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HomeMy WebLinkAbout1387DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.81 -1 -1 BOX 13 I,IIL 1. .. � L, 1� ' ' i - l i :' �1 'o r, is �, . . 01387 PUTNAM COUNTY HEALTH DEPARTMENT c DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO / Internal Use Only PERMIT # k� 1 ❑ I�� Repair Permit issued in last 5 years El FO in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑legated . ❑ Repair within 200 ft. of a wateecourse or DEC - mapped wetland I' Joint Review SITE LOCATION PWAt:;> - TOWN PAT TE Fxoo TM # %Sl� ( -I " OWNER'S NAME D�Nti S t- oosot� PHONE # 't7j -7570 MAILING ADDRESS I I` At > L: •. r oAn g�StCV 10501 APPLICANT j o a-f_3 "� i t-�, f-_.�A 10V4 . Name & Relationship (i.e., owner, tenant, contractor) DATE S III AC ZYPE I PAMI0y RfZ . PCHD COMPLAINT # PROPOSED INSTALLERy� PHONE # ADDRESS 49 „;irt i , //� � pae r REGISTRATION /LICENSE # %4l© Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. FKM74 T PMT I, as owner,agree to the co tions stated on this form SIGNATURE TITLE DATE (owner) I, the septic installer to compl the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (installer) Proposal ar)aroved with the folloL./conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Q Proposal Denied ❑ Z Inspector's Signature & Title uaie Exp ation Date Repair proposal is in compliance with applicable codes Yes CH' No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 June 9, 2011 Mr. Gene Reed Putnam County Department of Health . 4 Geneva Road Brewster, N.Y. 10509 Re: Loosen Residence SSTS Repair 1 Hadley Road (T) Patterson TM# 25.81 -1 -1 Dear Gene: --4-0 q—c (=- 1'4 -- have reviewed your comment letter regarding the above referenced project. As requested, have modified and/ or provided additional information on the attached plans and in this letter. To facilitate your review, I have keyed the following responses to your original comments: J, . The existing septic tank is made of concrete and is in sound condition. Its volume is 1000 gallons. 2. Comment acknowledged. A PCHD licensed contractor shall sign the application prior to final approval. 3. The repair permit fee is attached. 4. As per the DEP comment letter, the foundation drains and gutter leaders were located on the plan. They shall remain directed away from the septic area. Attached please find three (3) sets of the repair plan for your consideration for approval. If you have any questions, feel free to call me at your convenience. I can be reached at (845) Kalin, P.E. Enc. 0 E S I G N C O N C E P T S E N G I N E E R I N G P C 3 MEMORIAL AVE. SUITE 1 01 PAWLING, NY 12584 PH: 845- 655 -2000 a FX: 645 -655 -2605 E: JKALIN@VERIZON.NET NYC. Environmental Protection June 17, 2011 Michael Budzinski, P.E. Caswell F. Holloway Putnam County Department of Health Commissioner 1 Geneva Road Brewster, New York 10509 Paul V. Rush, P.E. Re: Loosen Residence —SSTS Repair Deputy Commissioner 1 Hadley Road, (T) Patterson Bureau of Water Supply prush@dep.nyc.gov TM # 25.81 -1 -1 East Branch Reservoir Drainage Basin 465 Columbus Avenue DEP Log # 2011 -EB-0291 -DJS. 1 Valhalla, NY 10595 -1336 T: (845) 340 -7800 F: (845) 334 -7175 Dear Mr. Budzinski: New York City Environmental Protection (DEP) has determined that the above- referenced application, received by the DEP on June 16, 2011, is complete. The DEP has no objection to the approval of the above - referenced regulated activity. This determination is based on the review of submitted documents including the plan titled "Subsurface Sewage Treatment System Repair Plan for Loosen Residence, 1 Hadley Road, Town of Patterson, Putnam County, New York ", prepared by D.C. Engineering, dated May 9, 2011, last revised June 1, 2011. Please have the applicant contact David Alderisio at (914) 742 -2010 at least two days prior to start of construction of the SSTS so that the DEP may inspect and monitor the installation. Sincerely, Danny Shedlo, P.E. Civil Engineer III Wastewater Design Review c: Roger Sokol, NYSDOH r.