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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.12 -1 -39 !7- , him hr#- 16 ,` - Is . L. -L. IN 00714 r�� t COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM II PCD CONSTRUCTION PERMIT # 2--L-7 �"l n 3 Located atS PO Q Owner /Applicant Name �z4d�;'t- COPI2.Ucilv,j Formerly ab e,, S P Town or Village Pa k4-g tr � C"7- Tax Map°" , I a` Block � Lot k1l Subdivision Name Subd. Lot # Mailing Address Date Construction Permit Issued by PCHD Separate Sewerage System built by Address Zip 10 5) Consisting of 12,'l? Gallon Septic Tank and �0 Z-r— 2-f-T % 04 Other Requirements: 11 0 Water Supply: Public Supply From. or: Private Supply Drilled by Address Address Building Type woo Has erosion control been completed ?e�` Number of Bedrooms Has garbage grinder been installed? /V I certify that the system(s), as listed, serving the above I built plans (copies of which are attached), in accordance plans and the standards, rules and regulations of Put Date: Certified by Address Any person occupying premises served by the above system(s) essentially as shown on the. as- istruction Permit and approved >f Health. P.E. x R.A. # J3 Z7 7 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 approvalRarbJect to modification or change when, in the judgment of the Public Health Director, such revocatificatio change is necessary. By: �/ Title: /�d/� Date: l _ White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy Design Professional Form CC -97 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �f WELL COMPLETION REPORT Well Location Street Address: firizirl et— At r13 Town/Village: Pt &6,:5( Tax Grid # Map' 3, lock Lot(s)a Well Owner: Name: Address: Crl2+czst�nS; Use of Well: 1- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion _x Compressed air percussion Other (specify) Well Type Screened Open end casing '_X Open hole in bedrock _ Other Casing Details Total length t9 / ft. Length below grade -.90 ft. Diameter _ 7 in. Weight per foot �lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded )( Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: -. Yes No _ Liner Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet ILA 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 Ali V - -- - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Comp eted Putnam County Certification No. 00-7 Date of Re ort 7 Well Driller (signature) %r " 1 NOT Ex Act location of well with distances to at least two perm men lan finarks to be provided on a separat6 sheet/plan. Well Driller's Namei Signature: Azar Address: .�� • d'� Oc�:1' j71� /"�,�Cr', 1��7� /V' Date: % White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 �-' . ` YML ENVIRONMENTAL SERVICES ' 321Kear Str et ` , Y017ktown Heights, N.Y. 10598 . (914) 245-2800 ` 11 1ber4- H. Pado van i, Director LAB #: 93.801262 CLIENT #: 8641 NON STAT PROC � PAGE � WALLACE, DOUGLAS � � DATE/TIME TAKEN: 09/03/98 10:O0- P.-. BOX 154 DATE/TIMEREC'D: LEAD'(IMS) 09/03/98 11:40 MOHEGAN LAKE, NY 1O547 ` REPORT DATE: NITRATE NITROG O9/09/98 ` PHONE:. (914)-734-1187 NITRITE NITRQG SAMpLING SITE: LOT 2, LITTLE POND HILL ESTATES SAMPLE TYPE,.:P8TABLE , P�cqq} r4�m� P�FqF�V4TTVFq, NONE COL 'D BY SAME �gNQTES...: ` DATE FLAGPRQCEDURE PUTNAM C 1 PROFILE ' / �w '�---''���-�--' �'-- ' TEMPERATURE..: COLIFORMMETH: MF. ' /100 ML ppb MG /L MG/L MG/L IV, G/L MG/L ' UNITS MG L MG /L NTU ABSENT 0-15 ppb 0 - 10 N/A 0-0.3 mg/l 0-0.3 mg/l `N/A 8.5 N/A N/A 0-5 NTU COMMENTS: BA CT THESE.':". RESULTS INDICATE THAT THE WATE AS NOT): OF A SA ISFArTORY SANITARY Q.ALITY ACCO�D NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS FOR THE PARAMETERS � . , TESTED, AT rHE l,IME OF*COLLECTiON. ` /Cu LEAD limits for public schools are set at 15 ppb. z!/ EPA Lead & Copper Rule for Public Svstems requires that no more ` than 10% of their distribution pbints have a LEAD value of more � t h nd 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 otal val6e combined shall not exceed 0.5 mg/L. - ` a No limits for S9dium 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 or .a moderately restricted diet, a maximum of 270 mg-" of Sodium ` is suggested. ' � � .. 1008. 