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01464
PUTNAM COUNTY DEPARTMENT F HEALTH -
5
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION 'I'MMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #�° 1
Located at 355—�T��P- 1Ir'f}�� Town or Village R472E-%01`4
Subdivision name 4g0 f9d M AZGCSubd. Lot #
Date Subdivision Approved �` a 1
Owner /Applicant Name 9900 coo r ry Yh 3
Mailing Address /s% TO M 4 ";0//— Tf , YO P-
Amount of Fee Enclosed
Tax Map 3 4 Block ;?-- Lot 6-4-
Renewal✓ Revision
Date of Previous Approval
o &-) /J NA 7--S
zip / C
Building Type 631 Oni A't- Lot Area I AK, No. of Bedrooms 6- Design Flow GPD 750
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of /,j oa gallon septic tank an d SbQ Or-
21" lh6i ba- I nqfg-3
Other Requirements:
To be constructed by Address
Water Supply: Public Supply From
Address
_.... v _ _ _... _ - - - - - -.._ Address
' � vor: � `� i./ Private.Supply- Drilled 'by �
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatmentsystem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Director /Commissioner will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed:
Address
R.A. Date
License # �;0564—
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Director /Commissioner. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
By: . "15 Title: / Date: �3 / y
Wh opy �HD Fil e; Yellow copy - Buil ng 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 !MATER WELL
please print or type 4. E
� r
Well. Location
Street Address: Town/Village: Tax Map #
2 -S`T4d0 D ot26 `V2#14- pnT enw4 Map 3' Block Z. Lot(s)
Well Owner:
Name: t?.jo+
Addresses Phone #: 9/L
Use of Well:
esidential _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 Est. of Daily usage gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
y- New Supply (new dwelling) Deepen Existing Well
Detailed Reason
t?S�
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _ Nom
Is well located in a realty subdivision? ......................................................... ................. Yes ✓o
Name of subdivision f�An'1 �� r� Lot No.--�--
Water Well Contractor: D Address:
Is Public Water Supply available on site? ....................................... ............................... Yes _ No e/
Name of Public Water Supply: '° Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provi ed on se arate sheet/plan.
/
Date: 311 Annllcant Signaturw
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 Departmei
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 Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam County.
Date of Issue Permit Issu' g Official: Ut�U,
Date-of Expiration a Title: S� - h-F�
Permit is Non- Transfdrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, p.E., MPH
Director ofEnvironmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
August 22; 2014 Phone # (845) 808 -1390 Fax # (845) 278 -7921
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
MARYELLEN ODELL
County Executive
Re: Complete Application Determination for North County Homes
35 Theodore Trail
(T) Patterson, TM 34 -2 -54
Middle Branch Reservoir Basin
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and revisions received by this Department on August 22, 2014 is complete.
The Department will notify you by September 12, 2014 of its determination.
0 The Project has been delegated to the Putnam County Health Department for review
pursuant to the guidelines set forth in the Watershed Agreement.
❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in
the Watershed Agreement.
If the Department fails. to notify you within the above referenced time frame, you may notify the
Department of its tailure by certified mail, retum receipt requested. The notice should be sent to my
attention at the above address. This notice must include your name, the location of the project, the
office with which you filed the application originally, and a statement that a decision is sought in
accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules
and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your
application will be deemed approved, subject to standard terms and conditions as set forth in the
regulations.
Please be advised that projects within the NYC Watershed may also require Department of
Environmental Protection review and approval of other aspects of a project, such as stormwater plans
or the creation of impervious surfaces, and the project applicant should contact the Department of
Environmental. Protection regarding such activities to see if Department of Environmental Protection
review and approval is required.
If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43157.
Respectfully,
J seph S. Paravati Jr., P.E.
Assistant Public Health Engineer
JSP:cml
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN:
FROM:
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
DELEGATED
New Application El Renewal
PROJECT: A41-4- (c�ut2�
LOCATION:
TOWN: DATE SUB "D APPROVAL 0�-J—a /
TM#
NOTICE OF COMPLETE APPLICATION DATE:
DELEGATED
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of �j o (e'r'/ C0011 a 4)M6%,
Located at 39- 'rH9 -0 P0t2F -
T P4I"rfzy&-!36 h1 Tax Map # 34 Block , 2 Lot 6 -4
Subdivision of G " M 4 TA4 -A!;&- �
Subdivision Lot # /
Gentlemen:
Filed Map # Zv '% Date Filed 9 2 O
This letter is to authorize /Roy, 4•
a duly licensed Professional Engineer ' ✓tSr Registered Architect to apply for the required
wastewater treatment and/or water supply pen-nit(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
I:aw,'and 1.he :Putna.m_County Sanitary Code. -- -_ - -
Countersigned:
P.E., R.A., #
Mailing Address Po (3,:D)( c/�a
Very to
Signed:
Mailing Address: /;& t oo?. 1 w Sr
N q rs.
State Imo- y Zip % 0!�"f I State 14.7 Zip l O5 76
Telephone: ` 1(3 —7&01 & - 0Z (05' Telephone: 714— " 441% 6 760
Form LA -97
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SCAGE: � ". 3p Fr
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYST
PERMIT #
Located at Town or Village f241flas6 /V
Subdivision name 451IZ4 1 gj2Er ( &�;o ,Subd. Lot # Tax Map 34- Block L Lot !-4
Date Subdivision Approved %O/ Renewal Revision
Owner /Applicant Name Naar* CwrtTy l-IoLle5 Date of Previous Approval
Mailing Address /54> %y lvl #H,4 �fG
Amount of Fee Enclosed r'�Oo
Zip d QS'y 9
Building Type C0/0141 A-L— Lot Area / IG No. of Bedrooms ef— Design Flow GPD -8053
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of 1 2S'Z> gallon septic tank and '500 r-4-
a . 2Pr WI01-e-, r�4Cg zs
Other Requirements: UaA4,
To be constructed by D Address
Water Supply: Public Supply From Address
Supply -Drilled-by
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed:
Address
P.E. R.A. Date &12&11?-
®S¢ 1 License #
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a njpe t. Approv ed for discharge of domestic sanitary sewage only.
