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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -3 -31 BOX 14 1 ru I'll r '1 c No J ' me ir ■ r■ , Alm ,I UAW- 01490 �D r� rPUTNAM COUNTY DEPARTMENT OF HEALTH _. � _ -� -_- DIVISION-OR.EN IRONMENTAL = HE�,TH - SERVIC CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # f p — It- 03 Located at Owner /Applicant Name Awiyotz Xrn�o Formerly 6,400 FA4tJcO Town or Village / /1 T Tf45dN Tax Map 3 V Block 3 Lot 31 Subdivision Name L3,/LD<<lc GGgti Aldf,7y Subd. Lot # 4rI46- 7 Mailing Address 4104f a/ /a AU S, ! �$ ��ST �''%, [� ✓� ✓� 6A/Pt -rk /&01,05Zip �dGo G tv Date Construction Permit Issued by PCHD /233 Separate Sewerage System built by Address Consisting of /Ooh Gallon Septic Tank and '33-3. k ! � W1,0 A f i"1Wr ; taw Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by AD&KA-✓ /`tNMAye •J Address / 9 -7- 13,44dl— J7- P`� Wil,47 11-71 _.._....:_Building Type Number of Bedrooms Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on' :the as built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations o the Putnam County Department of Health. Date: 2v06 Certified by P.E. R.A. Design Professional) Address )0-0 • t5 y Y ' t D %� �-w 41 C 7 C * i 1,(-P License # 6-7(,-7f.-) 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, such revocat'on, modifica ' or change is necessary. By: - Title: Date:? % `00 White copy - HD Fi ; YOU copy - Building Inspector; Pink copy - Own Or copy - Design Professional Form CC -97 ply �tw't.,�74�a in �^` Safi r' 10/12/2006 16 :00 9147341060 ENGINEERING PAGE 01/02 BRUCE R. FOLEY PaNk Health Dtrectwo' LORMA MOLINM R.N., M.S.N. A amiotr Publrc Xralth Director Director of Patient SerWw DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 Env ranmentel Health (1145) 278 - 6130 Pia (84S) 278 - 7921 Nursing Servim (845) 279.6158 WIC(245)278-6673 F•x (845) 278 - 6085 Tarty InterventlunMmsebool (645) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME- TAX MAP NUMBER: 3q 3.1 A? E911 ADDRESS: TOWN: &774-A--bAl AUTHI ..DATE.- RIZED TOWN OFFICIAL: The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E91 i verfim) 10/12/2006 16:00 9147341060 ENGINEERING PAGE 02/02 PUTNAM COUNTY DEPARTMENT OF HEALTH .,.... DIV- ISIONIOF --ENVIRONMENTAL-HEALTH, SERVICES' GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM f.4-w1 o44s 3 3 Owner or Purchaser o(JE61ding Tax Map Block Lot ;* 7-7 rL5aJ 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'detininination of the Public Health R� Director of the Putnam County Department of Health as to whether or not the failure ofthe system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. ---- ; C(- Year P - Signature Corporation Name (if corporation) Address: Mahopae Building Materials, Inc. uc s o low Road State Mahopac. NY I OAP Corporation Name (if corporation) Address: I.cL�fij, L � -1 n) Af%raso�d State Zip 1 Z S-� 3 Form OS -97 10/12/2006 16:00 9147341060 ENGINEERING PAGE 02/02 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION-OF ENV O1VMENTAt�HEALTU—SER CE9 - - -:� GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM f,4-rWrr-W A0 �9 .s '3 3 3� Owner or Purchaser of Bfiilding Tax Map Block Lot Building Constructed by Town/Village 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. Corporation Name (if corporation) Address: Mahopae Buildin Materials, Inc. ID uc shoilow Road State Mahopac. NYY 1 Oft Corporation Name (if corporation) Address: I'' t CL�� L W#1 Af %r�2sar� State —1 Zip I I S'� 3 Form OS -97 YML ENVIRONMENTAL SERVICEE 321 Kear Street Yorktown Hei hts, N.Y. 10598 Albert H.'Padovani, Director ` LAB #: 9.601124 CLIENT #: 59519 NON STAT PROC PAGE: I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~"~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RIZZO, ANTHONY D. 4 MARINA DRIVE F-1 MAHOPAC, NY 10541 SAMPLING SITE: 18 MICHAELS WAY : PATTERSON COL'D BY: ANTHONY D. RIZZO NOTES...: KITCHEN TAP ~=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-~~~~~ DATE/TIME TAKEN: 07/12/06 10:15 DATE/TlME REC'D: 07/12/06 10:30 REPORT DATE: 07/18/06 PHONE: (845)-621-4732 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD o'7/14/06 LEAK) 1,,2 ppb 0-15ppiD 9003 COMMENTS: PICK UP IN CARMEL COMMENTS: Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Cnpper 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 ---`-'- -trea,tment-must`1ze-undertaken to reduce the waters corros.1"ve- '- --' '— ---~-' potential. SUBMITTED BY: Director ELAP# 10323 `YML ENVI RONMENTAL SERVICE8 321 Kear Street Yorktown Alhert.H, d i, Director ��.