1234 9146 2037 2037 9043 09/O3/98 Mr. T. COLIFORM ABSENT 0998. LEAD'(IMS) / <1 09/03/98 NITRATE NITROG � 0.92 09/03/98 NITRITE NITRQG 0.010 09/03/98 IRON (Fe) , <0.060 09/03/98 MANGANESE (Mn) <0.010 09/03/9R SODIUM (Na) 09/03/98 p H 7 1 09/03/98 HARDNESS, TOTAL 22.0 ~ 09/03/98 AL'AL�N ITY (AS 16.0 09/03/98 TURBIDITY (TUR <1 '�---''���-�--' �'-- ' TEMPERATURE..: COLIFORMMETH: MF. ' /100 ML ppb MG /L MG/L MG/L IV, G/L MG/L ' UNITS MG L MG /L NTU ABSENT 0-15 ppb 0 - 10 N/A 0-0.3 mg/l 0-0.3 mg/l `N/A 8.5 N/A N/A 0-5 NTU COMMENTS: BA CT THESE.':". RESULTS INDICATE THAT THE WATE AS NOT): OF A SA ISFArTORY SANITARY Q.ALITY ACCO�D NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS FOR THE PARAMETERS � . , TESTED, AT rHE l,IME OF*COLLECTiON. ` /Cu LEAD limits for public schools are set at 15 ppb. z!/ EPA Lead & Copper Rule for Public Svstems requires that no more ` than 10% of their distribution pbints have a LEAD value of more � t h nd 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 otal val6e combined shall not exceed 0.5 mg/L. - ` a No limits for S9dium 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 or .a moderately restricted diet, a maximum of 270 mg-" of Sodium ` is suggested. ' � � .. 1008. 1234 9146 2037 2037 9043 . ' YMLENVIRONMEMTAi SERVICES ! 321 Kear Street ' Yorktown Heights, N.' . 10598 . (914 4;z, -2800 ` Albert H. Padovani, Director ` . LAB #� 93.801262 �CLIE: 86`1 ` � NON STAT PROC PAGE 2 NT # . WALLACE, "DOUGLAS; . DATE/TIME TAKEN: D9/03/98 10:00 P.O. BOX 154 DATE/TIME REC'D: C9/C3:/9S 11:40 MOHEGAN LAKE, NY 10547 / REPORT DATE: D9/09/98 / PHONE: (914>-734-1187 . SAMPLING SITE: LOT 2, LITTLE POND HILL ESTATES SAMPLETYPE... POTABLE PRESSURE TNK pRESERVATIVES: NONE ' COL'D BY: SAME_ TEMPERATURE�.: NOTES.. COLIFORM METH: MF ` DATE FLAG PROCEDURE RESULT NORMAL'� RANGE METHOD . PH pH SCALE.INWATER RANGES FRQM 1-14. MEASUREMENT OF pH IS ONE OF ' THE IMPORTANT AND FREQUENTLY US T�STS IN WATER CHEM1STRY. WATER WITH A LOW pH,MIGHT BE O OSIVL TO METAL PIPES AND TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM R. MAGNESIUM CONCENTRATI�N, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS OM THE SOURCE"' AND TREAT NT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-7� MG// VERY�HARD WATER: ABOVE 300 MG/L . _ MODERATELY HARD WATER: 70-140 MG/L M C MILLIGRAM PER LITER HARD WATFR: 140-3Q0 MG/L 1 grain,/gallon = 17.2`MGiL) � \SUBMITTED \ Alber \ \ | ' � | \ / .. ~ - ... . ^--._n-, .' .A__ � tor � ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH • DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Inspected by: ,e Street Location joeul -pg a Ejo2n/ ?ZAP, Owner pou& z,✓ttGL ALE Town pT,F.�d/ Permit # -- p — TM # 9-3 , Ig — j — q Subdivision Lot # Q— "yl6r-A DoLoYZ�5` 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lath. 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. Sep-tic tank- size - 1,000 ........ 1, 250....... other ................ b. Septic..tank installed level, ........................... ................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - properly set ..................... ....:.........................b ength required g dQ Length installed 2. Distance to watercourse measured +f L 00Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acce 0/)6 - 1/32" /foot... ....... 5. 10 ft. fr o popery 1 e ft.- dat r�.......... 6. Dept,� <30 inches fr ............... 7. Roorllowed for exp s' 0 % ......................... 8. Size of grav0")'/ - /z" eter clean .................... 9. Depth ch 12" minimum ................... 10. Pipe en c ... ...................................................... g. Pum .or Do, ed ems ize of pump c am er ................ ............:.................. 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ................................ :.................. 4. Pump easily accessible, manhole 'to grade ................. 5. First box baffled ................................ I......................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. HouseBuildin a. house located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans . ................... ............. b. Distance from STS area measured l 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 watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 YES I NO i COMMENTS 0 A Dr I /?Ov' -e G'C 724 -PPI -K l C7 r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot G Yolk sp C A 5 PC(dj,41? Building Constructed by -PO Ujd e r 9n r hi Vr),r4 IIJ Location - Street _PalierSoil TownNillage L 1, -tae �n��,�; /�,� Subdivision Name 1 _ra l L11 h Lai 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 1j Year -/ff.F General Co�fractogowner) - Signature V ro L4 S V' (4 A .S i r Ll dl N Corporation Name (if corporation) Address: 0 K. Laa N 26 ie State UQ U) to r Zip Signati Title: _6"US12 (Otis 1,rac_lz4, Corporation Name (if corporation) Address: P G, Ao X g^4 6-o/4 State . NCO' Zip w� r 7 Form GS -97 1, a..-- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT C- Q I -� 7 Located at Town or Village P477E�Z50 Al 0-) Subdivision name '177L AM)P /f l Subd. Lot # Tax Map .2 3.11- Block ) Lot Date Subdivision Approved 3 -11 _ "K 7 Renewal Revision Dout- W !k1-t�A-C & Owner /Applicant Name §&0566001 7MI CZZQAI Date of Previous Approval Q Mailing Address Zip Amount of Fee Enclosed Building Type W Lot Area 3:t,3No of Bedrooms Design Flow GPD0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 7- )'r Zg NCH Other Requirements: l z-S 0 gallon septic tank and 400 Lr To be constructed by 17 6, Address Water Suonly: Public Supply From Address or: Z Private Supply Drilled by s JD 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: P.E. 3Z% % R.A. Date i C/� -6& , /U / ��� �. License # Z,7 Address �Q �j ®�( _ o 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 pcffni Approved for discharge of domestic sanitary se ge only. I&A By: W Title: (�.�1 !C Date: l White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 � r4 7, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT / Located at U S A f) 0 0 S Town or Village 477t -. 50 AI C%J Subdivision name 1 -177ZF AftP MiL, Subd. Lot # Tax Map 2 3 =1 L Block ( Lot Date Subdivision Approved 3 -1 J —�j Renewal X Revision Owner /Applicant Name §&05,e-,(f0W$jX V Q1701V Date of Previous Approval Q —S -V_S- Mailing Address WD LA-1 %>_ � p Z, .A T rAP— J -& /V }`� Zip 1037L Amount of Fee Enclosed Building Type WD Lot Area No. of Bedrooms I/ Design Flow GPD 0D0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to, consist of 1 Z5 0 gallon septic tank and #00 Lr—, Z F'T- Other Requirements: To be constructed by 77 6 -D - Address Water Supply: Public Supply From Address or:_ Private Supply Drilled by _ %1 Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department..of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of.the original system or any repairs thereto. Signed: P.E. �' ,3Z% i R.A. Date 7--97 Address Pd 60 l 61 y f / W 6& , A) % �OJ 1� License # A573 �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 p i Approve for discharge of domestic sanitary se x4lic ge on ly. By: �ifi/ Title: e� Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit (" r* 2�- Well Location: Street Address: Town/Village Tax Grid # S) A &!i A+7. -(0A J I D p MapZ3a O 1,Block I Lot(s) Well Owner: Name: PN4W W.AiJAC& Address: U 51 C4 101flud, q 1:: IA �� =� CAW,, L, NY on1 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _�q` gpm # People Served _5- Est. of Daily Usage _ 11 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason //6k) . :e6 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 41T7'z -& ,A6( 1 1-;11&4 - Lot No. _ Water Well Contractor:, Address: Is. Public Water Supply available to site? ................................... ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: °- Proposed well location & sources of contamination be provid on separate eet/plan. i I i4lq- 4 A 7A, i I i Date: Z?� Applicant Signature: , 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 t� of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam t County. Date of Issue 1/N �� �' Permit Is Offi ' 3 Date of Expiration l Title: / , Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form AT-97 11° PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION 9O -SA . CvN S77Z UC_r7o AF Located at VISTA IDOL 0 iL4-5- . C POW G►}- i�Jf��.%^� -o�D�� Ti- PA7- 1E7ZSD OTax Map -far .2 3. 17Z Subdivision of Subdivision Lot .- Gentlemen: L —/TTL6- %-,dND 41Z-L Filed lvlap Block � Lot 3 Date Filed This letter is to authorize JZ H _77Z__ a duly licensed Professional Eng-ineer M o„ p �y-,�,_A �.'�: °mot to apply for the required wastewater treatment and%or ;eater Supply permits) to serve the above -noted property in accordance 'whh the standard;, 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 LL-ith this natter and to supervise the COnstlz2Ct10n ossaiCi tivastev :ater treatment and;`or L�;ater supply- systems in conformity with the provisions of Article 145 and /or 14' of the Education Lw , the Public Health Law, and the Putnam. County Sanitary Code. Net-/ truly `'Ours,. Countersimed: Signed: — �-�- -- P.E.. R.A., tr S 3 2.7 -7 (Owns! ; t Mailing Address d U114iLJ1f-A) ,P,477'75--SvlV State Zip /456 3 I elephone: Mailing A (10 -ess: A,0 ;d 9* //Z- �Z;E��, T State /Vy Zip /D61 _-jl Telephone: glcl— 9 7,fi�- ?, �t c�- . OCR3 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 John Karell Jr.. P.E. Tel. (914) 278 - 6130 Fax (914) 278 - 7921 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 #2 (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." "You 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) Location map is to be provided. 