- a m Environmental Protection Csswe# F - Holloway Commissioner Pawl V. Rush, P.E. -' Oeputy;Coinmissiondr Bureau: of Water Supply prushlbdep.nyo.gov . . 465 Columbus Avenue Valhalla, NY 1o5P5 -1336 T:(845)340.7800 F: (845) 334 -7175 Jun 17 2011 14:15 P.02 Jude 17, 2011 Michael Budzinsk, P.E. Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 ;. Re: Loosen Residence —SSTS Repair 1 Hadley Road, (T) Patterson TM # 25.81 -1 -1 East Branch Reservoir Drainage Basin DEP Log 4 2011 -E13- 0291 -DJS.1 Dear Mr. Budzmski: New York City Environmental protection (DEP) has determined that the.above referenced application, received by the DEP on June 16,- 2011, is complete. The DEP has no objection to the approval of the above - referenced regulated activity. This determination is based on the review of submitted documents including the plan titled "Subsurface Sewage Treatment System Repair Plan. for Loosen . Residence; 1 Hadley Road, Town of Patterson, Putnam County, New Y_o>rV . prepared by D.C. Engineering, dated May 9, 2011, last revised June 1, 2011. Please have the applicant contact David Alderisio at (914) 742 -2010 at least two days prior to start of construction of the SSTS so that the DEP may wi spect•and monitor the installation. c: Roger Sokol, NYSDOH Sincerely, Danny Shedlo, P.E. Civil Engineer III Wastewater Design Review NYC Environmental Protection Caswell F. Holloway Commissioner Paul V. Rush, P.E. Deputy Commissioner Bureau of Water Supply prush @dep.nyc.gov 465 Columbus Avenue Valhalla, NY 10595 -1336 T:(845)340 -7800 F: (845) 334 -7175 zu- C cz�t, ;cv May 24, 2011 Michael Budzinski, P.E. Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 Re: Loosen Residence —SSTS Repair 1 Hadley Road, (T) Patterson TM # 25.81 -1 -1 East Branch Reservoir Drainage Basin DEP Log # 2011 -EB- 0291 -DJS.I Dear Mr. Budzinski: New York City Environmental Protection (DEP) has determined that the above - referenced application received by the DEP on May 23, 2011, is incomplete. The following information is required before the DEP may commence its review:. • Show the size of the existing septic tank on the site plan. • Show the roof/footing drain discharge site on the site plan. If you have any questions regarding this matter, please contact the undersigned at (914) 742 -2010. c: Roger Sokol, NYSDOH Sincerely, David Alderisio Associate-Project Manager Wastewater Design Review SHERLITA AMLEI; , ND, AN, FAAP Commissioner of Health ROBERT MORRIS, PE Director ofEnvironmental Health . May 25, 2011 John Kalin PE DC Engineering 3 Memorial Avenue Pawling, NY 12564 Dear Mr. Kalin: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Office (845) 808 -1390 Fax (845) 278 -7921 or (845) 808 -1937 Re: SSTS Repair Residence of Dennis Loosen 1 Hadley Road (T) Patterson, TM 25.81 -1 -1 PAUL ELDRIDGE COMO Executive Review of plans and other supporting documents submitted at this time relative to the above regarded project has been dompleted. Comments are offered as follows: 1. The septic tank size needs to be verified'and noted on the plan. 2. The repair permit needs to be signed by a PCHD Licensed contractor prior to final approval 3. The repair permit fee has not been submitted with your application. 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 of Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. Upon receipt of a submission, revised to reflect the above comments, this application will considered further. Very truly yours, Gene D. Reed Assistant Public Health Engineer GDR:cw } NVC Envirunmentar • Rrotec'tiori • '�asw'ell F "Holloviay •- •- Geri�i�iissio►�ir .. . -- PauLN..-Rusti, -P.E. DAputy.Commissioner ' au:of Water Supp Bnre ly :- ;prush(d�dep_nyc.gov ' A65.columbus Avenue Valhalla, NY 10595 -1336 'T: (845) 344-7800 334 -7175 May 24 2011 14:44 P.02 May 24, 2011• Michael Budzinski, P.E. Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 _ Re: Loosen Residence —SSTS Repair _ 1 Hadley Road, (T) Patterson TM # 25.81 -1 -1 _ East Branch Reservoir Drainage Basin DEP Log # 2011 -EB- 0291- D1'S:1 Dear Mr. Budzinski: New York City Environmental Protection (DEP) has determined that the above- referenced application received by the DEP on May 23, 2011, is incomplete. The following information is required before the DEP may commence its review: • Show the size of the existing septic tank on the site plan. • Show the roof/footing drain discharge site on the site .plan. if you have any questions regarding this matter, please contact the undersigned at .(914) 742 -2010. c: Roger Sokol, NYSDOH Sincerely, David Alderisio Associate Project Manager Wastewater Design Review MEMORY TRANSMISSION REPORT TIME MAY -25 -2011 04:56PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 328 DATE MAY -25 04:55PM TO 88552605 DOCUMENT PAGES 002 START TIME MAY -25 04:55PM END TIME MAY -25 04:56PM SENT PAGES 002 STATUS OK FILE NUMBER 328 * ** SUCCESSFUL TX NOT ICE * ** s>�nu.srw ®ter -*�� lv�, less, zt•ww>Pr;�.. Cvmmissioner pfd Ith ,� � R®BE)C;T IVic>murc I.g �l�-cclor gj'Ellvss n crsxal Xcallli [�Ei�A1�TME1�lT O� HEALTd -a I Gleneva Road, Brewster. New York 10509 Olrzco (845) 808 -1390 Fax (94-'53:2791-7921 or <845)o SOS -193'7 May 25, 201 1 John Kalin PE DC Engineering 3 Memorial Avenue Pawling, r T e 12564 Re: SS-17S Repair Residence of Dennis Looscn 1 Hadley Road (T) Parterson, TM 25.81 -1 -1 Dear Mr. IGalin: I'�XTIL 3MXJDXtX113PC -M Co:o'ety Ezeeullve 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: 1. Tile septic tank size needs to be verified and noted on the plan. 2. The repair permit needs to be signed by a PCPID Licensed contractor prior to final approval. 3. The repair permit fee has not been submitted with your application. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact ct loeI wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department of Environmental Protection on this lot, percolation tests must be witnessed by a representative ofthis Aepartmcnt. Upon receipt of a submission, revised to reflect the above comments, this application will considered further. Very truly yours, Gene D. Reed Assistant Public Health Engineer GDR:cw PUTNA_M COUNTY DEPARTIYLENT OF HEALTH DIVISION OF ENYY'IRON+YIENT_ -kL HEALTH SERVICES DFSIO D.-AI TA ShrET = SUBSURFACE SEWAGE TREATyIFNT SYSTEM Ov�ner: L m Address: y 12 7, Located at (street": TM T Section: I Block _! Lot Municipality: _�i�rT 72sp� Watershed: eA ' /� �T t�7z,�.� k� SOIL PERCOLATION TEST DATA Witnessed b4 G Date of Pre-soaking- 3 / Date of Percotation Test:. Hoie+o, Run No. ! I I Time i Start— ( r Stop I p Elapse Time (min.) Depth to water from a ound surface (inches.) Start.- Stop, Water ` level drop in inches Percolation Rate min/inch i • 'sa I 30 i 9',� 3 .4 li�;'ga- ��� �� 3o i I y %a- 2- ya I ;L { 6 I I I I ! i s 1 I I I I I 2 i I I I I i l l 2 4 ! 2 I ! I I I i I lNotes: 1 T -c-: rr..ir ru:J.,..: �.,.. w....•.. nwwo�....um,.wn.:rxow,.u:�cs,.a ....... «: �iw .a'vuYivu.t:,l ✓.law.¢u�T1re1;)_ ". uCJU: tiwvuiMes�iul4Mmw:vu;.rriuui':W: Wig. aL�t. 1v. a.. .....rw...u«.w.�w......,s -:.:rl ::. wnuu: Yn.:. uui:..:..:, i..,.......,..............,..::. A.•.. u. ..,J.:.vi ;::a..w.:,.:...w.aWL:J �y.ac,e TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES G. I G. 2.0' 2.. 3.0' 3.S a �✓ 4.5' 1i ,j .v 5.� J.J 6.51 7.0' C 'J' 8.., 9.5 10.0' HOLE = HOLE » HOLE T Lndicate !evl -! at which pour--dw-aier is encount - red Indicate le e! at which mottling is observed A)oA/,,,:� xjo-i �'M Indicate l.ev- -1 to wEch wat °r lev, -! rises a:^-,er being encountered Dee^ hole obse_ Yatior�s Lead_ cv: - V. 1 , Desia—_? 'Proressiona! N&ne: _ 5 Address: ature: nOL.= T MEMORY TRANSMISSION REPORT TIME APR -08 -2011 03:25PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 495 DATE APR -08 03:23PM TO 819147730343 DOCUMENT PAGES 004 START TIME APR -08 03:23PM END TIME APR -08 03:25PM SENT PAGES 004 STATUS OK FILE NUMBER 495 * ** SUCCESSFUL TX NOT ICE * ** y Rf}BERT J_ BONOi rL� SHERt -.1TA AMLER- MD, MS. F•AAP � .