By Title: Date: Wh - HD File; Yellow copy - Bui ing 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 MAC ;RDuif
Well Location
Street Address: Town/Village: Tax Map #
a:5 fAir000 ag- ` -ru r fe/2so /j Map -34- Block
Lot(s) 4
Well Owner:
Name: ktCP',fJJ
Address:
Phone #: 9 4
C"'
�3wlts . a.a
/,'Z48-
534
Use of Well:
L,,-- 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 Est. of Daily usage gal.
Replace Existing Supply Test/Observation Additional
Supply
Reason for Drilling
tXew Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
7B7 Efian4L
Comstrz-aELLcm
Well Type
rilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ...............................
Yes _ No r✓
Is well located in a realty subdivision? ........................................... ...............................
Yes i,e!fNo
Name of subdivision ' RA!n&TJ94-J G.
Lot No.-7---
Water Well Contractor: %a Address:
Is Public Water Supply available on site? ....................................... ...............................
Yes No ti
Name of Public Water Supply: -- TownNillage --
Distance to property from nearest water main:
Proposed well location & sources of contamination to be pro ' ed on s arate sheet/plan.
oo
_...
Date: & 0&h2-- - - - Applicant�Signatu�e _
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.
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 Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam County.
Date of Issue a Permit Iss ing Offici
Date of Expiration n Title:
Permit is Non
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner;
Orange copy - Well dr ler
Form`WP -97
Rev. 3/06
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of CSI. O
o wt-V 140
�
Located at 3 _ !4 r-O Po (z L
T/V 94 TIe R-,-q O K
Tax Map # 34 Block Lot -16-4
Subdivision of Of aq m AFT ( Assoc,.
Subdivision Lot # Filed Map # 28 7 �% Date Filed q 2S D
Gentlemen:
This letter is to authorize Roy 4.%Z�2/ /chi
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_tlie 'Pufnarri County Sanitary Code.
Countersigned: Zt64Q-A-
G
P.E., R.A., #O�
Mailing Address PO
State - y Zip
Telephone: S/g — 28- b2_&S"
Very truly yours,
Signed:
(Owner of Property)
Mailing Address: %��0 M A 14AWK Sr
State Zip l C6 [�
Telephone: S34-�,
Form LA -97
PUTNAINI COUNTY DEPARTMENT OF HEALTH
DMSION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE
TREATMENT SYSTEM
Owner: Noa-rI4 coulla 1--S —S Address': 166 To-nq14,4wk Yr
r - ,
Located at (street): -35-fMgODoP-4 7AIe_
Tim A! Section:34B[ock I—Lot 1<4
Municipality: aTr z.-s ON Waters6ed: M/wz/,- a!�'tm
SOIL PERCOLATION TEST DATA
-soaking:. Witnessed by: 0)106'4EL 90122 -I 1.5k%
Date of Pre Date of Percolation test: -431/0
Notes:
I `'Tests a;"4'ame' depth until approximately equal percolation rates are
,"�tained at eaO�percb,�'a n test hole. (i.e., < I min for 1-30 min/inch, < 2 min for 31-60 min/inch).
"r review.
2. De ih', ieasure ti nts to be made from too of hole.
Form DO-97, pir I of '2
Depth to
Time
Elapse
water from ground
Water
Percolation
Hole No.
Ran No.
Start –
Time
level drop
Rate
Stop
(min.)
surface
(inches)
in inches
min/inch
Start - Stop
jo:35, /0:S'(P
S1
1 -7 2-o
70
2
10:!5'6 ff-211
-- 0,5,
11 - za
- 3
a-3
3
Z 2 //:Ij
2,5'
i o
I
A.3
5
Z.o
I
10 3 k /0: -5'7
ZI
7-o
2 —LU-0
W2 ' 2.
zo
3
6. 3
3
I:22 11.41
05'
1 'Zo
3
4
'5-
-3
1
ib:3 9 11-ts
Z?
12 zo
-3
2
il -',X J/: 3J
-36
1 2
7- -;h
0. 1
3
/1:� itice
30
1 -1 zo
/0-2
4
.
:P_ q
15 1p
3
30
07
15',
2
--30
15314
j3.3
4,
30
Notes:
I `'Tests a;"4'ame' depth until approximately equal percolation rates are
,"�tained at eaO�percb,�'a n test hole. (i.e., < I min for 1-30 min/inch, < 2 min for 31-60 min/inch).
"r review.
2. De ih', ieasure ti nts to be made from too of hole.
Form DO-97, pir I of '2
TEST PIT DATA ,
DESCRIPTION OF SOILS EN COUNTE],2ED IN TEST HOLES
Indicate level .at which groundwater is. encountered N 0 h( V--
Indicate level at which mottling is observed
Indicate Level to which water level rises after being encountered
Deep hole observations made by: AD,4!n Date
-So iL esTS* Co 14 oyLr4-Z) (Y 131660 C_:
Design Professional Name: RD,, gse-A
Address: �0 ox 6jo
F NE�Y
{ P. FRgOR��
Signature: �
A Z �
T
z I W
2
JUL 12 2012 Design Professional = Seal ® s05 ���
DEPTH
HOLE #_ft
HOLE # HOLE # HOLE # HOLE #_
G. L.
Coy
0. 5'
1.0'
2.0'
ine Smo�S�
/t'
21
914E GRAue
I
3.0'�//�
3.5'
4.0'
MOD cv7f�i
Y,
4.5'
5.0'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
7.
