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HomeMy WebLinkAbout1465DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -55 BOX 13 01465 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Map # GPS 'x 1z 39 Theodore Trail Patterson Map 34 Block 2 Lot(s) 55 F7_�Hours Well Yield Test Well Owner: Name: Address: Yield 711- gEl Depth Date Ginsburg Development, LLC, 50 North Street, Danbury, CT 06810 Dunng yie d test (ft) 325' Use of Well: X Residential _Public Supply Air cond /heat pump _Irrigation Depth From Surface 1- Primary Business Farm Test /monitoring —Other(specify) Formation Description 2- Secondary Industrial Institutional Standby Land Surface Drilling Equipment X Rotary _Cable percussion XCompressed air percussion Other(specify) clay, Well Type Screened _Open end casing __L Open hole in bedrock _Other Hit Total Length 32 ft. Materials: X Steel Plastic Other Joints: Welded X Threaded Other 32 Casing Details Length below grade31 ft. Seal: Cement grout Bentonite Other 32 365 Diameter 6 in. Drive shoe: X Yes _ No Liner: _Yes X No Weight per foot 19 lb/ft Diameter (in) ISlot Size Length (ft) JDeptto Screen (ft) Developed? Screen Details First _Yes _No Second F7_�Hours Well Yield Test _Balled _Pumped X Compressed Air Hours 6 Yield 711- gEl Depth Date Measure from land surface - static (specify ft 30' Dunng yie d test (ft) 325' Depth of completed 365' Well Log If more detailed information sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface 17 Drilling in overburden, clay, and boulders Hit 17 32 Drilling in ro k set casi routed 32 365 Drilling in ro k granite f yield was tested 3t different depths luring drilling ist: Feet lions Per Pump Type Depth 6 Voltage -s Tank Tvoe.' -1 ige i anK information er5 t capacity rn odelr�iS� O�HP 4II h Volume � � NOTE: Exact LoC69on of well with distances to at least two permangnt landmarks to be provided on a separate sheelan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 RECD 140V 17 2010 Rev. 3106 K �'� � � �, . }, �, � ( ��� � � � � SID ! �" •� E'� I i 1 ! � I d1� ! F � � •� � � ��� DMSION OIL ]ENWRONI ENTAL HEALTH SERVRCES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIIT # 'F- o 2 -10 Located at S°1 TiAeot*(Ls T2,Att_ Town or Village �1 Owner /Applicant Name Oov -,rte Coo .jlY 0�t me-S Tax Map Block Z Lot Formerly Subdivision Name IjM!� 1& 6gii dIA- a ASSoLEAM- Subd. Lot # ) 0 Mailing Address 151 -rom H A" sT. _ 7Ad-&.ra'0") 140 -14drS .. /al. K. Zip ! oS+2X Date Construction Permit Issued by PCHD Z. - Z Ld - /Q Po Separate Sewerage System built by UwE Address AAAAI#A -V- , N� iaSb Consisting of 1 I- 5-o Gallon Septic Tank and Sao L F AsSa.r- p-rlaa l Tjg gA LE1 Other Requirements: Water Sunoly: Public Supply From. Address A 4A or:- �— Private Supply Drilled by �F g��t- SONS Address � I &W IOCC -11 Building-Type- �„ Has erosion control been completed ?� Number of Bedrooms Has garbage grinder been installed? A/o 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: Noi , Certified by P.E. r,/ R.A. (Design Profes Tonal) Address, f% 44o 14ssoci- , z zza a2 ct,3 ®, fie /OGI,S'u. ye � d3 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 Director /Commissioner, such revocation, White copy - HD Fi is necessary. Title: - Building Inspector; Pink copy - Owner; - Design Professional !0 Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Well WELL COMPLETION REPORT Well Location Street Address: 39 Theodore Trail Town/Village: Patterson Tax Map # Map 34 Block 2 Lot(s) 55 Well Owner: Name: Address: Ginsburg Development, LLC, 50 North Street, Danbury, CT 06810 Use of Well: 1- Primary 2- Secondary X Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary _Cable percussion XCompressed air percussion —Other(specify) Well Type _Screened _Open end casing __L Open hole in bedrock _Other Casing Details Total Length eft. Length below grade31 ft. Diameter 6 in. Weight per foot 19 lb/ft Materials: X Steel Plastic Other Joints: Welded X Threaded Other Seal: Cement grout Bentonite Other Drive shoe: X Yes _ No Liner: _Yes X No Screen Details Diameter (in) Slot Size Length ft Dept to Screen ft Develo ped? First I _Yes _No Hours Second I Well Yield Test _Bailed _Pumped X Compressed Air Hours 6 Yield T; gpm Depth Date p Measure from land surface- static (specify ft) 30' During yie d test ft) 325' Depth o completed we m . 