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Home My WebLink About0635DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -67 BOX 7 00635 Ll r lb�r:.� 00635 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION. REPORT Well Location Street Address: a Town/Village: �f� Tax Grid # Map �3 Block ;L Lots) 6 Well Owner: Name: Address: % J n . 7- C� ()(A l Q r Poal, Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoing Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length _,3D_ft. Length below grade _ _q ft. Diameter Sin. Weight per foot - j 7 lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: — Cement grout Bentonite — Other Drive shoe: X Yes No Liner: Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed __ Pumped ,X Compressed Air Hours Yield gpm Depth Data Measure from land surface - static (s pecify ft) L. 71©4Cc During yield test(ft) C�IJ ji,- Depth of completed well in feet / Well Log If more detailed information descriptions or sieve analyses are available, please attach. . Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 1' 7 9d '-e+ % If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Q Pump Type '& llbapacity �oH 5 Depth 3��ff Model 57�� -v f C Voltage 2_4a HP Tank Type W asa Volume fe -nm, k Date Well ompleted Putnam County Certification No. Date of ReT rt Well Driller (signature) NOV: Etact location of well with distances to at least two permanenVandnArks to be provided on a separfiteoeet/plan. Well Driller's Name 'L soh6 Signature: Address: 19')1k&-,F11 106 te. �► %> / + Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 ri � -: t+ N �a 'NA couN� � �� OEP 0 C 4` 5 5 5 1 Geneva Road (845) 278-6130 f , Brewster NY 10509 r Received'of%i J MN YOUR as ❑Check O ❑Credit Card 7 l� �UfNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE- FOR.SEWAGE TREATMENT SYSTEM U� PCHD CONS4TRU SON P`ERMIT#? Located at V T �ii� Town or Village ��- �5�� CT) D 0 0 Owner /Applicant Name CQ 566 C.& r. Tax Map - Block Lot Formerly Subdivision Name L ! %" em.D %�! L�-- Subd. Lot # [Y Mailing Address 5-r G; %��i'r%� /� Zip ja 0-... Date Construction Permit Issued by PCHD Separate Sewerage System built by Cau S,- (fd h 5J - Address C4 -9_11l C` Consisting of 12-E-0 Gallon Septic Tank and ooe_� O� Z / = T?ze vcl4 Other Requirements 6 Fit C. Fi7Z— A) 6 7-0 Water Supply: Public Supply From, Address or: C Private Supply Drilled by T Address _ /G/r Building Type Has erosion control been completed? l�s Number of Bedrooms Has garbage grinder been installed? AJO 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 ote Pram CTyty pepartment of Health. Date: Address P.E. )< R.A. 5�2zJ -7 1 ZJ�g Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation" mo ificatio change i necessary. r � By:. � Title: 0 Date: 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: /' L l ' Town/Village: �,, r<r- `�� Tax Grid # Map ),3 Block a Lot(s) t� 7 Well Owner: Name: Address: oaf, % C�.ai� ' cti a - 0 (ni a a Ct� lr o Use of Well: I- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length eft. Length below grade °4.," ft. Diameter n. Weight per foot - . j 7 lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded _X Threaded _ Other Seal: _ Cement grout X Bentonite _ Other Drive shoe: Yes No Liner: Yes Y No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed Pumped W Compressed Air. Hou=eld gpm Depth Data Measure from land surface- static (specify t)) 7 l - c_c_c ` During yield test(ft) & o- Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 7 C/Aa F'' 4 At/poltr6d aj If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 02 d Pump Type 'li - ,,,,cb�apacity � floo s Depth 3300 Model S �%t�- 1 �C Voltage aDn HP Tank Type W x asa Volume Date Well Completed Putnam County Certification No. Date of Re rt Well Driller (signature) NOV: Elact location of well with distances to at least two permanenVananwKs to be proviaea on a separatepeevpian. i,�� L) Well Driller's Name �� -�— "Joii'`kS Address: /dl� 5y/ k rS e Signature: , Date: ge, 3 I White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 j � 1 PUTNAM COUNTY DEPARTMENT OF HEALTH, DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM ,i4 Owner or Purchaser of Building le8c,4TVei2 6 c' Building Constructed by POW)", T pdaj Location - Street a3 a- K7 Tax Map Block Lot -- Town/Village Subdivision Name f0t * M k/ PP Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the, system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month_ Day Year oZ 00 Signab POU6 `.d- Rec; Title: Genera ontra r (Owner) - Signature geec�7yee,o ��,c4d/ h ec� Poe 69h s &C2-A h Corporation Name (if corporation) Corporation Name (if corporation) Address: V 0 d / Address: c B 0 X e a 4 /6F State Nmwyo r k Zip State � C w Y Zip 1 Form GS -97 RUCE R. FOLf Y Vic Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF BEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Pluming 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 OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE: - 4' -7 6� L ✓�e�d�_�,/ ��v v v °jam• 4 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 addros is assigned by an authorized town official. This form is to be submitted with lie application for a Certificate of Construction Compli ance. (E911 VRFRIvi) YML ENVIRONMENTAL SERVICE-,:.) 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.302266 CLIENT #: 8641 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NON STAT PROC ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 1 WALLACE, DOUGLAS DATE/TIME TAKEN: 08/21/03 10:30A P.O. BOX 154 DATE/TIME REC`D: 08/21/03 11:20A MOHEGAN LAKE, NY 10547 REPORT DATE: 08/29/03 PHONE: (914)-734-1187 SAMPLING SITE: 24 POWDER HORN ROAD SAMPLE TYPE..: POTA8LE : PATTERSON, NY PRESERVATIVES: NONE COL'D BY: D. WALLACE TEMPERATURE..: < 4C NOTES...: KIT TAP ------------ ---------------------------- -- m -------- ------------ COLIFORM METH: m -------------- MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 08/21/03 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 08/21/03 LEAD (IMS) <1 ppb ' 0-15 ppb 9101 08/21/03 NITRATE NITROG 0.33 MG/L O - 1O 9139 08/21/03 NITRITE NITROG <0.01 MG/L N/A 9146 08/21/03 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 2037 08/21/03 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037 08/21/03 SODIUM (Na) 1.24 MG/L N/A 0021/03 pH 6.9 UNITS 6.5-8.5 9643 08/21/03 HARDNESS,TOTAL 22.0 MG/L N/A 08/21/03 ALKALINITY (AS 48.0 MG/L N/A 08/21/03 TURBIDITY (TUR <1 NTU 0-5 NTU COMMENTS: GACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN�z��-)HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. 