100,
Indicate level .at which groundwater is. encountered N 0 h( V--
Indicate level at which mottling is observed
Indicate Level to which water level rises after being encountered
Deep hole observations made by: AD,4!n Date
-So iL esTS* Co 14 oyLr4-Z) (Y 131660 C_:
Design Professional Name: RD,, gse-A
Address: �0 ox 6jo
F NE�Y
{ P. FRgOR��
Signature: �
A Z �
T
z I W
2
JUL 12 2012 Design Professional = Seal ® s05 ���
PUTNAM COUNTY DEPARTMENT OF HEALTH ..
DIVISION OF EN'VIRONM:ENTAL, HEAL TII--SER'VICES
...._....._...... - x,..�..,A - R
...�'�'r. N_.rn�.,��PPROUAL• �E- PLANS. ED..
— A WASTEWATER TREATMENT SYSTEM
1. -Name and address of applicant: o(2-1/ - C y11"5/ f - �oe�GS
V d
2—Name of project: 3. Location TN: �ib `Tfi�2s owl
-Design Professional: O.4 124,rSeh . 5." Adifress: _ Po Box
6: Drainage Basin: 13R- 4c o 05 1
7.... e of P sect:
........ ..
_ Private/Residential Food Service Commercial-
Apartments - Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify) n -
T
8 Is -this project subject to State Environmental Quality Review (SEQR)?
Type check one),-.*
YP Status ( ::.....:............ .:.....:...::::.:....:......... Type I
-
Type-II
9. Is a Draft Environmental Impact Statement (DEIS) required ?. .........................
10. Has DEIS been completed and found acce table by Lead Agency?
11. Name of Lead Agency
12. Is this project in an area under the control of local planning,..zoning, or other .
officials, ordmances? _n...,. ,... ... ......:.:..::. ...., :.........:...:.:.........
_ - - .........:............... - e _- __
13. If so, have plans been submitted to such authorities? ....... .. ::... : ..............:..........
.__._.l-4.-:-Has relimin � Y a PP roval been granted by such authorities? e Date
granted:
........... .15. Type of Sewage Treatment S sten Discharge- surface water ✓roundwater
16: If surface water discharge, what is the stream class designation? ....................
17.- Waters index number (surface) .......................................... ...............................
1.8. Is project located near a public water supply system? . --
19. If yes, name of water supply Distance to water supply -
20. Is project site near:a public sewage collection-or treatment system? ................
1. , Name of sewage system. Distance; to sewage system
22: Date test holes observed 20 h u — 23. - - Name of Health Inspector SOp am 12v6 k/:) - --
ft!O 24. Project design (gallons per day) ................................. ...............................
25, Is State P9114tant`Discharge Elimination System ( SPDES). Permit required ?... e,
26. Has SPDES Application been submitted to local DEC office?
Foem PC -97 ..
8/99
27. is tiny portion of this project located within a designated Town or State wetland?
2E. _.Wetlands ID Number,,.....
...................... ...............................
29. Is Wetlands Permit required ?- : :................................................ . .................
............
Has application been made to. Town
or Local DEC office?
............ ................
_ 0. Does r ' ... _
p ode' t require.a DEC Stream Disturbance Permit?
31. . ...............................
_Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or. hazardous waste disposal,
- - -- landf fling, sludge application or industrial activity? Yes/No
OJ o ,
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous'Wdste site, salt stockpile, landfill, sludge disposal site or any
other potential) known
Y source of contamination? ............................... Yes/No
DESCRIBE:
33. Is there a„ l,pcal master la
p .n on file.with the Town or. Village? ...............
..........
_ 34. Are community water and/or sewer facilities planned to. be- developed within
15- -years in or adjacent to project site ? - -
35. Are any sewage treatment '
_. -_. g areas to excess of 15% slope?
36. - Tax Map.ID Number
,Map Block 2 Lot .54 .
37-.-.-A- proved plans are to be returned to .....
Applicant e i
- -- - P -
NOTE.- All applications for review and a oval: o nAiv SS' c t� be c, - - - -
-: - - - - -. _ _ .. ppr f a eaiea -
esign.Professiona�l�
ee eeiit'to the Department, and need not be sent in duplicate to the DEP, although the project m�ayalersuue shallll
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-appiopriate forms for such activities from
T1LP 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 rovision"
may be grounds for the rejection.of any submission. P
crffrrm, under penally o f perjury, that information
provided on this form is True
to the hest of my knowledge and helicf False statements made herein are punisbahle as
a Class A mistietneanor pursuant to Section 2l0.4S o the Penal Law.
SIGNATURI.S c4c OFFICIAL TITLFS: .
Mailing Address :.............................. 4 / - -
JUL_ 1 2 2011
14 -16-4 (9195) —Text 12 S Ei� R
PROJECT I.D. NUMBER 617.20
Appendix C
State Environmental Quality Review
_....w�- __...:...._..... � ............_ .... _ ... _ _..._ ;a aT. E-NI alp! :.RO*•4^!- E- -�-lTAL- -.ASS.ESS .f NT_ . ORM..
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
.1. APPLICANT /SPONSOR
2. PROJECT NAME
S? I r41 SST-S
t�lc,a-ol Coumu a
,o Do� _
3. PROJECT LOCATION:
Municipality Tre-Iuc) County
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map)
3 5- r lq g o D017 j& '12A /C.
a j
T 34 — 2 — 54
5. IS PROPOS ACTION:
Eliqe-w ❑ Expansion ❑ Modification/alteratlon
6. DESCRIBE PROJECT BRIEFLY:
o � � Ir�o�se� cJ cl 11 �d �' Y Tr
C ofj Sj'j"ucTit�
/
7. AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8. WILL P SED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
es ❑ No If No, describe briefly
9. WHAT IS RESENT LAND USE IN VICINITY OF PROJECT?
C3 ❑ 0 Agriculture ❑ Park/Forest/Open space ❑ Other
esldentlal Industrial commercial
Deacrlbe:
"107-DOESS- ACTION NVOLVE,XPERMiT A PPRO VA* L;I OFiFU.4U64G,- NaO' 4- C) R- ULTIMA T— ilY' i- R0I&A- NV-O THEII GOVERNMENTAL AG5NCY- •;FF[?FR.Ak +.
