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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.71 -1 -71 BOX 12 01303 kIq LIE rfL- 16 ir L T r ' 01303 PUTNAM COUNTY DEPARTMENT OF HEALTH _DIVISION OF ENVIRONMENTAL. HEALTH__ SERVICES....____..... � CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE T ' .MENT- S_ STEM PCHD CONSTRUCTION PERMIT '# P 3 _y oL Located at 6P2_ U�Zit�' .S /72/U Town or Village Ttk T Owner /Applicant Name �,QL gr %r /N GTCS Tax Map ZS• -7 I Block I Lot —71 Formerly Subdivision Name 3A�L6CC Subd. Lot # Mailing Address `ins -pW A&.60x,G 9%. BCw J-*F1C , ,G%Y, Zip /0-5-09 Date Construction Permit Issued by PCHD 8[2,D/0J I--,- 3? 64C*11 • &.,a- Separate Sewerage System built by Q M ,4s Gi 414-%1 /i y Address 104c.iU44 G f Al y I Z r6-f Consisting of U.5-0 Gallon Septic Tank and i, Z S-y �9 �} L• /��/1�1� C.JJ9&) QC ` o t- •h.- ..0r,.? Other RequireriMr containing more t):�r:r ": s:�^r' .. „r3 scdstim should not be used for ing drinking Y PeoP e on ' , o »am di M. a er con taiff Water Suruolv;nore than used by peAO&M Moderately restricted sodium ciiaS. '.. .. i + &" X)NTY DEPT. OF H or: Private Supply Drilled by !"� `7 SO4J 1k)6 Address y7AJ4n iQ✓'�L - Building. -Type ke s1 o ti/ r,4'1✓ -Has. erosion control. been completed? �,et' S' : ......._....- Number of Bedrooms 3 Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance wit�the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of Date: elg,4 vCertifred by Address Zty Department of Health. P.E. R.A. 00 License # 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 ject to modification or change when, in the judgment of the Public Health Director, such revocationVZ'dii ca tion hange is necessary. By: Title: d12__ Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy Owner; Orange copy - Design Professional Form CC -97 0 "COUK7 DEP PUTNM- ,Y---.,AEALT,,H-' t�- Z' 4. -(845)"W 30' 'AY105 e-ceived'6f T--.,h6- Sum Of THANK-YO Gash ❑Check O' "Credit `Card -By P. W. SCOTT .Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net ..__ . _ _ • -• '(91�) 278 -2110 - FAX (914) 278 -2166 TO Putnam County Dept. of Health 4 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU 'Attached LL=.-- U U 1_aLit OL= UAfE� J � SOB NU. ArrEN SON RE: Septic As- Built. L -LOTS/ ❑ Under separate cover via the following items: ❑ Shop drawings 'F Prints ❑ Plans = Samples ❑ Specifications G Copy of letter /❑ Change order p COPIES DATE NO. I DESCRIPTION 1 I I Certificate of Construction Compliance 1 I , I Well Complet•rnn Report 3 1 Guarantee of Subsurface Sewage Treatment System 3 I I 1 As- Built'Septic Plan Fee: $200 (G 4`� y� �i /�i % 64d r. THESE ARE. as checked below: For approval 0 Approved as submitted Resubmit copies for approval C� For your use ❑ Approved as noted C Submit copies for distribution As requested ❑ Returned for corrections . Return corrected prints ❑ For review and comment C El FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO //J GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM All'old A5_5,oe1dTe_s F—cal s T# rr Owner or Purchaser of Building ©/" 14 7. s /41;l .C+ S 16 Building Constructed by ,1 /2 ,6 7- , �DCI !/fir Location - Street 1 OV d Building Type Tax Map Block Lot ��S�ISo�I T TownNillage .046&_WA9 Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location,' workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act. of the occupant of the building utilizing the _system.—_. _. :..._ ._ ..... . . ....:....__. _ . _,_ _......_... _ The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month do' Day �' Year D o2 Al eneral Cr ( r) - S' gnatur Corporation Nam, 4# corporation) Address:46G J� State Zip Signature:�0 Title: 4,,, 6�, 4,1 c,r�r�l� ,�f �j LTP Xorporaflon Name (if"corporation) Address: State /orh Zip Form GS -97 ..__...- - - -• -- - - - - - -- -. .... .. 9148782019 P . e 1 9148782019 AUG-29-02 12:13 PM TOWN OF PATTERSON 1�� 1�-� �gl qtl: dkf: ?.2 15:1'7 FW Sl -G"T � :+1487821'113 UUM X FOLEY LOAEiI'.L MOLL`r.►RS R.V, W.N. P�11ra Xsei +h Drresror �y drrocaa PvbUa MC411A Dimftp Dbea:or of Renew Zip"aw DEPARM% 1ENT OF HEALTH 1 Geneva Road Srewitsr, Now York 10309 ' gavireeaeR4l HWth igl�)176•4130 fa(914) 271.7021 !YsMet 7ie'Mftl (5�1�) 275 • bsSi WiC (!14) ;71 • K71 Fit (912) =7i • foi! Eertr Iftsrnetloo (9tf):lf •t101b ?rtfcAeot (!t�)27i.6011 fan(9l�lx:i • eaati E91I ADD '�y�VFRIF.� .�RjM O NERSN44NM: C'7"ioti/,}SSDC`rg7 'f ES1.971 /,c/C. T1'X 1ZAP I TMZ ER: E911 ADDRESS. C1�4'7 .5 DOUVC TOWN- PR?Y6X Sp��f� IDS'Ocl' ' e! I AVT"SORIZEA TOwN OmCYaL: (Signature) DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certifcate of Coustructioa Compliance. 1tiT� , NORTHEAST LABORATORY OF DANBURY .. -39, MILL PLAw- ROAD -- -DAl°I>BuRy, CT. -- 06842 .