365' Well Log If more detailed information, descriptioris -or ' sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface 17 DrillinR in overburden, c1dy. and boulders Hit rock at 17 17 32 Drilling in rock, set casing. grouted 32 365 Drilling in rock granite If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type eoer5., �apacity 1 Depth_ ode P-71 T Voltage HP Tank Typ ro/ Volume o� Wte wen completed 6/30/20Q0 V1/ell Driller PC Certificate # 019 NY State #NYRD10105 Date of Report Purnp Installer P,C Certificate,# NY State # X1/2/10 Well Driller Name 8� Address •:Inc. 4 ,Putnam; ve Br .z Wel IL(sigrature) :: 4. ` Pump, Installer Name & Address Pump Installer (signature) � xx NOTE: Exact Loc on of well with distances to at least two perman nt landmarks to be provided on a separate sheet/ an. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 11/10/2010 15:33 8458782019 PATTERSON PLANNING PAGE 02/02 BRUCS R. FOLEY public Ifealrlt Director LORCTTA MOLINARI k,N., M-5-N. ,Isseci&e Public pleallh Mretlor ,QirectOr of Fativir Scr�ices DEPARTMENT OF Hr-ALTH 1 Gcneva RoQ;c1' Browster, New 'York 10509 E,nvlronmen1al 11e41111 1914)z7S.600 ft- (914) VS-7921 Nur�B1g Setvicet (9 u1) 27s - 6558 'IYAC (9l4) 773 - 6618 Faa (914) 278 - 665 Early Intervelltion (914).273-60W 1'resehool (9 l4) 278 -6082 Fax (914) 276 -6648 OWNERS NAME, �02�►� Co�Nr'r' 1��5 1IJiL4 4 TAX L A.P NUMBER: 3 Lj y r',911 ADDRLSS: TOWN: AUTHORIZED TOWN 0Ir1FICIAL: (Siguature) DATE. The Futn,am Couuty Department of Health. will not issue a Certificate. of Const ;•uctionl Compliwice unless the above form is completed, i.e -, a legal E911 address is assig,ncd by an authorizer) toivn official. This form is .to be submitted �vith tape application for a Certifcate of Construction. Compliaxice. cb9I I VElu-1w) 2002 d71I SHI IOOSSV oRf1TA nT7Q 1.1.7 tTR rruT i -T:77T er'SAI nTYnT /TT 11/10/10 WED 15:25 [TX /RX NO 60881 11002 PUTNAM COUNTY DEPARTMENTOF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building N o ?-T 14 C_&u•J iii' V6t.&re s , t �rL Building Constructed by Location - Street 5.r Building Type -9& z 5,5- Tax Map Block Lot 1��aTrs =�so� TownNillage SMC . w Subdivision Name �0 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 ofapproval 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 p' th building utilizing the system. Dated: 'Month Day Year ).C) i 0 o� Gene al Con ractor- Owner) - Signature Corporation Name (if corporation) Address: �, <, T C`, vl"_i4\ . ,k4 State �- , �,f? `f Zip Signature: (,q i Title: C� 5cu ­ I Corporation Name (if corporation) Address: `J� o L 4 t State tv i Zip Form GS -97 Oct 29 2010 12:33 HP LnSERJET FnX YML ENVIRONMENTAL SERVICES ..... - . . .. 321Kear Street y n'i9p YJrkt1wn- -- 14e.4 ght5 .b .. (914) 245 -2800 Albert H. Padovani, Director P.1 AB - #: 1 .004575 ^r' CLIENT - # : -- 6471 ------ -------- NON -STAT- PROC ---- PAGE :- l- of -2 -- �RTH COUNTY HOMES DATE /TIME TAKEN: 10/22/10 11:30 TOMAHAWK ST DATE /TIME RECD: 10/22/10 12:30 56 '56 TS, NY 10598 REPORT DATE: 10/29/10 TO MA TOMAHAWK PHONE: (914)- 447 -8780 ;AMPLING SITE: 10 THEODORE TRAIL, PATTERSON, NY SAMPLE .O .. :PTA LE : WELL TANK 'OL'D BY: JOE FESTO TEMPERATURE..: < 4C COLIFORM METH: MF COTES------- :- -_..--------- __ti_-- _--- _,, - - --- - _..--- ..- ..----- _-- ..r -__- --------------- DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 10/23/10 MF T. COLIFORM 10/29/10 LEAD (IMS) 10/22/10 NITRATE NITROG 10/22/10 NITRITE NITROG 10/25/10 IRON (Fe) 10/29/10 MANGANESE (Mn) 10/27/10 SODIUM (Na) 10/22/10 pH 10/28/10 HARDNESS,TOTAL 10/28/10 ALKALINITY (AS 10/22/10 TURBIDITY (TUR RESULT ABSENT /100 ML 6.0 ppb 0.45 MG /L <0.01 MG /L <0.060 MG /L <0.01 MG /L 91.7 MG /L 7.2 UNITS 346 MG /L 206 MG /L 0.8 NTU NORMAL - RANGE ABSENT 0 -15 ppb 0 - 10 1.0 MG /L 0 -0.3 mg /1 0 -0.3 mg /l N/A 6.5 -8.5 N/A N/A 0 -5 NTU METHOD SM 18 -20 9222B SM 18 -19 3113B SMIS- 20450ONO3 SM18- 20450ONO2 SM 18 -20 3111B SM 18 -20 3111B SM 18 -20 3111E SM18 -20 4500HB SM 18 -20 2340C SM 18 -20 2320B SM 18 (2130B) COMMENTS: tFTC T liform = This result indicates that the water was. (was not) of a satisfactory sanitary quality according to ew York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. 'e /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. is 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. )H 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. 10/29/10 FRI 10:11 [TX /RX NO 60701 0 001 Oct 29 2010 12:33 HP LRSERJET FAX p.2 YML ENVIRONMENTAL SERVICES 321 Kear Street .Yorkt.ow,n_RHeiahts., N.Y. .10598 -(914)x24'5 -2800 :. __.... .. Albert H. Padovani, Director .AB #: 1.004575 CLIENT #: 6471 _ .