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HomeMy WebLinkAbout0823DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -2 -55.4 BOX 9 1 `1 ., Ir Is , ` ',s i f'L 7 r- �. ss. 11" Ills I , ■ ' ��� { �'r 0 Is 00823 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL (� please print or type PCHD Permit # 7 ' O Well Location: Street Address: TownNillage Tax Grid # Vj IilTIF tki4— L, PKi IO-' P Map I.A. Block %.. Lot(s) SS-4- Well Owner: Name: Addr ss: 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 1-f _ gpm # People Served Est. of Daily Usage 62n gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes 5C No Name of subdivision LAJ" Q Lot No. 4 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 location & sources of contaminatiW,6 be provided on separate she t/pl Date:_ ©%��F01 _ Applicant.-Signature: V 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 11 driller certified by Putnam County. Date of Issue q11 61 Permit Issuing 0 Date of Expiration D Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 X13 71 PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLYO B=DE001,13 AIL SUB I?LANS V. HAK. "'13 ---CD,011 FOR APPROVAL A_; I -, a ., PUTNAM -QQUNTY1)E.PARTM ENT OF,_..HEALTH DIVISION-OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM AH 6U Address �H6 Located at (Street) W40 141\4, V*46K tWA% Tax Map Block~ 9- Lot'55'64 (indicate nearest cross" sitrieet) Municipality pprTrS IGOH Watershed- SOIL PERCOLATION TEST DATA Date of Pre-soaking Cal 6\ qA Date of Percolation- Test I.V,*P opcittod at same depw unin approximaimy equal percolation rates-are obtained at each 1,�u:pp rr test hole. (i.e. :g -1 min for 1-30 min/inch, :5 2 min for 31-60 mfinhnch) All data to be percolation ' ' submitted for.. review. 2. Depth measurements to be made from top. of hole. N.8. R RVOi� .7 x i `�D Ah`0 :gx A Q XF:' W U J. i% • ........ .... ... . ... . ... -R, ...... .3-M - Hole :Start:: t j 12C X., '114. 51 • lbo - 2 3 2q �� 23 0 °j 4 I'll I E) 11Y IA-, I 2 I 3 4 5 2 3 4 I.V,*P opcittod at same depw unin approximaimy equal percolation rates-are obtained at each 1,�u:pp rr test hole. (i.e. :g -1 min for 1-30 min/inch, :5 2 min for 31-60 mfinhnch) All data to be percolation ' ' submitted for.. review. 2. Depth measurements to be made from top. of hole. TEST PIT DATA 2 DESCRIPTION OF•SOILS ENCOUNTERED IN TEST HOLES /7 - DEPTH HOLE N0. HOLE N0. __ HOLE N0. G.L. 0.5' - 1.0' r topSc►L I. 2.0' ` 5 ll�* 3.5' 1_oi�M (�jnm 4.51 V5A''V\rl„ Lai- OC(a To _- 5.5 CkV 6.0' _µo. kul•- 6.5' lyc CIO ... 7.0'0. �-OvIL 7.5' _ 8.0' 9.5' 10.0' - Indicate'level at which groundwater is encountered Indicate level at which mottling is observed. Indicate level to.which water level rises after being encountered Deep hole observations made'by: :P -ockLs Itu i MW 9'=)A%1 699) Date (618��� Design Professional Name: V4A w, HkL"� Aj �-yO Address: J-� So - Itof NEW x °C _ / = W C7 LU ..f / Signature: l/ No. 56124 C1 QFESS%o�� Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES .__ LETTER OF AUTHORIZATION RE: Property of PEILAHPcR- +- A�4N1iU SA 009-A Located at W 1+n I}Av46c- Twit✓ T/V Tax Map # '14, Block Lot s �' Subdivision of Subdivision Lot # �" Filed Map # Date Filed 8 li 10� Gentlemen: This letter is to authorize 14AW W` ��Gµ °�`�- JP-" P5 a duly licensed Professional Engineer _Y or Registered Architect to apply for the required wastewater treatment and/or watdr supply permit(s) to serve the above -noted property in accordance - with the standards, rules or regulations as promulgated by the Public Ifealth 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 Coi}n�t..Sanitary Code. �� pF NEW ya9 "'off, Very truly yours, Its * r Countersigned: Signed: _ r � P.E., R.A., # (Owner of Property) .66124 �, Mailing Address:-: sst Mailing Address: BAYP)EPP-V LAH I�®Vra�_ 15Al—EM State Zip 14 4°1 State y4y Zi to a �0 1' Telephone: ( � 7-"1 of - 4 °O3 Telephone: (114) e.! P-.