- CTCert: PH- 0404... (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABS www.NORTHEAST LABORATORIES.com LABORATORY REPORT REPORT TO: S�0 %0 ACC0#0 e � v U -+ ACTION ASSOCIATES DATE SAMPLE COLLECTED: 08/06/2002 465 DOANSBURG ROAD TIME COLLECTED: 12:45 PM BREWSTER, NY 10509 COLLECTED BY: MAUREEN LUBRAICO DATE RECEIVED @ LAB: 08/06/2002 TESTED BY: LAB #11471 & 11301 LAB I.D. # ACTION ASSOC- NY1081 REPORT DATE: 08/16/2002 SAMPLE SITE: MAUREEEN LUBRAICO, PRESIDENT, 62 GATES DRIVE, PATTERSON, NY SAMPLE POINT: KITCHEN FAUCET SOURCE: WELL TREATMENT: NOT STATED MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR STANDARD BACTERIAL: o Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml PHYSICALS: o Color (Apparent) 10 - EPA 110.2 15 units . o Odor ND - - 3 Units o pH 6.80 - ASTM- D1293 -99 No designated limits o Turbidity 0.68 NTUs EPA 180.1 5 NTUs CHEMISTRY: o Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 1.0 mg/L • Nitrate Nitrogen 0.29 mg/L as N EPA 353.3 10 mg/L • Alkalinity 100 mg/L SM 2320B No designated limits • Hardness 304 mg/L EPA 130.2 No designated limits • Iron 0.11 ( <O) mg/L EPA 236.1 0.30 2 mg/L • Manganese <0.01 mg/L EPA 243.1 0.30 2 mg/L _ CombirieQ limit foriron'plus ]GIanganese =,0.5'O mg/L • Sodium 77.4 mg/L EPA 273.1 No designated limits 3 • Lead <0.001 mg/L EPA 239.2 0.015 mg/L * ** • Chlorine Residual <0.05 mg/L - - - - -- ml= milliliter mg/L= milligrams per Liter ND --none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count <Q=Analyte detected below quantitation limits. Data deemed estimated. * *Notification Level ** *Action Level 3 =Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing rr than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or ... OT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) RESULTS BASED ON SAAWLES SUBMITTED: 08/06/2002 Quality Control Officer Laboratory Director °NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037° (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 o OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Gates Drive TowriNillage: Brewster Tax Grid # Maps �7/ Block l Lot(s) '7 Well Owner: Name: Address: Action Associates, 465 Doansbur Rd, Brewster, IVY 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X 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 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _Plastic _Other Joints:. Welded X Threaded Other Seal: X Cement grout _ Bentonite Drive shoe: X Yes No _Other 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 X Pumped X Compressed Air Hours 6 Yield 30 gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 265' Depth of completed well in feet 305' 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 5 Drilling in over urden clay and boulders Hit roc at 5' _ ,....5 _ .., �.....,. 32.- ....Drillin in rock set casing,-. - routed •• • - •�•• -••. •••- •• 32 305 Drillin in rock ranite 6/13/02 002 7/16/02 We i r (s' Well Location Street Address: Gates Drive TowriNillage: Brewster Tax Grid # Maps �7/ Block l Lot(s) '7 Well Owner: Name: Address: Action Associates, 465 Doansbur Rd, Brewster, IVY 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X 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 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _Plastic _Other Joints:. Welded X Threaded Other Seal: X Cement grout _ Bentonite Drive shoe: X Yes No _Other 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 X Pumped X Compressed Air Hours 6 Yield 30 gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 265' Depth of completed well in feet 305' 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 5 Drilling in over urden clay and boulders Hit roc at 5' _ ,....5 _ .., �.....,. 32.- ....Drillin in rock set casing,-. - routed •• • - •�•• -••. •••- •• 32 305 Drillin in rock ranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump TYPe •� r ,!Capacity z,,: G z 1 Depth Model FC 144R Voltage 230 I-IP 3/4 Tank Type BladderVolume44 Gal Prac::aryed Date Well Completed Putnam County Certification No. Date of Report , Beal NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's N P. F. Bea & Sons, Inc. Address: 4 Putnam Ave. , Brewster Signature: Date: 7/16/02 Ph i J. Beal White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONT ElL"I AL HEALTH SERVICES FINAL SITE INSPECTION 1 ate: r� - .. �_a... Inspecte. y: . g" Street Location S lD %Z , Owner 7zE�LT.0 Town Permit # P- 3 5 - o/ TM 9 a � , 7/ - / - 7/ Subdivision Lot # _/7 1. SeivageeSSystetn Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/wetlands.,---..1 ........................ II. Seivage System a. Septic tank size -1,000 ..:.....1,250.. / .Other ................ b. Septic tank installed level .......... :..................................... c. 10' minimum from foundation .......... ............................... d ;Distribution Box z. 2. Protected below frost ............. ............................... .. 3. Minimum 2 ft.Original soil between box &trenches e. Junction Box - properly set .......... ............................... __ ..__... f. renThes T-T-e-n-gth required moo© Length installed 3 ©o 2. Distance to watercourse measured -t/ oo 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.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 -11 /2" diameter clean .................... -9.--Depth -of gravel in trench 12" 10. Pipe ends capped .................................. :.................... g. PumD or Dosed Systems .. - -- - izeof pump c am er ....:........... ............................... 2. Overflow tank ............................. ............................... - - - -._ _.3.. Alarm,. visual/ audio ........................... ......... ....................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ....................... .................:.........:... III. ouse/Buildin - ' a. house located per approved plans ............. ......:.... b. Number of bedrooms. ...................... 