL 3.5' L, SZ, IN.6 -CDIV)� PS 4.5 7 . ... .. ... 5.0. 5.5 6A, INC 6.5 SANb& CIQ \\JCL CMI 7.0' T 4( <C; 7.5 8.0 YY ..-YT 9.01 po 9.5' 10.0 . ..... . ... . ... Indicate level-at which -groundwater is encountered Indicate level at which mottling is observed &0 AoL.C- Indicate -level to which water level rises after being encountered Deep, hole observations made by: b K ri N N 0 "CONN Date'-71-36/02- Design Professional. Name: W, ptbou- A PE, C3� mpyy � Address: -D NIC Signature: 4 L -BKW�T IAA Design Professional's Seal ZL NEIGHBORHOOD NOTIFICATION - McDermott 23.2 -33 (Town of Patterson) 23. -2 -27 Vista Development, LLC 555 Jackson Drive Palo Aeto, CA 94304 23. -2 -31 Entler, Joseph Jr., & Carolyn 3 Heather Court Upper Saddle River, NJ 07458 23. -2 -34 Fieldman, Henry & Janet 499 Bullet Hole Road Patterson, NY 12563 23. -2-48 Fieldman, Henry & Janet 500 Bullet Hole Road Patterson, NY 12563 23. -2 -52 Deaton, Inez 450 Bullet Hole Road Patterson, NY 12563 4 V r; �f .I�r • �J�i•' Z4 1' 1�'.. • • • ••c: i�, 0 V - i'MixtWel te PERSON INTERVIEW PC(D Caaplaint # Nam & Relationship (i.e, owner,tenant, etc.) TYPE FACI iI REGISTRATI011 # Q! Primal (include sketch lasting all adjacent walls): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. Inspector's Signature & Proposal Disapproved '%- Proposal approved with the followinci conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Nana, Town and Tax Map number. c. Iocation of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and.conditions. I, as owner, or reported agent of owner agree t. SIGNATURE QI B: Bhite (PM); YeUnw (Tapin BV; Pink Utpliamit) PC -RP 97 to the above conditions. TITLE M'%°E ,tom �\37 -9-�) 2ut-t.,40-7 llxmtr- &- I �>e- Z79-606-q El PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL Iii TD VUDAL ADDITIONIREPAIR FORM SECTION A: GENERAL INFORMATION Name of Project ��r9Y (T)(v) �4�: e�1 �' ^� TM# -2 ,7 Year of Construction / Size of Parcel J' /IC- /-a SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hilly ❑Rolling, 0teep Slope C) 'Gentle Slope ❑Flat 2. NEvidence of wetland Clow area subject to flooding, 5 Bodies of water ❑Drainage ditches Mock outcrop YES NO 3. Property lines evident? ❑ 4. Water courses exist on, or adjacent to parcel: ❑ 5. Existing individual wells within 200ft of the existing SSTS? ❑ SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. []Level OGentle Slope ❑Steep slope B. ❑Well drained Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited 0Somewhat limited ❑Adequate ft x ft F1 D. INSPECTION Date =" C 7 Inspector � • �����' _ - 0No evidence of failure ®Evidence of failure ®Evidence of seasonal failure -----------=-----=-==-==-- - - - - -- - I K (Indicate North) We V v ��N o r r R� N M to M M 110 y 11 O-ivEwAy SGo PLC -� (1) Indicate location of SSTS A. Size and type of septic tank /QUD gallons MiMetal OConcrete NPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft.-If. 7:nV F1 (-'r R ,9-'o R j (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY 1]PWS []Shared well OIndividual well MDrilled MDua. LACasin; above ground CONTSENTS: SyJ;Em t9c.fZ,WY Z�.P- > /9cc.�0,, �U �0 y16- �af tiCy �vyaAe;, -, OA) REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: # L 27 -+ 3.95 AC. 104.47 AC. CAL. 199.99 CAL 46 s 4' 2VI.50 AC. CAL. 7.7 C. y Z S 35 INI A \ x66 ACry� 230 CAL 1326.03 I I I ` •\ 246.03 a Ir,49 _ 44T.92 - - AC. 31 3.41 • �0ba 26.05 AC. s CAL 75.96 AC. 34 50 CAL 32 g N 33 F r �1e s I&IS AC. CALI 3 1i AC ° s 32.68 AC. CAL. 1': .'' 511 , 1.54 At 52 61261 24446 l 32.18 Ac. i r' y 44 1 v v AL 960.N 24.76 X / 41193 r 30 1 1 f X3.40 A` A _ -_ P/0 34 -3.63 AC. 4 6156 ' ^m7� = = _ _ __ =PLO 34 =5 -5= _ -\ _ /0_327 _P /0 `*DZ1.92 AC. _ 59 63 0� . I y -�= `- nA• 2 10.91 AC. • j �, - .45.61 30.91 AC.,CAL. a' / bi02zs 1 92 ACR % I A ' R `. AL IA ` AL ✓ io 62 60 1'x32 AC. 61 1 3 Ie 17 x �QO `� %� f t • TT2 3 rxn 20 ° 19 g I I 102 69 AC. CAL X \..� �5.81gc. u 4,• A. / ' °'� 16 ' 19 Hn 249 . n>n '164 s 27 4s twt .46 AC. .. AC.• L31; • •'`..i- .. -.._. ._.. 900• � � . � a A6 61 � CAL. .T.JL 14 17 AC. 411 44.6 yY 42 AC./ 179.1 JL /2�q9 I 0 6 JL i % , y 9.55 AC. % ra twos two it14' 8 7 •I 4.00 AC. • . e 10 s n,, n 2sc.o \ r \6 AC. 4z 'b$ 9 ; o Il t 15 .�1 / 64.98 AC. s• 27s 35�AC. CAL. 26 �67 AC � J a/ ti 14 • 75.97 AC. o \• ' 11os 26.60 AC. 12 71.91 AC. I f � r i O 25 74.41 AC. /CE SITE K g,3-9- q7 dla-P-111� m = 7 - -73 240 a 2 , 2 - HAI1ZNG AD MESS PNC*W nfraMEM r Pm amva&int Nam & Relationship (i.e, owner,tenant, etc.) DATE -q TYPE FACILITY PROPOSED INSTAIJM &gL �� 17-Z %Q REGISTRATION # 1-2 ELc2eg!-�j (include sketch locating all adjacent wells): MM: Repair must be in same location and of same type as original sewage disposal syst=. Different location may require submittal of proposal from licensed professional engineer or registered architect. F�-- r .......... Q -Wj' ,gp or, A Proposal approved Proposal Disapproved Inspector's Signature & Title 3. conditions: I--, Submission of as built repair 'sketch in dupli cate shceingl, a. Owner I s name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,hcuse corners) 0"': d. System description (e.g., 1250 gal. concrete septic ta-k,, three precast 60 dimo drywells surrounded by one foot +-.gravel). e. Installer's name and number. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE MTE - Mite (PAD); Yellow ( EI); Pink LbVqUamt) PC-RP 97 x 6, dWP <' " --fi S?e- - 73/3 IIQ14pk� CSC LQ '16vi" ra 3K, C, � O' n�� I /�C f✓ e r !� 0-7�- AG S; cl c n c e 7 U � g, 11 e"fX10% e4 33' - -6" c` � ►'S 6 N /il,V /_2S5-62 15=9 Liv./ ®an -"oa Nb �-� f 1 o1J /)EOUc 0 0 V N -�511910 61