` - LAB #: 9.600926 CLIENT #: 59456 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DiRIZZO, ANTHONY 4 MARINA DRIVE MAHOPAC, NY 10541 DATE/TIME TAKEN: 06/19/06 09:80 DATE/TIME REC'D: 06/19/06 09:55 REPORT DATE: 06/26/06 PHONE: (914)-686-6082 SAMPLE TYPE..: POTABLE SAMPLIN8 SITE: 18 MICHAELS WAY .. : PATTERSON PRESERVATIVES: NONE CQL'D BY: ANTHONY DIRIZZO TEMPERATURE..: < 4C � NOTES...: POWDER ROOM CDLIFORM METH: MF DATE FLAB PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 0-15 ppb 9003 06/19/06 MI= T. COLIFORM ABSENT /100 ML 06/22/06 LEAD (IMS) 32.3 ppb ' 06/23/06 NITRATE NITROB 0.33 M6 /L 06/21/06 NITRITE NITROG <0.01 MG /L. 06/23/06 IRON (Fe) 0.147 MG /L. 06/21/06 MANGANESE (Mn ) O.133 MG /L 06/21/06 SODIUM (Na) 2.87 MG/L. 06/19/06 pH 6.2 UNITS 06y20/06 HARDNESS,TOTAL 46.0 MG/L. 06/20/06 ALKALINITY (AS 32.0 MG/L 06/23/06- -TURBIDJTY'(TUR 1.2 NTU COMMENTS: PICK UP ABSENT 1008 0-15 ppb 9003 0 - 10 9052 N/A 9162 0-0.3 mg/l 9002 0-0.3 mg/l 9002 N/A 9002 6.5-8.5 9043 ' N/A N/A 9001 ---O-5-NTU'---- ------ COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI�6���~THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FQR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule fur 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. YML ENVIRONMENTAL SERVICES 321 Kear Street | yor � `914/ 245-2800 Albert H^ Padovani, Director � �\��� LAB #: 9.600926 CLIENT #: 59456 NON STAT'PR8C PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DiRIZZO, ANTHONY 4 MARINA DRIVE MAHOPAC, NY 10541 SAMPLING SITE: 18 MICHAELS WAY : PATTERSON COL`D BY: ANTHONY DIRIZZO NOTES...: POWDER ROOM ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE F LAO PROCEDURE DATE/TIME TAKEN: 06119106 09:30 DATE/TIME REC'D: 06/19/06 09:55 REPORT DATE: 06/26/06 PHONE: (914)-686-6O82 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted dlet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mQ/L of Sodium is suggested. pH pH SCALE IN WATER RANGES FROM 1-14' MEASUREMENT OF pH 3S ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMlSTRY., WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 1*0 8.5. Hd - TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM MAGNES} 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 (I grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert A. ' '__ Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION l Date: f3&2 o Inspected by: _ Street :Lgcation M.,,, 14 .� r /&V 10 Town e& persa14 c Permit # -p ° TM # 3 — 3 3 i Subdivision Lot # 1. Sewage System Area YE NO COMMENTS a. STS area located as per approved plans .......... .. ................ b. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water co wetlands ...... ............................... IL Sewage System coHK�c{, %� o ao.e a. Septic tank size - 1,00 ...:.....1,250......... other ........ ..tiv fo 6� zo�.ole b. ' Septic'tank ' ' eve .............. ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3... Minimum 2 ft.Original soil between box & trenches e. Junction Box properly et ........................ 6. '1'renc es . 1. Length required 3 3 3 Length installed 3 33 2. Distance to watercourse measured f / vo Ft.......... 3. Installed according to plan ..................: 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line -. -20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ................... T Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ......... . .........: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ................... ......................... g• ....._ , _ _.. . Pump or -Dose Systems -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/Buildi ig a. house located er approved plans. . .�► b. Number of bedpo ms IV. Well �s Un•��K i5 e e k�- • r 9 9 Well located as per approved plans . ......:........................ 8d s b. Distance from STS area measured / o . ft.......... c. Casing. 18 above grade d. Surface drainage around well acceptable .................. /G� V. Overall Worlananshin . ` 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 pl. f. Curtain drain outfall protected & dir.to exist waterc r g. Footing drains discharge away from STS area .............. o h. Surface water protection adequate ............................... i. Erosion control provided ................. ............................... Rev. 12/02 nrm . 3�y /os S1o�� �i<r - :SITE 1NSPECTION I+'OIt 1E+� 17PAD 7/2 2-/0 - atr; en-k Date: 7 / 8 O b Inspected by:�� Fill pad located per the approved plan X,n Fill Pad Length AY Required Length Fill Pad Width i- Aa A Required Width Fill Pad Depth Required Depth /'��r �� 5 f 4- G Run -of -Bank Fill Quality QlC , Slope from Top to Toe 0 k , Impervious Layer Installed Yes lrrosion Control Installed Ye 5 Sieve Test Results (if applicable) Additional Comments: X, o��ef 1 S /Veep eels � f e K svr e-. . Reserved for Field Sketch if Applicable N1 � e dI u I I r. I �- PUTNAM COUNTY DE,PAR7TA NT OF HEALTH DMSION OF ENVIRONWffAL HEALTH SERVICES ATTENTION JOSEPH IQ. GENE RE -0-MI PQR FINLINSPEC'TION For: Fill f All info cation must be fully complctcd prior to any Trenches inspections being made. "PCHD Construction P it # P L i _ 0J- , Located: M 1C - w (' ( 4 Tlf /f-fo Owner /Applicant Nam d, F G U TM 3_. Block 2 Lot —L Formerly: Subdivision Name: 004oir(4- Geld) &±M Subdivision Lot # Is system fill completed? ��S Date: Z& os- Is system cor pleteT Date: Is system constructed as per plans? Is well drilled? Is well located as per plans? Are erosion control measures in place? sS Date: I certify that the systems), 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, t r rr� Certified by: PP, , �_ R.A. Design P fcssional Address: �� �� `' I Lie. # 07678 a7V Comments: Form FIR -99 JUL- 13- 2005"WED 09:24 TEL:e45- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 d SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health July 19, 2005 Stephen J. Ferreira 103 Perry Drive New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Flavio Michael Way & Carolyn Way (T) Patterson, Lot #l, T.M. #34. -3 -31 The following comments need to be addressed. 1. It appears portions of the fill pad are over 15 %. 