2) Details and notes are not legible. 3) Erosion control measures for the house has not been shown. 4) Deep hole data is incomplete. 5) The minimum of one deep test hole is required in the primary area. 6) Location map has not been provided. 7) Standard well yield note has not been provided. Upon receipt of a submission, revised to.reflect the above, this application will be considered further. Very truly yours, �fl14,v mkwo Robert Morris, P. E. Public Health Engineer RiM/mh watershed PU NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL TAL HEALTH SERVICES r DESIGN DATA SHEET - SUBSURFACE* SENVAGE TREATMENT SYSTEM Owner Lb UE L,¢-S CyA.(. &Cg: :address 94! ,Q 9 FAi/Z 92t (590US-&- COMP-RUC-770N Located a (Street) VI5T4DoL044 S (powo Tax MaP A5.12-Block �_ Lot 3 y (indicate nearest cross street) "nol -2, Municipality Pi4-7-7-,,_5,6N rT) . Drainage Basin ',461k/F7L 7L4U'0X0n1 ' A1V4- SOIL PERCOLATION TEST DATA Date of Pre- soaking gate of Percolation Test Role No. 1 stun No. Tine Start - Stop Elappse Time (�fia.) Depth to Water rom Ground Surface (Inches) l Start Stop Water Level Drop In Inches Percolation Rate Min Ancn 7 i I J 1 4 I I I I i e515 to ce repeaiea ?t same ae0l", u ll am*''o v percolation rare bt ir, a• �- nit, ��.. ;- �iir�c. , equal p rco�,.t or, s er:. o..�� cG �.� �:.c�� Percolation test hole. (:.e. s 1 min for l -30 imir inch.. 5 ? min for'i L -60 ininNlnch) Ail data to be subritined for review. Z. Deoth measurement_ to be rude from top of dole_ Form, DD -97 DEPTH 0.5' . 1.0' 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' 3.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUN. TERED IN TEST HOLES. HOLE NO. HOLE N0. L 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 b1v Date /o 7 Design Professional Name: 7bhriV k Address: CU S� A4A9 PA77ERso tJ ti Y 2 3 Signature; Design Professional's Seal N Y �F N y YPREL 4 ".��' ' -^ _ Ask MA A�-'?fNkL- (-t "-v w/ . PUTNAM COUNTY DEPARTMENT OF HEALTH (-° T-4+ Z'' DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION Property of y I OU:S & C0I1STR U"C,77d A1 Located at V ,S ,/ A i> ® L-o T/V 4 "WO iy (T) Tax Map # 2 -3, I Block / Lot 3Z 3 ,L 3J_ Subdivision of 2.7 3, 5; L Subdivision Lot # v, >�� v- Filed Map # Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer X_ opRcc d- Arehiteet . 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 P:E., R.A., # Mailing Address Code. 44 011 Very truly yours, -_Y Signed: V r 0 a s c° . Co K S (Owner of Property) l� Mailing-Address: /4! ' State A) Zip 0 %� State C..4dwZ A)l Zi Telephone: 1/ _ S71-21 Telephone: W4— r7e.' V�F Form LA -97 Z PIr111iAM COUNTY DEPAMi11EP T OF MATH + � Dhkiea d Hevlb Seevbea. Camel. N Y 1061? 1 to Paorlde Ptiauit / 1 eta CERY ICAT_E POO Paedt R CO(T=QCVION PEUP FOR SEWAGE DISPOSAL SYSTEM Tatn9.P�t �•Z Bbek - Ogee /App &NO. Nume PH � �t ❑ Dale of Pmvloss Ap ^parovrd,� t n Addaeae O 7� v Town�wl I�KAJ- t�- +v%�1f�Zin��s�_ Date Subdivision Approved � —� Fee Enclosed ❑ Amnil'nt- B 11111111102 " O Lot A+al � � J � T � gip Seetlon Orb Li Depth volume Numdl r of Boeblopms - If (�'�� �, �DWp Fbw. G P D PCHD Nodllmdoa In Regahed Wben FM Is completed sepaeafls se comae sy"M to conchs of lGailon' Took and 0 Z C To be cumbecfed by ' p ' Address Water snpPb': Pd Ae Supply Fam - Q, Address an If D.iyate Supply Deed by 1 f !!! t Address htrt Otter Ragakiemenb 1 represent':that 1 am wholly and completely responsible for the design and local above described will be constructed as shown on the approved amendment there County Department of Health. and that on completion thereof a ^Certifkate be submitted to the Department, and a written guarantee will be furnished pace in good operating condition any part of said saw MR diioilul' system and of the approval of the.Certifkate of Construction Compliance of the will be located as.shawn on the app►ovetl plan and that mid well will be'Instal County / Department -to f Health. Signed Date lf/ •�� APPROVED FOR CONSTRUCTION: This approval expires two years from the d revocable for cause or may be amended or modified when considered necessary 6 require$ a new permit. Approved for disposal of domestic sanitary sew g Rev. wta� 72• / f$ •10/88 - I(' .^ at the separate sew des YI t stem S ds, rules 377 regulations o 4, Putnam n sass tory to the Commissioner of Mealthwill a by the bulkier, that Paid builder will (2) y, s i medkitely following thedate of the Ise- iairt t at 2) that the drilled well desa*W. above std Ws, ulas and ragu U0 Af the, Putnam e P.E.K— R.A. c il- ` I License No v `—W ctioil of the building has been undertaken and is ith. Any change or alteration of construction ply"ef►l�� Title DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL Nft I PCHD PERMIT # WELL-LOCATION V Street Address 115 Do Town Village City Tax Grid Number Z- - .� WELL OWNER Name Mailing O f_0 C d Address 1b9i 12-P /ai76 rivate O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL U INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT _gpm /# 13 REPLACE EXISTING SUPPLY 2kEW SUPPLY NEW DWELLING PEOPLE SERVED /EST. ❑ TEST/ OBSERVATION 13 DEEPEN EXISTING WELL OF DAILY USAGE 0y 8a1 Gb ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING 0 &Q— WELL TYPE V!HBILLED ®DRIVEN DDUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: I-/� Lot No. WATER WELL CONTRACTOR: Name U.�-� , ® Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET C Y —t0 r9i ` (date) (,s:10ature) l ' PERMIT TO CONSTRUCT A WATER WELcrr U f ;ra Y This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt3• (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the 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 man r as not to degra a or otherwise contaminate surface or groundwater. Date of Issue: 5� 19 lop Date of 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 r�r PC -1 PUTNAM COUNTY DEPARTMENT OF HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSA,LL SYSTEM 1. Name and Address of Applicant: T) D eS G1,c'�9'T 1 �► 80)(3-30 rF S i 2. Name of Project: !� 7 —fT Z 3. Location T /V /C: ---'.4. Project Engineer:- 5. 4'n►' U;t � 5. Address: (K-O� LEI �v License Number: �0220 Phone: 7 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? D 9. Has DEIS been completed and found acceptable by Lead Agency? ........... N A 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or other 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 �✓�� -S 19. Is project site near a public sewage collection or disposal system ?..... 20. Name of sewage system Distance to sewage system 21. Date test holes 1+1t r A,Iir OF observed: Ste' 22. Name of Health Inspector: 23. Project design flow (gallons per day) �© ....... ............................... 11/93 (ajjk7 tF { 2. 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 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? ............... ............................... . 27. Wetland ID Number ........................ ............................... 28. Is Wetland Permit required? .............. ............................... `% ? Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, p landfilling, sludge application or industrial activity? ........ YES or NO 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? ........... S 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ �J 0 35. Tax Map ID Number ........... ... ............................... .......... 36. Approved Plans are to be returned to: -""z 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 Pena 1 law- SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: F &7"ROWSBIDI ;IDF• ht mkV C-100IRS) a 0-hfA1*zr*hXU1* k's VA m;1 371; k:jm37-gj Led DESIGN DATA SHEET'-SMU.FACE SaQM DISPOSAL. SYSTEM FILE NO. Ownerpojo� ellU ,A4 Address Ad Located at (street) V kk A 1b0 L-0 aZ:,,S sec. A3.) 2-Block t Lot (indicate nearest cross street) municipa-Lity... Watershed Y6, SOIL PERCOLATION ZEST DATA RBX= TO BE SMC= WITS APPLICATIONS Date of Pre-Soaking Date of Percolation Test 5 HOLE . NUMBER C= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 2 4 SLAW 5 bY. 7 W... i*1,Y, f�, - mdz 2 3 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at.,,same depth. until approximately equal soil rates .are obtained'.at each percolation''test hole. - All data t& be - submitted for review.. 