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 are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.302266 CLIENT #: 8641 NON STAT PROC PAGE 2 WALLACE, DOUGLAS DATE/TIME TAKEN: 08/21/03 10130A P.O. BOX 154 DATE/TIME REC'D: 08/21/03 11:20A MOHEGAN LAKE, NY 10547 REPORT DATE: 08/29/03 PHONE: (914)-734-1187 SAMPLING SITE: 24 POWDER HORN ROAD SAMPLE TYPE..: POTABLE : PATTERSON, NY PRESERVATIVES: NONE COL'D BY: D. WALLACE TEMPERATURE..: < 4C MOTES...: KIT TAP COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~^~~~~~~~~~~ DATE FLAB PROCEDURE RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS 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 6.3 TO B.S. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM 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: Alb — H. Padovani, y�.��(ASCP> Dire�tor ELAP# 10323 PUTNAM COUNTY DEPARTAIENT-OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 6Z. 2 Street Location V15'Ti�l 70l_pk' S Owner ��G�te y: _<�;, Town _ ��9�� Permit # J — a 1 —9--3 TM # 023 — -7 Subdivision Lot # 6 1. Sewage Systein Area Y a. STS area located as per approved plans ........................... a b �F4ill�section� ;date of placement 3:1 bamer Lgth. Width Avg.D th c. Natural soit-not stripped .... ............................... P.......... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course /wetlands..... II. Sewage System a. Septic tank size -1,000 ..:.. ..1,250. ......other ................ b. Septic tank installed level ................ :.I............................ _ c. 10' minimum from foundation .......... ............................... _ d. Distribution Box 1. Ail outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. Trenches Length required z1 6D Length installed8 2. Distance to watercourse measuredfi /oo2 Ft.......... 3. Installed according to plan ...................... 4. Slope of trench acceptable 1 /16 -1/32" %foot ............. 5. 10 ft. from property line - 20 ft: foundations.......... 8. Size of gravel -3/4 11/2 "-diameter clean.......... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .................................. :.................... g. Pumo or Dosed Systems I. Size ot 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........... III. House/Building IV. "b. Distance from STS area measured 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 ouifall_pro.tected & Air.to exist watercourse h. Surface water protection adequate ... ......................:........ i. F.rnsinn nnntrnl nrnvided COMMENTS BRUCE R. FOLEY Public Health Director June 24, 2002 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 Fax (845) 278 - 6648 s Preschool (845) 228 - 5912 Fax (845) 228 - 6113 John Karell Jr., PE 121 Cushman Road Patterson, NY 12563 Re: Field Inspection - Wallace Vista Dolores, (T) Patterson Lot #6, TM# 23 -2 -67 Dear Mr. Karell: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1) The expansion area fill can only hold four runs, (six runs are required). 2) The house and well need to be inspected upon completion. If you have any further questions, please contact me at (845) 278=6130 ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR :jc fieldins o o SENDING CONFIRMATION DATE : JUN -24 -2002 MON 21:16 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 96287085 PAGES : 1/1 START TIME : JUN -24 21:16 ELAPSED TIME 00'21" MODE ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... Re: Field Inspection - Wallace Vista Dolores, (1) Patterson Lot #6, 1M# 23 -2-67 Des Nr. Yxc L- Tho above referenced separate sewage hoatment system can be backfilled. The following comments must be canceled in the field: 1) 138 expansion area fill can only hold four runs, (six runs are required). 2) The house and well need to be inspected upon completion. If you bave any fw1her questions, Please contact me at (845) 278.6130 en 2261. Sincaroly, F/a ��• Gen: D. Road Bmdmnmemal Health Eoencering Aide GDR;jc fielding BRUCE R FOLSY LORMA MOLMARI R.N„ K9N. P6NIr fluYA Daerls A ftA - 74b70 8-1A Dbegw, &-mw qf powu S'6rrfcrr DEPARTMENT OF HEALTH 1 Genova Road Brewster, New Ywk 10509 D6"rt -.ea -1 rude (NOM -6130 F-(91S)279.7611 . ..._ S-.ime (965)279 -6559 W0a ({67)276.6676 F-e(1145)379 -6695 7fe91.W —,des (W)279 -ioii F.PO)m -6618 June 24 2002 ft—hW (165)279.5912 F- 065)229 -6113 John Karen Jr., PE 121 Cushman Road Patterson, NY 12563 Re: Field Inspection - Wallace Vista Dolores, (1) Patterson Lot #6, 1M# 23 -2-67 Des Nr. Yxc L- Tho above referenced separate sewage hoatment system can be backfilled. The following comments must be canceled in the field: 1) 138 expansion area fill can only hold four runs, (six runs are required). 2) The house and well need to be inspected upon completion. If you bave any fw1her questions, Please contact me at (845) 278.6130 en 2261. Sincaroly, F/a ��• Gen: D. Road Bmdmnmemal Health Eoencering Aide GDR;jc fielding Sent By: LLL; 1234567 ;5un�t9 04,12 3�-a Page 1 /1 1 cgS2/ k� -- �-- �-� # •ate v 1' " :ssa�pp'y Tom a9tsoq ;o luamw a 4ono3 Wv%nd 09JOI pe Pm vq% ` XPMIS aqi Pvs Mid panojddn Pm #.=d '90RO sao-3 MM Paws! M R ft. OMPOM at umP16 00 )Pqs pggu.3k pne paumdcq aAiq I pm POPUMM U004 ssq 10=W 244p Wo A'po g61'(s)aa W2 OV RM 4p. = I xv# Z - 0 -.'.o.L -'7 Mfr UN 0 10 dO df 3 'IL. ola ' I /„° -vd 1 'd sagoua1y — ' Lwgd u! sam v= lonooa notion ON .� �,s+oret8 rid ro P"col Tiim sZ :a1�aQ bPn ll! nom sI nod ss pi»nwoa mo3 A 61 :a3Yq 5 pwidmaa woms sI :911(1 Lpm�ldozoa pg aaa # io'i "m.. . n5 svraKoa� .pgnS � :�saur�og . 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I�. dr, hy,,�Fptip �i(ru. 4hr$,id :AI F.,r f�A,!t , .f5 :•�`•! �. , A ,:I'3" f'i ,. ,Y,'tr �i �� .. .LJ' r 7�it�'`" A' dR d t A`sf.... .,. .,t A' h ....; L:I,�� t.,` .- .,;.,y�A�s�,ni11 ..t��l" '' ..i., >J -,;•.; ` 10 ..iq0 �'•'r I . (; >,:, Pya>a�,1� r ,. ".., ! n1L,:,h� �. 14( 4•lill4r , Wi � F I , .:,x. t�. ; r N.SM 14 Sf _ �7 • � � �� .. I ` � '�r , ` _________________ ____-A_ MAMA _______________mm___m | ® ■' § ® � � � ■, -�._\ � • \� � | r e � » 2� :a� a:° _ ■, , &�� z ! | t § • ` �_2 . ® � , ` � . f � � '¥ _ wkt .■ } | ■ ■ &,_ m______m PUTNAM COUNTY DEPARTMENT OF I3EALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at v I S- T A- b 6LO R4. S Subdivision name I il'i.E P61-JO At( -Subd. Lot # � Date Subdivision Approved 3 �� Owner /Applicant Name WUL1 W MLA-e— e �C�PDUS.