2. It appears the fill .depth may not be per the approved plan at the top of the pad, re: location of first proposed trench. Ifyou- have -any- further- question- ,•pleasecontact•me at( 845)- 278 - 6130; -ext -226 :..._._..... -_ .._ _. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 I.: acknowled - 6- receipt of this report GNAT 0.2/96- Title: e SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA- MOLINARI, RN, MSN Associate Commissioner of Health August 5, 2005 Mr. Steve Ferreira 103 Perry Drive New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Site Inspection — Flavio Michael Way & Carolyn Way (T) Patterson, Lot 1, T.M. 34. -3 -31 A re- inspection of the fill pad at the above referenced project has been completed. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the sub- sufface sewage treatment system. Please note that field measurements by this Department in no way suggest the exact size, depth and location of the fill pad. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR:cw Sincerely, Gene D. Reed Sr. Environmental'Health Engineering Aide Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax(845)278-7921 Nursing Services (845) 278 -6558 WIC(845)278-6678 Fax(845)278-6085 Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 08/25/2005 15:24 1026 T PAGE 02/02 PUTNAM COUNTY DVARTW.NT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ❑ JOSEPH GENE For: Fill All information must be fully completed prior to any Trenches JL1 _ inspections being made. PCHD Construction Permit # T' 0 Located: i A/- (T) (V) LSac✓ Owner /Applicant Name: 4 TM Block Lot Formerly: 'Subdivision Name: dmk- 44 � ! ?r-lox-w Subdivisivn.Lot # Is system fill completed? Date: 0- Is system complete? Date; tlillp> Is system constructed as per plans? Is well drilled? y Date: -11t i br _ Is well located as per plans? Are erosion control measures in place? � I certify that the system(s), as listed, at the above pternaim has boon constructed and I have inspected and vexi£ed 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: Certified by: ' PI? k PLA Design Professional Address: / Gt/A,/���- Lie. # —0� Comments: l~ aml FIR -99 AUG -25 -2005 THU 15 :28 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 - - -- - SIIEItLITA AIVILER,_1VID,:MS, FAAP- Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health October 12, 2005 Mr. Steve Ferreira 103 Perry Drive New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road,: Brewster, New York 10509 •ROBERT.J: BONIDI County Executive Re: Site Inspection — Flavio Michael Way & Carolyn Way (T) Patterson, Lot 1, T.M. 34. -3 -31 A re- inspection of the SSTS at the above referenced project has been completed. There are no further comments to be addressed at this time. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR: cw Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT It / l`° "� `':` -�; g r �� Located at e%c qM--, �� � `yN Town or Village T A- Mrc,OsoA) &f -MG(-1 Gk<N Subdivision name N0 -XI-11 Subd. Lot # Tax Map Block 3 Lot 3 / Date Subdivision Approved /.I" Renewal Revision Owner /Applicant Name /-:71Z-A Jz:a �CZ-44110 Date of Previous Approval Mailing Address -2-o Z/Yl -h Sir aftfl";r A011 Zip 113 (aq Amount of Fee Enclosed SOU 06 Building Type Lot Area No. of Bedrooms 3 Design Flow GPD_(&-00 Fill Section Only Depth Z U // Volume 3 5-0 G- PCIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of %O gallon septic tank and�a� L o Z4 w p6 A3 Soo P-; -Iv,J 7 o 1-/ O. L Other Requirements: 2- -1-v y-i u /Z To be constructed by 'Address Water Sunnily: Public Supply From .> Address Private Supply Drilled by /�j1/10 S� WWQ- �&iZGiic - Address •50-7 . - - - - - -- I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the sggarate sewage treatment s, stem 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: '�'� P.E. R.A. Date Address SyF AF---cxe, -,ya /03 zip. - /✓ � ��' License # O'Z/o 793 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 whe , o idere d necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. rov d f discharge of domestic sanitary sewage only. By: Title: l � 1D1ate:jj7,3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL print or ty' pe. _ :. .. :.. :.. _ .._ - '. PCHD PEIYTlIt #'4 Well Location: Street Address: Town/Vilage Tax Grid # AnZ11 -50 / Map 3't Block 3 Lot(s) 3 Well Owner: Name: bwe-0 F4-*" Address: 1 /3 3 6 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought —S- gpm # People Served __L-L Est. of Daily Usage 1&0 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason N, %2" S'ep /".ve- for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes Y No Name of subdivision C-i J A)OATq Lot No. I Water Well-Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No 1! Name of Public Water Supply: N A- Town/Village ',4 Distance to property from nearest water main: N A- Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: f -k w— o-2�--Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This .permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water, e 1 driller certified by Putnam County. 1. Date of Issue Z ° 5 Permit Issu fficial: Date of Expiration v Title: ( Permit is Non - Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 :. LORETTA :�MOLINARl - R ..N.; .