2 ........... .. ............... . IV. Well a. Well ,located as per approved plans . ............................... b. Distance from STS area measured 4- io y 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 vrotectiori °adequate.: .:. COMMENTS %m O� �� I�w TO: FAX: T 'd d0 1N3WI8bI830 M -Nf100 WbNind :3WUN T261- 8L2 -968 :131 bS:TT 3f11 tow -£Z -mf P.W. SCOTT email pwscott@dren.com ENGINEERING & ARCHITECTURE, P.C. 3871 ROUTE 6 1845! 278.2110 8REWSTER; NY- .10509 - _........_ r SAX (8451 ;78.2166 Fax TIMNSMITTAL PROJECT: 13 id ry TO: �T ° FAX: al ?- Ilan TO: TO: FAX: FAX: NO OF PAGES INCL. TRANSMITTAL. FROM: * Comments: f DATE:_ ,c4�n Please call 845 - 278-2110 if this tcanstnission is illegible or unclear T00 £L0'ON TZ6L- 8L2 -9v8 f 1100S Ind SS: TT Z01£Z /L0 07/23/02 11:55 PW SCOTT 4 845- 278 -7921 NO.073 D02 a,.!. - v s o.b. a,. 601 Tjj —4ttL h 41 0-w�' Nm -30ti�O WO 43T-PV �WIT 30 W , 9u-.orq Sv/n ,,Cr—f3 r9,--p °rjv7d► - �v -TWend r! :s3uauKuoo # Ot'I m 9's ssa Fuoissajoid ugpoo 11PH 3o juam�daa Awno: ma7*gI4 7ouvjn0a, puu salt `epnptralS aqa pue smjd paAOjdd$ pao CEOd pans otp gtya a:)uupi000v at uop1dmoo .a pip p2ljU. an pas pa wdsm anvq I pule p ipmMoo uaaq Rq sasimaBd anoge aT it `paasq se '(9)umS & aqI M 4;gW I / _ 721s( lea Loovid ue saau uom 10Bauoo uorson aa� Id Bad su powwj ganm sg LpaiB. p pm si S imid Bad o partmu o wisgs sI �,aaald�oo uaa�/�s sI 4poildaao9 Ug malsM sI me, - -- # aol notswpgnS :aumM uozstntpgnS Ba�ao3 I5 :2UMK1U9gddV /BaUMo S3rLy -zol:pa�aao� •opim Bueaq saopoadsm . <, agoual Aua of Boud popldmoo Ag aq 8snul u0numoR uy A ►.� :ao� - Sab 11AIIIS ICI,) w3H W,l;WANNOW"Z Ac 901SLUG lzIL -91 4, JUL -23 -2002 TUE 11:54 TEL:845- 278 -7921 A NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 4 , _ BRUCE R. FUI;EY Public Health Director July 26, 2002 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LOuttA MOLINARI RN, M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845)278-6130 Fax(845)278-7921 Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085 Early Intervention (845)278-6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Peder Scott, PE PW Scott Engineering 3871 Route 6 Brewster; New York 10509 Re: Field Inspection - Action Associates Real Estate Inc., 62 Gates Drive, Lot # 1 (T) Patterson, TM# 25.71 -1 -71 Dear Mr. Scott: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. Fix up and/or reinstall silt fence in areas of disrepair. 2. A pump test needs to be•witliessed by this-Department once the electrical inspection has been completed and notification of such has been submitted to this Department. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR: cj Environmental Health Engineering Aide DATE : JUL-29 -2002 MON 08:20 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92782166 PAGES : 1/1 START TIME : JUL -29 08:20 ELAPSED TIME : 00'21" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... 0 a BRUCE R FOLEY LORETTA MOLDIAM R.N., M.S.N. P.Wk H d A Damr� Auorrak Pubac H4NfA D'- AW.ua Pabkn+ Surlm DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Z.A..n V Irmb61 (945)271.6130 Fm(A15)271.7921 nmrlw &Mm (145)271.6151 WIC (445)271.6670 Fa(945)271.6015 Fatly IvM 01-(447)276 -6014 71x(145)271.6441 Prmd,d(445)221 -5912 th4(445)221.6113 July 26, 2002 Peder Soott, PE .... .. . PW ScottEnginearing _ . . >.. ......._ , 3871 Routo 6 Brewster, New York 10509 Re: Field Inspection - Action Associates Real Estate Inc., 62 Gates Drive, Lot # 1 (f) Patterson, TM# 25.71 -1 -71 Deer Mr. Scott: The above referee —A separate sewage treatment system can bo baciditted. The folbwing comments must be corrected in the field. 1. Fix up and/or reinstall silt fence in areas of disrepair. 2. A pump teal needs to be witnessed by this Dopartmant once the electrical inspection has been completed and notification of such has been submitted to this Department. If you have any further wastions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide P. W. Scott Engineering & Architecture, P.C. 3871 Route 6 Brewster, NY 10Y509* August 8, 2002 Gene Richards Putnam County Department of Health Re: Pump Test Dear Gene: email: DWSCOtt(cDrcn.com (845) 278 -2110 - FAX (845) 278 -2166 As we discussed, the PCDOH has authorized my office to complete the pump test and shall send to the PCDOH the following. 1) Float elevations. 2) Pump dose volumes calculations 3) As- built. 4) Final Survey. 5) Well testing. Please find enclosed the UL certificate as requested. I will complete items 1. & 2, as soon as possible. Regards, Peder W. Scott, P.E., R.A. President ARCH ITECTURE *ENGINEERING *SITE PLANNING tl t?V RASECRE1;cRYkOper, ProjectslBARKER\JVAY.99- 129 \LTR.pcdoh.08082002.doc Z 'd 30 1N3W180d30 AiNnoo WdNind :3WUN T262_- 81.8 -Sb8 :331 213:9T 3ni 2002-9 -onu PUTNAM COUNTY DEPARTMENT OF HEALTH DMSIfON OF ENVIRONMENTAL HEAL 'IR SERV{CES ATTENTION ® AJDAM All information must be fully completed prior to any 'trenches _ inspections being made. (yp PCID Construction Permit 4 3�ro _ Located: (T) (V) ' Owner/Applicant Name: - j k'1� 6�4 TM Bloch � Lot 13 Formerly:"' Subdivision Name : — �� Subdivision Lot 0 Is system fill completed? � Date:,r _ Is system complete? Is system constructed as per plans ?. — " Is well drilled? Date Is well located as per plans? — Are erosion control measures in place? I cer ify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCH D Construction Permit and approved plans and the Standards, Rules and Regulations of the Putuam County Department of Health. mate: � 0 �- -- . _. / Certified by: ... � PE RA Design Professional Address- K G — WSjf`L Lic. # � � 4 Form FIR -99 z019 900'ON Tz6Z -8LZ -Sb8 F 1100S rid 2s :9Z z0/90/80 R: FOLEY . . Public Health .Director _ LORMA IvIOLINARI 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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 20, 2002 Peder Scott, PE PW Scott engineering 3871 Route 6 Brewster, New York 10509 Re: Field Inspection - Action Associates Real Estate Inc., 62 Gates Drive, Lot # 1 TM# 25.71 -1 -71, (T) Patterson Dear Mr. Scott: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. No further comments. If you have any further questions, please contact meat (845) 278 -6130 ext. 2261. P. Sincerely, Aze Gene D. Reed GDR:cj Environmental Health Engineering Aide SENDING COMM DATE : AUG-21 -2002 WED 08:33 NAME : PUTNAM COUNTY DEPARTMENT -OF HEALTH TEL 845 - 278 -7921 PHONE : 92782166 PAGES : 1/1 START TIME : AUG-21 08:32 ELAPSED .TIME : 0012011 MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a � w BRUCE R DOLBY 1.0R=A MOUNARI RN, MAN. PON )Adhh DbnW W AA..d b Pa6hc Ak hb A—W Dboarar Q/ PmA g 8rrvfnas DEPARTMENT OF HEALTH 1 Geneva Road, Brewster. New York 10509 P+Mraamenbd trr ah (845)276.6136 F=(84S)278 -7921 . Norriea &M— (645)276.6SM WIC(INS)279-6618 nm(343)278.6M Farb IaW *HGw?rnawl (845)778.6014 Fol(B45)278 -6641 August 20, 2002 Peder Scott. PE PW Scott engineering 3871 Routc 6 Brewster, New York 10509 Re: Field Inspection - Action Associates Real Estate Inc., 62 Gatos Drive, Lot H 1 TM# 25.71 -1 -71, (T) Patterson Dear Mr. Scott: The above referenced scparate sewage treatment system can be bacldtl)ed. The following comments must be corrected in the 6c(d. No further comments. If you have any further questions, please contact me at (845) 278-6130 ext. 2261. Sincerely, e Gene D. Reed GDR:cj Environmental Health BuSineedng Aide I IE 10 FUTNAM COUNTY DEPARTMENT 09` ALTH DI�SION OF ENVIRO.NMENTAL.HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT #r- 3J - of r-S a Located at 0 ,�- (7*" VQ Vt,,- Town or Village Vf-" I mss D tJ Subdivision name rzMWA-j Subd. Lot # I Tax Map Ag Block Lot h Date Subdivision Approved Aj 2 % D 1 Renewal Revision Owner /Applicant Name ACrj OA/ ;A550G, 2EAt- E51 )RR Ijkl�ate of Previous Approval Mailing Address �.� n �/�! 3 ka& RD�)> '1312 -i vy i l��f'� ki V Zip i DS-Di Amount of Fee Enclosed Building Type 1ZF- 51DEAM AL- Lot Area b 53S No. of Bedrooms 3 Design Flow GPD bD 1) Fill Section Only Depth Voflume PCHID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S ystena to consist of � Z SD gallon septic tank and Other Requirements: To be constructed by Ti)t) Address `Water Sununly: Public Supply From Address u': x Private Supply Drilled by "r`f 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 sy, is em 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 Signed: Address ,r, _ P.E. P-0 4A-r&-6 R.A. Date DI License # - S47 -3 L /,& 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 n nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. pprove discharge of domestic sanitary sewage onl . By: Title: Date: 2� a White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A: WATER WELL ._ please print or type PCHD Permit # Well Location: : Street Address: Town/Village Tax Grid 71 j JZ,1 U7� • A —,T SA Block i Lot(s) Well Owner: Name: AG-T-t0 AJ Address: 14 �,S Q F-A-A✓ )31kR -& ZO A -550&1 F5 READ ' -�3 --fr 5'T"f /J'f 1 Q - Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _ gpm # People Served __S Est. of Daily Usage '7� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X New Supply (new dwelling) Deepen Existing Well Detailed Reason New c_ � S I �i =� ' ©N Nflt,v LA- i V 151 O lv l-O T 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 V No Name of subdivision 1-5 A-(2-1t -E,(L W A-`/ Lot No. � Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No' C Name of Public Water Supply: A- Town/Village Distance to property from nearest water main: /V Proposed well location & sources of contamination to pro ' d on separate sheet/plan. 0I.... 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 a driller certified by Putnam County. Date of Issue helo) Permit Issuing Offi Date of Expiratio Title: Permit is Non- Trans&rrabl White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WP -97 BRUCE R. FOLEY Public Health Director DEPARTMENT OF BEAI,'TH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 September 17, 2001 Peder Scott PW Scott Engineering 3871 Route 6 - Brewster NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System at Action Associates Real Estates, Inc. 62 Gates Drive, Lot #1 (T) Patterson, TM# 25.63 -1 -33 Dear Mr: Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on aon September 4, 2001 is incomplete. Please be advised that the following information i.s.required before the Department may commence its review..... _ o Corporate Resolution has not been submitted. o Two sets of house plans have not been submitted. o Tax map number is the same for Lot 1 and 2, please revise as warranted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. RM:tn Ve ,pyjruly yours, l Robert Morris, P. E. Senior Public Health Engineer P. W. SCOTT Ehgineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net. (914) 278 =2110 FAX (914) 278 -2166 TO E `=TTE2 OGP 4 ° Gr@W044LaL DATE Q / JOB NO. ATTE TIO - a- - WE ARE SENDING YOU P6Attached ❑ Under separate cover via the following items: ❑ Shop drawings .!9P Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ FEE ARE _!