� County F�cscurrvn Commissfonar or/ %ewn" ROBERT MORRtS. PE LORETTA MOL1NARl, RN. MSN +( plracror of E>:vlro�amanrol Health Assoclore Commissioner ofHsalrh DEPARTMENT OF HEALTH 1 Ci0n�va Road, Srews[ar- New York 10509 COV RS ET Datct To: -.4rKJ '� %� �C� -� — �•7- ���i.� a./' !�-,!J ����� -sf.� l No. Pages: (including cover sheet) From• C�rene D Reed /� Putnam County Department of mealth ✓ For your information Ylease respond For your review Attached as requested As discussed please call Notes /Messages /��7r�t� ✓3 /// /o� �� O In the evcttt of transinissionlreception difficulties please contact this office at (845) 278 -6130, ext. 2261 • >E nva ronmonaaa Haaae+. taea) = �a -�t�0 Pun tg.ss) 278_7P =I Water supply S an (845) 225 -5186 :=nx (845) 225 -$418 Nuraing Sarraaos (845) 278 -6558 Fa�c (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Cara Pax (845) 278 -6085 Early inter. ntlonfpras hool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Date: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 FAX COVER SHEET To: ✓W Zq From: Gene D. Reed Putnam County Department of Health For your information For your review As discussed Notes /Messages M ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Fax #: 7 7 `5 -- c�9 No. Pages: (including cover sheet) Please respond Attached as requested Please call In the event of transmission /reception difficulties please contact this office at (545) 278 -6130, ext. 2261 Environmental Health (845) 278 -6130 Fax(845)278-7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845).278 -6014 Fax (845) 278 -6648 STUART W. BATESY O Co Now Septics & Repairs © Excavating ® DmalltbW TrucWng ® ®luMOP © Bank Run 0 Sand & Gravel a SnOW iii ®wing 114 Starr Ridge Rd., Brewster, W.10509 o 845- 279 -8952 a FAX 845- 279 -7075 All claims and returned goods MUST be accompanied by this bill_ 1484 7hankcYou c PUTNA.M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed completed prior to any scheduling. Date: _W(I Engineer or Firm: Phone #: z7 — 71: Person to Contact: ❑ New Construction __ eRepair Program El Addition Program ' Reason: 2"/Deeps Q'Peres ❑ Pump Test Road /Street: Town: z- 5coh Tax Map #: Subdivision: Lot #: Owner: / rs ❑ Project not within NYC Watershed NYCDEP CRITERIA FOR OUNT REVIEW AND WITNESSING OF SOIL TESTING YES ❑ Proposed SSTS within the drainage basin of West Branch $ , Croton Falls, or Soyds Corner reservoirs. ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ ' Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ �Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered vexes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: THME: COMMENTS: Ze Req.for field test:kly- 4/16/2009 R NP cr NO ka, PARTRIDGE LA RIO 99 2 J a3 YATES 0 10 O D,4 xEN11 vo —M LLA o E4 65 YOUNG R o 0 o m SW, N, NILES Littlef ROMED D "i DRIED Pond* C O p /� FREE)-ivLu- - BIRC RD U0 X 0 OW LIZ I. " 0 Z tu — Z 0 AND p 9a Q Cc 0 Z c Cl) r lER G CD O AFt*y LA Q r EVOLUTIONARY t4 �[E PVD ANNA 9 O� \e- all 41A R RAO 4 IOD13 , po I& y ei PROPOSED SEWAGE TREATMENT SYSTEM REPAIR LOOSEN RESIDENCE 1 HADLEY ROAD TOWN OF PATTERSON, PUTNAM COUNTY, NEW YORK MAY 2011 WARNING: IT IS A VIOLATION OF SECTION 7209, SUBDIVISION 2, OF THE NEW YORK STATE EDUCATION LAW FOR ANY PERSON, UNLESS ACTING UNDER THE DIRECTION OF A LICENSED PROFESSIONAL ENGINEER OR LAND SURVEYOR TO ALTER IN ANY WAY, ANY PLANS, SPECIFICATIONS, PLATS OR REPORTS TO WHICH THE SEAL OF A PROFESSIONAL ENGINEER OR LAND SURVEYOR HAS BEEN APPLIED. COPYRIGHT 2011 DESIGN CONCEPTS ENGINEERING, P.C. Prepared by: Design Concepts Engineering, John A. Kalin, P.E. 3 Memorial.Avenue Pawling, NY 12564 Submitted herewith is a report containing the engineering design data relative to the emergency repair of a failed Sewage Disposal System (SDS) to serve a single family residence within the Town of Patterson, Putnam County, New York. PROJECT