-M:S:N: Acting Public Health Director Director of Patient Serves > .._... '"ROBERT` J. ` BONDI County Executive . . �f� DEPARTMENT OF HEALTH p 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool 845 278 - 6014 Fax 845 278 - 6648 vl March 14, 2003 } Stephen Ferreira, P.E. 103 Perry Drive New Milford, CT 067776 Vyy�3 Re: Proposed SSTS: Flavio /Rizzo Michael'and Carolyn Way, Lot #1 (T) Patterson, TM# 34 -3 -31 Dear Mr. Ferreira: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. //ovill profile is to show house elevations, septic table and effluent line. 2. All separation distances are to be taken from the toe of the fill section, therefore. the / minimum distance from the fill to the property line is 10 feet. J. ✓ The well is to be. labeled as proposed and the location is to be dimensioned from the . 4. �roperty line. _ ✓ e system is proposed on a slope greater than 15 5. C Curtain drain stand pipes are to be shown and detailed. 6. The minimum offhree feet)f fill is. to be provided for the entire SSTS as per / subdivision design schedule. 7 / All waterbodies, wet!andis and watercourses within 200 teet of the property line are /to be located on the plan. 8. V All proposed and existing SSTS's within 200 feet of the proposed well location are Rio be shown or a note stating none exist added. 9. / All proposed and existing wells within 200 feet of the proposed SSTS are to be shown or a note stating none exist added. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this. regard. Upon receipt of a submission, revised to reflect the Ogv,,,e . omments, this application will be considered further. J L .�1 y..; J t._9 ! t RM:tn V y ruly yo rs, .V f Robert Morris, P.E. Senior Public Health En,ineer --]PUTNAM COUNTY-DEPARTMENT OF-HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 611�lv es �G Address Located at (Street) Tax Map 331 j Block 3 Lot (indicate nearest cross street) Municipality Watershed,/4zz>0/_,,g_-- :BgA"4�� SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test /,:z, NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each 'percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 er X XX ... . ....... ............... ... lad tu .... ..... /1,0_ -7 /;2 3 3,3 2 1 15,5 zz_-7 7 3, X, 3 A/ 4 5 ez 5 2 2U --.2-3% 314 `/, a 3 a 5 - 10) a 0 L 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each 'percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 - - - - -- -- .- _ ...... _ _.. _ -.. TEST PIT DATA - -- -- DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES aDEPT"rI:::..:: HOLE NO. At G.L: 1.0' , 1.5' �� s 2.5' 3.0' 3.5' 4.0' a. r 4.5' e 5.0' w cosh /� 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' HOLE NO:__` - = BOLE NO....... Indicate level at which groundwater is encountered Indicate level at which mottling is observed A,)oA. Indicate level to which water level rises after being encountered Deep hole observations made by: `(Z� E � G ,�/�� Date 71;25 Z-o2 Design Professional Name: Address: Signature: Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF.ENVIItONMENTAL HEALTH SERVICES'_.-. A;. TINITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project 7Z /Z Z. a () T� County Site Location /t��l �_ �„ /yo / Building construction begun Extent — Is property within NYC Watershed ? ................. Yes Q No SECTION B. TOPOGRAPHY (Pleas check all appropria a boxes) 1. : a Hilly 0 Rolling St ep slope Gentle slope Flat , .575 2. Q Evidence of wetlands Low area subject to flooding F7 Bodies of water Drainage ditches t 2 Rock outcrops g ✓Y,� z.o l �Py 3. Property lines or comers evident ....................... ............................... 4. Do water courses exist on or adjoin the property? .........:... .............. 5. Will these affect the design of the sewage system facilities ?............ 6. Do watershed regulations apply in this development ? ....................... 7 Will extensive grading be necessary? ....:............ ............................... 8. Will extensive fill be necessary for SS rS? ......... ........... .: ................ ... . 0 es 6eLg' Yes Yes F_lYes Fz-(IYe's E2TNo �No 0 No No %�No . 0 -No - ... . 9. Do filled areas exist within the S STS area? ........ .................... ............ 0 Yes . [E]*No If yes, what is the condition of the fill? SECTION.C. SOIL OBSERVATIONS 10. Appearance of soil: E Sand Gravel Loam F Clay Q Hardpan Mixture 11. Observed from: Q Borings F_� Bank cut Backhoe excavations 12. Soil borings/excavations observed by % `REF_-q on 13. Depth to groundwater �(1 C2 A j j� ' on 14. Depth to mottling tU t) AJ on 15. Are test holes representative of primary . & reserve areas ...... ............................... EYes a No 16. Soil per6olation tests made by JE� 17Z. A on 17. Soil percolation tests witnessed by . f 1C E�p on SECTION D (on back) Form ST -1 2 e- y yak SECTION, D. DRAINAGE-,, _ - -- _ y1Z.- J Q. 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes No. 19. Will groundwater or surface drainage require special consideration? ............... . ...,. Eafes . D No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... F7 Yes a No SECTION E. REMARKS 21. If a common water supply is proposed; has an inspection been made of the existing or proposed source and facilities? .............:.................. .....................:......... F Yes io Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ............................... Yes 0 -No 23. Additional comments 24. Site observer /inspector and title _� �E6"r> r !