STATE OR LOCAL)?
es ❑ No If yes, list agency(s) and permit/approvals
To04 131d g pep f-
P C-H D
11. DOES ANY ASPE OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
C3 Yes o If yes, list agency name and permlUapproval
12. AS A RESULT OrF� PP OSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? — -
❑ Yes L�!lP o
1 CERTIFY THAT^ INFORM TION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant/sponsor name: I.— %
Date:
Signature:
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
!> ®at
a
PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
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
3: `.aJILl• i �OPt RFCESVE f t?_?f?C FATED FGVIEV A3_FROVIDED FOR UNLISTED-ACTIONC 11•:6 NYCRR. PART 617:6° �I �d .•� nag l!q$ dec al.a;,.r...:
may be superseded by another involved agency.
❑ Yes ❑ No
C. COULD ACTION RESULT IN ANY.-ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disocsa
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 br,=t,•.
03. Vegetation or fauna,!fish, •shelllish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing: plans or. goalsas officially adopted, or a change in use or intensity of use of land or other natural resources? Explain c i
i
CS: Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
I
C6. Long term, short term, cumulative, or other effects not identified In C1 -05? Explain briefly.
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly.
i
i
D. WILL THE PROJECT HAVE AN IMPACT: ON THE ENVIRONMENTAL 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 IMPACTS?
❑ Yes
n
- ...,�No If Yes. _explai- br(el.ly_
I
I i
PART III— DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified abovo, determines whether it is substantial, large, Important or otherwise significant.
Each effect should be assessed in connection with its ja) setting (i.e. urban or rural); (b) probability of occurring; (c) duration: (d)
Irreversibility; (e) geographic scope; and (f) magnitude..lf-,necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that alP relevant adverse impacts have been identified and adequately addressed. It
question D of Part II was checked yes, the determination -and significance must evaluate the potential impact of the proposed action
on the environmental characteristics of the CEA.
❑ Check this box if you have identified one -or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration.
❑ Check this box if you have determined, based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Print or Type Name of Responsible officer in Lead Agency
Signature of Responsible Officer in Lead Agency
Name of Lead Agency
ate
Title of Responsible Officer
Signature of Preparer (11 rf event from responsible oincen
IRRC 24 T��
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT` MORRIS, P.E.
Director of Environmental Health
July 20, 2012
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
MARYELLEN ODELL
County Fxecutive
Re: Incomplete SSTS Application Determination
North County Homes
35 Theodore Trail
(T) Patterson, TM 34 -2 -54
The Putnam County Department of Health (Department) has determined that the above
referenced project, which was received by the Department on July 12, 2012 is
incomplete. Please be advised that the following information is required to be submitted
before the Department can determine the application complete and commence its review:
• Short EAF form
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'ptocedures 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 further, please contact me at
(845) 808 -1390, ext. 43157.
Respectfully, .
7Joeph S. Pav arati Jr., P.E.
nt Public Health Engineer
JSP :cw
SSTS -NOI
ALLEN BEALS, M.D., J.D.
Commissioner of Health
- ROBERT MORRIS, P.E.
Director ofEmirommental Health
August 24, 2012
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921.
Roy Fredriksen, P.E.
P.O. Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
MARYELLEN ODF.LL
County Executive
Re: Complete Application Determination for North County Homes
35 Theodore Trail
(T)Patterson, TM 34 -2 -54
Middle Branch Reservoir Basin
The Putnam County Department of Health (Department) has determined that the above
referenced application, including fee, and revisions received by this Department on July 12,
2012is complete. The Department will notify you by September 14, 2012 of its determination.
0 The Project has been delegated to the Putnam County Health Department for
review pursuant to the guidelines set forth in the Watershed Agreement.
❑ Joint review with the NYCDEP will commence pursuant to the guidelines set
_ . _ _._. a Watershed Agreement,,.._.
forth in th . ^ - - - --w -, -M.- --.. .. _
If the Department fails to notify you within the above referenced time frame, you may notify the
Department of its failure by certified mail, return receipt requested. The notice should be sent to
my attention at the above address. This notice must include your name, the location of the.
project, the office with which you fled the application originally, and a statement that a decision
is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection
Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the
receipt of the notice, your application will be deemed approved, subject to standard terms and
conditions as set forth in the regulations.
Please be advised that projects within the NYC Watershed may also require Department of
Environmental Protection review and approval of other aspects of a project, such as stonmwater
plans or the creation of impervious surfaces, and the project applicant should contact the
Department of Environmental Protection regarding such activities to see if Department of
Environmental Protection review and approval is required.
If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43157.
R spectfully
oseph S. Paravati Jr., P.E.
Assistant Public Health Engineer
JSP:cw
ALLEN BEALS, M.D., J.D.
Commissioner of Health
'ROBER -T'. 0R -'RIS; ' -E7
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN: (
FROM: Jac
�� -�h T✓
DELEGATION STATUS
I Tom
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
DELEGATED
New Application:
PROJECT: X11= �.���.
LOCATION: 3"�- The oa-o'-z
e,r--- .3
Renewal ❑
TOWN: DATE SUB'D APPROVAL
TM # j q - d
NOTICE OF COMPLETE APPLICATION DATE:
DELEGATED
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
July 20, 2012
DEPARTMENT OF 'HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
MARYELLEN ODELL
County Executive
Re: Incomplete SSTS Application Determination
North County Homes
35 Theodore Trail
(T) Patterson, TM 34 -2 -54
The Putnam County Department of Health (Department) has determined that the above
referenced project, which was received by the Department on July 12, 2012 is
incomplete. Please be advised that the following information is required to be submitted
before the Department can determine the application complete and commence its review:
• Short EAF form _
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 further, please contact me at
(845) 808 -1390, ext. 43157.