-- --NON- STAT- PROC -- -- PAGE :- 2-of -2 FORTH COUNTY HOMES DATE /TIME TAKEN: 10/22/10 11 :30 .56 TOMAHAWK ST DATE /TIME.REC'D: 10/22/10 12:30 'ORKTOWN HGTS, NY 10598 REPORT DATE: 10/29/10 PHONE: (914)- 447 -8780 >AMPLING SITE: 10 THEODORE TRAIL, PATTERSON, NY SAMPLE TYPE..: POTABLE WELL TANK PRESERVATIVES; NONE 'OL'D BY: JOE FESTO TEMPERATURE..: < 4C TOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD pH IS A FIELD MEASUREMENT AND IS REPORTED FOR REFERENCE ONLY. Id TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM 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) THE ABOVE TEST PR URES MEET ALL REQUIREMENTS OF NELAC, AND RELAT O T ;7ESE AMPLES RECEIVED BY THE LAB '3UBMITTED BY: A t H. adbvani, M.T.(ASCP) Director ELAP# 10323 10/29/10 FRI 10;11 [TX /RX NO 60701 2002 BIBBO ASSOCIATES, LLP TO: PUTNAM COUNTY HEALTH DEPARTMENT DATE: NOVEMBER 10, 2010 ATTN: MICHAEL BUDZINSKI, P.E. RE: NORTH COUNTY HOMES - LOT 10 — SSDS FINAL 1 GENEVA ROAD 39 THEODORE TRAIL- PATTERSON (T) BREWSTER, N.Y. 10509 SECTION: 34 BLOCK: 2 LOT: 55 WE ARE SENDING YOU ( x ) ATTACHED ( ) UNDER SEPARATE COVER THE FOLLOWING ITEMS VIA USPS # COPIES DESCRIPTION 4 AS -BUILT PLAN 3 SSDS GUARANTY 1 CERTIFICATE OF CONSTRUCTION COMPLIANCE APPLICATION 1 WELL COMPLETION REPORT 1 WATER ANALYSIS 1 E911 ADDRESS FORM 1 BANK CHECK FOR $300.00 — CONSTRUCTION COMPLIANCE APPLICATION FEE THESE ARE TRANSMITTED AS CHECKED BELOW: FOR_YOUR_APPROVAL _. ( x) AS REQUESTED_ __ ._.,.... . ( ) FOR YOUR USE ( ) FOR REVIEW AND COMMENT REMARKS: MIKE, THE ATTACHED IS FOR YOUR REVIEW AND APPROVAL. PLEASE FEEL FREE TO CONTACT US WITH ANY QUESTIONS YOU MAY HAVE. COPY TO: SIGNED: 293 ROUTE 100 — SUITE 203 SOMERS, NY 10589 (914) 277 -5805 — (914) 277 -8210 FAX — bibbo @optonline.net IF ENCLOSURES ARE NOT AS NOTED, KINDL Y NOTIFY US AT ONCE AT (914) 277 -5805 Sherlita Angler, MD, MS, F AAP Commissioner of Health Robert Morris, PE 4 w..._..._. -_. Directur uj ^Er`rv:rofi�r:ental s'- fealth . .. �. . I�.��._.... .........__...,. �.._.._,.... >- _..... Department ®f Health 1 Geneva Road, Brewster, NY 10509 Office (845) 808 -1390 Fax (845) 808 -1937 October 25, 2010 Joe Buschynski, PE Bibbo Associates Mill Pond Offices 293 Route 100, Suite 203 Somers, NY 10589 Re: SSTS Final Inspection at 39 Theodore Trail (T) Patterson, TM # 34. -.2 -55 Dear Mr. Buschynski: Robert J. Bondi County Executive A final inspection was conducted by this Department and the following items are noted: o The silt fencing below the absorption trenches was not installed. The silt fencing is to be installed. immediately as per the plan. A re- inspection will be made. 0 The absorption trenches can be F et h led' Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. MJB:kly Respectfully, Michael J. Budzins -- P Director of lynl ineerlh-,o PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SI E INSPECTION ©_ —� Date: 3 �.��•. Inspected by: - Street -Lo do Town Permit TM # -�3 tj — Z — ,ss— Subdivision Lot # / O 1. Sewage Svstem Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement })�/L 3:1 barrier Lgth. Width &vg.Dpth V`�/ �T c. Natural soil not stripped ..... ........... ....................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage Svstem a. Septic tank size - 1,000 ........ , 250 ........ other ................ b. ' Septic'tank installed level . :..... .... ............................... c. 10' minimum from foundation ......... ............................... d. Distribution Box I, 1. All outlets at same elevation -water tested ................ 2. Protected below frost .................. ............................... 3 : Minimum 2 ft. Original soil between box & trenches e. Junction Bog - properly set .......... ............................... 6. T renc es Length required 4e- 1. OD Length installed 6V 2. Distance to watercourse measured Ft ... 71.bo 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot .........::.. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1' 12-" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... ] ends ca ed ................... ....... ................... .......:.... . g. Pump or Dose vstems 1. Size of pump chamber .............. ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Building a. House located per approved plans . ....................... ......... b. Number of bedrooms ................ ............................... .. IV. Well Well located as per approved plans .......:..................L. b. Distance from STS area measured �_ ft ........