/ FEE I THESE -ARE TRANSMITTED as checked below:. - ❑ For approval ❑ Approved as submitted AJ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FORBIDS DUE ❑ REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints PRINTS RETURNED AFTER LOAN TO US i COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. .. -. - BRUCE - -R.- FOLEY ......... Public Health Director TO: PROJECT: - . 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 (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGA TED .TOWN:.. C . 5 P . PV .. _- DA- TE-SUB'D APPROVAL: _.. NOTICE OF COMPLETE APPLICATION DATE: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the ma Ieau represent that I am an officer or empl Name of Corporation: Having offices at: Whose Officers Are: President.- Name: Address of the corporation and am authorized to act for: U 'ee�vsl . I/ C GS�s'S% c &4f3 Vice President - Name: Address: Secretary -Name: Address:. _.. _ . _ ............. a .............. , ...a _... ..... _ . Treasurer - Name: Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Title: Sworn to before me this day of (month) aoo/ (year) Not6Oublic JOANN MAROTTO Notary Public, State of New York No. 4936338 Corporate Seal Qualified in Putnam County Commission Expires July 5, 20j Form CA -97 Im PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH .SERVI�E�` k - LETTER OF AUTHORIZATION ION Property of r_ATe Kt�E ��� N1 �.6CMl) Ld 4(Ci� Located at TN R�°A� Tax • .%% • • > .na-it') Subdivision of %' Subdivision Lot # Filed Map # ZLZ "Z Date Filed 04 b Gentlemen: This letter is to authorize F66r 62 L't sco a duly licensed Professional Engineer or Registered Architect into 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. Countersigned: P.E., R.A., # Mailing Address '316-71 (ZoA Very truly yours, Signed: (Owner of Property) Mailing Address: State kj 01 State N E ,1v Telephone: 'C 1p Telephone: I C+ �Vy�'0 n,C Im PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH .SERVI�E�` k - LETTER OF AUTHORIZATION ION Property of r_ATe Kt�E ��� N1 �.6CMl) Ld 4(Ci� Located at TN R�°A� Tax • .%% • • > .na-it') Subdivision of %' Subdivision Lot # Filed Map # ZLZ "Z Date Filed 04 b Gentlemen: This letter is to authorize F66r 62 L't sco a duly licensed Professional Engineer or Registered Architect into 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. Countersigned: P.E., R.A., # Mailing Address '316-71 (ZoA Very truly yours, Signed: (Owner of Property) Mailing Address: State kj 01 State N E ,1v Telephone: 'C 1p Telephone: Zip Form LA -97 C+ �Vy�'0 n,C v Zip Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES '._ . , •, APPLICATION FOR, APPROVAL OF-PLANS FOR... A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: AC_l'i DA-) _ As S0Q Air_-5 REAL- E5-4` E—, i NC. 2. Name of project: FAM WM -- Ur(fd 3. Location TN: P��1 4. Design Professional: CQ 5607- EL6Q,, J fK(3' t 5. Address: 391( IZou -M- �v 6. Drainage Basin: `,i'� ( Cat &Z&569Z Pf (0 60 � 7. TVDe of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... kJ0 10. Has DEIS been completed and found acceptable by Lead Agency? ............... - 11. Name:ofLead Agency* 'To N OF PhTMS0 i P6&AvuwG ($per 12. Is this project in an area under the control of local planning, zoning, or other ..._. officials,. ord. inances......._.:...,.: ........:.............:.. �:.,..:...._::....... .::.........n.................. _.,C�.......... . 13. If so, have plans been submitted to such authorities? ........ ............................... Y6 14. Has preliminary approval been granted by such authorities? V Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water oundwater 16. If surface water discharge, what is the stream class designation? .................... k) _ 17. Waters index number (surface) 18. Is project located near a public water supply system? ....... ............................... WA- 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 Distance to sewage system 22. Date test holes observed < < 23. ° N! ame of Health Inspector NJk 5 -MMq 24. Project design flow (gallons per day) ............. &70 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 0 26. Has SPDES Application been submitted to local DEC office? ......................... ojf� Form PG97 8/99 2 27. Is any portion of this project located within a designated Town or State wetland? NO 28. Wetlands ID Number ....: :.... WA . . : 29. Is Wetlands Permit required? .............................................. ............................... iV0 Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... No 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? .......... Yes/No �� 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No QO DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ...............:......... Lft,S 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? �S 35. Are any sewage treatment areas in excess of 15% slope? ........... No 36. Tax Map ID Number ..:..................... ............................... Map Block Lot Wl4 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All applications for review and approval of a new SSTSto 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. II hereby affirm, under penalty of perjury, that information provided on this,fbrm is true to the best of my knowledge and belief. False statements made herein are punishable as a glass A misdemeanor pursuant to Sec tio 21 of the Penal Law. �> SIIGNA TUR ES & OFFICIAL TITLES. w, sc 9 s { mar• Mailing, Address; :!. P CJ Su%r �U�2 �2C�t J�?r��i,; °;s!u :.