Res ectfully,
Jo eph S. Pavarati Jr., P.E.
ssistant Public Health Engineer
JSP:cw
SSTS -NOI
i
i
PUTNAM COUNTY DEPARTMENT OF HEALTH i
_ DIVISION OF ENVIRONMENTAL. HEALTH SERV._ICES,.___.__. ; ___
CERTIFICATE OF CONSTRUCTION.-COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT #
Located at =f I �O ®i2 1 �� �. Town or Village
Owner /Applicant Name �i P4 (�JOQ HOMe-3 Tax Map _34 Block
Formerly
Mailing Address /'S(0 7_0M
Date Construction Permit Issued by PCHD
2 Lot :94
Subdivision Name 62 gr",9r4AJ &MGC.
Subd. Lot #
i %f
Zip / 0!E;-%
Separate Sewerage System built by 4 ,2,,y4 Address %40 rQh2,4NAAJk K cW4V1
Consisting of Z.'50 Gallon Septic Tank and 4oz oz Q� 20"'t"o y9kode¢IEg
Other Requirements:
Water Sunoly: Public Supply From Address
or: %,-f"' Private Supply Drilled by �y,� �%i(J �j'� �_*ddress
Building Type C_� r1 /pd' _ -Has erosion control been completed?
- k(J.
Number of Bedrooms 4 Has garbage grinder been installed? too
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: l Certified by �,D/21/C,Vi4 P.E. R.A.
Address
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 subject to modification or change when, in the judgment of the Public Health Director, tuch
revocation, modification or change is necessary.
By- F Title: �� Date:
-:HD copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
c(�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISIQN.OF ENVIRONMEh1TAL, HEALTH SERVICES
twe11Permii# A �%
WELL COMPLETION REPORT
11 Location Street Address: Town/Village: Tax Map # GPS r
If yield was tested
at different depths
during drilling
list:
ons
Pum
Pump Type
ank
e Tank Information
mJ Capacity
Model
HP
Volume 52._ 6allao
N(VE: Exact Locatidn of well with distances to at least two permanent laAdmarks to be provided on a separate Peet/plan.
White copy: HD File; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller
Form WC -97
Rev. 3/06
Use of Well:
1- Primary
2- Secondary
I ResidenflIA _Public Supply Air cond /heat pump _Irrigation
Business Farm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary _Cable percussion Xcompressed air percussion _Other(specify)
Well Type
Screened _Open end casing X Open hole in bedrock _Other
ep
/'&
PtPZ7�f
Joints: Welded XThreaded Other
Map 3q Block Lot(s)6"
Drive shoe: )( Yes _ No
)wner:
Name: ` ` `.
Address:
Diameter (in)
If yield was tested
at different depths
during drilling
list:
ons
Pum
Pump Type
ank
e Tank Information
mJ Capacity
Model
HP
Volume 52._ 6allao
N(VE: Exact Locatidn of well with distances to at least two permanent laAdmarks to be provided on a separate Peet/plan.
White copy: HD File; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller
Form WC -97
Rev. 3/06
Use of Well:
1- Primary
2- Secondary
I ResidenflIA _Public Supply Air cond /heat pump _Irrigation
Business Farm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary _Cable percussion Xcompressed air percussion _Other(specify)
Well Type
Screened _Open end casing X Open hole in bedrock _Other
Casing Details
Total Length ft.
Length below grad) ?ft.
Diameter jin.
Weight per foot Ib/ft
Materials: Steel Plastic Other
Joints: Welded XThreaded Other
Seal: I Cement grout Bentonite Other
Drive shoe: )( Yes _ No
Liner: _Yes No
Screen Details
Diameter (in)
Slot Size
Length ft
Dept to Screen ft
Develo ped?
First
I
---dHours
Yes No
Second
I
Well Yield Test
_Bailed _Pumped Compressed Air
Hours �_
Yield gpm
Depth Date
measure from land surface - static (specify ft
During yield test (ft)
uoVom
Depth of competed well in ft.
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.
[arid'su
ft.
- rfncp
U0
2
ff-
-11 `i 5,
V
rt , 9 n
If yield was tested
at different depths
during drilling
list:
ons
Pum
Pump Type
ank
e Tank Information
mJ Capacity
Model
HP
Volume 52._ 6allao
N(VE: Exact Locatidn of well with distances to at least two permanent laAdmarks to be provided on a separate Peet/plan.
White copy: HD File; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller
Form WC -97
Rev. 3/06
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
l�l �r2 Cojmr ) r__ 34 2 : ;4
Owner or Purchaser of Building Tax Map Block Lot
j w2-,r - (2agA i y 0tw_3 P4TI -Jess o r-1
Building Constructed by TownNillage
Location - Street Subdivision Name
Building Type Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition
any part of said system constructed by me which fails to operate for a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
_ system:......._.. __._..... :_...__ - _ _ .._ . - -- .___ ... - _.... . ..._.._...... _.- _ -- ..._. - ._._ ... -_.:- _...
The undersigned - further agrees to accept as conclusive the determination of the Public Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing the
system.
Dated: Month Day Year , Signature-
20/
✓ Title:
n al C ntractor (Owner) - Signature
Corporation Name (if corporation)
Address: % 5'& b )4 J4 0/4
oiZilTv+.��r A57fs
State � Zip 1 q�
1-14 Cou41 `/ 4740&1 eS
Corporation Name (if corporation)
Address: 156 `j 6.74 44" .Sr
State (; Zip -105yd
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
,
.. D.IVISj0N 0F...ENV1- ONMENTAL..HEA LT H .SYRVICE.-
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
� n
Qx)foy 34 2 �4
Owner or Purchaser of Building Tax Map Block Lot
d (L Co om9_3 947"1 J52.Sa h1
Building Constructed by TownNillage
Location - Street Subdivision Name
Building Type Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition.
any part of said system constructed by me which fails to operate for a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
system.