�� , H 25. Date(s)-of observation(s)inspection(s) V, 12 TEST PIT PROFILES Hole # Lot # Hole # 'Lot # Hole # Lot # Depth to water Depth to water Depth to mottling .Depth to rock/imp. G.L. Depth to mottling Dep_fh to.rock/imp. G.L. 1.0 1.0 2.0 2.0 3.0 3.0 4.0 5.0 6.0 7:0 8.0 9.0, 10.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 Depth to water Depth to mottling Depth to rock/imp. G.L. 0.5 1.0 2.0 3.0 4.0 5.0 6:0 7.0 8.0 9.0 10.0 a �1 6 37 X49 � ,• 10 1.0 7 9 < 48 m 36 ' 4.6.8 AC. °2� ��` 4 ' AC a 2.83 AC. AC. ,� g 30.3 �6QSS °' a 0199 1A 4�TS 35 y 42 a Ac. 1 2 AC. _ 1.46 AC. ti0° 45 �; a�'�♦ �3 AC.. 34 ■ �k �� 2.32 C. a t5° '`24 Is 43 Q 2 t2; t �3�t< •a / {�� ?tea ASP 2 3 36.3 / 3a. 12 25 2.49 AC. , o -�,� �2� // 6 �� 9 288.94 �' �eQ 33 2 eP 1 T`Cy ,0.1 a � � � 2;c 0�1 t1� 3r ■ 3 p R.a 28 �r `2415 00 � 510 29, tR� 1.42 . 23.2 sra 1.41 AC. ti� A�•'� $ t2e`�� .00 82 AI S-10 g AC. 3.97 AC. •. 27. � a 4 �' 26 �� ` 1.sue. / e 26 1os.23 � � � 31 Q� 1.557A( a N 2C7 $ 32 - ry .,33 192`x' p 27 Br �4 i 34 a ■ fig'/ 2 1 1.74 A3. i 1. 45 - s • 1q� �ti 1.91 AC. 1.59 AC. C. 2094 AC. AC. 2 r �3 188 II ,, -- 191.00 258 155 4C./ i e Q wok Sg-,o-w-s (,cx isri ,04) 9 oovorlot,4rliomf • ro w 1 w ■ ...� N / . . 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Ln (Domestic Mail C 1=1 y; No Insurance Coverage Provided), 3n visit our website at www.usps.co I 4__ -0 17� For delivery inform '10 11 Postage $ ru Certified Fee O C3 C3 Fla Fee Return t" UNIT ID : 0149 (Endorsement Required) - Was I rTj (Endorsement Required) E3 rU Total Postage &Fees 1.75 clerlk. K"'SHIP5 E:3 Restricted Delivery Fee M (Endorsement Required) C3 4.42 rU Total Postage & Fees ru ILi r3 Sent To C3 ft � A). C3 ---------- ..... 17- (`- or PO Box No. ---------------------------------------- IL/ Ll PS Form 3800, June 2002 See Reverse for Instructions C3 m Wiffl-TUTW4 N Or-w-MMIT.911T. Ln I Er PAOREN, EY -0 17� nj Postage $ ru Certified Fee O C3 C3 Fla Fee Return t" UNIT ID : 0149 (Endorsement Required) E3 Restricted Delivery Fee rTj (Endorsement Required) E3 rU Total Postage &Fees RECEIPT *U&W,W'Apt. No.; - --- ----- or PO Box No. cwrance Coverage Provided) M 17� u-r website IAL at www.usps.como USE Ln I O.37 UNIT ID : 0149 u nj 7,10 Postmark C3 C3 1.75 Here C3 Clerk: KKLIM P5 E3 M 0 11/04AK nj PC` I A L USE NO-11 Postmark 1.75 Here Clerk: KKSDP'5 4.42 111/04102 Sent To *U&W,W'Apt. No.; - --- ----- or PO Box No. ------ ---------------- - -------- ----------- ----- ----- ------------------- — ------- r. or PO Box No. ................... -------------------------------------------- ------------------ 2�= PS orm 3800, June 2002 See Reverse for Instructions' PS Form 3800, june'2002 -See Revcirselbi Instruction .... Z"i U.S. Postal ServiceTNI U.S. Postal ServiceTM s Re ee, verse' instruction CERTIFIED MAILTM RECEIPT CERTIFIED MAILT. RECEIPT - (Domestic Mail Only; No Insurance Coverage Provided) (Domestic Mail Only; No Insurance Coverage Provided) 'o For delivery information visit our website at www.usps.conno For delivery information visit our website at www.usps.corno W211, W-011111 I I'Ll C3 Certified Fee n Return Reclept Fee 0 (Endorsement Required) 0 Restricted Delivery Fee M (Endorsement Required) C3 ru Total Postage & Fees Postmark Here C I e r Ir, : 11(K S I I P 5 14-412 111/04/02 ru 0 Sent To 0 or PO Box No. -- City, State, ZIP +4 PS Form 3800, June 2002 See Reverse for Instructions rti C3 Certified Fee C3 C3 Return Reclept Fee (Endorsement Required) C3 Restricted Delivery Fee M (Endorsement Required) C3 ru Total Postage & Fees Postmark Here Clerl.:.-: KKSDP5 4.42 111/04/02 nj C3 Sent To C3 coA7-rt ----------------- - - x -------- or PO Box No. (710 -- ----------------------------------------- .......... .... - --------- ------------ City, State. ZIP+4 miw,� vl PS Form 3800, June 2002 See Reverse for lnstruction� I'Ll C3 Certified Fee n Return Reclept Fee 0 (Endorsement Required) 0 Restricted Delivery Fee M (Endorsement Required) C3 ru Total Postage & Fees Postmark Here C I e r Ir, : 11(K S I I P 5 14-412 111/04/02 ru 0 Sent To 0 or PO Box No. -- City, State, ZIP +4 PS Form 3800, June 2002 See Reverse for Instructions rti C3 Certified Fee C3 C3 Return Reclept Fee (Endorsement Required) C3 Restricted Delivery Fee M (Endorsement Required) C3 ru Total Postage & Fees Postmark Here Clerl.:.-: KKSDP5 4.42 111/04/02 nj C3 Sent To C3 coA7-rt ----------------- - - x -------- or PO Box No. (710 -- ----------------------------------------- .......... .... - --------- ------------ City, State. ZIP+4 miw,� vl PS Form 3800, June 2002 See Reverse for lnstruction� Postmark Here Clerl.:.-: KKSDP5 4.42 111/04/02 nj C3 Sent To C3 coA7-rt ----------------- - - x -------- or PO Box No. (710 -- ----------------------------------------- .......... .... - --------- ------------ City, State. ZIP+4 miw,� vl PS Form 3800, June 2002 See Reverse for lnstruction� *J AO 1N3Wi6Ud30 AiNnoo WUNind:3WUN T26)L-8,L2-9t,8:131 9t7:80 IdA 2002_9T_AUW 2. May-16 2003 5 a V.: Robert Morris, RE Putnam Co. Health Dept. 0; 4 Geneva Road Brewster, NY 10509 Re: Burdick Glen Subd.