� g7( rOJ4e 6 w-w5te2. tjl Cow d w.� 'JA f FLOOR PLAN SCALE, 3/16- . 1'-0' — CEILING HEIGW el-o- op-(oL5 Zu IVY PAPX CUMM SMOT. PA JOill m . 3 z Op O ' ' W S a Q fl E3 ® + ® El 0 BELOW THIS POINT REAR ELEVATION ON SITE BY OTHERS SCALE- 3/32• 1• -0• m ° y .F U < 3 12 12 8 �0 I p ' - BELOW THIS POINT v ON SITE BY OTHERS PORCH ON SITE L . BY OTHERS LEFT SIDE ELEVATION RIGHT SIDE ELEVATION mro a L, SCALE: 3/32• - 1' -0• f SCALE: 3/32" 1 * -W W 2 0 m W U w ;�Om mZU cr aanN vJuo ° n3Nw i�U 2 F jws YCU ¢ m L °Oa02 (A�OW v 3 U��io F �i z Ron- C. 2 U _L y O K U d �® rn m O a -mK�Z/ K O mHZZ ,`OO� w�10 �OU wL'1� r0 -ga- N 2 Z v = 3 - ,IL PORCH CN SITE BE: - OW THIS POINT cr,ltrs s cPivrPA I6!_I IRON t EL,/ATICN HE� ' ON SITE BY OT :Efi y b' x 7' 17' x 7' N a• I I N I ih I I I I I I I I I I lo"! ri I I I I I I I I I I I I FURNACE "w/ 10' x 10' 5/8" SHEETROCK 4R' -�" 15' -6" 8` -6" - 0�---------- - - - - -- - - - - - - - - - - 8' -6" 15' -6" ' -4 7/8 19' -10" R.Qi - - - -- --------------------- R, -n., -R, r I ----------- - - - - -- - -- - - - - -- - WINDOW - - - - -- - - - - -- SLIDE - - - - - - - R CHANIC L 1 23' -0 1 /2" AREA 22' -11 1/2" j TOOL j 1 ROOM N MAIN •GIRDER MAIN GIRDER 1 (3)2x10 AND (2)1/2"x9" •` _ o (3)2x10 AND (2)1/2"x9" 1 I STL. FLITCH PLATE STL. FLITCH PLATE I � I °- 3'x6'8 I I r , F.P.' - -1 42x10 Gil RDERr - I , r - �L___j(4)2x10 GIRDE - J 2216 "x 2'6'x1' CONC. FOOTING I w/ 4 "o CONC. FILLED I I LALLY COLUMN (TYP.) 1 1 23' -4" ` 5-4 1/2" 6' -7" 10' -8 1/2" I N GARAGE f LAUNDRY FAMILY I 1 1 HOUR FIRE RATED ROOM ROOM I I WALLS AND CEILINGS I i I DN 20 "x12" STRIP FOOTING UP I L--- ---------------- ---- - - - - -- - - - - -- — - -- — ------- - - = - -� I f W2421 TW3046 TW3046 - - - - - - - - - - - - - - - - - - - ----------------------------------- WIN .WINDOW WINMA R.O. R. 0. R.O. 5' -9" 2'-6 1/3" 8' -9 7/16., 6'� 3-13/16" 8' -3 1/2" 3' -p" 4' -2" -2 1/! 7 i arm I � I I r r N I I I Ir 10" I I I I 'STUD: WALL 110" ICONC. WALL 11' -8" 1 N I I , PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF EM'IRO \ \fE \TAL HEALTH INDIVIDUAL WATERSUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS ! _,. _. ..,...... - -• -__ _ _ .REVIEW SHEET FOR CO NSTRUCLd0\.P.ERi\1TF- .- _._ - -.• _..._ NAME OF OWNER: �. STREET LOCATION: REVIEWED BY: R; AS, SRDATE: TAX bLAP =: ( 0, D 1' \ DOCUi•I i TS 1' \ (REQUIRED DE 1 N L PERi•IIT APPLICATION HOUSE SEWER - . 4" �- TYft IPE CAST IRON - WELL PERMIT OR PWS LETTER e NO BENDS; DIAX BENDS 45° V /CLEANOUT L�PC -9i _ RENEWALS LETTER OF AUTHORIZATION �TTE NOTE (NO CHANGE) JDESIGN DATA SHEET (DDS) FILL SYSTEMS UCOR.PORATE RESOLUTION 0' HORIZO \TAL; PAST TRENCH SLOPES 3:1 TO GRADE LJSHORT U EAT U FILL SPECS! FILL NOTES 1 -5 UUPLANS -THREE SETS (__) FILL PROFILE & DIMENSIONS (__)(HOUSE PLANS -TWO SETS FILL IN EXPANSION AREA VARLANCE REQUEST FILL GREATER THAN-2 FEET SUBDIVISION -FILL BARRIER (�r)LEGAL SUBDIVISION FILL CERTIFICATION NOTE U SUBDIVISION APPVAL CHECKED DEPTH GAUGES PERC RATE VOL. ON PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS FILL REQUIRED °DEPTH "SEPARATION DISTANCE FROM TOE OF SLOPE LUUCURTAIN DRAIN REQUIRED TRENCH GENERAL LF TRENCH PROVIDED 60FT MAX. (C).( -' )LOCATED IN NYC WATERSHED PARALLEL TO CONTOURS L6(fJPLANS SUBMITTED TO DEP 100% EXPANSION PROVIDED (JJDELEGATED TO PCHD 1�—')DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL (J�UDEP APPROVAL, IF REQ'D (� /(�GEOTEXTILE COVER ((__)DEEP TEST HOLES OBSERVED SEPARATION DISTA`iCES ON PLAN - FROM SSTS U.(�PERCS TO BE WITNESSED 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL ("`ttt/"'� EX- APPROVAL SSDS ADJ, LOTS 20' TO FOUNDATION WALLS WETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 200' IN DLOD,150' TO PITS (__)( DATA ON DDS PLANS & PERMIT SAME 0100' TO STREAM, WATERCOURSE, LAKE ('inc. expaQ) �(�PRE 19G9 NEIGHBOR NOTIFICATION 50' TO CATCH BASIN, 35' STOR`IDRA11N, PIPED WATER (,6� LETTER BUZBA (_j 10' TO WATER LINE (pits - 20') _ 100 XR, FLOOD ELEVATION W/I200' ( 50' L\TERmrfTENT'DRAl'46E COURSE ()USOIL TESTING LOTS >10 YEARS OLD 200'/500' RESERVOIR, ETC. _ 150' GALLEY SYS! EivIS REQUIRED DETAILS ON PLANS (10' 01 1 IL`1 TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK ( SSDS HYDRAULIC PROFILE UU10' FROM FOUNDATION; 50' TO WELL U( ___)GRAVITY FLOW ALL U()CONSTRUCTION NOTES 1 -15 (� DILNIENSIONS TO PROPERTY LINES UDESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNBCTIO\ �T CONTOURS EXISTING & PROPOSED tiIL`i 15' TO PROPERTY LINE & SLOPES, CUT ' UU SLOP (,___) FOOTING /GUTTER/CURTAIN DRAINS 520% o ./ USDA SOIL TYPE BOUNDARIES )SLOPE IN SSTS AREA ( ) S OWNERS NAME ADDRESS U REGRADED TO 15 %, IF REQUIRED ( JTTTLE BLOCK; DOSE/PUMP SYSTEMS TNI9, PE/RA; NAME, ADDRESS, PHONE# UpUbIP NOTES UDATE OF DRAWINGIREVISION DOSE 75% OF PIPE VOLUitifE/))OSE VOLUME NOTED (�(�DATUM REFERENCE LJLOCATION OF WATERCOURSES PONDS LZ> DETAIL FOR FORCE MAIN, (PIPE TYPX, ETC.) 0 'f LAKES WETLANDS WITHIN 200' OF P.L. L� PIT AND D -BOX SHOWN & DETAILED (� PROPOSED FINISH FLOOR AND LU1 DAY STORAGE ABOVE ALARiti1 BASEMENT ELEVATIONS CURTAIN DRAIN DWELLS & SSDS'S W/IN 200' OF SSTS STANDPIPES, 5' BOTH SIDES, DETAIL PROPERTY METES &BOUNDS 15' MIN to CDS = >5 %, 20'4 %, 25' -3 %, 35' -1 %,100 % - I% (__)UEROSION CONTROL FOR HOUSE WELL & LU 20' MIN to CD DISCHARGE 1100' with 182 cons clay discharge SSTS, EROSION CONTROL NOTE U 10' NIL`f to NON - PERFORATED PIPE COMMENTS: (REVSHEET)09 /01 /00 P. W. SCOTT Engineering & Architecture, P.C. ' 3871 Route 6 BREWSTER. NY 10509 E -Mail: pws @bestweb.net _.