The undersigned further agrees to accept as conclusive the determination of the Public. Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing.the
system.
.,Dated:
Month._ Day Year 20/S� Signature:
Title:
C ntractor (Owner) - Signature
Corporation Name (if corpbration)
Address: / Sao 0 hi
02iIToLj►4 I-1gTs
State N y Zip 1 e 9cg
f4 oat4 eo u ll T'y .1�bni s
Corporation Name (if corporation)
Address: 156
State ( N Zip l y8.
Form G &97
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598 ,
(914) 245 -2800
'Albert' R% Padovan ;= `DIYA -b oY-
** TEST REPORT **
-- -- #:N1M502509NNNCL2 ENT N #NNN6471NryN ---- ------ - -NONNS TATM PRO CN----- NNNNNNPAGENry----------- ---- --
NORTH COUNTY HOMES
156 TOMAHAWK ST
YORKTOWN HGTS, NY 10598
DATE /TIME TAKEN: 09/03/15 01:OOP
DATE /TIME RECD: 09/03/15 01:50P
REPORT DATE: 09/18/15
PHONE: (914)- 447 -8780
SAMPLING SITE: 35-9 THEODORE TRAIL SAMPLE TYPE..: POTABLE
: WELL FAUCET (TANK) PRESERVATIVES: HNO3
COLD BY: JOE FESTO TEMP RECEIVED: 8C ON ICE
NOTES...: COLIFORM METH: MF
START DATE /TIME END DATE /TIME FLAG PROCEDURE
RESULT NORMAL - RANGE METHOD
PUTNAM
CNTY
PROFILE
09/03/15
0430
09/04/15
0330
MF T. COLIFOR
ABSENT
/100 ML
ABSENT
SM
18 -20 9222B
09/16/15
LEAD (IMS)
<1.0
ppb
0 -15 ppb
SM
18 -19 3113B
09/04/15
1000
09/04/15
1030
NITRATE NITRO
5.70
MG /L
0 - 10
HACH 10206
09/04/15
0930
09/04/15
1000
NITRITE NITRO
<0.01
MG /L
1.0 MG /L
SM18- 204500NO2
09/14/15
IRON (Fe)
0.27
MG /L
0 -0.3 mg /l
SM
18 -20 3111B
09/14/15
MANGANESE (Mn
<0.01
MG /L
0 -0.3 mg /l
SM
18 -20 3111B
09/15/15
SODIUM (Na)
41.43
MG /L
N/A
SM
18 -20 3111B
09/14/15
0415
09/14/15
0418
* pH
7.0
UNITS
6.5 -8.5
SM18 -20 4500HB
09/14/15
HARDNESS,TOTA
244
MG /L
N/A
SM
18 -20 2340C
09/18/15
ALKALINITY (A
144
MG /L
N/A
SM
18 -20 232013
09/03/15
TURBIDITY (TU
<1
NTU
0 -5 NTU
SM
18 (2130B)
MFTC Totjo form = This r esult indicates that the water
(was not) of a satisfactory sanitary quality according to
t rk State and EPA federal drinking water standard for
this parameter. This comment applies to the Total Coliform test
only.
Pb /Cu LEAD limits for public schools are set at 15 ppb.
EPA Lead & Copper Rule for Public Systems requires that no more
than 10% of their distribution points have a LEAD value of more
than 15 ppb and a COPPER value of 1.3 mg /L, else water
treatment must be undertaken to reduce the waters corrosive
potential.
Fe /Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg /L.
IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER
SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT)
NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER
RUNNING FOR 10 -15 MINUTES MINIMUM)
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598
r.... r..._. _.... __...._.... _.. _.... __ __. - - _ - •.._.... - - .....
(914 245 2800 _
Albert H. Padovan'i Director
** TEST REPORT **
LAB #: 1.502509 CLIENT #: 6471 NON STAT PROC PAGE: 2 of 2
--------------------------------------------------------------------- ------ --- ---- -- --- --- - -- - --
NORTH COUNTY HOMES
156 TOMAHAWK ST
YORKTOWN HGTS, NY 10598
DATE /TIME TAKEN: 09/03/15 01:OOP
DATE /TIME RECD: 09/03/15 01:50P
REPORT DATE: 09/18/15
PHONE: (914)- 447 -8780
SAMPLING SITE: 3-% THEODORE TRAIL SAMPLE TYPE..: POTABLE
: WELL FAUCET (TANK) PRESERVATIVES: HNO3
COLD BY: JOE FESTO TEMP RECEIVED: 8C ON ICE
NOTES...: COLIFORM METH: MF
-----.------------------------------------------------------------------------ ------ ------ - - - -�_
START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
Na No limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg /L of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg /L of Sodium
is suggested.
* pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE•NORMAL RANGE OF pH IS 6.5 TO 8.5.
pH IS A FIELD MEASUREMENT AND IS TESTED OUTSIDE THE HOLDING TIME.
pH REPORTED FOR REFERENCE ONLY.
3cz T0TAL-"HARDNESS'- -IS- DEFINED AS" THE -Suiv7 -OF THE CALC TH & RAGNES1L el
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE
HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L,
MODERATELY HARD WATER: _ 70 =140 MG, /L MG /L = MILLIGRAM PER .LITER
HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG/L):..:.
ALK (ALKALINITY REPORTED AT pH 4.5)
IMS IMS = IMMEDIATE METAL SAMPLE.
(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED
A MINM4W OF 6 HOURS OR OVERNIGHT)
THE A13OV;,,TEft PROCED RES MEET ALL REQUIREMENTS OF NELAC,
AND RELXTE 01 X TO-TJJEM SAMPLES RECEIVED BY THE LAB
SUBMITTED BY:
Albert vani, .T.(ASCP
Director
ELAP# 10323
Roy Fre r-ik- sera-y —RE..
Consulting Engineer
Design Planning Construction
Phone (518) 928 -0265
rafredriksenpe@gmail.com
Putnam County Health Dept.