DESCRIPTION: The parcel to be serviced by the proposed SSTS is located at 1 Hadley Road. The parcel is identified on the Town Tax Maps as Grid # 25.81 -1 -1. The building is an existing 2 story structure with three (3) bedrooms. The existing septic has completely failed and is surface discharging within the system disposal area. The building is supplied with water from a individual well. GENERAL DESCRIPTION OF SYSTEM: The lot currently has an SSTS which consists of a concrete septic tank, concrete drop boxes and stone and pipe absorption trenches. In interviewing the Owner, the system appears to be the original system from the 1960's. Test holes were excavated and witnessed by representatives of Putnam County (refer to data on plan). During the soils investigation, the proposed SSTS area was found to be a mix of topsoil, sand and silt loam. The existing septic was hit in several locations. There was no water, rock nor mottling in the test pit. Given the limited area for disposal near the failure, a new fields will be in same area as the original system. Any existing components that are discovered shall be removed and replaced with SSTS R.O.B. Utilizing the soil test data and remaining within the setbacks of the property lines, well and adjacent wells, the best area was selected for the treatment system (refer to plan). Attached please find the proposed plans for the layout of the sewage treatment system. The system is proposed to consist of the following components: Reuse existing septic tank 273 LF of standard 2' wide trenches Surface swale above SSTS area; clean out Town swale at road edge This repair represents a practical solution to the failure within the constraints of the parcel. r' .1 PROJECT I.D. NUMBER 14- 16- 4(9/95) -Text 12 617.20 Appendix CSEQR State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1 - PRr)rHCT ThEMPMATTOM rrr h.. h.. A —limo. t — 0—i—I 1Z.,....­1 1. ARPLIGAP SPONSOR D.C. Engineering, PC (JOHN A. KALIN, P.E.) 2. PROJECT NAME LOOSEN RESIDENCE 3. PROJECT LOCATION: Municipality Town of PATTERSON County Putnam 4. PRECISE LOCATION (Street address and road intersection, prominent landmarks, etc., or provide map) . 1 HADLEY ROAD 5. IS PROPOSED ACTION: ® New ❑ Expansion ❑ Modification/Alteration 6. DESCRIBE PROJECT BRIEFLY: Emergency replacement of failed septic system 7. AMOUNT OF LAND AFFECTED: Initially 0.1 acres Ultimately 0.1 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ® Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential ❑ Industrial ❑ Commercial ❑ Agriculture ® Park/Forest/Open Space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ® Yes ❑ No If yes, list agency(s) and permit/approvals SSTS approval — Putnam County Health Dept. 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ® No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes ® No ! 4 .:•. �. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE, -BEST OF :9 EDGE r.. A P.E. �, Applioent/Sponsor Name: John A. Kalin > Date: ✓ Signature: 4A 61mr-1� If the action is in the Costal`AreaV and you are a state agency, complete the Costal Assessment form before proceeding with this assessment PARTII - ENVIRONMENTAL ASSFSSMENT (To he cnrnoleted by A—cv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF. ❑ Yes ® No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTION IN 6 NYCR, PART 617.67 If No, a negative declaration maybe superseded by another involved agency. ❑ Yes ® No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers maybe handwritten, if legible) Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waster production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: No C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: No C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: No 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: No C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: No C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: None C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: None D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONIv1ENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ® No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL INIPACTS? ❑ Yes ®No If Yes, explain briefly: PART 111- 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 or 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. 