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ...............:............... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate........: ........................... i. Erosion control provided ................................................ Rev. 12/02 _.._2_..... PUTNAMCOUNT 'X1YEPARTIVIENTOFMALTH-_.__ .. .. - ....._ .. __..... DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ❑ J'OSEPH d GENE 104&1 RE VEST FOR F AL INSPECTION ON For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit #.� Located: 15 SAC a j%w M (V) FAtrMeS 6P-j Owner /,Applicant Name: t p&.r4A G 0&*Aa6 %N4 TM -Sq - Block Z. _ Lot _.!�E Formerly: Subdivision Name: -6,-%A4 Q Ac 0-WE-56 Subdivision Lot # ib Is system fill completed? Date: Is system complete? Y$ — Date: z' IR Is system constructed as per plans? Y jIES — Is well drilled.? `e & S Date: Is well located as per plans? `C S Are. erosion control measures in place ?, %?eS _ 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 Regulations of the Putnam County Department of Health: Date; —90/4P Certified by: PE RA 81F111 AaG0CfMb 5 LLB sign Professional Address: "" �� - Lic. # ©� — • s Comments: Form FIR 99 TOO 01 (IHOd FFF all SaLVIDOM oggiq OUR LLZ M lal tE :OT INN OT /ZZ /OT I'� I I °� •� i i i (�> (� 11 II) I I't •,. I� I� i I ti l (t) I III •� I III DRWSIICN GIF IENVURONMIENTAL IHIIEALTH SIERWC' s CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM ]FIERMICII' # � ` � 0� , Located at Town or Village Subdivision nameGi.�oy- fs'o�s; Subd. Lot # /O Tax Map 3+ Block _ Lot Date Subdivision Approved Arq, 2—n a ®d/ Renewal Revision Owner /Applicant Name Akan � - c, Date of Previous Approval Mailing Address /cf'�G' jlorwy �k 0�2 %nn4��V y M , 4 Al �_ Zip Amount of Fee Enclosed l� ®O Building Type Lot Area®.`11 No. of Bedrooms f— Design Flow GPD ,04%P Fill Section Only Depth I — Volume PCHD NOTIFICATION IS REE UIIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of /02SF'® gallon septic tank and c� ®ELF Other Requirements: To be constructed by 770F, 10 . Address Water Sup ly: Public Supply From Address or: Private Supply Drilled by /, St � • Address. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the 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 a2 -1,2 -/D License # 67cr,:f'7oZf " - ,�a11"e- ri A�y /a5'81�p 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 nec sary by the Director /Commissioner. Any revision or alteration of the approved plan requires a new per/nit. Approved fo d charge of domestic sanitary se age only. By: �� Title: White copy - HD Fi ; Yel ow c py - Building Inspector; Pink copy - Owne Orw copy -Design Professional Form CP -97 ►SSOCIATES, L.L.P. leers - Planners February 22, 2010 Putnam County Department of Health 1 Geneva Road, Brewster New York, 10509 ATTN: Michael J. Budzinski, Director of Engineering Dear Mr. Budzinski: Joseph J. Buschynski, P.E. Timothy S. Allen, P.E. Sabri Barisser, P.E. John P. McNamara, P.E. Robert A. B. Howe, B.S.. Phys. RE: SMG & Gramatan RS 39 Theodore Trail, Lot #10 Section: 34, Block: 2, Lot: 53 Patterson — (T) Please find attached the following in support of our application for a Construction Permit for the above referenced property: • 4 - copies of revised SSDS Plan in respon`8010'00m"M0ht8Teceived "from y6tit'iett-& dated February 1-9',-201-U; We- offer the following: 1. The plans have been revised to show 500 LF of absorption trench proposed. 2. The proposed length of absorption trench is 500 LF therefore dosing is no longer required. 3. The septic tank detail has been revised to specify a minimum cover depth of 12" and if cover depth exceeds 12" access manholes to grade will be used. 4. The footing and leader drains have been revised to maintain 10' min separation from the absorption trenches. 5. The junction box detail has been revised to specify a minimum of 2 feet of solid pipe prior to the start of perforated pipe. Planning . Site Design . Environmental Mill Pond Offices 293 Route 100, Suite 203 • Somers, NY 10589 Phone: 914 - 277 -5805 Fax: 914 - 277 -8210 • E -Mail: bibbo@optonline.net Please7feel'free:to contact us with any questions or are in need of addit' ' ' information. Very truly yours, 4e�� Ray Hamill Enclosures .:..SHE.RLITA AML%R, Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Joseph Buschynski, PE Bibbo Associates Mill Pond Offices 293 Route 100, Suite 203 Somers, NY 10589 r: . _ ...... -. -• _ I:OBIRT.-:�:.,1wC11'�'� - - -... _...