2. Depth measurements to belmade,from top of hole.. TEST PIT DATA RD�UIRED. -TO SE'SOBMITTED:WITH APPLICATION DESCRIPTION' OF S011S ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 1' 2' 31 4' "o 5' 7' 8' 9' 10' 11' 121 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH DATER LEVEL RISES AFTER BEING V U V7 DEEP HOLE OBSERVATIONS MADE BY: DATE :. Soil Rate Used Min /1" Dropr S.D. usable Area Provided 50 F7- Z- No. of Bedrooms Septic Tank Capacity 1 Z Q' gals. Type CON Absorption Area Provided By 400 L. F. x 24" width trench asw_M Name /��C� Signature Address //�FJ % (r /9 /�/.'Gr SEAI44 AWA0,6 Av V 16*,5- ae THIS SPACE FOR USE BY HEALTH DEPARMENT ONLY: Soil Rate Approved sq.ft/gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date a/9 '/"T__� Re: Property of Located at (T) NITEY,�IV Section , 12, - Block Lot Subdivision of �� T�- 00 Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize--ZA;I 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. i� oun er igned: P.E. , . , # [ O�✓� dress ivy -33 Telephone Very truly yours, Signed , Owner of Property Aox �0 Address 4Town laa04? epnone rff:ale Mn roe swags DWOM iiMM INaleift r rcb% �eMye YidMN lime , Via" f !'t3t 4 i 1 ti wi Wt _. Yft q iek • - - - t�rwaL- � brkriw ..O ,� - � DAM fi ZtodNe A�wit . ,_ Mlieilfiiw S' l 3C pg - TiwliS L x�:,,y„ � 3�� �7 _ .: F Eiiclgaad y Y lyN'— , �� J �t + _ IM Aga v * % • F� sown Oar, Depa ilslieiee d - V Da$ ^FINIF G JP D PM Moon" Y =w�M IYYw M M IOral. Sat)M M aOtfait ft.� n''° g Tick A �. 'b.M'aO��YOttlai:b • _ _ _ Aii'fr - walie fib► Baao Dim" Iw 1 ►�MOMnt that 1 awl MrhOMY fNM Q0111MKNlI nf0011fa1It iw tha aftn af10 mcitlOw_ Of. tad OrOpOMa,.fyftem(�)i- 1) that the w wete Mwa a di OfN f item ...- alMt+a MCNrN wiM:M Mottr"Od at mown an Me " "had amMflwlMlt than to aM in aCf70rdaflp With tad "itawea►flf, ruNf e u � of -tlii CnwttY OMMRw!Ont N Itrrillp. ,alfd that on we t!" !'Cfftiitisite Ow "J YtMaawy.to tad Cofmalsom r. N MMNAwm M oifwMbfl:.N tad DMMg MM. •M a wrateek TeoraMie wtais,M fumbihed tad ewwa►.: Ata fw:ennM M1►s a ! MINbf by EM WNei. "Wit miff b~ wet wf� in 'pfd .NMMM Madman. MY -MR .N MI! "Ww item du►MM fM:00►1of1 Oi tMN (!) � nMwiatMy fO1MwM1!'tMMte N tad NIY• MM, N tln'a/MwM` N tMeCfMtKIwN.of Ca+intnfetiaf CawMWwe fit; tad aaeYMl syftaw w anY,rMain f, that the dr iefw�N aiwn Mink be IoMteil as dmm OgtIM aMrofiiit /law aiii that MM we"'! N NntalNp �.,in = aeoe w o the r f r aad M the til�ilm ' MMefl ArMItOVEO.f011 ne�q�M.10r ieMfa sad 1neY N,afdwM/ a wfOQiN ° Iatufd °pwMM fxnsrvft of tad twlMfe has been undertaken aM if CON T nNte N wM MwfWRN wiatfNY tiY.ttM Cogithfujiphoor N MMm11. Any - eMfNe Of attwataow N eeftftnfetbn 1awNOf a; "W a�fnfilt. AM►ofM f► mifoMN N fNwfiftk MwNrY MwMb of oravate-water su�WY -Only � v A r� fi. $��+ /rte '° y .. i e ✓ e"`C � � y .. . r f ^ ` TAN r -a y s� i mi Sri,. , s.n�:xS •, -� M v i a 4 •C .1 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 Y l V aftivate O Public USE OF WELL 0- primary 2 - secondary G- 16SIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION C] INSTITUTIONAL O STAND -BY .D ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT .6— gpm /# PEOPLE SERVED /EST. OF DAILY USAGE (gCo gal O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13 ADDITIONAL SUPPLY WEW UPPLY (4EW DWELLING) Ci DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE MAILLED ODRIVEN DDUG OGRAVEL a OTHER IS WELL SITE SUBJECT TO FLOODING? YES L-o NO IF WELL IS LOCATED IN AIREALTY SUBDIVISION, NAME OF SUBDIVISION: t..l... Lot No. WATER WELL CONTRACTOR:' Name `"C":'6 . Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L_-NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY w? �,�• DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ® SEPARATE SHEET f (date) (signature) yr PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant.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 suc a manner as not to degrade or otherwise contaminate surface or groundwater. r Date of . Issue : 19 Date of Expiration 19 �7 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller T-repr*WA thoil, 8�00 Wh011*W4 i6@601it* f*111666610 for the Move d9mmed Mll be c; onstruted ss ihiwhiA thei00l 6ved i :1,10 . Dpartomt i , t�"Rk` thet bit cifflilsiioh. there be wMlnitM to a airatem - PON (a volldljOWINUM OFMOW ance of "a . amfew . 'of CO!q" c0i -01. cimli� 00 *4 WOMM"Wimi0soft tile "Weped p4m aiid titst aid win m4n aid location af ths. prom g systa"(a 1 1) that the *Wet$ -di' - I . Sraqiil Adowit there to and in accordance with the Staimfordil. rums Ovolulallo" Of loo �V%X"T a "Cortitkato . of Construdion CowWWnW matisfactory to the c omm"Wormiio, 04411ftwW JP 4urvviAsd tow o~. kft smemers. Mfrs or &SIW by the bmikler. tielst said livadst w40'. "M **am durkV the,pariod of We (a) 't1weste Abe ilileiim, Ilanics of.th's."brigbial system or any fwws s ) "at tbo *law Vs", d"Irl" IN M katallIC—in accordams with the r and rel—Am -W, the Addrels Appadvao fro* r TRUCTIONI Tub' approvel esph-WAWO Years "M the Afte IUW0d OnNIN CORM mos" iw crift or, WAV Or MOW w 0 M*lWid Incestary by the CoMmIWOW Of 60 SWA"W OGWAU a pw#vWL' AppeoW for Owsom Of 40WANAlt OWMWY tsnw We star No Rev,. _PAL M.