(914).278-2110.. FAX (914) 278-2166, TO Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 i DATE ioe Nu. ATTENTION Qoi�C'� m0('ii 5 RE: '•qy M q Lof Subsurface Sewage Treatment System (SSTS) WE ARE SENDING YOU Attached ❑ Under separate cover via the following items: > ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE I NO. I DESCRIPTION I I I I Application for Approval of Plans (PC -97) 1 I 1 Construction.Permit for Sewage Treatment System (CP -97) 1 1 Letter of Authorization (LA -97) 1 i I 2 Design Data Sheet (DD -97) IHouse Plans (2'sets) I I Check #4q3qqq3 for the amount of $X00.00 1 I I Short Form EAF THESE ARE TRANSMITTED as checked below: ;= For approval For your use As requested X; For review and comment FOR BIDS DUE G Approved as submitted I✓ Approved as noted Returned for corrections Resubmit copies for approval 0 Submit copies for distribution Return corrected prints PRINTS RETURNED AFTER LOAN TO US REMARKS List Continued: 4 1 Septic -�� -e Plan Drawings COPY TO SiGNE7:�._ If enctosures are not as noteo.:cindly notify vs at urtrs: 14.16.4 (2187) —Text 12 ' PROJECT I.D. NUMBER 617.21 Appendix C State Environmental Duality Re "view' SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant or Project sponsor) SEOR 1. APPLICANT ISPONSOR 2. PROJECT NAME 3. PROJECT LOCATION: , � - .fin C,, ` Municipality I County WAL 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) GAZES PKiVE 2,00 MCI- 46TH OF M.Se P amll � 5. IS PRO OSED ACTION: ew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: nyvs-10W c..o1 vF SS-f (A ELL TL->2. Sw 6( 6- AxktuY LOT 7. AMOUNT OF LAND AFFECTED: L}(� Initially + acres Ultimately r `' acres 8. WPROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No If No, describe briefly 9. W������i,,,ATTJS PRESENT LAND USE IN VICINITY OF PROJECT? �idential ❑ Industrial ❑ Commercial Agriculture ❑ Park/Forest/Open space ❑ Other Descr e: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY, OTHER GOVERNMENTAL AGENCY (FEDERAL, STYyes R LOCAL)? ❑ Nom If yes, list agency(s) and permil/approvals , / i v "{ �pL', � &5-r S 11. DOES ANY ASP CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes o If yes, list agency name and permitlapproval 12. AS A RESULT F ROPOSEO ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes 0 1. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE 8 / e �W.. S� `^�`aDate: Applicant/sponsor name: � ,.•��3it1 w Signature: C If the action Is in the Coastal Area, and you are a state a §647 the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by regency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B...WILLACTION RECELVE.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: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. - ...C6..Long term, short term, cumulative, or other_effects not identified in Ct•C5? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D: _IVTRERE; OR 1S THERE LIKELY TO BE; CONTROVERSY RELATED TO POTENTIAL A )VERSE•ENVIRONMENTALAMPACTS? • • -- ❑ Yes ❑ No If. Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large orsignificant 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: Print or Type Name of Responsible Officer in Lea Agency . Signature of Responsible Officer in Lead Agency Name of Lead Agency Date 2 Title of Responsible officer Signature of Preparer (if different from responsible officer) PIS TNAM COUNTY DEPARTMENT OF HEALTH 'DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE,SEWAGE -TREATMENT SYSTEM Owner Ac,-nolJ ASS a9, Located at (Street) CArl--S Tax Map 95.63 Block Lot 33 (indicate nearest cross street) Municipality Fq fig--pl-% M Watershed 'i jZft SOIL PERCOLATION TEST DATA Date of Pre - soaking 7-•/2 - 9 9 Date of Percolation Test 7-/3-71 :Hole No un I Time e S too (1'4113.) J.;/0- 72-7- 7v/ - In,;; - ?I.,- ?,&I 933 — � 6 to 2 "J7WN - I ;Rot 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolati( percolation test hole. (i.e. s I min for 1-30 mWinch, -5 2 min for 31 -6 submitt'ed for review. 2. Depth measurements to be made from top of hole. '*::::�':"- Doth 't*o-NVa'te"r*'........ :-.- :..Water...:. 2 r 'G d om roun 3 APqg- 4 In 5 -Start ;Stop nehes C. -2- 3 4 5 Time e S too (1'4113.) J.;/0- 72-7- 7v/ - In,;; - ?I.,- ?,&I 933 — � 6 to 2 "J7WN - I ;Rot 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolati( percolation test hole. (i.e. s I min for 1-30 mWinch, -5 2 min for 31 -6 submitt'ed for review. 2. Depth measurements to be made from top of hole. '*::::�':"- Doth 't*o-NVa'te"r*'........ :-.- :..Water...:. r 'G d om roun :;Level APqg- Surface (Inches) In .;.,:Perco. . -Start ;Stop nehes C. O'_ 2Va 3 1 3. ,3 3. Z. -3 Q M di JW-,. i ! hies ark'Wilaffid at Form DD-97 PUTNAIV1 COUNTY DEPARTMENT OF HEALTH -DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SKEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner >iO!J ASSMi.ATe :� Z&Prt- C5—JA-TEAddress Located at (Street) C-7-1 CE-5 A04P Tax Map gO Block % Lot _ (indicate nearest cross street) Municipality Drainage Basin SOIL, PERCOLATION TEST DATA Date of Pre - soaking / 0/0 Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal perc percolation test hole. (i.e. s 1 min for 1 -30 min/inch, <_ 2 min for submitted for review. 