= Mailing Address. � 9 T f` P-S j CA-gm-6� N Amount of Fee 1' Town or Village P,+—rTe-r,.,&6AJ ( —fj Tax Map 2 3 Block 7— Lot (-7 Renewal X Revision Date of Previous Approval . ! l e `I [j —1 d563�— Zip Building TypeMOD 4 Lot Area 1 � 3 F No. of Bedrooms I Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of (z,50 gallon septic tank and Other Requiremen ?s: ��' l,� CW ()-I To be constructed by T Address fj 6I-D IS1-'Ast Water Supply: Public Supply From Address or: )( Private,Supply Drilled by % Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 61? ,Z-10V 2SW License # S,73 2-1.7 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t. Approv for discharge of domestic sanitary sewa a only. By; Title• 61PUAt- 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 p please print or type PCHD Permit # Well Location: Street Address: T wn/V llage /'a—) Tax Grid # Map )-3 Block Lot(s) 1 Well Owner: Name: Address- Use of Well: � Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Stan by Amount of Use Yield Sought _ gpm # People Served Est. of Daily Usag al. Reason for Replace Existing Supply Test/Ob rvation Additional Supply Drilling New S ply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? .............................-...... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: TownNillage Distance to property from nearest water main: Proposed well loc ti ion &sources of contamination to be p vide on separate sheet/plan. Date: `L Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water 11 driller certified by Putnam County. Date of Issue a Permit Is su' i 'al: Date of Expiration _ 102--- © Title:' Permit is Non- Transfe •abl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 +�, 11 J7 PUTNA1Vg COUNTY DEPARTMENT OF HEALTH (4 + 1� DIVISION OF ENVIRONMENTAL HEALTH SERVICES , DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM OwnerWA VJ ALLA<E-� 67 k Adaress �S%— Wft ( � Located at (Street) L10 L�s Tax Map 3 Block 2-- Lot (7 (in icate nearest cross street) Municipality �� A44K Drainage Basin /V \//C, SOIL PERCOLATION TEST DATA Date of Pre - soaking W i a t 00 AIVV Date of Percolation Test 6111100 Hole No. Run No. Time Start -� Stop Ela se Time �Nlin.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch j .2 ILI - -L I I 7 3 4 5 1 Z1_ 2�u Zy /y �� l,, 3,3 3.3 3 �'� �� 6 3 ''� lei,. 0'/r- e3 4 5 1 2 3 , 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation . rates are oommea aL caw, percolation test hole. (i.e. s 1 min for 1 -30 minlinch, 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 4 71 . 4.0 CONSTRUCTION PERMITS `~ Prior to any construction of a SSTS plans for such system must first be approved by the fi P Y Department. There are generally two types of construction permits reviewed by the Department; those requiring 2 feet of fill or less, and those requiring greater than 2 feet of fill. The submission requirements for each type are specified below. A. Construction Permit Submission Requirements For Lots Requiring No fill or Fill Two -Feet Deep or Less �1. Construction Permit Application. (Appendix K) V2. Letter of Authorization for Design Professional. (Appendix K) L/ 3. Application for Approval of Plans For A Wastewater Treatment System. (Appendix K) � A'4. Corporate Resolution (if corporate ownership). (Appendix K) 5. Short Environmental Assessment Form (EAF).(Appendix K) ,,/6. Design Data Sheet. (Appendix K) NOTE: All submitted Department application forms shall contain original signatures (no photo copies). 7. Three (3) sets of plans bearing the seal and sigdature of a Design Professional, licensed and registered to practice in New York State. These plans shall be to scale (minimum 1 inch to 30 feet horizontal and 1 inch to 10 feet vertical) and shall include, as a minimum, the following: 8. Two (2) sets of house plans with title block as specified in 7. k. above, one of which must accompany copy of approved Construction Permit to the Building Inspector of the local municipality. Upgn approval of the Construction Permit, tke house plans will be signed and stamped: "Approved For Bedroom Count Onlypp. LA 1l . Applications for Construction Permits for lots created prior.to 1969 will not be reviewed until such time as the Department. is provided with proof that If water service is from a public supply or community supply, a letter from the water supplier will be required stating that they will be able to supply the property with water at adequate pressure. Well Permit Application, if required. (Appendix K) Y Fee - See Appendix I. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: 1� "�"� STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: TAX MAP =: (CONFIRMED) Y N DOCUMENTS Y N (REQUIRED DETAILS ON PLANS CONT'Dl (_JUPERMTT APPLICATION (� HOUSE SEWER - %" FT. 4 "0'; TYPE PIPE CAST IRON LL)UWELL PERMIT OR PWS LETTER `i0 BENDS; MAX BENDS 45° W /CLEANOUT UUPC -97 / RENEWALS U(_)LETTER OF AUTHORIZATION /J( �S &NOTE (NO CHANGE) C_J(__)DESIGN DATA SHEET (DDS) FILL SYSTEMS (_JUCORPORATE RESOLUTION' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE C_)C__)SHORT EAF C_JC__JPLANS -THREE SETS UUHOUSE PLANS - TWO SETS C__JUVARIANCE REQUEST SUBDIVISION UULEGAL SUBDIVISION L_)USUBDIVISION APP OV CHECKED � C(__)PERC RATE (_JUFILL REQUIRED DEPTH (_JUCURTAIN DRAIN REQUIRED GENERAL )LOCATED IN NYC WATERSHED (_)(Z—)� PLANS SUBMITTED TO DEP LEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED U SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) UDATA ON DDS PLANS & PERMIT SAME 969 NEIGHBOR NOTIFICATION.. 11 ( __ It i,T.�ER BUZBA 100 YR. FLOOD ELEVATION W/I200' ( )SOIL TESTING LOTS >10 YEARS OLD AGE SYSTEM PLAN - (NORTH ARROW) ; HYDRAULIC PROFILE VITY FLOW l CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED (� RIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS U USDA SOIL TYPE BOUNDARIES (TITLE BLOCK; OWNERS NAME ADDRESS -TM#, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE (= ))LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS EWELLS & SSDS'S WAIN 200' OF SSTS l/l)'6(_jPR0PERTY METES & BOUNDS COMMENTS: SPECS / FILL NOTES 1 -5 FILL PROFILE & DIMENSIONS U FILL IL`i EXPANSION AREA FILL GREATER THAN2 FEET (CLAY BARRIER U FILL CERTIFICATION NOTE ;� DEPTH GAUGES ;__)CYJVOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS �_J SEPARATION DISTANCE FROM TOE OF SLOPE T E C F TRENCH PROVIDED 60FT MAX. ARALLEL TO CONTOURS �) 00% EXPANSION PROVIDED U DETAIIJDUST FREE CRUSHED STONE OR WASHED GRAVEL CJGEOTEXTII-E COVER SEPARATION DISTANCES ON PLAN - FROM SSTS 0' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL ( 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS (� 100' TO STRE Vyl, WATERCOURSE, LAKE (inc. eapan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits - 20') 50' INTERMITTENT DRAINAGE COURSE 200 /500 RESERVOIR, ETC. _ 150 GALLEY SYSTEMS � TO LEDGE OUTCROP SEPTIC TANK (� 0' FR011 FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION (_ -NIIN 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA V; (520 %) (�(EGRADED TO 15 %, IF REQUIRED p / DOSETUMP SYSTEMS UMP NOTES OSE.75% OF PIPE VOLUME/DOSE VOLUME NOTED ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) IT AND D- BOX _SHOWN & DETAILED DAY STORAGE ABOVE ALARM CURTAIN DRAIN rANDPIPES, 5' BOTH SIDES, DETAIL 5' MIN to CDS = >5 %, 20'4 %, 25' -3 %, 35' -1 %,100 % -<1% D' MIN to CD DISCHARGE /100' with 182 cons day discharge D' MIN to NON - PERFORATED PIPE JUN -26 -00 TUE 9:09 AM PUNAM CTY ENV HEALTH FAX N0, 19142787921 P, 4 �. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SYTBSURFACE SEWAGEI TREATMENT S STEM Owner A L _ Address 4BP– ��Shl� -- Located at (Street) Tax Map P.3 Block Lot % (indicate nearest cross street) Municipality _�' Watershed 'r, AAA) 3'a 41 Date of SOIL PERCOLATION TEST DATA Date of Percolation Test —49Z/ 51 percolation test hole. (i.e. s t min ror i -ju ►-►„► ► --p , - -• - --- -- - submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH GZ,. 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 ENCOUNWED l'�i T TEST ]SOLES I:OLE NO. f iD P58 It, i� HOLE NO r� SAiJ HOLE NO. Indicate level at which groundwater is encountered U%V Indicate level at which mottling is observed Indicate level to which water level rises after being encountered AJd A Deep hole observations made by: 46 &Ad Date 19 Design Professional Name: Z//A,/ X,417ZL-�./ Address:. ` C{f'14A4-AAJ 1zd Signature: Design Professional's Seal u 9 A -4 . JUN -26 -00 TUE 9;10 AM PUNAM CTY ENV HEALTH FAX N0, 19142787921 P. 5 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 6T ld DESCRIP'T'ION ON SOILS ENCOUNTERED IN TEST HOLES HOLE NO. � HOLE NO. Z HOLE NO. Indicate level at which groundwater is encountered��, Indicate level at which mottling is observed to/V Indicate level to which water level rises after being encountered Deep hole observations made, by: 4!5, %Z Ogp Date Design Professional Name: Address: Signature: Design Professional's Seal pUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONWNTAL HEALTH SERVICES RE: Property of P6 LETTER OF AUTHORIZATION Located at ' U l S 7�-` b 10 "S TN PIZ ' dyi Tax Map # e Block Lot Subdivision of�� Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize /-W a duly licensed Professional Engineer or ft; rl�A to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very Countersigned: Signe P.E., RA., # Mailing Address Mailing Address: 9 State n State zip Telep .Telephone: I /�_ 5Id- 9d Z-3. Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES yl APPLICATION FOR APPROVAL'OF PLANS FOR . A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: b U C L -A-S W AA � A-CK, , 67 Vg� C4 IV QJPD S. 0-A Am 2. Name of project: �p -T* ( 3. Location TN: P4-77E-y--50'A/ 4. Design Professional: T6 " JV 5. Address: 1 Z C. C U 5HA l A-fJ 12® tip 6. Drainage Basin: L©L��%�0Sdh! — �, PA -17EJ U' 6rA/ /V y � . �,----o 7. Type of Project: K 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? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project.in an area under the control of local planning, zoning, or other �Q officials, ordinances? .....:................................... ............................... . ................ 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities? 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? ....... ............................... 19. If yes, name of water supply Distance to water suppI 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 a 23. Name of Health Inspector C� 24. Project design flow (gallons per day) .............. r................ ............................... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DF.0 office? ......................... 2 27. Is an y portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ........... ............................... ................................................ 29. Is Wetlands Permit required? ................................ }............................................... % Has application been made to Town or Local DEC office? 30.* Does project require a DEC Stream Disturbance Permit? .. ............................... % 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, " landfllin 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 /y 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 a y 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 ?!::!:� Block - --Lot 6 37. Approved plans are to be returned to..... Applicant K 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 true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant A SIGNATURES & OFFICIAL TITLES. Mailing Address: ................................... 14.10.4 (2107) —Text 12 CT I.D. NUMBER 617.21 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM. For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (O be completed by Applicant or Project sponsor) 1, APPLICANT /SPONSOR 1 r /G 2. PRO NAME , 3. PROJECT LOCATION: p �^ Ar B� Munlcipallty County r' 1.� !/�A, 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) vej-j �Riv &Aj rep- i,.) de,.,-A -a r., 5. IS P OPOSED ACTION: • now ❑ Expansion ❑ Modiflcationlalteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF y ND %AFFECTED: �— / Initially ! ofc_ acres Ultimately acres 8. WILL'PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Ayes ❑No If No, describe briefly 9. W AT IS PRESENT LAND USE IN VICINITY OF PROJECT? asldentiai ❑ Industrial ❑ Commerclal ❑ Agriculture ❑ ParklForestl0pen space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes ( o It yes, list agency(s) and parmlUapprovals 11. OES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes ❑ No If yes, list agency name a, d permitiapproval 12. AS A RESULT O&PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? r ❑Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Date: AppllcanUsponsor na ��Ile Signature: L2 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 PAR*, !!— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 611.127 If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration I 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) Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, signiflt:ant 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 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 C1-05? Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ 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 (n magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box If you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency I'rhu ur '1 YIN. Name %if Rmpuml d e 01114 er ilk 1 Aeeury TU n u Re�pumi �t ll rot Signature of Responsible 5fficer in Lead Agency Signature of Preparer (if different from responsible officer) Date 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES C NSTR�UjCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PE T # ` l Located at�� Town or Village Subdivision name 1—)Tl 1 Sub Lo # Tax Map 23 Block 7-' Lot Date Subdivision Approved , 3 —1 e4 DQv ('45 iJ e- Owner /Applicant Name 6 aJ 1-, (.d Ai'S`73U 070 )J Mailing Address Amount of Fee Enclosed Renewal P� Revision Date of Previous Approval 2 - J-,. % I) �_ zip UI -�- / 1---- Building Type W 004 Lot Area .3 VNo. of Bedrooms q Design Flow GPD SV--?) Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of k4 �-/ � Lc- t 21—d gallon, eptic tank and Other Requirements: To be constructed by J Q 1) Address Water Supply: Public Supply From Address o: Private Supply Drilled by 11SIQ 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 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 o Signed: Address R.A. Date 9 License # T -3121 7 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pprov r discharge of domestic sanitary se g`eo�nly. kam--14Date: B Y• Title: %lC �� Ah � White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH Da"I ION OF ENVIRONMENTAL HEALTH SIERN710ES DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM Owner DO UCH �,¢- S GU/# -(.�, ? _ address 9 Fif -//2 C7X0US-&- C01VS'MV677oN e,�2N —� /v SIB Located a (Street) VISTA -Doto, S (poi✓o AV - Tax Map 3 Block Lot ? (indicate nearest cross street) 4d%`r Municipality aN 0-). Drainage Basin -:4WF,-vZ- -hjU,t7S0n1 Allen- -- SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 1 CSIS IQ DP reoeaCeQ ?:531.12 0- n until appro ir- na!'eiv equal percolation rates are oDtaincd at pe"colatlorl test hole. (i.e. S 1 min for 11-30 i 1iP��1i:C• ".'S 2 min ?,r J 1-60 inin/inch) viii data to be submitted for review. Z. Deoth measurement_ to be made from top o- -hoie. Form DD -97 be th to Water Water = j { E rom Ground Level Percolation Role? Run'�o. Time Start Elapse Time i Surface (inches) 'Start Drop in `�. Rate 0. -Stop t.: fin,} Stop Inches !: 17in,qncn I < < j j 4 j J i � i 1 tA b Ui I i f i S I{ 1 f I 4 1 CSIS IQ DP reoeaCeQ ?:531.12 0- n until appro ir- na!'eiv equal percolation rates are oDtaincd at pe"colatlorl test hole. (i.e. S 1 min for 11-30 i 1iP��1i:C• ".'S 2 min ?,r J 1-60 inin/inch) viii data to be submitted for review. Z. Deoth measurement_ to be made from top o- -hoie. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOLN- TERED IN TEST DOLES DEPTH HOLE NO. G.L. P290 � 0.5'- 2.0' 2.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' ?.0' 7.3' 8.0' 8.51 9.0` 9.5' 20.0' HOLE NO. HOLE NO. 1 Indicate level at which groundwater is encountered 1t10N&- Indicate level at which mottling is observed A/V N� Indicate level to which water level rises after being encountered Deep hole observations made by: I4 �-1- Date /0/iq/?7 Design Professional Name: Address: CU s�}njq*% A0 A-0 PA -776ERS0 1J A; Signature; r-- Design Professional's Seat r oV N y0 1A. .M., 1 i i 7_ - ^tj r1a UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE= FroperlY of 170 U LETTER OF AUTHORIZATION P'0U M UC770 N Located at y 1 S r A- DO 1 MA_-';� C &W Qk`=�AIAJ /204-P) — Teti 12A7- 1E7ZSdA1 oTax Map M Subdivision of Lj PLC— BONA "Y-14-4- Subdivision Lot - Filed Map Gentlemen: Block ,;2- Lot 6 Date Filed I letter is to authorize z)-6 1,41V rte` a duly licensed Professional Engineer =t to apply for the required %wastewater rrear ent n-6- "or water supply pe:mit(s) to serve the above -noted property in accordance Wl& the st=dards, hales or regulations as promuigated by the Public Health Dureccor of the Putnam County Health D,eparlment, and to sign all necessary papers on my behalf in connection with this matter %nd to st`pervisz the construction of said wastewater treatment ardor water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Latin; the Public Health Law, and the Putnam County Sanitary Code. Countersigned' .P.F., R.A., 5 3 2.7 7 Mailing Address d U -r1 fM1f-A) 14W.4'0 /° ,4 r7�r..,SvA/ State 14,56 3 Very truly yours, Siped: 0�- Mailing A Mress: &11t 5212E T dA-1zN-'j( 4— State JUy Zip 10,5101, 9iy —�7 '7�9 iU- (F7� Telephone: `7� Telephone: i 9 Form LA -97 . . e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL M please print or type PCHD Permit # Well Location: Street Address: To llae Tax Grid # G ollo _%a V'Vk Map Block '7--- Lot(s) ' Well Owner: Name:CIRO IS-& CONS - - Address: 16 1 P-� A(' At, Y-� &/,/"f /kj C C' Use of Well: eS, 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_ New Supply (new dwelling) Deepen Existing Well Detailed Reason VJ1-- for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yeses_ No Name of subdivision L4 `7`11-(.' Pd " /i(i L L-- Lot No. Water Well Contractor: IL 6-D 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 contamin tion to be a sheet/plan. Date: �� `��' Applicant Signature: Ily i 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 wate ell driller certified by Putnam County. A Date of Issue !l Permit Is 0 is _ Date of Expiration Title: A Y, dP = e--A 6 = Permit is Non- Transferrab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Mr. John Karell Jr., P.E. P.O. Box 644 Carmel, New York 10512 Dear Mr. Karell: BRUCE R. FOLEY Acting Public Health Director October 15, 1997 Re: Proposed SSDS: Wallace Vista Dolores Road, Lot #6 (T) Patterson 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." " 'I'ou are referred to Article 128.1 of the official compilation of Codes, Rules and regulations of the State of New York, Title 10, relative to the need for approval of individual sewage disposal systems by the City of New York. You should contact city Officials in this regard." 1) Photopies and group Letters of Authorization are not acceptable. 2) Notes and details are not legible. 3) Location map is to be provided. 4) Erosion control measures for the house and well has not been shown. 5) Deep test hole data has not been completely noted. 