�- >... -- County Executive DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT MORRIS, PE Director of Environmental Health February 19, 2010 Re: Proposed SSTS for SMG & Gramatan RS 39 Theodore Trail, Lot # 10 (T) Patterson, TM # 34. -2 -53 Dear Mr. Buschynski: This Department has received and reviewed the application and plans for the above referenced project and the following comments are offered for your consideration. /1. The submitted construction permit specifies 500 LF of absorption trenches although the plan shows 504 LF. 1: lease nVLI.' Liia� "4tSJt��g "f'ihG"abJGL%itlGn JySi:�LU 1' J" ici�Uli�. u' for -JY: iLL. ri1S "�.Giltaiiilnb'b:iutel''tiia�i— V�500 LF of absorption trench. The septic tank detail is to be revised to specify a maximum cover depth of 12 inches over the top of the tank. If there is greater than 12 inches of cover than an access to grade manhole is 1/ required. The footing and leader drain is to be a minimum of 10 feet from the absorption trenches. . The junction box detail is to be revised to specify a minimum of 2 feet of solid pipe prior to the start of the perforated pipe. Should you have any comments concerning this matter, please contact this office. MJB:kly Respectfull- hi-LA Michael J. Director of 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 SHERLITA AMLER, MD, MS, FAAP - Commissioner of Health.. LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Joseph Buschynski, PE Bibbo Associates Mill Pond Offices 293 Route 100, Suite 203 Somers, NY 10589 Dear Mr. Buschynski: ROBERT J. BONDI Count;.Execut ye . ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH February 18, 2010 1 Geneva Road. Brewster, New York 10509 Re: North County Homes, Inc. 39 Theodore Trail (T) Patterson, TM # 34. -2 -53 Middle Branch Reservoir Basin The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on February 17, 2010 is complete. The Department will notify you by March 10, 2010 of its determination. D 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 oribirally, -, -d 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) 278 -6130 ext. 43148. MJB:kly Michael J. Bud P Director of 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention /Preschool (845) 228 -2847 Fax (845) 225 -1580 BRUCE R. POL' EY Public Health Director - LORETTA `MOL7NARI RN., - M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509, Environmental Health (914)278 - 6,130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool . (914) 278 -6082 Fax (914) 278.- 6648 TO: 44p�&MAENT60FF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM PROJECT: Z07 7f��Isoc_ TOWN: C SE�K PV DATE SUB'D APPROVAL: n cI NOTICE OF COMPLETE APPLICATION DATE: ^' �8 AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the {patter of application for: Coss c�GJ i oe� d-Gr% /� / -eo-� r� ' fa'r /10 G, 0a - �Al- rep es t that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: N V% V� � H u- o- Having offices at: Whose Officers ArP- President - Name: Address: 1 s , (05-9e' Vice President - Name:t�i,1,QQ Address: C� T . qtz�,V� Secretary -Name: Address: Treasurer - Name: Address: )S -V and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: Title: / Sworn to before me this /t' day of month /U (year) Notary Publ ®E J. TIMONE NOTARy PUBLIC, State of New York No. 60- 3988985 Corporate Seal Qualified mmission Expires Ap it 30,u P aII t Form CA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF NVIRONMENTA _ .. HEALTH. SE R ..0 ES . LETTER OF AUTHORIZATION RE: Property of orb Located at 7; g!a �c��'✓ T/V 1&?7 e_1Kra Tax Map # Block ,2 Lot 5`S Subdivision of Subdivision Lot # 125�1 Filed Map # aZ877 Date Filed Gentlemen: This letter is to authorize 7-1 S'=© / F 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 treatment and/or water supply systems ..._..,.in.c.onfornaity. �rith:.the. rrovisiens €Article 1 5 and/or.:1.477 of -the- Education Law' ,A�e Public-1-1.ealt1h ._a..........._._ _ Law, and the Putnam County Sanitary Code. Countersigned: ��- P.E., R.A., # OS,-' ,R 9- Mailing Address B1SSO ASSOCIATES LLP 293 Route 1 co - Suite 0niers, NY I0539 State (914) 2Zr3�9 Telephone: Very truly yours, k Signed: O ner of roperty) Mailing Address: i(.aiiCc�•,7y1i`or�es,�c_ Ifs To 'wo'o�'& , yarr�r wh f�7s. State Zip Telephone: ?14- —,9,9 jj:�? - Form LA -97 LSSOCIATES,uL.P. Joseph). Buschynski, P.E. Timothy S. Allen, P.E. neers - Planners Sabri Barisser, P.E. - John P. McNamara, P.E. Robert A. B. Howe, B.S., Phys. February 12, 2010 Putnam County Dept. of Health 1 Geneva Rd Brewster, NY 