[Rizzo Lot 1, SSTS Michael Way Patterson-Putnam East Branch Reservoir DEP Log # 12819 (Joint Review) Dear N4r- Morris: '! �4 This letter is to inform you that the New York City Department of Environmental Protection (Department) has determined that the above-referenced application is complete. In addition, the Department has no objection to the approval of the 'Aft he review of -referenced regulated activity, This determination is based on t above- referenced submitted documents including the plan titled "SSTS for W Anthony Rizzo", dated 12/20102, and revised 4/3/03. The applicant must contact Sissy De La Ossa of my staff at (914) 773-4416 at least 2 days prior to the start of construction, of the SSTS so that a Department --representative may inspect and raomtor te-misuflatdon- Sincerely, OA Danny Shedlo, P.E. Project Manager Engineering Design & Review xc: James Covey, P.E., NYSDOH' a. ZO'd OT:OT �O, 91 MO-BIZ-VT6: xPJ 9NId33NI9N3 d3Q DAN — °.•. - LORETTA MOLINARI R.N., ±M.S.N. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Serviceg (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 March 14, 2003 Stephen Ferreira, P.E. 103 Perry Drive New Milford, CT 067776 Re: 'Proposed SSTS: Flavio/Rizzo Michael and Carolyn Way, Lot #1 (T) Patterson, TM #.34 -3 -31 Dear Mr. Ferreira: Review of plans and other supporting documents submitted at this time relative to the above- regarded project has been completed. Comments are offered as follows: 1. Fill profile is to show house elevations septic tank and effluent line. P � p r 2. All separation distances are to be taken from the toe of the fill section, therefore, the minimum distance from the fill to the property line is 10 feet. The_ f,,l i.- tole -Ub If d.as pr-oposed-and-th *e- locatioh-iB to- b&dimensioned-4rom-tht —� -°----_ property line. 4. The system is proposed on a slope greater than 15 %. Curtain drain stand pipes are to be shown and detailed. The minimum of three feet of fill is. to be provided for the entire SSTS as per subdivision design schedule. All waterbodies, wetlands and watercourses within 200 feet of the property line are to be located on the plan. All proposed and existing SSTS's within 200 feet of the proposed well location are to be shown or a note stating none exist added. All proposed and existing wells within 200 feet of the proposed SSTS are to be shown or a note stating none exist added. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:tn V rely yo s, 11A� Il Robert Morris, P.E. Senior Public Health Fnginee.r PROJECT I.D. NUMBER 617.20 SEOR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To: be =compla.4,ed-by Applicant or Project-sponsor) 1. APPLICANT /SPONSOR )�U« 2. PROJECT NAME XI ? aO 3. PROJECT LOCATION: c -itq f C%t/toG�w `✓ Municipality Count 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 77f 5 Cc.,Liv>E� 6 D1/LlC*-[0�r L i`/ CifYLoLy 6. IS PR OSED ACTION: ew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially ' ZV acres Ultimately 2--1 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? )QYes El No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? lkyes ❑No If yes, list agency(s) and permit/ ! pprovals - __ _ _- _- , -___, . -_ -.._ _._._. _._.._ _ _ .._ -_ -_ _- •_ r- - _ . . 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes LLl O If yes, list agency name and permitlapproval 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 P� ` 7 l ApplicanUsponsor name: '"' 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 PART 11-- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 617.1? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative-declaration may be superseded by another involved agency. r .� ❑ Yes ❑ No »..._ - . C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. c:) �. C... 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)? P ( 9 9 q ry yp gy)? Explain briefly. D. WILL 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 ❑ 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 identfffed and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide ort attachments as necessary, the reasons supporting this determination: Name or Lead Agency Print or Type Name of Responsible Offic er in Lea -Agency it a of Responsible Officer ignature of Responsible Officer in I ead Agency Sqnsitire of reparer (if different from responsible officer) Date 2 i 1 514 U T\ R< 25.00' 82W4'a.6" �-= 35-e8' �G•F, G�.gN 3V� �,G Z�N'E�. a gv0.� IF NAP O� T >zoozc yr*-rry mvJL.Odd1,oL.5. car.e),M.Y. w5i2 too) 225 -oi,64 m ayN. �t•.s.vrd %NY�C/��aYp�1�IM t04 fiD�iO.��mdQ �f. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SY�TEIVI r r C rERMIT # - Y Located at Caw" ,,ayX4C Town or Village ,P7ra5� Subdivision name gu a o t c& C� /�°- Subd. Lot # �_ Tax Map _ Block -3 Lot % Date Subdivision Approved �!?y T Loo Owner /Applicant Name -rgoq-(J Co r/� d Renewal Revision Date of Previous Approval Mailing Address 'Z-L- u„� e:�r9 -DIY �/`� ?T'S /� / !!%-z Zip _ Amount of Fee Enclosed (Pxr� Building Type Lot Area 2j No. of Bedrooms - 2-) Design Flow GPD SOO Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of leco gallon septic tank and 33.3 L -I- of-- Zy L< wt o�c A�S,�O�d 7'C&-A) —C Other Requirements: x-a el Oy-/� To be constructed by ;"/-?>_ ©- Address Water Supply: Public Supply From Address PP y y � � XA,1;A -* ' Address_.. ---off-- Privets- Su -1- - Drilled -b - 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 repaihereto. Signed: P.E. R.A. Date Address �S a0 . y2f � �iG��4 e C-->�- z.6 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 w c sidered ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe i . pprove ischarge of domestic sanitary sewage only. By: Title: ��i Date. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner fit- At/ Lvl- Address 9Q— Located at (Street) v1- a /,4, ( f li [ P&X Tax Map SK Block 3 Lot -3% indicate nearest cr ss street) Municipality A-"-r- - - rt 4oJ Watershed /;;fSr l3%f�✓¢ SOIL PERCOLATION TEST DATA Date of Pre - soaking /o 5- Date of Percolation Test rl 1 Is -9.4 � r 21 -7a` Q- 2 g ' -- 9 Y3 27 � � — 30 `/' , 3 3 '- i =O� C� 2-7 - 3-0 `` 3 4 �4 - ='L� �v 26 4 J 5 2 9,30 l� 77 " _ 3,, 3 �`o- i o i� Z �f 3� 4 5 1 2 3 • NN, r 1 NOTES: 1 : Tes�ats"fS`be�repealed at same depth until approximately equal percolation -rates are obtained at each t ercol att'onatest hole, .(i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be ,L jubmi4d for review. 2 %Depth measurements to be made'from top of hole. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES -DEPTH NO. .. G.L. 0.5' 1.01 1.51' 2.01 2.5' 3.0' 3.5' 4.01 4.51 5.01 5.51 6.01 6.51 7.0' 7.51 8.01 8.51 9.01 9.5',— 10.01 HOLE NO.- - -HOL&NO., - 2 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: Design Professional Name: 1, Mpf-4r- 1 Address: _10,3 je Aire-ou aiL-rv" r-r &;6-7-7 C Signature: Design Profes#44NAeal Date Q 0 I SUPPLY." jpVFf BY." -BUILT SL AS P MATE 7HELL DIOD L ODELL P.L.S.- 4. o5o074 -"iflRMA,N ANDERSON, lK UCENSE R; T1� 152 BARGER S 1 ELT PUTNAM VAU3 E'; ly I ��O':C�A 1�f 2`r I lq ` 3z` I' 6 S9 7 is Putnam Cou-ry "07ar`ment of Health Division o$ rro�:.:., sit Health Services Approved as I (I- ;e'er conformance with applicably Rnd Regulations of the team Coc, with Department.. G -- /- -I -�70 /3 Signatur & T ti c Date h n � / \ k � E�tr a I' pT � N N THIS LS- - t' INDICX IT WAS '� �`FC ✓ Z STAND! P \ @ �-- i v!_�' cifsi 2.Qe ✓ �s'E AND TI O / • . / ' s FOV Np s i,e y O� F �o AS -BUILT PLANT "SF� GRAPHIC SCALE 0 15 3D I IN FEET ) 1 inch = 30 It /.ark PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner „rte /, -A: Ag-z-o Address Located at (Street) ✓I �cu !� e c Tax Map -sq Block 3 Lot (indicate nearest cross street) Municipality 4E,�Z- /AoA Watershed A,tc D-P. %/44*.Wt SOIL PERCOLATION TEST DATA Date of Pre - soaking GI Ztt 0z— Date of Percolation Test 9 as°'0y 1 2 3 4 5 L 2 3 4 5 1 2 3 -peraolati 2, - r`Veptl(: "Riaii >:: ..::.:':. ...: ...:T�e': o;a;r:v av p� a .. ::: >uri . c::...nc...:: ::::::i :4p: :........:::::.... `:.:.:gin; ::«::<:::::.... >: >::ta; >;:; :to Iuebes ..:::;::;:::MnfInelt ::: 222, <r — ZS-Z 4, 3,33 ZO 12- Y3 Z,L(S7-3 :/0 25 ov — Z') v :,fteated at same depth until approximately equal percolation rates are obtained at each n #test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be :for review. a'surements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' . 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8:5' 9.0' . v 9.5' . 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS EN. COUNTERED IN.TEST HOLES HOLE ISO, % HOLE NO. HOLE NO. 0-Y � 7 o,P SaiL �r�/c cu✓Q�S' K cw Indicate level at which groundwater is encountered /V©Nve, Indicate level at which mottling is observed /yo.Vif-- Indicate level to which water level rises after.being encountered /aAW . Deep hole observations made by: �rG - P, #.o 5, P4M OSM Date aL- Design Professional Name: Address: 603 Pi �/liU,� 4Z 7A Signature: -�—� ell- Design Professional's Seal ® ®gam s®RAVIC®N Stephen J. Ferreira, P.E. 1031'erry T3rive' - New Milford, Connecticut 06776 Gene D. Reed Putnam County Health Department Devision of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit Sect: 34 Blk: 3 Lot: 31 "Burdick Glen North Subdivision" Michael Way and Carolyn Way Patterson, NY Dear Mr. Reed: Please find enclosed: January 8, 2003 A. - (3) copies,of Fill Plan (Sheetl /2) and (3) copies of fill plan and SSDS. 2. Two sets of modular home plans. 3. Construction permit application. 4. Letter of Authorization. 5. Application for approval of plans. ...6 —.— __Application to constrict a water.well.- 7. Soil Data Sheet. 8. Short environmental assessment form. 9. Property Survey. 10. $300.00 Certified Check-IV/ 11. List of property owners notified in accordance with the required neighbor notification. The information enclosed is provided based on our recent conversations and our field inspections. Please feel free to contact me if there are any fiu-ther questions or information required. Sincerely Yours, Stephen J. Ferre' a i BRUCE R. FOLEY LORETTA MOLINARI RN., M.S.N. Public Health Director .. .. -.,, .. - _.. .. _. .....,,,_._..,.. F 0� .. -. .Associate Public,. Health - Director •.- Director of Patient Services. DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 S WIC (914) 278 - 6678 Fax (914) 278 - 6085 Gf r .._ COVER SHEET .. PROJECT (Owners Name): STREET: I4 t Cwf'q 6 iN UNICIPALITY: TAX MAP NUMBER: DESIGN PROFESSIONAL: _5�reJg- fOU Imo- DATE: 1 E REVISION ` REQUESTED ADDITIONAL INFORMATION CC P /&'5 OTHER �Arl C pG BRUCE :R. FOLEY . ON M.S.N. I R Public He,fth 1lirgctor s .._Associate. Public -> Health Director Director of Patient Services . DEPARTMENT OF. ' B EALTH 1- Geneva Road Brewster, New. York ' 10509 . Environmental Health (914)278=600 . Fax (914) 278-7921 Nursing Services (914) 278 - 058 WIC (914) 278:- 6678 Fax (914) 278 .:6085 Early Intervention (914) 278.