6) Standard well note has not been provided. Upon receipt of a submission, revised to'reflect the above, this application will be considered further. R, mh watershed Very truly yours; 2 b -,( Nw> Robert Morris, P. E. Public Health Engineer le PUTNAM COUNTY DEPARTMENT OF HEALTH L0 L DIVISION OF ENVIRONMENTAL HEALTH SERVICES.,_ LETTER OF AUTHORIZATION RE: -= Property of us -Located at V s %A T )l-O T/V f�Trt O iT) Tax Map # 3! I Block / Lot 3Z �.3J7 Subdivision of 27 3, 5-; -1, /SubdivisiOn:Lot#_/o,j/, y- Filed Map # Date Filed Gentlemen: This letter is to authorized -- a duly licensed Professional Engineer_ 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 provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam Plea Code. KAREQ, Very truly yours, r ;ar r Countersi e � signed: P.E., R.A.; # S— 1^ v (Owner of Property) EL Mailing Address State /'J zip of Mailing Address: State )t;� // 14y' C4"azNYzip /6S/e2 Telephone: gay" 7� -%� y Telephone: A i A.4 A Type Lot Arai FM Settled Only LJ Depth —V.Gkme— NM Dodge Flow G P D PCHD Notillmdows Is Required When FM Is cousplabd Sopmeft soverew Sydm to can" ediaGWIM SW* Tack odd 2- o To be causkoded by i Address Water SUPPIM—P-4 R, Sop* Flies Ad&vm an ---htvmft Supply DzIlled by -D-L—Addr- 01bur Repultusussub 1 7r rierenrit1hat I am wholly and completely responsible for the design and location at the above described will be constructed as shown on the approved amendment there to and In a County Department of Health, and that on completion the►eoUa "C"i1cate of Constri be =mltted to the Department, and a written guarantee will be furnished the owner. place In good vaoratino condition any part of said' sowe" disposal system du" the arm of the approval of the Cortifliate of Construction. Compliance . of the W, I Y. wisobstiocetedesshawsion the app4ow plan and that sald.will.willbo, Install County bessirtmenit of,H"l Date 'Signed J APPROVED FOR CONSTRUCTION' This approval expires two years from isary y the revocable for cause or May be 8m;;;iQWor modified when considered necessary y the fake 1 u rels, • now per it A f of domestic unitary sewage. a Rev. 10/88 way- ...I) that ici" satisfactory to the Commissioner of Hailithwill heirs 0'r, assigns 6y'thi�'bUlkl*r. that said bUIMW Will 12f YOWS immediately �411ckwlng the "to of the issm- a Is s thereto; 2) that the drilled Well described above Bandar utes-iA4 raiii-M7 lens of the Putnam 4 P.EX— RA. AhILIA4Z -)2-30 6K'of Ahe building has been undertaken and is knh.' Any- change or, altioration of construct ion -onlyr Title PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM V P5 A Owner . Address Z pb wn c-7 uorear red Located at (Street) ` E°t, /6 e Tax Map Block Lot (indicate nearest cross street) Municipality Watershed h�A S % -8, e,4,44e H rf 9 y 3�2,. SOIL PERCOLATION TEST DATA Date of Pre - soaking �' %/-7 Zeg. Date of Percolation Test 41� / Zeo NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review.` 2. Depth measurements to be made from top of hole. Form DD -97 1 1127 - :2 /3 2�f' - 7' -3. 2 2s�i —; l — 7% 3 9; 54-- 30o 1:3 //a- 4 5 1 1 rr2 -2 ;3/ / 2y- 2 2 `��-3, 0C 9 7 3 3',00-3!9_/ 1Z :2Y— 7 3 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'. 1.5' ' 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. I HOLE NO. 2. HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is observed 1tityAI< Indicate level to which water level rises after being encountered Deep hole observations made. by: g:�', Ro, D D G -J% H Date _V-47, , Design Professional Name: Address: Signature: Design Professional's Seal 2 J. a;. Sheet # ;* PUTNAM C,O,_UNTY DEPARTIVIENT;OF HEALTH. - DIVISION OF ENVIRQNMENTAL 1EATLII SERVICES E'W04 FIELD ACTZVI`I'Y REPORT Tel 'ty ADDER W at Street • x Town State; Ztp ._H , PERSON IN CHARGE g T,.TTu�7iF�xr,: natP_ '� / ✓ % /or'� Name: aril Title:: TYPE OF FACILITY u A NAA- u .'e . J s ; e � r s ` Signature and g PORT' I acknowYedge "receipt of thsTeport: "- SIGNATURE;" 02/9.6 'x Title.. :. . . Sent By: TOWN OF CARMEL ENGINEERING; 9146287085; Jun -14 -00 7:09; MAR- 6-00 TUE MW AM PUKAR UY BY HEALTH FAX AU. IyI4•LYVUI BRUCE 'L POM Public Kedtb Doraor DEPARTbiENT EEALTH Geneva Road Browder. Now York 10509 Page 2/2 r. LOR>sP'1'A MOLiNAM RNb MSN. Db%Ww IV Pout &rWtW ATTENTION: 0 ADAM STUDELiMG )(GENE REED I All information below must be tax completed prior to any sdwddh* n+t,TF; b,13100 ENGINEER OR FIRM: -To o !'` 4 i(Ar a-4a , MONS #. G � -2087 REASON: DEEPS: x PBRCS4 PUW TEST: 0 ROADVSTIt>~E/T�: V Sea �„ Ot % TOWN:— PA-7i FYzS D Nl TAX MAP#:._ Z3 SUEDIVISION: 1-1 wwo # ,I- 1,OT #: OWNER- NYCDEP CRITERIA FOR JOINT REVIEW &SLUMMSING OF SIR 2 TLct_UM YES NO a )K Proposed SM within the drainage basin of West Branch or Boyds Corner Reservoirs. a )Q Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. o X Proposed SSTS within 200 feet of a watuvowse or a DEC wetland. o Proposed. SSTS desip now greater than 1000 gaIlons/day or SPDIiS Permit required. El Proposed SSTS for a Commerical Project. It Is the responsibility of the design professional to provide the above information prior to soil tasting. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered Ices to any of the questions, NYCDEP mast witness the soli testing. This Departn mt will coordinate a muh ally suitable time for field testing with tLe PCDOH, the Design Professional and NYCDEP. If a project bas been determined to be Delegated based oft the above response and the snlssequent information indicates NYCDEP is required to witness the soil testing, it will be the sole raaponsibility of the design professional to sehedule mwimeaaiug of the soil Sating with NYCDEP. 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IK 1. ;9;z AC Iqt 1 \\ \ \\\9yo 11 \ 42 0 o X1.96 � 16.9369' � AC. •.15 AL 64an.a `65 A aA•e � • • � • • A • 47� 41.36.AC. �� 1.13 At L 0S AG 41 N a .66r Ar4 �•� g 330.09 S � 45 40 10.41 AC. t 39 CAL. o� w 53u-' \ e �• 9.21 AC.. _ I p f 63 7y im 36 t r z3s.ss a � 243.99 9 6.33 AC. CAL. 32.98 AC. ' 3 %43 \ `►�, / = , w I 37,g� a 3.95 At m '47 * I 46 .98 AC. CAL CAL + n° \ • 94 �, N 1 � StH I �1y 2,, .50 AC. CAL. 7.74'1AC. $ CAL : C i 1.7 A x 196.26 ,,� , Y AL I _ 4j'•aCAL 59 a loll 59 J` / 35 rr4q a 1556.03 230 i r' ,`O ; 60 a 56 . ' 266 AC8, 1326.03 / *J, fi /861 CAL y AL >< 57 N I s 246.03 ' � 49 AC. 1O 4'ti, � IN.. 48 /3.41 ��' 7 a 1 •. 26.05 AC. i CAL. A ` / I.BALAC. 34 \ 5sy.f9 AL t 56 t fib 55 / ye e� 526.91 ti 50 42.0 AC. DAL. a I At ,m 33 18.16 AC. CAL' s o m ° I FC 51 r 1 wq� +S / o e ' AL =I ,• 4 .y . 52 I.M A ( >< / o 219.16 32.16 AC. ' 1 0221 A 2 G3t n ><��1 55 42o �.90 AGyI+ v 624.70 S CAL JL 549.2 / % $1.92 AG CALF n 72 417 ' / I ` 54 4 4.1 j�IC. ti 3.30 At Ct - / A` / `. ws 53 Y 1i 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 # WELL LOCATION Str et ddress Town Village City U 0ST &L 40O1 /�' Tax Grid N ber u 93_2 - WELL OWNER Name '�� Mailing Address .� AP—/ olle o r o Wrivate � N D Public USE OF WELL 1� r y 2- secondary SIDENTIAL D BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP Q ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify, b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT .5— gpm /# PEOPLE SERVED /EST. OF DAILY USAGE04�Vgal REASON FOR DRILLING O REPLACE EXISTING SUPPLY O TEST /OBSERVATION GL ADDITIONAL SUPPLY SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE 2!kRILLED DRIVEN DUG GRAVEL O OTHER IS.WELL SITE SUBJECT TO FLOODING? YES ! \ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: T Lot No. 4. WATER WELL CONTRACTOR: Name / C '.