10509 -2339 Attn: Mr. Michael Budzinski P.E., Director of Engineering RE: Lot #10 GDC Subdivision North County Homes, Inc. (T) Patterson, TM 34 -2 -55 Dear Mr. Budzinski: Enclosed in the above matter are the following items: 1) Construction Permit Application 2) Design Data Sheets 3) Letter of Authorization, Affidavit, EAF, PC -97 forms 4) $ 500 Application Fee 5) 4 prints - SSTS Site Plan 6) 2 copies - House Plans Please note that a well application is not included since the well on Lot #10 was drilled as a test well for the subdivision. The re- testing of soil percolation rates in the sewage disposal area on Lot #10 which you observed on February 4, 2010 resulted in rates ranging from 3.3 to 9 min /in. The original tests conducted in December 1998 were 11 and 30 min /in. In our opinion it would be reasonable to apply an adjustment to the controlling rate established for this lot. Five out of six tests conducted on the lot are less than one -half the original controlling rate. We are proposing that the soil be placed in the category of 11 to 15 min /in. We have prepared the enclosed SSTS site plan accordingly and respectfully request your approval for the percolation rate adjustment. Planning o Site Design o Environmental Mill Pond Offices 293 Route 100. Suite 203 • Somers, NY 10589 Phone: 914 - 277 -5805 Fax: 914 - 277 -8210 • E -Mail: bibbo@optonline.net _0 `• ; �7 ZZ Please note that a well application is not included since the well on Lot #10 was drilled as a test well for the subdivision. The re- testing of soil percolation rates in the sewage disposal area on Lot #10 which you observed on February 4, 2010 resulted in rates ranging from 3.3 to 9 min /in. The original tests conducted in December 1998 were 11 and 30 min /in. In our opinion it would be reasonable to apply an adjustment to the controlling rate established for this lot. Five out of six tests conducted on the lot are less than one -half the original controlling rate. We are proposing that the soil be placed in the category of 11 to 15 min /in. We have prepared the enclosed SSTS site plan accordingly and respectfully request your approval for the percolation rate adjustment. Planning o Site Design o Environmental Mill Pond Offices 293 Route 100. Suite 203 • Somers, NY 10589 Phone: 914 - 277 -5805 Fax: 914 - 277 -8210 • E -Mail: bibbo@optonline.net PCDH — M. Budzinski, P.E. Lot #10 - GDC Subdivision February 12, 2010 Page 2 of 2 Very truly yours, Joseph J. Buschynski, P.E. JJB/mme Enclosures 11 ,1 n PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA HEET r- SUBSURFACE SEWAGE TREATMENT SYSTEM C'i YIS�J�L' C.t` Owner: �} Address: Located at (street): TM # Section: _ Block _ Lot r- Municipality: Watershed: ` 0 SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: 2. v Date of Percolation Test:�_� Hole No. Run No. Time Start — Stop ]Elapse Time (min.) Depth to Water from ground surface (inches) Start - Stop2 Water level drop in inches Percolation Rate min /inch 1 � L r�j• ' L 1' � �) 2 +� 4 5 3 _42 4 5 2 WOO Z0 3 4 5 • I N* 24 0- Z' - 3 3 C; �. 4 5 Notes: n orl n`',D .�0 1. Tests to be repeated at same depth until approximately equal percolation rates are f' obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min /inch, < 2 min for 31 -60 min /inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. 1 Form DD -97, pg 1 of 2 ' `O PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: /tbt%/f &u v7Y A'^6_5 Located at (street): Municipality: P47- Telz5041 Address: yQViT %wh y1�J'., N y• TM # Section:..31/ Block -Z Lot rd- c ,CL 1 Watershed: %'&Ia /rghadir�Zc?;f`�`�I� SOIL PERCOLATION TEST DATA Witnessed by: A, /4--l" // I M / (,tea Date of Pre- soaking: ;tb f /O Date of Percolation Test: of Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to Water from ground surface (inches) Start - Stop water level drop in inches Percolation Rate min /inch " 2 1 OIL / r/ ///I a - Z 3 ! ar -_ /1,,,3 a, 7 Z. 5 i 2 /O: 37 - I o:SV /7 / _ Z -z- 3 z- 4 5 10 -/0i yo ' r r L Sr J ,r# 2 ld: yo -Il:oo 0 / - Z2 4 5 1 t3 /U -- z z 3. 