1 Geneva Road
Brewster, N.Y. 10509
ATT: Joseph Paravati, P.E.
Dear Mr. Paravati:
PO Box 950
Mahopac, N.Y. 10541
October 26, 2015
RE: Field Inspection
North County Homes
35 Theodore Trail
Patterson, TM 34 -2 -54
The items in your site inspection letter of August 10, 2015 were corrected and verified by
me before the system was backfilled.
Very Truly Yours,
C
Roy A. Fredriksen
ALLEN BEALS, M.D., J.D.
Commissioner of Health
^g2013ERT MOMS ,rP.E., MPH
Director of Environmental Health
October 21, 2015
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509.
Phone # (845) 808 -1390 Fax # (845) 278 -7921
Re: Construction Compliance — North County Homes
35 Theodore Trail
(T) Patterson, T.M. 34 -2 -54
This office has received and reviewed the most recent set of plans for the above mentioned
project. We would like to offer the following comments for your review and consideration.
" -" "` ° "i: Please provide a letfer signed'anil sealed stating tfia.t -661d- commenfs-' 1, 2, 3, 4'and ' were
addressed.
2. Relocation dimension A -1 appears to be incorrect and dimension A -2 has not been
provided.
This office will continue its review upon consideration of the above mentioned comments.
Please feel free to contact me at ext. 43157 if any questions arise.
Ve truly yours,
Pseph S. Paravati, Jr., P.E.
Assistant Public Health Engineer
JSP:cml
ALLII✓i N BEALS, M.D., J.D.
Cpmmissioner of Health
- - ROBERT MORRIS, P.E., MPH
Director of Environmental Health
August 10, 2015
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390 Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
Re: Field Inspection — North County-Homes
35 Theodore Trail
(T) Patterson, TM 34 -2 -54
A site inspection was made for the above referenced project on August 10, 2015
The following comments must be corrected in the field.
i.
The cover 1111` junction box #4+ is cracked Arid is to be feplacdd.
2. The filter fabric is torn and appears to tear upon the slightest pulling of the material.
3. Please verify that the tank size is 1,250 gallons. Provide a manufacturer's cut sheet with
as-built submission.
4"A NYSDOH approved well cap,is to be provided.
5. The pipes in the junction boxes are to be trimmed so they are flush with the box.
V A bedroom count is to be conducted by a representative of this Department when the
house is completed.
7. Once comments 1 -5 are addressed, the system can be backfilled.
If you have any further questions, please contact me at (845) 808 -1390 ext. 43157
Very truly yours,
J seph S. Paravati, Jr., P.E.
ssistant Public Health Engineer
1SP:cml
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date:
ctT ±,T,�cation ..- �f�e1�:? .%pct, (..- - - caner ^fi�'i °:
_ O-
Town �; � ,� Permit #' -.co- l
TM #— a - - y Subdivision Lot #
1. Sewage - Svstem 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. 1 00' from water course /wetlands.........., ............
II. Sewage System ,-t:;
a. Septic tank size - 1,000 ...:....(1,250... ?..'.other ................
b. ' Septic'tank installed level ....... _ ...................................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
1. All outlets at same elevation -water tested .................
2. Protected below frost .................. ...............................
3. .. Muumum 2 ft. Original soil between box & trenches
e. Junction Bog - properly set .......... ...............................
6. firenc ri es -. ( ;_
1. Length required 3/�Length installed f
2. Distance to watercourse measured Ft..........
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1/16 - 1/32" /foot .............
5. 16 -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 3A - 11/2" diameter clean ...................:
9. Depth of gravel in trench 12" minimum .......:...........
10. Pipe ends capped..: ..............:.
Pump or Dosed 5vstems
1. Size of pump chamber ................ ...............................
2. Overflow tank ..................
........... ...............................
3. Alarm, visual/ audio ........:........:.. ...............................
4. Pump easily accessible, manhole to grade .................
5. First box ball e d ................. .........................................
6. Cyycle witnessed by H.D.estimated flow /cycle...........
III. House/Building
a. house located per approved plans ................
b. Number of bedrooms ................. .... - �`,(V...,,5, ,,, jr,
IV. , Well
Well located as per approved plans . ......:........................
b. Distance from STS area measured / L?b-K ft...........
c. Casing 18" above grade ................ .....v.......:.................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship .
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfdled ..........................................
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 & dinto exist watercourse
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate .......... ...........................
i. Erosion control provided ............:.... ...............................
Rev. 12/02
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COMMENTS
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Form -3
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- _ALIEN BEATS, M.D.,_J_.D..... - .._.. 1`� t RYEL UEN 011) re£�
Commissioner oj'Ifeaith x' County Executive
ROBERT MORRYS P E�` ��
p
Director of Erwironmental Health
DEPARTMENT OF HEALTH
1 Geneva Road; $rdwster, New York 10509 ..
Phone # @45) 808 -1390
Fax # (845) 278-7921.
E-911 Address Verification Form
Owner's Name:
Tax Map Number: _ J ' �' ��
E -911 Address: 3 S `7 Fo e1c/1C 1., ?Ar L
-Town.— I r4
Authorized Official:
Town
o Ile
(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 E-911 address is assigned by an
authorized Town offical.
This form is to be submitted with the application for a Certificate of Construction Compliance.
RM. /jmg
112013 E -91 L address verfi.
11
Gds Bridge Unit Step Co., Inc.
1240 Rt. 52
Carmel, NY 10512
Bill To
North County Homes, Inc.
156 Tomahawk Street
Yorktown Heights, NY 10598
Ship To
914 - 490 -9338 Mike cell
Invoice
Date + Invoice #
7/1/2015 IN8467
Phone #
Fax #
P.O. No.