`fir U I 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 RON SEPARATE SHEET PERMIT TO CONSTRUCT A WATER This permit to construct one water well as set forth above is gran.' �4'Ll.6. ;+tihe 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 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 manne as not to degrade or otherwise contaminate surface or roundwater. Date of Issue: 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 PC -1 PUTNAM COUNYY DEPARYMENY OF HEAL -Y H APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: T) (� -�eiS G�,a�-6, &L 2&N -90 )(3 2. Name of Project: 7 1a 3. Location T /V /C: 4. Project Engineer:-L Yf� N'!'�iti'� `-'� 5. Address: I ee; L am' Z3d Cr 19 License Number. Phone: 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 (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 1 �+ 9. Has DEIS been completed and found acceptable by Lead Agency? ........... '/`t 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, orother officials, ordinances? ......... ............................... 12. If so, have plans been submitted to such authorities? .................. 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water _ Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? 18. If yes, name of water supply Distance to water supply��1 -S 19. Is project site near a public sewage collection or disposal system ?..... 20. Name of sewage system Distance to sewage system X11 /�rT yr �rz�'f�aU'Oz� 21. Date test holes observed: 22. Name of Health Inspector: 2 23. Project design flow (gallons per day) ....... ............................... ye 91 0 11/93 2. 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. K-1)0 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State ,� !� wetland? .................................. ............................... !y 27. Wetland ID Number ........................ ............................... 28. Is Wetland Permit required? .............. ............................... /7 _ Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... �.�C 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO NJ O 31. 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 DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ...... 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ %! Q 35. Tax Map ID Number ......................... ............................... 36. Approved Plans are to be returned to: ................ Applicant Engineer 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. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: 'toiCetur 03 VA 1R) ILOU ffi� DESIGN DATA SHEET- SUBSMCE SEWAGE DISPOSAL SYSTEM FILE NO. Ownerpo 44W5AN Address &,Y o f Located at (Street) �� ! Sec. Block Lot (indicate nearest cross street) Municipality � �� %V Watershed N Y61 Date of Pre- Soaking Date of Percolation Test 1 2 3 4 ,S£ y �vB.L� BILE //�G/fi!/S 2 3 NOTES: 1. Tests to be repeated at same depth. until approximately equal soil rates are obtained.at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made from trop of hole. rev. 9/85 HOLE NUMBER CI= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches 1 2 3 4 ,S£ y �vB.L� BILE //�G/fi!/S 2 3 NOTES: 1. Tests to be repeated at same depth. until approximately equal soil rates are obtained.at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made from trop of hole. rev. 9/85 TEST PIT DATA MWIRED" BE` SUBMITTED° WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTIItED IN TEST HOLES. DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 2' 3' 5' i 0 O 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING PtA14_ DEEP HOLE OBSERVATIONS MADE BY:' `j DATE: -- - Q- DESIGN Soil Rate Used I 0 Min /1" Drop: S.D. Usable Area Provided SOCOF7 No. of Bedrooms _ Septic Tank Capacity gals. Type COY �- Absorption Area Provided By L.F. x 24" width trench ,.:A�, .woGre�stc,,a��n. Other Name N <<aL Sigma Address -Y /dj 'r ' t THIS SPACE FOR USE BY HEALTH. DEPARTMENr ONLY: Soil Rate Approved sq.ft/gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at Date 6 —/", MW (T) �"Jr��C� -�Q� Section Block Lot Subdivision of Subdv. Lot #�� Filed Map # Date Gentlemen: This letter is to authorize-JOA11 //�-- a duly licensed professional engineer�� (Indicate) to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned P.E. , A-.. , /-# f 'S1, F ..� Address 6'mtoeo--ex-P /L//,/ lei Telephone Very truly yours, Signed '�✓� U Al2, Owner of Property lac : � Address Town TIP Telephone 0 r 4J. i DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Ceneva Road, Brewster, New-York 10509 (914) 278 -6130 APPLICATION.TO CONSTRUCT A WATER WELL rj'/- �.-- PCHD PERMIT # WELL LOCATION Street Address To Village City Tax Grid.Number WELL OWNER Name Mailing Address " GD e- apf_ivate O Public USE OF WELL primary - secondary ..,,.. ��.. y'x�;!! LS.IDENTIAL ® PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® ABANDONED ® BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify ® INDUSTRIAL O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED a /EST. O REPLACE EXISTING SUPPLY ® TEST/ OBSERVATION W wEPLY NEW DWELLING ® DEEPEN EXISTING WELL OF DAILY USAGEg81 E3. ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING -' WELL TYPE MAILLED . ®DRIVEN ODUG OGRAVEL 0OTHER. IS WELL'SITE SUBJECT TO FLOODING? YES (-"ENO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. Cry WATER WELL CONTRACTOR: Name "Y"'; Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L.,..-NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED �10 ,,SEPARATE SHEET (date) t 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:. •x_19_ -� 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 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 # -_ WELL LOCATION Street Address To Village City Tax Grid Number WELL OWNER Name Mailing Address ,a �, ®- Private O Public USE OF WELL 0 - primary 2- secondary ��.. `` 8.6SIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 17 ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify D INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT - gpm /# PEOPLE SERVED & /EST. 0 REPLACE EXISTING SUPPLY O TEST /OBSERVATION B4dW SWEPLY N _DWELLING) 13 DEEPEN EXISTING WELL OF DAILY USAGE&©p,gal Q ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE RILLED ®DRIVEN ODUG ®GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES L - -'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: G o Lot No. _ 22 WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES t... -NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED e i ��S�EPARATE SHEET (2,V—xe14L &Ar (date) s gnatu 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 s a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: A'e S.-- 19� —. 