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 Office in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) N MAY-06 -2011 12:27PM FROM - ENVIRONMENTAL HEALTH 84527BT821 T -665 P- 001/002 F -86T w PLI'T' 'A I COL N7Y DEPAR'x` IENT OF HE.Aj TU. D n-ISION OF EITVIRaN�, Ep4rTA E�LTH SER4 -ICES DESEGN DATA SHEET= SUBSURFACE SE -WAGE TR.EATtvMN7 SYSTE)vf Owner; ZQ1:�>SCAI Address: Located at fstreetl: ` T�+t fi Section:' 13ioc'n �� Lot Hturicipatity: c��t Watershed :.�7- SOM PER.COLATION TEST DATA of Fre- soiti:irty 3 / W itrtessed by- Dare Date of Parcolatifln Test:- Depth to Hole No. Run No. Time Srarr— Elapse Time Water from round Water Perco[afiori Stop {�iu.} surface Lervel drop P Rite (Inc in inches muvi.a6 start - Seo� i ®�s ! ` �a ! x-- ! z ! �s i � 30 —Pj 30 `+ � rV I I Z �� A K SPIN I I I III ( f 2 ! 4 ( I ! 1 I 5 ! ! ! I Y I I ! I ! I 2 I ! I ! ! I ! I 4 I ( ! ! i l� CeS: r I � 7'•C�: !!^ i!p PP.'SPJIs•'; •lT i.'i r,r fIP'�Ci ��iIRI .7!1TT°7Vi1TIZfw11! n ..y� -ate .,fn.:nn �.ae� . -. MAY-06-2011 12:27PM FROM-ENVIRONMENTAL HEALTH 8452787921 T-655 P-002/002 F-967 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED DTEST MOLES HOLE = HOLE rt i G L H. Ci L G L 0.5' W 2.0'. 3, 5' d A 50, C. 7.0' 7 5' IN LIF Lid-icpue lev-z! at which is enc 0 Lin. [ar:td, Indicat.- le-;--1 at wEcin mordiag 15 obsevved; A)ir2A/.--- Ogg: � j- 1n,1nca!-3 levtl co water Lel;e[ [13e5 a-1--7 being n- Cou---t,:r!:d Devc- hole ob-3 Yador -5 made DF-L Desia—n-. Profess-tonal S&.dcirers. r1acion-ConceDts Engineeriog P Memorial Ave. uite 301 - Pawlina, Nem, York J 2594 bit 1A, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at I� D'1oAr� CPN IPWTT%So'J Tax Map # Block i Lot Subdivision of -� Subdivision Lot # Gentlemen: - Filed Map # Date Filed This letter is to authorize J ON � ^ • h-A L , •.i r6 a duly licensed Professional Engineer ✓ or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. OF Countersigned: /� P.E., R.A.,II #� Mailing Ad 'S'NiH;'R State N Y Zip I 7-56 Telephone: BlS '1000 Very truly y rs, Signed: , (Owner of Property) Mailing Address: ( O^C-)�V �pq� State- - N Zip 0� o Telephone: 7 q . 75-7,6 Form LA -97 .00 ENGINEERING., RC -A LETTER OF TRANSMITTAL To: Putnam County Health Department Date: May 9, 2011 Job No: 050911 4 Geneva Road Attention: Gene Reed Brewster, NY 10509 RE: SSTS Submission We are sending you: ✓ Attached ❑ Under separate cover via _ • Shop Drawings ❑ Prints ✓ Plans ❑ Samples • Copy of Letter ❑ Change Order ❑ The following items: ❑ Specifications Copies Date No. Description 3 5//11 Loosen Residence SSTS Repair Plans 2 5/11 Engineering Reports, Design Calculations and Data Sheets 1 Repair Permit 1 Letter of Authorization These are transmitted as checked below: ✓ For approval ✓ For your use Remarks: Signed: cc: File ❑ As requested ❑ For review and comment D E S I G N C O N C E P T S E N G I N E E R I N G P C 3 MEMORIAL AVE. SUITE 1 01 , RAWL,ING, NY 1 2564 PH: 645 - 655 -2000 0 FX: 645 -955 -2605 E: JKALIN @VERIZON.NET OUG -22 -2011 06:50A FROM:OUTDOOR CONCEPTS INC 845 - 724 -4459 TO:2787921 OC ENGINEERING, RC To: Cris Dellaripa Company: PCHD From: John Kalin Subject: SSTS Inspection FACSIMILE Fax Number: (845) 278 -7921 .Date: August 22, 2011 You should receive 2 page(s), including this cover sheet. If you do not receive all the pages, please call 845 - 855 -2000. Comments: Cris, P. 1/2 The Loosen residence septic will be ready for inspection this afternoon. Please stop by and inspect. Thanks, John D E S I G N C O N C E P T S E N G I N E E R I N G , P C 3 MEMORIAL AVE. SUITE 1 01, PAWLING, NY 12564 