&I- d Lkel1M HoIA 0 o the oulmum has beli-il" uniWtakin, `64 is ink. Any Cheep or Migration of construction only. Tills 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 # �lf=�j WELL LOCATION Street Address To Village City Tax Grid Number —� WELL OWNER Name Mailing Address aPrivate O Public CBSE OF WELL - primary 2- secondary EWESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM (]TEST/OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT�gpm /# PEOPLE SERVED & /EST. OF DAILY USAGE_Q0f0 gal O REPLACE EXISTING SUPPLY O TEST /OBSERVATION CI ADDITIONAL SUPPLY WEW UPPLY (NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE !, tILLED D DRIVEN []DUG [3 GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES L--O' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �-rrn-r=; Lot No. WATER WELL CONTRACTOR: Name T; 8 :'"7 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 01M SEPARATE SHEET (date) ( (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within 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 suc a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19___1 �`� 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 J!k; Re: Property of Qot oy D,l A 6P.eP- A%t?AA1 Located at (T) /2-(400U ectionL�5 - 1 L~ 3 Block �. Lot 3i Subdivision Subdivision of 1 1 9 (C' Pon ce N'i Subdv. Lot # ✓ Filed Map # 1 t"d Date Gentlemen: T. MICHAEL DALY, P.E. CONSULTING ENGINEER This letter is to authorize P. 0. BOX 243 cra�NnFi ^61r,NT i6587 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 Owner of Property P.E., R.A. , # `t' � • BDX�C7 Address T. MICHAEL DALY P.E. W� Address CONSULTING ENGINEER Town P. 0. BOX N. 243 �� 2260 '' +! "'!)l;K, N. Y. 10587 9 40 Te ephone Telephone APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DMSION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION P R�iIT OF OWNER /A 5, STREET LOCA ON S r/ 4 "__4s DATE TAX MAP # .2 2, J-- +--- D ENTS. PERMIT APPLICATION !'r ISCHARGE (OK) PC -1 DEEP HOLES LOCATED WELL PERMIT P RESENTATTVE OF PRIMARY AND EXPANSION ENGINEERS AUTHORIZATION 47- AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE DESIGN DATA SHEET(DDS) ►s ED PIT & D BOX SHOWN & DETAILED �,� SF - NO. OF BEDROOMS DEEP HOLE LOG ts & SSDS'S WAIN 200 FT. OF PROPOSED SYSTEM CONSISTENT PERC RESULTS (3) 4.+'' PERC HOLE DEPTH ,�" RO METES &BOUNDS CORPORATE RESOLUTION OUSE SETBACK NECESSARY (TIGHT LOT) PLANS THREE SETS OUSE SEWER - U4 "/FT. 4 70; TYPE PIPE HOUSE PLANS - T�AO`STS 0 NO BENDS; MAX. BENDS 45 W /CLEANOUT � FILL SYSTEMS VARIANCE REQUEST 1eCLAY$ARRIER — _- — GENERAL LEGAL SUBDIV SUBDIVISION PERC RATE_ FILL REQUIREI CHECKED CURTAIN DRAIN REQUIRED AL: SLOPE 3:1 TO GRADE OM GAUGES FILL PROFILE & DIMENSIONS VOLUME TRENCH EX- APPROVAL SSDS ADJ. LOTS Q . CH PROVIDED WETLAND (TOWN/DEC PEKMIT R & D) 60 FT-MAX DATA ON DDS PLANS & PERMIT SAME 1 M ppRALt.Fi. TO CONTOURS ?RE -1969 - NEIGHBOR NO CATION ID 100% EXPANSION PROVIDED LETTER BLZBA SEPARATION DISTANCES SPECIFIED ON PLAN 100 YR. FLOOD ELEVATION _ . UIRED DETAILS ON PLANS p.L, DRIVEWAY, LARGE TREES, TOP OF FILL SEWAGE SYSTEM PLAN - (IYO FOUNDATION WALLS SSDS HYDRAULWPROFILE GRAVITY FLOW 0 TO WELL, 200' L 1 D.LO.D., 150' PITS D/ J BOX Ci LGALLEY C��p�= DETAILS_ W O STREAM WATERCOURSE LAKE (INC.EXPAN) SEPTIC TANK - SIZE, DETAIL O CATCH BASIN, 35' STORMDRAL 1, PIPED WATER WELL DETAIL, SERVICE LINE IF OVER 10' TO WATERLINE (PITS -20') EPT :ONSTRUCTION NOTES (GRINDER RATE) EgMIT DRAINAGE COURSE DESIGN DATA: PERC AND DEEP RESULTS 20�Q FT. RESERVOIR, ETCM 150 FT. GALLEY SYSTEMS CWO -FOOT CONTOURS EXISTING & PROPOSF,�y/ ziol SEPTIC TANKS )RTVEWAY &SLOPES CUT M FOUNDATION; 50' TO WELL -OOTING /GUTTER/CURTAIN DRAINS WELLS 2 15' WELLTO P.L MENTS: Z, 0 70C # 2 PC-1 . PUTNAM C OUNTY D E PARTMENT O F H EAL TH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: DO L4AZ :�h Ca- n���i5�i��► _B 1A C iEP MAC OL 2. Name of Project:. 3. Locatio T, V /C: 4. Project Engineer: M il- V.aLY( 5. Address: T,::O - License Number: 46466 Phone: 6. TTvoe of Project: V Private /Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial , Mobile Home.Park Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted ✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. f U 1 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 1 0. Name of Lead Agency 1. 