3 NOS': `!1l., ; Tests to be repeated at same depth until approximately equal percolation rates are obtained at:each percolation test hole, (i.e., < I min for 1 -30 min /inch, < 2 min for 31 -60 min /inch). ` '`Ald-data-to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, pg I of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #- HOLE # HOLE# HOLE# HOLE # G.L. 0.5' 1.01 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' .5.5' 6.0' 6.5' 7.0' 7.5' 8.01 8.5' 10.01 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: J& C4 zn_s� Address: BR. B.0 253 Signature: L f Design Professional = Seal NE 0 t asst PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICA`I'ION'FOR AP IYOVAI. OF �PL AM.'rOW ._ . A WASTEWATER TREATMENT SYSTEM L. Name and address of applicant: / SG %s►- r�t��v� tS7- 2. Name of project: L�f `/Q 3. Location. TN: 4. Design Professional: "6�a,jScsGS , G 5. Address: j..q 7%7C'oG�or�1 6. Drainage Basin: 7. Type of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office. Building Realty Subdivision Other. (specify) 8.. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ................................... I................... Type I Bxempt Type II - Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ............ ......... V 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency y� 12. Is this project in an area under the control of local vlanni n zonin , or-other, officials, oidinances? .............................................. .........:.......,............. 13.. If so, have plans been submitted to such authorities? ........... :............................. e S 14. Has preliminary approval been granted by such authorities? ee' u Date granted:f �W 15. Type of Sewage Treatment System Discharge ................. surface water � groundwater 16. If surface water discharge, what is the stream,class designation? .................... 17. Waters index number (surface) ....... ................................. ................:r.........:,.: 18. 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? :............... /Uo 21. Name of sewage system Distance to sewage system 22. Date test holes observed //- �_y- 9B 23. Name of Health Inspector/4,J')','4'-//n9. 24. Project design flow (gallons per day) ........... ......................................................... 51 .............. .......... ............................... X00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... v _ 26. Has SPDES Application been submitted to local DEC office? ......................... /x.14, Fnrm P(_97 2 27. Is any portion of this project located within a designated Town or State wetland? Na 28.. -WA ±tand .Tl N, .r. r ........ ...................... ............................................................ 29. Is Wetlands Permit required? ..................................... ........ . .............................. lua Has application been made to Town.or Local DEC office? ............................... /iLI, 30. Does project require a DEC Stream Disturbance Permit? ................................... yllo 31. Is or was project site. used. for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity. /U 32.. Is project located within 1,000. feet of existing or abandoned landfill, hazardous. waste site, salt stockpile, landfill, sludge disposal site or any' other potentially known source of contamination? ........................... .... Yes/No /t% DESCRIBE: 33. Is there a local master plan 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? ........... ::.................................................... /(JO 35. Are any sewage treatment areas in excess of 15 %o slope? .................... 36. Tax Map ID Number .. :..:..................... .......:....................... Map_2L Block 2- Lot S°,Sr 37. Approved plans are to be returned to ....: Applicant X Design Professional - _ - -• ,--- pp- icatiOns- fo.rcv--;e�wandjaff cvaiofanew, SSTStohe `locatedwithiritheNYCWatershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to Final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwaterplans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is 'signed by a person other than the applicant shown in Item l .;the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision . may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury; that information. provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law, SIGNATURES & OFFICIAL TITLES: B.188.0 ASSOCI T A I I Mailing Address: 293 Route 1(),9 - Suite 203 Somers,. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: z(BrAh Lamm Alkwoz,-ZaC , Address: yoi'� /O�d�/ Located at (street): ✓7��lTheo�r�T/27i'� TM # Section�Block o? Lot Municipality: Watershed: lylYa& 3 'ghc-�,4 /'GS'- SOIL PERCOLATION TEST DATA Witnessed by: 114,1p. I Date of Pre - soaking: Date of Percolation Test: /-1/1:9r Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from Found surface , (inches), Start - Stop Water level drop in inches Percolation Rate min /inch 1 ,1#2 -9r¢ iz ¢ 3 2 .s's,d. ac 7 4-'z 4 X7-1/= 7 �3g / 5 2 .' - O'�6 O 9f ,Z o 4 5 .1 - 2 3 4 5 1 °,-,hArPests tolbe.r p'ated at same depth until approximately equal percolation rates are \0.;.sa obtained at 'ch percolation test hole. (i.e., < l min for 1 -30 min /inch, < 2 min for 31 -60 min /inch). zAlhd= -r b submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, po I of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #_A HOLE # HOLE # HOLE # HOLE G. L. 1.0. 2.5'- 3.0' Ake e y-w- A 3.5' 4.0' r) -1;e" 4.5' 5.0' 5.5- 6.0' cJA. wit 65 7.0' 4,r,010ae- 7.5' 8.0' 8.5'. 10.01 Indicate level at which groundwater is encountered Indicate level at which mottling is - observed Indicate level to which water level rises after being encountered — Deep hole observations made by:, e(,? 4& Ja, T, Y,, k Date e- - Design Professional Name: toy Address: i-B-B, 0 A G- SO C L, J E 8 L L P 293 Rou".3.1,100 - SuKa, Signature: a Professional = Seal Design ki 5 617.20 . Appendix C State Environmental Quality Review :.........S O i ENVIRONMENTAL ASSESUfFENT FORM For UNLISTED ACTIONS Only PART I - PROJECT INFORMATION (To be completed by Annlicant nr Prniact -Rnnncnrl 1. APPLICANT /SPONSOR 2. PROJECT NAME Lof "' /O 6.107 3. PROJECT LOCATION: / ]r, fpl�/ 7nawf Municipality a County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) `l Th v- �c, ; ::5! Carnes -s ��c� 5. PROPOSED ACTION IS: 0 New [] Expansion Modificatiordalteration 6. DESCRIBE PROJECT BRIEFLY: %,eve %tI 4-V -R, 7. AMOUNT OF LA ND AFFECTED: Initially 0 acres Ultimately — 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 [j Industrials Commercial E] 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)? Nl YYes F� No If Yes, list agency(s) name and perrnit/approvals: ,/`tit // �',soH I��� . f — / r/ AeT ./erh7, 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? Yes No If Yes, list. agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Yes . ® No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor n e: Coo,? C _ 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 Pe17T 11 _ IMPArT ASSFSSNIFNT 1Tn he rmmnleted by Lead Aaencv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR. PART 617.4? If yes, coordinate the review process and use the FULL EAF. B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. El Yes 11 No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C 1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: 62. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefty: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? Yes No If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes No If Yes, explain briefly: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials.. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes; the determination of 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 FL 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 WI NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this detemtinati Name of Lead Agency Print or T ype Name of Responsible Officer in ead Agency Signature of Responsible Officer in Lead Agency Date Title of esponsible Officer Signature of Preparer (if different from responsible officer) Lot 4 DMH ' 1 1 Drainage Easement -- DMH Soo Z::ILHIIPE 1 N� V7; w p1 J�—��W 145.96 Z �"- N10 -0 36 .o 0 \ co a Wire a w y eis 90 cn vs 00 � a is 0 r 0 Lot 10 Area= 0.9911 i iii/VLViW TRAIL R= 50.00' L=23.4>' OFFSET DIMENSIONS # ITEM "A" "B" 1 ST-IN 13.8' 46.8' 2 ST-OUT 23.4' 51.2' 3 JB 61' 71.4" 4 JB 62.4' 68.4' 5 JB 64.4' 66.4' 6 JB JB 6T 70' 65' 64' 7 8 JB 73' 63' 9 JB 76.4' 63' 10 TE 108' 100' 11 TE 106' 100' 12 TE 105' 102' 13 TE 103' 103' 14 TE 102' 103' 15 TE 100' 105' 16 TE 99' 102' 17 TE 24' 42.4' 18 TE 27' 37' 19 TE 31' 32' 20 TE 36' 28' 21 TE 41' 26' 22 TE 47' 25' 23 TE 52' 25' PUTNAM COUNTY DEPARTMEI� ALTH ER ICES::,. U HOUSE LOCATION AND PROM FROM SURVEY PREPARED BY SURVEYING, P.0 , YORKTOWN SHEET. 34 BLOCK:2 LO FIELD REQUIRED: 500 FT. 24 It FIELD INSTALLED: 500 FT 24 II THIS IS TO CERTIFY THAT THE SEWAGE CONSTRUCTED AS INDICATED ON THIS WAS INSPECTED BY BIBBO ASSOCIATE COVERED OVER. THE SYSTEM WAS CC WITH ALL STANDARDS RULES AND RE( COUNTY DEPARTMENT OF HEALTH ANI DEPARTMENT OF HEALTH. Water analysis result for sodiaun (Na) is Water containing more than 20 mg/L of sod drinking by people on severely restricted s, more than 270 mg/L of sodium should not b restricted sodium diets. PU'TIVA. Z O cc DATE: DESCRIPTION BY/C DATE: C