Terms
Ship Date
Net 30 Days
7/1/2015
Description
Qty
Rate
Amount
1250 Gal. Septic Tank
1
1,025.00
1,025.00T
4 Hole Distribution Box w /cover
5
45.00
225.00T
'i
V
S
Thank You For Your Business
Subtotal
$1,250.00
Job site must be accessible & ready as follows: Water lines, electric lines,
and lumber all affect installation- CHECK CAREFULLY. Truck must be
Sales Tax (8.375 %) $104.69
Total
$1,354.69
able to get within 15' of setting. Trucks enter Buyer's site at Buyer's risk.
Waiting, re- setting, re- delivery- $275.00 per hour. 1 1/2% PER. MONTH
LATE PAYMENT CHARGE. Any questions please call.
$ 50.00 charge
on returned checks.
Payments /Credits $0.00
Balance Due
$1,354.60
Phone #
Fax #
(845) 878 -3737
(845) 878 -3832
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Asojlt-T LA>00T of MIEN
ROY FREDRI.KSEN, PE
Consulting Engineer
950 136sing Planning Construction
NY 10541 Phone (518) 928-0265.
010 C-0 L) 4
5*& TOMA/4M4
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Date:
SHEET / of I
NEW YORK STATE LICENSE No. 50505
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ROY FREDRI.KSEN, PE
Consulting Engineer
950 136sing Planning Construction
NY 10541 Phone (518) 928-0265.
010 C-0 L) 4
5*& TOMA/4M4
3�5-74tor->oe,et- MqjL
/4 of P6-T7�6esoAl
4"-
Date:
SHEET / of I
NEW YORK STATE LICENSE No. 50505
PUTNAM COUNTY DEPARTMENT OF HEALTH a ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #
Locatedat 37 TH60[bt2F ;,44/1
Subdivision name (424MA rot Subd. Lot #
Date Subdivision Approved f/
Owner /Applicant Name No2-rY Q�unry eS
Mailing Address a,44 uJ k
Amount of Fee Enclosed0
Town or Village 041 C) e4
Tax Map 34 Block Z Lot 4
Renewal Revision r: `
Date of Previous Approval V;z s ¢
/;` 9-1) k4 y/ Zip love
" Building Type A9�5, Lot Area No. of Bedrooms __4 Design Flow GPD &00
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of / 2-5'c) gallon septic tank and 4C C�
Other Requirements:
To be constructed by 23 a Address `-
Water Supply: Public Supply From
or: - .:�---Vnva`ce- Supply Drilled by
Tis-0
Address
Add ess .
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
sgparate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed: C P.E. R.A. Date 27 gig'
Address SOX KO, A A kt vVVi)e; N Y U
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
B P,.e Title: Date: $ '3 /.5--
ite copy - HD File; Yellow copy - B ilding Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
07/21/2015 10:25 FAX 518 566 0903 PLAT STORM RM
PUTNAM COUNTY DEPARTMENT OF HEALTH
]DIVISION OF ENVIRONMENTAL HEALTH SERVICES
E.-
ArrnmON El JOSEPH UGENE
REQUEST FOR FINAL MPF9MQN For: Fill
All information must be My completed prior to any Trenches
inspections being made.
9001/001
PCHD Construction Permit # P -06—/ ?,
Located: 35 -rhec-dop-e- Twolc_
(T) (V) _1
Owner/Applicant Name: &6M Q2unfY d2pne* TM .34 Block 2 Lot _L4_
I I ' f
Formerly: Subdivision Name: 6MrnA74-k_A!LSax..
Subdivision Lot # 2-
Is system fill completed?
Is system complete? Y165
)�ry is system constructed as per plans? 146
Is well drilled?
Is well located as per plans?
Are erosion control measures in place? . —7- ykna
Date:
Date: -7=1,�;—
Date:
I certify that the system(s), as listcd, 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 Regulations of the Putnam County: Department of
Date: IZZO h� CCrtifl-,Dd by: PE RA
D69ip Professional
Address: Lie. 4
Comments: 847S A
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oWy j3udf q 13R 4ouse wi-r6 6 J256 cv,+C. ink. 1402 r-f f rle-za
T1,fx.6 r( Vii: 41 -r kk,4
Form FIR-99
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT .-- O'RR•IS; P E:, - - --
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN:
FROM:��,f�L`
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
DELEGATED
New Application ❑f. Renewal ❑
PROJECT: jt, rj r, (t✓�
LOCATION:
r
TOWN: DATE SUB'D APPROVAL+~
TM # 9q - .� - �"`� -.
NOTICE OF COMPLETE APPLICATION DATE: 67 t
DELEGATED
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E., MPH
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
August 3, 2015 Phone # (845) 808 -1390 Fax # (845) 278 -7921
Roy Fredriksen, P.E.
PO Box 950
Mahopac, NY 10541
Dear Mr. Fredriksen:
MARYELLEN ODELL
County, Executive.
Re: Complete Application Determination
for North County Homes
35 Theodore Trail
(T) Patterson, TM 34 -2 -54
Middle Branch Reservoir Basin
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee,'and revisions received by this Department on July 30, 2015 is complete.
The Department will notify you by August 24, 2015 of its determination.
0 The Project has been delegated to the Putnam County Health Department for review
pursuant to the guidelines set forth in the Watershed Agreement.
❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in
the Watershed Agreement.
If the Department fails to notify you within the above referenced time frame, you may notify the
Department of its failure by certified mail, return receipt requested. The notice should be sent to my
attention at the above address. This notice must include your name, the location of the project, the
office with which you filed the application originally, and a statement that a decision is sought in
accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed
Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the
notice, your application will be deemed approved, subject to standard terms and conditions as set
forth in the regulations.
Please be advised that projects within the NYC Watershed may also require Department of
Environmental Protection review and approval of other aspects of a project, such as stormwater plans
or the creation of impervious surfaces, and the project applicant should contact the Department of
Environmental Protection regarding such activities to see if Department of Environmental Protection
review and approval is required.
If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43157.
Respectfully
oseph S. Paravati Jr., P.E.
Assistant Public Health Engineer
JSP:cml