Phi: 845- 656 -2000 a FX: S46- 865 -2606 E: JKALINGVERIZON.NET .PUG-22-2011 06:50A FROM:OUTDOOR CONCEPTS INC 845 - 724 -4459 TO:2787921 PUTNAM COUNTY DEPARTMENT OF ]HEALTH IIMSION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ® JOSEPH 13 GENE ar c >- I S REOUEST FOR F AL INSPECTION For: Fill All information must be fully completed prior to any Trenches inspections being made. P. 2/2 PCHD Construction Permit # ? " 0 Located: f MAr° � VnA g::a Owner /Applicant Name: tag' Conc5aN-'-1 T'M ZS -0f Block �� Lot j,_ Formerly: Subdivision blame: Subdivision Lot # Is system fill completed? .— Date: Is system complete? ,yam mate: Is system constructed as per plans? —' Is well drilled? — Date: Is well located as per plans? -� Are erosion control measures in place? _ I certify 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 PCHD Construction Permit and approved plans and the Standards, Rules and Rogulations of the Putnam County Department of Health. Date: 8 %/ ! Certified by: �d (,I0 PE ZRA Pesign Concepts Engineering PC Design Professional Memorial Ave. Suite 301 Address: ► wijng, Now Yndi 1? -64 . Lie. # 07900V Comments: Form FIR -99 l � w O O N �cr- � O CD r Q nW iLL 5O aw Z Q z O U O N Z p Q l o m w U Y LL Z Q J m cN • V � L o� w a ! Z z O IP a CL CL 1- J CL 0 M CL w WO m O I .. W O C J O m m0 0 LL w c> w CL F" ui O � 5 z n Q ~ d 0 W Z J H�OQOJ Z w w NW O U a -t -t / �0 PO 4.to_� \ f O�C-Q CL N Q w > O Q Q J �QQ¢ HOME) W } 7E 000-zg ZC�da- -96` UO2Z0 "' z W O w OwQ. UM 0�uWjOZ / MLLJ 'm / O J (7) U J w JQ V N W N J Z N -ZL- w a ! � IP \ \ W W Z O V ,. W I ZQ oQCpo LLJ U' W -:Q z o LL w c> w � 5 z n Q ~ d p � J H�OQOJ if zW� ia- V)i w W 0 CL.� L' d 0 .JCL -6 - V) , 9 r Llb� ��zzCAM - 9 \ x U_ w XzQ V)JQ Ll QN - \ O CY a- Lo f- V �i. p z of z�� Z U Ld Q.��F -ZL- w a �89� W Z O V ,. W I ZQ oQCpo LLJ U' W -:Q z o LL w c> w � 5 z n Q ~ d p � J H�OQOJ �N zW� ia- V)i w W 0 CL.� L' d 0 .JCL V) ZWHO 9 LLLJ:'..Z Llb� ��zzCAM f= x U_ w XzQ V)JQ Ll QN = Z o Q� CY a- Lo f- V �i. p z of z�� Z U Ld Q.��F o ¢a U L V) 0 (= Ln Ln N Q w o NO N U Q m \ � .. w U �V' w Z W O \ V- a \ ,. ri; gs *?'as�r�s�',`" y�:C S�i�r�'"ars`.'- 4$''✓T.�rn. ^3:r- �'rs Rte.- ..�a�t ...+ "i:Ei�sr -: ... _ PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES - -- ._.22.5 - 353 -8;/_ 225 - 383/225- 3641..----- _- ..__-_ PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME SITE LOCATION PHONE TK# a-)q- 7S 7 MAILING ADDRESS PERSON INTERVIEWED f Jp 4t) ,1j; ; j_ �t °I : e) &J Al .,�. PGEID Complaint # It & Relationship (i.e, owner,tenant, etc.) DATE 4, -.6 TYPE FACILITY 0 PHONE t�P -)41 Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. �� Proposal Disapproved Proposal amroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. -t,-,._,�-7 Date (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or- reported agent of owner agree to the above conditions. SIGNATURE �s %yy7✓l�l�/ �?r� TITLEy��r�JC/t DATE" PIES: W-Abe (PCID); YeUcw (Tom HE); Pink (Afplicant) j to Proposal Disapproved Proposal amroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. -t,-,._,�-7 Date (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or- reported agent of owner agree to the above conditions. SIGNATURE �s %yy7✓l�l�/ �?r� TITLEy��r�JC/t DATE" PIES: W-Abe (PCID); YeUcw (Tom HE); Pink (Afplicant) j Er- I :.501901 PUTNAM COUNTY- DEPARTMENT OF HEALTH _n FzhL SECTION Division ofT,Enwronmenial; Health Services Carmel N ; Y 10512 i "1 r ! - CONSTRUCTION PERMIT FO.R ;SEWAGE, DISPOSAL .SYSTEM Pdtterson ` k f Town or Village i Had1 ear Rd &Lakeshore Drt ve 26 ___ __._ Lceated ,at _ E Tvx- R1als Diu c = M� ti Subdivision Putnam_ Laker (Lots 79148 & 192.4;i4, ncl .) Lot . -. 3 & 4 ,ob SO 901." Marylou &Robert= Cu11y ,Owner 1 Hadley Rd. Address Existin 17000' Building Type Lot ,Are(D;a Brewster, NY 10509 D:.. Number of Bedrooms Three `Design Flow ��� 4Ua1 Total Habitable Space' 000 •Square Feet I 1:000 '52' - 4'x4' Gal Tertes Separate Sewerage" System. to ,consist of, Gal. Septic Tank and To be constructed by ? Address Water Supply. `Public.Supply From ' J1 Rrivate ,Supply to be drilled 'by. Address Other Requirements R o -6 FX11 Sect�pn= 80,'x26`x2;411 Deep (130 Y_d,. •Net) 12" .'Crushed Stone Under.'