1 2. Is this project in an area under the control of local planning, zoning; or other officials, ordinances ?._.._.. ................. ....................y�� -"7 If so, have plans been submitted to such authorities? .................. 0 3. Has preliminary approval been granted by such authorities? Date Granted:"' 4. Type of Sewage Disposal System Discharge.f?�'F'? 5� Surface Water Ground Waters 5. If surface water discharge, what is the stream class designation ?........ — 6. Waters index number (surface) ........................................... _ T. Is project located near a public water supply system? .................. K\ 0 1 3. If yes, name of water supply Distance to water supply" 3. Is project site near a public sewage collection or disposal system ?..... ). Name of sewage system Distance to sewage system 1 I. Date observed: 23. Name of Health Inspector: 1. Project design flow (gallons per day) .............. e?oG ................ °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 O wetland? .................................. ............................... 11 28. Wetland ID Number ....................................................... 29. Is Wetland Permit required? ................. .......................... Has application been made to Town or Local DEC Office? .................. `i 30. Does project require a DEC Stream Disturbance Permit? ................... N! 0 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial Activity? ....... YES or NO ` 32. Is project located within 1,000 feet of existence of abandoned landfill; hazardous waste site, salt stockpile, landfill, sludge disposal site or, ,t D any other potential known source of contamination? ..............YES or NO N DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? •� 35. Are. any sewage disposal areas in excess of 15% slope? ........................ _ 36. Tax Map ID Number ......................... ............................... 2 bo It 37. Approved Plans are to be returned to: ................ Applicant LEngineer 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. SIGNATURES & OFFICIAL TITLES:�1 i%�`L/L�% MAILING ADDRESS: ` PUTNAM COUNTY DEPAFO]M NT OF HEALTH DIVISION OF HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner %M[y_aT%�LZPa Address'(�,O,C�vx X30at1�1.ft� ��. ��b5 lC7 l� Located at ( Street) .V[ y'�a1'o Sew :j, 17, Block Lot —:15C11 (indicate nearest cross street) Municipality �j� r[ Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking Date of Percolation Test Run Elapse Depth to Water Prom Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches ZA S�F �5 4- i 2 q.4 -7, 9 iZ V- 3 q-: ,54-10:06 it, It, 4- Z 3 4- I- 4 iD.Q& -il9 , Z1 11-5' 7,4- S-1- �� 5 2 q''Al - 10'01 1� L 4 2 3 -10'OS- r6:7a 18 z4- 2 5 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submittea for review. 2. Depth measurements to be made fram top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS EN)OUNPERED IN TEST HOLES .DEPTH HOLE NO. i HOLE NO. HOLE NO. G.L. 1' 1 mixop 3' 4' r 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY.: (,Nip& DATE.--;56 19,6 DESIGN Soil Rate Used — Min /1" Drop: S.D. Usable Area Provided No. of Bedrocros Septic Tank Capacity IZ 3D gals. Type * tN Absorption Area Provided By 6 L.F. x 24" width trench Aker oxm �JcJ Pity' l SL�e..) + of ►�� �r Name T. MICHAEL MY. P-E_ Signat � v CONSULTING ENGINEER . S � ti Address P. e. BOX 243 SHENOROCK, N. Y. 10587 ' THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date UI S� tic 1 ,,4 1. �N.I�wF,t -L "1'niS is. to certify that the serace disposal. systpn was cons tN =t°3 as indicated-on' this plan and that the systems was inspected by me before it was covered over. The syste was constructed in accordance with all standard rules and regulations o£ the Putnam County Department of health and the Ira Y °rA State Department of Health." .. . Putnam County Department of Health Division of Environmental IIealth Services ith conformance m �pprov as noted for slations of the Rules P.e� ap81 ° b alth Dopartmen ` l[ // --- — ate mature &Title AS —BUILT MEASUREMENTS- No A $ REMARKS 54 r8o Y, 311 1 91 � L--W0 Zq q� 5 13y io`7 7 105 I 9 q r-Is b 8 l t to 1+ too a eWi IZ I I. I Zl� 13 IZb 13U . Is air- s WEL - �/v L-f=-eq.D 'YOU -rM-.W .A3. I -1-3 PLA N . lu �1 7/2J/4 �T °s5D t.0Tt* - )V1ST+DGL6P -�s WT-nB ooniA l�Iw l PArmMSOt✓ CT) f / O � n n !rl !ll lI !i QI 0 !1 !/ Q lI Il 1l IT 0 zQ Il 11 �� 1fl 411 1250 GAL. MA50NRY u Il 1f! - 5Et°TIG 3 TANK EAD R -z OOTI G a 4F z RAIN D15GH. " j: O � u S PLAN 5GALE V' = 20' To PROP. WELL 4" GI NO 5505 WITHIN 100' �/IST 1005.15'