-a BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH .1 Geneva Road Brewster, New. York 10509 f- LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278, -6648 March 13, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Bindra White Hawk Trail, Lot #4 (T) Patterson, TM# 24 -2 -55.4 Reservoir Basin East Branch Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 1, 2001 is complete. The Department will notify youu- by..Apri1.2, 2001 of its determination. - - - -- - -- - ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a prof ect, such as stormwater plans i7 Letter to: Harry Nichols, P.E. - March 13, 2001 -2- or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If.you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2261. Very truly yours, . ""� Gene Reed Environmental Engineering Aide GR:tn PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: gVWI-E 1144Vk r" /L REVIEWED BY: RM, W AS, SRDATE: /2 D TAX MAP #: (CONFIRMED 2- Y N Cpq UMENTS Y N (REQUIRED DETAILS ON PLANS CONT'Dl PERMIT APPLICATION (�LJHOUSE SEWER - %" FT. 4'; TYPE PIPE CAST IRON' WELL PERMIT OR PWS LETTER �)(�NQ BEND$;-MAX;BEINDS 45 °�W /CL T -9 h of✓ 'wo X15 d lbc v PC -97 /s+ •8ax ETTER OF AUTHORIZATION (__)(__)SITE NOTE (NO GE) (� DESIGN DATA SHEET (DDS) FILL SYSTEMS (_)(_)10' H PAST TRENCH SLOPES 3 O GRADE SHORT EAF L___)LJFILL SPECS/ FI 1 -5 —_ .. — PLANS -THREE SETS UL�FILL E & DIMENSIONS -- _ �)IaIOUSE PLANS - TWO SETS U L IN EXPANSION AREA SCE REQUEST SUBDIVISION LEGAL SUBDIVISION ( SUBDIVISION APPROVAL CHECKED E r C—) •'RATE o a . (_) L REQUIRED DEPTH C) l CURTAIN DRAIN REQUIRED GENERAL �) OCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP L, LEGATED TO PCHD DEP APPROVAL, IF REQ'D (� EEP TEST HOLES OBSERVED PERCS TO BE WITNESSED (� APPROVAL SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) (_)LJDATA ON DDS PLANS & PERMIT SAME E 1969 NEIGHBOR NOTIFICATION =- (— =X:::jE'fTER BI/ZBA R. FLOOD ELEVATION W/I200' U / SOIL TESTING LOTS >10 YEARS OLD REOUTRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW • ' CONSTRUCTION NOTES 1 -15 (�D SIGN DATA: PERC & DEEP RESULTS (� CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES �(.,)TITLE BLOCK; OWNERS NAME ADDRESS / TM #, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE U(_J,LOCATION OF WATERCOURSES, PONDS j LAKES,WETLANDS WITHIN 200' �OF P.L. U PROPOSED FINISH FLOOR:AND CLBASEMENT ELEVATIONS WELLS & SSDS'S W/IN 200! OF SSTS • . PROPERTY METES & BOUNDS EROSION CONTROL FOR HOUSE; WELL'& SSTS, EROSION CONTROL NOTE i COMMENTS: (REVSIiEET)09 /01/00 .' - , FILL GREATER M N 2 FEET j_)DEPTH..G7AUGE Y BR FILL CE N VOL. O .B., UNCLASSIFIE ?i'IbIPERVIOUS TIE FROM TOE OF SLOPE E C LF TRENC r 7 60FT mAX. 4 6 7 PARALLEURS 100% EXPVIDED U GEOTEXTILE COVER SEPARATION DISTANCES ON P LAN - FROM SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (� 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan) (� 5.0- TO CATCH BASIN, 35' STORb1DRAIN, PIPED WATER - 10' TO WATER LINE (pits - 20') �• ' 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS f(_)C )10' MIN TO LEDGE OUTCROP SEPTIC TANK (,(C. 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES LU)ULOCATION OF SERVICE CONNECTION Lj MIN- 5JO-PROPERTY- INED SLOPE (�USPE IN SSTS AREA (S20 %) (� EGRADED T015 %, IF REQUIRED DOSE/PUMP SYSTEMS UUPUMttQTES (___)LJDOSE 75% OLUME/DOS NOTED (�UDETAIL FOR FORCE , U( )PIT AND OWN &DETAILED L� STORAGE ABOVE ALARtii CURTAIN DRAIN UUSTAND 5' BOTH SIDES, DETAIL UU15' MIN to CDS=> ' °0 2-'- ° , - /o,100 %-<1% (_)LJ20', MIN to CD D GE /100' sit ischarge ( r__)Lj10' ON- PERFORATED PIPE 14-16-4 (9195) —Text 12 PROJECT I.D. NUMBER. 61%.20 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For. UNLISTED ACTIONS Ohly PART 1— PROJECT INFORMATION (To be,compieted by Applicant or Project sponsor) 1; APPLICANT /SPONSOR MIN - 4 W Mau -NA 15JH IIA 2. PROJECT NAME PT 4 lbeif j 3. PROJECT LOCATION: PU NAM Municipality 1"TfH County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, eta., or provide map) S. IS PROPOSED ACTION: ® New ❑ Expansion ❑ Modlflcallon/alteratlon 6. DESCRIBE PROJECT BRIEFLY: INOt��t�at.aTS , v��1� +ESiD)r`i-1 7. AMOUNT OF LAND p /FFECTED: � ' 4• Initially w acres Ultimately acres B. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? Ayes ❑ No If No, describe briefly 9• WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 9Re31dentlal ❑ Industrial . ❑ Commercial ❑ Agriculture ❑ Park/Foresl/Open apace ❑ Other Descrlbe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING,' NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes KNo If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 13 ICY Yes No If yes, Ilal agency name and permit/approval , 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REOUIRE MODIFICATION? � ❑ Yes KNo 1 CERTIFY THAT THE. INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE RAP- ,, W, ;H'C L6 jo— fat Appllcandsponsor n e: Date: Signature: V 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 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617,4? If yes, coordinate•the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. 'Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or. threatened or endangered species? Explain briefly: i CA. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. 06. Long term, short term, cumulative, or other effects not Identified in Ct•C5? Explaln briefly. x C7. Other Impacts (Including changes In use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? . .Y ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb 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 Ills substantial, large, Important or otherwise significant. Each effect should be assessed in connection with Its, (a) setting (i.e. urban'or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer In lea Agency I We of Responsible picer Signature of Responsible Officer in Lead Agency Signature of reparer (If different from responsible officer) Date 2 V February 16, 2001 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 Re: Individual SSDS - Lot # 4 Parker Subdivision White Hawk Trail Patterson, N.Y. TM #24.-2-55.4 Dear Robert: Enclosed are the following: Harty ,,W. Nichols 7r„ P.E. Patterson Park, Suite 106 2050 Route 22 _ Brewster, NY 10509 Telephone (845) 279-4003 Fax (845) 2794567 1. Five (5) prints of Drawing SS-4, "Proposed SSTS," dated 2/16/01. 2. "Short EAF," dated 2/16/01. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 2/16/01. 5. "Application to Construct a Water Well," dated 2/16/01. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Two (2) copies of Residence Floor Plan(s), for Bedroom Count Only." 9. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry . Nich s Jr., P.E. HW23:JM jm 00178.04 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 r -. LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 March 13, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Bindra White Hawk Trail, Lot #4 (T) Patterson, TM# 24 -2 -55.4 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1. Show on plan (201 ft. minimum to SSTS) in replacement of 201 ft (TYP). 2. The pipe from the septic tank to the first junction box appears to have a bend of 90 °. The maximum bend allowable is 45° with a cleanout. 3. Revise trench detail note for gravel or stone. It must read (dust free crushed stone or washed gravel). 4. The well needs to be shown and labeled 15 ft. minimum from property line. Upon receipt of a submission, revised to reflect the above comments, this application will be consider further. GDR:tn Very truly yours, Gene D. Reed Environmental Engineering Aide Harry W. Nichols Jr., RE Patterson Park, Suite 106 - - 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 April 11, 2001 Mr. Gene D. Reed Department of Health One Geneva Road Brewster, New York 10509 Re: Proposed SSTS: Bindra White Hawk Trail, Lot # 4 (T) Patterson, TM # 24 -2 -55.4 Dear Gene: In response to your letter dated March 13, 2001, we note the following: 1. Wording of Note has been revised as requested. 2. Plan has been revised to eliminate 90- degree bend. 3. Trench Detail Note has been revised. 4. Well has now been shown and labeled 15 feet from property line. Kindly continue with your review of the SSTS application. Very truly yours, -Harry W. ichols Jr., P.E. HWN:JM.jm 00- 178.00 f�� -0I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,.,OF;:ENV,IRONMENTAL HEALTH -SERVICES - APPLICATION FOR APPROVAL-OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of apprca6t:..0444 DgR- #P P HHAL4 S 6 Aov*-. 2. Name of project: 3. Location TN: 4. Design Professional: V' k4 A -te 5. Address: UTQ k 6: Drainage Basin: 7. T of ro•e 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)? TypeStatus (check one) ...............,....,.... .....0........ .........:........ , Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... eta 10. Has DEIS been completed and found acceptable by Lead A enc 9 11. Name of Lead Agency NA 12. Is this project ih`an area under the control of local planning,, zoning, or other _ . __... ...officials, ordinances? : ...........:.......................................... ............................... D 13. If so, have plans been submitted to such authorities? :...:... ...........:................... ma 14. Has preliminary approval been granted .by such authorities? Np Date granted: NA 15. Type of Sewage Treatment System Discharge... .. ............. surface water groundwater 16. If surface .water.discharge, what. is. the: stream class designation? .................... l4 17. Waters ind. ex number (surface);: :............ ........ � .. . .................... ................,,. N 18. Is project located near a public water supply system? ....... ............................... 0 19. If yes, name of water supply ' Distance to water supply 20. Is project site near a public sewage. collection or treatment system?.. :.:....::..:.:: 21. Name of sewage system 44 Distance to sewage system I0, 22. Date test holes observed Co� �� °��. 23. Name of Health Inspector MO e)47�4KiM 24. Project design floW(gallons per"day) ..... :... ........................ ............................... _G. 25. Is State Pollutant Discharge,Elimination System (SPDES) Permit required ?... N4 .. .... ... . . 26. Has SPDES Application been submitted to local DEC office? .......................... �AA Form PC -97 27. Is any portion of this project located within a designated Town or State'wetland? ND 28. Wetlands ID Number .....................................:.::::................ ...............:............... NR 29. Is Wetlands Permit required? N0 .............................................. ............................... Has application been -made to o wn of Local DEC office? ............................... 30. Does project require a DEC-Stream Disturbance. Permit? .. ..................... ......... ... 31. Is of was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, . N� landfilling, sludge application or industrial actiyity? .............. .. ........:...... Yes/No 32. Is project located. within 1,000 feet of existing. or abandoned landf li;, hazardous waste site, salt stockpile, landfill, sludge disposal site or-'any , other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .................... ...... 34. Are community vater and/or sewer facilities planned to be developed within. 15 years in or adjacent to project site? ................................. ..............................° 35. Are any sewage treatment areas in excess of 15% slope? . ............................... M!1 36. Tax Map ID Number .......................... ............................... Map Block `�- Lot '6 -'- 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate4orms for such activ_ ities -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 to Section 210.45 of the Penal La;A SIGNATURES & OFFICIAL TITLES. 14"f W>JH1c- ftt_A, iViV%;: A'7 AtOiK Mailing Address:.... ........... .................... 1-060 i( 2� 1AIMIRAIAAIAMAAIAAIAAfAA1AAl" IAA! AAIAAIRAIAAfAAWAAIAA lRAIAAIACaAMAAI"4AAIAAi1V11AA 7AA1M10 IAAIA AIAAIA AIAAIA m 0-w1N yn 'f n . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P-/ 4_0 1 Located at �1J�t1T� ��-Pc1 En Town or Village f PrlT59-60H Subdivision name p �' Subd. Lot # 4 Tax Map 24' Block IL Lot 654 Date Subdivision Approved Renewal Revision Owner /Applicant Name ?E9-M%A% -k Date of Previous Approval Mailing Address Hilo bsv L. m4e Soor h Z P ,EM► r�i Zip Amount of Fee Enclosed Building Type 9-5;06� 5 %(M111- Lot Area 4'(0*' No. of Bedrooms ") Design Flow GPD ( 000 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of i ®�� gallon septic tank and 41')► LX P Other Requirements: IF To be constructed by fiaID Water Suonly: Public Supply From _ or: - - )( - Private- Supply Drilled by T"OD. Address Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate s, ewaee treatment sx, them described above will be constructed as shown on the approved amendment thereto and in accdidance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. A Signed: Address 'So P.E. N R.A. Date ©7- -1t, ° 01 '4t-SJ 44M;p-, N41 4os0 License # 5(017LA APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe , ' . pproved . discharge of domestic sanitary sewage only. By: Title: (rj � Date: #,61 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design rofessional Form CP -97 t0 13? t43 ' a 1 :t I0 Y f 41 5 4 94 17 q.7 107 2 5'2 f1� y : r I, T , r N ..