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date &16LK �t Re: Property of'Ock- 'e`7V�f� ��'7I? /�L'� 61_��/tf >0iW I�tlfl�oeps Located at V 5l-n (T) ZOO ection Z Block Z. Lot 6 Subdivision of Subdv. Lot # Filed Map DateB Gentlemen: T. MICHAEL DALY, P.E. CONSULTING ENGINEER This letter is to authorize P. 0. BOX 243 su�unonry N.:V. 10507 a duly licensed professional engineer V or (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, Signed Countersign ad,C -� Owner of Property P.E. R.A. # - Address T. MICHAEL DALY P.E. f i r��C.�� 1�`�c`�,� P� 1 Address CONSULTING ENGINEER Town P. 0. BOX 243 N. Y. 10.587 (�� "% q 141 0 Telephone Telephone APPENDIX PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION P R� (IT fE OF OWNER. lz< 'S, _r__�- STREET LOCA ON S C ZJ...o DATE TAX MAP # DdeVMENTS. —.2 .P ZV�C;�GE (OK) -'� PERMIT APPLICATION - PC -1 DEEP HOLES LOCATED WELL PERMIT P RESENTATNE OF PRIMARY AND EXPANSION ENGINEERS AUTHORIZ ,TION 6d" AREA, SHOWN; GRAVITY FLOW, SUFF.SIZE DESIGN DATA SHEEI (DDS) m. ID PIT & D BOX SHOWN & DETAILED �► SF _ NO. OF BEDROOMS DEEP HOLE LOG U & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM CONSISTENT PERC RESULTS (3) PERC HOLE DEPTH 9F� METES &BOUNDS i SE TBACK NECESSARY (TIGHT LOT) CORPORATE RESOLUTION"IOUSE SEWER - 1/4"/FI. 4"0; TYPE PIPE PLANS THREE SETS Q NO BENDS: MAX. BENDS 45 W /CLEANOUT_ HOUSE PLANS - T' O MFS VARIANCE REQUEST GENERAL - LEGAL SUBDIVISION SUBDIVISION APPROV CHECKED PERC RATE � ol I 1 • • • 1• fit• Ei i • !• � FILL SYSTEMS AL: SLOPE 3:1 TO GRADE GAUGES PROFILE & DafENSIONS, VOLUME TRENCH L - V Q CH PROVIDED WETLAND (TOWN/DEC PER;NIIT R & D) 60 EI MAX DATA ON DDS PLANS & PERMIT SAME ' > �PARA�� -TO CONTOURS PRE- 1969 - NEIGHBOR NN CATION m 100% EXPANSION PROVIDED LETTERB1/ZBA I SEPARATION DISTANCES SPECIFIED ON PLAN 100 YR. FLOOD ELEVATION UIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NO SSDS HYDRAULICIPROFILE GRAVITY FLOW D/ J BOX LQl CH/GALLEY m ZJWDETAILS SEPTIC TANK - SIZE, DETAIL WELL DETAIL, SERVICE LINE IF OVER CONSTRUCTION NOTES (GRINDER RAT. DESIGN DATA• PERC AND DEEP RESU ' 1,`O P.L., DRIVEWAY, LARGE TREES, TOP OF FILL WALLS TO WELL, 200' IN D.L.O.D., 150' PITS TO STREAM WATERCOURSE LAKE (INC.EXPAN) F0 CATCH BASIN, 35' STORMDRAIN, PIPED WATER 70 WATER LINE (PITS -20') DRAINAGE COURSE W 20 .. . RESERVOIR, ETC.CD 150 FT. GALLEY SYSTEMS TWO -FOOT CONTOURS EXISTING & PROPOSF,jy'" SEPTIC TANKS DRIVEWAY & SLOPES CUT ��°°'"` 10' M FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELLS :MENTS: 11 5' WELLTO P. L. PC-1 PUT NAM COUNTY DEPARTMENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: Do LcAZ,�h "L-3 MAKOE 2. Name of Project: 3. „ Locatio T, V /C: 'RA 4. Project Engineer: T �� -- r�� ,5. Address: i,:270Y- -0-4 3 License Number: 46A68 Phone: 6. TYQe.of Project: V 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 (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted ✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. I 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 0. Name of Lead Agency 1. Is this project in an area under the control of local planning, zoning; or other officials, ordinances? .......... ...............................I ylcD ,yapT' 2. If so, have plans been submitted to such authorities? .................. q D 3. Has preliminary approval been granted by such authorities? Date Granted: _ 4. Type of Sewage Disposal System Discharge.��).F - Surface Water Ground Waters S. If surface water discharge, what is the stream class designati�oO ........ 6. Waters index number (surface) ........... ............................... 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 Distance to sewage system 1. Date observed: 23. Name of Health Inspector: 4. Project design flow (gallons per day) .............. e?�2Q................ 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?..,� 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State '+ wetland? .................................. ............................... 28. Wetland ID Number ....................... ............................. -' 29. Is Wetland 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, aid landfilling, sludge application or industrial activity? ........ YES or NO ' l 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 DESCRIBE: 33. Is there a local master plan or file with the Town or Village? 34. Are community water, sewer facilities planned to be..develop5d within 15 years? t 35. Are any sewage disposal areas in excess of 15% slope? ........................... 36. Tax Map ID Number .... ............................... .................... 37. Approved Plans are to be returned to: Applicant Engineer 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. 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 pursuan o Section 210.45 of the Penal Law. / I i) SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: SfLc�r�lOj�iCIC llI � /GSE3 -� • •' • D, mp /' •' - 10- V ; I 4MR1041-ALIAed ce DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner,VoLc»•Plh Address V-5,yx ?55Q�E f w VT- qAAV, l�- _�P�,_los� is Located at ( Street) �� r.,-�_ p Lnp� fee : j 3 Block Z Lot -� (indicate nearest cross street) Municipality �Pj Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking 4- L(O - B 6 Date of Percolation Test 4 - l(v -F3 6 HOLE Z Z 4- 3 NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches `Z 1 4- 3- 1 2 $: sl -° t 2 Z Z 4- 3 39'1-t- 9: 3(7 f,4- 4 --/', %- 10100 Z 4- 7.4- Z 3 8 5 1 g° 4o --26r 'Z I Z-4 Z 3 - 2 2 q ° eat - q:2s Z4- ?sl- Z ZS c3 Z 3 V t - "?49' Z4- 14- 3 S- 4 9•`49 - l0' 1(o `Z � -4 4 'L'*- 'S 9 5 1 2 3 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 submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCiRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. 1 HOLE NO. HOLE NO. G.L. 21 g6TV&ka* 3' 41 r�aa G1 e.>tq 5' V��, 6' 12aCS Pno� '� 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING EN0OUNTERED DEEP HOLE OBSERVATIONS MADE BY: bpi �. 06!so DATE: ;;-I1 14( 2Z /9-6 . DESIGN Soil Rate Used a —LQ Min /1" Drop: S.D. Usable Area Provided No. of Bedroams - Septic Tank Capacity 1S436 gals. Type Absorption Area Provided By L.F. x 24" width tren OF rvE� no Name T. MICHAEL DALY, PZ • - [3 j� 9 CONSULTING ENGINEER Address a ,()X 9 z SHENOROCK, 10587 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date C-111 1250 GAL. 4" C-111 1/4"ZFT. MASONRY 5EFTIC TANK LEADER 4 FOOTINC, DRAIN DISCH. RftM a 6ervior- oe with a of the PROFILE HM I"=20' VERT 1 "=10' 4" PVC I/b"/FT. rA (tj - u AL. C�'- 4" faN(C, 5LE IN r OX LEANOUT VIM 10 ml, lqo.15, —A MAN tJ al � I �. . . all not jfl-fli . 1 " , PF - p v o;, 'N' "A I r I W., �,4-v 43 W40 TOW "y MIKE, B&A v w :11m;J11— IVA 1 L A 'CO PA 4,;r `0 Tweyl voll loop e MY- "You Tft :44 pip ANT. pig I WON MIKE, 20 a �Oi I -B REMARKS, 5 2.5 -- -------- ,72 4-L Al rrk Nm 7 17 t I