2. Depth measurements to be made from top of hole. n Depth to Water rom Ground Water Level' - Percolation Hole No. Run No. Time Start - Stop Ela se Time Tin.) Surface (Inches) Start Stop Drop In Inches .R ate N in7Inch PT3 la a )_�" toA3� C '� '30 / Bolton 3 1a10S �(ai� 4 ° 5 ° ° o 2 � ° a 4� I ` 5 a ° a ° 2 ° ° 4 NOTES: 1. Tests to be repeated at same depth until approximately equal perc percolation test hole. (i.e. s 1 min for 1 -30 min/inch, <_ 2 min for submitted for review. 2. Depth measurements to be made from top of hole. n DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLENO. _ i ; HOLE N0. HOLE NO. U j 5>AmVP LOA- 5 i L 5 0 A,- 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: ApAw, sT,&6Lt rj5. C PcH-o) Date 7 2 95 Design Professional Name: e w s c-o Address: .-t ( 2�,, ;ti 3 2.,�'L.i S ��2,... Dom:; t��J � cs-►��.,i� -- � v hZ� �1 Signature: Design Professional's Seal DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 3 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. 1G HOLE NO._ HOLE NO. Indicate level at which groundwater is encountered 4A Indicate level at which mottling is observed �0 A Indicate level to which water level rises after being encountered ;Q A Deep hole observations made by: ApA-,A,, <,,-n G:r3�-LI o!� (`�c p"Lltj Date ac: of Design Professional Name: Address: . w. 3 Signature: Design Professional's Seal u PVC u te 2 . PU T NA.M COUNTY DEPARTMENT OF HEALTH 'DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 3wn -rte. � �C.�}C C 4 � b�Rr a ) Located at (Street) GVY5 (Z0j9jD Tax Map 95:63 Block _� Lot 3 _ (indicate nearest cross street) Municipality FA 146RI-% M Watershed $ i 0;2h iJGH SOIL PERCOLATION TEST DATA Date of Pre-soaking 7.• j2 q Q Date of Percolation Test 7—/-3-71 Tests to be repeated at same depth until approximately equal percolation n percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 mi submitted for review. Depth measurements to be made from top of hole. Form D PUTNAM COUNTY DEPARTMENT OF HEALTH -DIVISION OF ENVIRONMENTAL HEALTH SERVICES - DESIGN DATA SHEET - SUBSURFACE SEWAGE'TREATMENT SYSTEM - Owner �7Lt7AJ QsS�C �A�S 1y ��� Address P v Located at (Street) c-7 -ICES A04® Tax Map 4163 Block % Lot (indicate nearest cross street) Municipality PC°�'t'�iB'� Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre - soaking . 130 /0 / Date of Percolation Test �- Lv� NOTES: 1. Tests to be repeated at same depth until approximately equal percolation percolation test hole. (i.e. < 1 min for 1 -30 min/inch, s 2 min for 31 -60 submitted for review. 2. Depth measurements to be made from top of hole. i Depth to Water rom Ground. Water Level' - Percolation Hole No. Run No. Time Start - Stop Ela se Time �111in.) Surface (Inches) . Start Stop Di-op In Inches .Rate Nfinylnch PT3k 1 toba* laA3� l >7 '3 o 3 1� X7 � � 2 lT 3,5 ta'm 3 10©t 7 ff >7 3D 3 4 ° ° a 5 ° o o ° 2 ° a � a a 44 o ° 5 1 a ° I ( 2 ° 3 ° o (L NOTES: 1. Tests to be repeated at same depth until approximately equal percolation percolation test hole. (i.e. < 1 min for 1 -30 min/inch, s 2 min for 31 -60 submitted for review. 2. Depth measurements to be made from top of hole. i 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' 7.51 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE N0. HOLE N0: / HOLE NO. TOPSo,t. j 5>-rS1P 07t— S1 s O M++. �QcNN C-I I��L•:v..:!% Ci1Lt�l S l L 5 A-n► � Pcrti °31 S Indicate level at which groundwater is encountered --- Indicate level at which mottling is observed Indicate level to which water level rises after being encountered tip= ►�-rt-,� Deep hole observations made by: sTi& o, t t 1j 4 C P cwo) Date 7 �09 5 Design Professional Name: f. w . s c oTT- Address: 2�-W -'�-Y to --U Signature: - Design Professional's Seal DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 3 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN 'PEST HOLES HOLE NO. '� G HOLE NO._ 'l .D 9.5 -r0 nVA-- -oe,-O r ttm 8' T-0—iAn. D t-nn-t f 10.0' 1 HOLE NO. Indicate level at which groundwater is encountered 14A Indicate level at which mottling is observed ;}J A Indicate level to which water level rises after being encountered ;Q A Deep hole observations made by: p� p a <,,� G, ,.�� /� c P v rt•, Date ac o f tpCbc12 coT- Design Professional Name: Address: , w. 3 c� r- t -r.�c; . ��., p,, 16 eel., Signature: Design Professional's Seal t ,A 2 10 o��; WOOD DECK / 0�j0 , (Stairs Under) FOUND LOT ,-/1 n_ 1 SVCiynRES FO 00 ��. $� n • � 50.87' i CP 12 CV 4 m GRA VEL DRIVE N86 °17:24 "yy 249.00' i-,r MONUMENT i FOUND fir- i' ' .. J GRAPHIC SCALE 40 0 20 40 so 160 ( IN FEET ) I. inch = 40 ft. I IRON h AT AN( ALONG LINE IS m LOCATION CHART LOCATION DESCRIPTION FROM POINT A B C 1 TRENCH- 135' -0" 120' -4" 2 TRENCH- 128' -8" 113' -5" 3 TRENCH- 122' -10" 107' -4" 4 TRENCH- 117' -3" 101 -2" 5 TRENCH- 110' -7" 93' -10" 6 TRENCH- 105-1" 87' -7" 7 TRENCH- 101' -9" 81' -6" 8 TRENCH- 95' -3" 74' -0" 9 TRENCH- 148' -6" 120' -6" 10 TRENCH- 144' -0 115 -0" 11 TRENCH- 139' -1" 109' -4" 12 TRENCH- 135' -9" 104' -5" 13 TRENCH- 132' -6" 99' -5" 14 TRENCH- 1.28' -0" 93' -10" 15 TRENCH- 124' -7" 89' -0" 16 TRENCH- 120' -4" 83' -8" D -BOX 1331-010' 120' -2" T1 -A 33' -0" 33' -7" T1 -B 41' -5" 26' -5" T2 -A 43' -0" 25' -6" T2 -13 51' -8" 22' -0" C D WELL 40' -0" 75' -0"