& {' i Sur ouna��ng ., .r Gallernes I`: a 'iasent that I em wholly antl completely responsibie for the design "and location of the proposed system(s); lr than the separate sewage disposal system above described will be constructed as shown on the approved; "amendment there to and in accordance with the'standards,,rulesan regu a ions o °';t e . u nam County `Department of :Health, ;antl thatbn'cornpietion•thereof a Certificate of Construciion.Compliance satisfactory.to• the Commissioner of Health will b'e submitted to ahe ;Department; aantl a .written,;guarantee. will be; furnished the owner, his successors; hei►s or,assigns'by the`buiider, that said' builder wilt piece in good operating`.condition,'any °part of -said sewage.gisposal system .during the period: of. two (2r years immediately following;thedate , of the.issu - ante of the a ._ . ; . - „ pproval:'of " the Certificate :`of `Constiuction;'Coi will be located as shown om the approved.plan antl that said well County Department of Health Orfig1'nal Periafit 3j Date 1.3 JMal "ch 1980 e' Address �A4 APPROVED FOR CONSTRUCTION: This approval•"expires o revocab.ie'.for cause or maybe, amended or- modified When coni requires 'a ne'w� permit Approvedd or disposal of. domestic.. Date `� '— �. s? 6 °-� gy igned St. • trQ•t till ial'system or" any' repairs, thereto;- 2j 'that-the drilled well described above :cordance'.with the standards, rules -and;. regulations of the Putnam tit ✓ �V 4 P.E. X R A. tl AT 1:0512 License 'No. 29206 .issued unless construction of the building •has been. unpertaken and is he. Com ` ssi ner of Health. Any change or•alteration of construction .. :Ir. priva . wa ter -s i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Gentlemen: Date 24 November 1979. Re: Property of Marylou & Robert Culley Located at Hadley Road, Putnam Lake Subd., T. Patterson Section TM 26 Block 4 Lot 3 & 4 This letter is to authorize John H. Prentiss, P.E. a duly licensed professional engineer X or registered architect (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 �:V1111CC �1V11 wt in Uti5 ma L i er ailii to. SupeYwise the cons rruc ciun of said system or systems in conformity with the provisions,of Article 145 or 147, Education Law, tary Code. tersigned: P.E., R.A., R.D. 9, Fair St. Address Carmel, NY 10512 914- 878 -6170 Telephone the Public Health Law, _;_and the Putnam County Sani- Very truly yours, Signed Owner of Proper 1 Hadley Rd. Brewster, NY 10509 Address 914 7279 -2542 Telephone PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N.Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner ®►ru %„� ,� [��Address X.: Tic l4► Located at . (Street �. Block__4_`Lot ca a n WV earest cr s s ree Municipality Watershede�. .SOII, PERCOLATION TEST DATA.RMUIRED TO BE SUBMITTED.WITHTAPPLICATIONS o e Number.. CLOCK TIME PERCOLATION PERCOLATION —dun Elapse Depth to Water Water ve . No.._:... Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in .Min. /in drop Inches Inches Inches 1 Ax 2 2 4 5 Notes: 1) TeAts to. be repeated at same depth until approximate) equal soil rates are obtained at each percolation test hole,. All data to e submitted for review. :2) Depth measurements. to be made from top of hole. TEST PIT DATA REQUIRED TO-BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. TF N_ f1:0 G.L. 6" ii OW /17 0 hr .a :A o : M p° FM SeeU.". ae L: 4Aef Q o S K a Z,19lb MAR 1 of \\..\�pPP^ssa/8 W,n uN u nuurst LC oP tp,4' a if "T o)/ oGf. a , DIVISION W' ` Tc Q% P� aRaJNMIN7� tlE6bIU`` SI rto]3 44— j N36 ?3 i 33 iJ din :A o : M p° FM SeeU.". ae L: 4Aef Q o S K a Z,19lb MAR 1 of \\..\�pPP^ssa/8 W,n uN u nuurst LC oP tp,4' a if "T o)/ oGf. a , DIVISION W' ` Tc Q% P� aRaJNMIN7� tlE6bIU`` SI rto]3