- 6014. Prescbool. (914) 27$ -6082. Fax(914)279'.664& TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW 0 DELEGATION STATUS FOR, SUBSURFACE SEWAGE TREATNIENT SYSTEM.PROGRAM JOINT REVIEW PROJECT: LZ TOWN:fd'11 (rrxEV2) Z 'd d0 iN3WIdUd38 AlNnoo WdNind : 3WUN 70'j ti2U-- 8Z2- Sb8:13i SO :bZ Nns 2002 -2-dbW February 28, 2003 Robert Morris, RE Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Burdick Glen Subd./Rizzo Lot 1. SSTS Michael Way Patterson - Putnam East Branch Reservoir DEP Log # 12819 (Joint Review) Dear Mr. Morris: Please note, the following comments regarding the system design: 1. Toe of slope of fill must be at least 10' from property line. 2. Show all watercourses, stream and wetlands boundary within 250 feet of the property line. 3. System slope exceeds 15%. If you have any questions regarding this matter, you may contact me at (914) 773 -4416. Sincerely, g ;"4 6), Sissy De La 4ssa Assistant Civil Enoneer Engineering Design & Review xc:.James Covey, P.E., NYSDOH 9Z:Sti �0 8Z qa3 £b20- i1�- bl6:x:e3 9NI�133NI9N3 d39 SAN PUTNADI COUNTY DEPARTLNIE \T OF HEALTH _ DMSION OF ENVIRO \MENTAL HEALTH I\DIVIDUALWATER SUPPLY & SUBSURFACE SENVAGE TREATME N T SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT' NAb& OF OWNER: STREET LOCATION: REVIEWED BY: RIM, GR, AS, SRDATE: 1' �ERDNIITAPPLICATI'ON DOCU`IENTS � ' 5 WELL PERMIT OR PWS LETTER UP T.4X 1,,LAP =: (CONF�\fED) ;!5-L ' �\ (REQUIRED DETAILS ON PLANS CO\TD) HOUSE SEWER-/4" FT. 4 "0'; TYPE PIPE CAST IRON `7Z' J \0 BENDS-, AIAX BENDS 45° NV/CLEANOUT• RENEWALS T 0 HORIZATION (�/ (_)SITE NOTE (NO CHANGE) GN D SHEET (DDS) / FILL SYSTENTS (� �Cy' ATE RESOLUTION f (_e 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE CZLJ.SHORT EAF (FILL SPECS! FILL NOTES 1 -5 `2fLANS THREE SETS n Cr FILL PROFILE & DI`IENSIONS HOUSE PLANS -TWO SETS FILL D EXPANSION AREA (,�iCARLA.NCE REQUEST ,� FILL GREATER THAN 2 FEET � � SU$DIVTSTON CLAY BARRIER UL___)LEGAL SUBDMSION FILL CERTIFICATION' NOTE . ' UUSUBDMSION APPROVAL CHECI,'ED DEPT$ GAUGES U FILLRE DIRE -D DEPTH 'OL ON PLAN FORRO.B., UNCLASSIFIED & IMPERVIOUS (--) Q -'rte- . 1 �-"-': EPARATION DISTANCE FROi1 TOE 'OFSLOPE (�UCURTATN DRAIN REQUIRED �L'� RENCft GENERAL LF TMAX RENCH PROVIDED LOFT MA LOCATED IN NYC.WATERSHED ' PARALLEL TO CONTOURS fi . J(fJPLANSSUBiVITITED•TODEP - �j In0 4-E —Nv ION PRQVIDED- ._.- ..:__......... ._.:.:. ...., (�DELEGATED TO PCHD > DETAIL/DUST FREE CRUSHED STOKE OR WASHED. GRAVEL. DEP APPROVAL, IF- REQ'D, GEOTEXTTLE COYER DEEP TEST iiOI:ES'OBSERVED SEPAR4 FIOY DIS7 A`i CS 0\ PLAN = FTtOi4I SSf S . r PERCSTO BE WITNESSED ' • ( 10' TQ I':I., DRTVEWAY, LARGE TREES, IT OF FILL . . (SEX- APPROVAL SSDS AD7, LOTS- ( 20' TO FOUh'D?;TION WALLS _ (� WFTLANDS � Q"IDEC.PER?y4T.AEQ'D ?) 0100` TO'WELL, 200' IN.DLOD,150' TO ?.ITS (�D,&TA•ON DDS:PLANS.&.'PEPiNUr SANM TO STREl�ti1, WATERCOURSE 'PRE, I O C OY "-' ' ' -� , LAIM CLdG ex Brij 9G9NEIGHBORN TIFI ATI i ,,) 'TOCATCHBASIL`(,3a STOWNIDRAL\,PIPEDWATER LETTERBLZBA 14'TO WATER,ICiE (pits -20') 100 YR FLOOD ELEVATION W/I200' jg0, IN'TR�ti11TiE`IT DRATI`i�GE:COURSE .: SOIL- TESTVG LOTS'�TO YEA S OLD (�'OOY500' RESERV`OTR, ETC 150' GALLEY SYSTEMS �EOUTRED DETAILS ON PLANS UU10'.hILYTO LEDGE OUTCROP _ _ ...._ SEwkGE SYSTEM PLAN- (NORTRARROW), SSDS HYDRAULIC PROFILE SEPTICTANK LxnI0' FROM FOU\'DATIOY; 50' TO WELL ' GRAVITY FLOW CONS [�GTjON.P[OTES_1.15_ -- 'WELL' D1SII:NSIONSTOPROPERTY -Lr - - -� (�DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED y; LOCATION OF SERVICE COI; IEC'TIO\ , ( _6(�__)ML`i 15' TO PROPERTY LINE 2DRIVEWAY & SLOPESf. CUT ' SLOPE FOOTING /GUTTER/CURTAIN DRAINS ( SI on L AREA (520 %) • " ::. �`3• ::: . ' (� USDA SOIL TYPE - BOUNDARIES (_,TITLE BLO CK; OWNERS NAME ADDRESS . JREGRADED T015 %, IF REQUIRED L% . DOSEIPUhTP SYSTEMS Th X PE/RA; NAME ADDRESS, PHONE (DATE OF DRAWING/REVISION (_}tNPUMP NOTES U( )DOSE 75% OF PIPE VOLUMEMOSE VOLUME NOTED DATUM REFERENCE UUDETAIL FOR FORCE MAIN, (PIPE TYPA, ETC.) UULOCATION 0 OURSES, PONDS C )UPIT AND D -BOX SHOWN &DETAILED 6LLAIIESI�('M' L ANDS WIT 200' OFP.L. — U(_1 DAY STORAGE ABOVE ALARiti1 PROP SED FINISH F RAND CURTAi� iDRAR I B ME IOI" WE LS & 'S WAN 200' OF SSTS _ UUSTANDPIPES, 5' BOTH SIDES, DETAIL' ( PRO Y METES &BOUNDS vEROSION,CONTROL FOR HOUSE, WELL & UU20' M NZ to CD DISCHARGE/100' with 182 cans day discharge . SSTS, EROSION CONTROL NOTE . U�10' h1IN to NON- PERFORATED PIPE COMMENTS: (ItEVSHEE r)oProu00 i BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 February 7, 2003 Stephen Ferreira, P.E. 103 Perry Drive New Milford, CT 06776 RE: Flavio Michael Way & Carolyn Way, Lot #1 (T) Patterson, TM# 34 -3 -31 Reservoir Basin Dear Mr. Ferreira: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on January 16, 2003 is complete. The Department will notify you by March 1, 2003 of its determination. ❑ The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ® Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of a� Letter to: Stephen Ferreira, P.E. - February 7, 2003 -2- 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. 2166. Ve tly yours, /�1/ / RIOW Robert Morris, PE RM:tn Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of'12�� -1 Located at CA 12 b. �`f _!,! W TN UA T i ;, =SpA} Tax Map # 39� Block 3 Lot __ Subdivision of Subdivision Lot # _ . _Filed Map # 11 Date Filed 2 r9 v$ Gentlemen: This letter is to authorize 57X'O O�'f,� � I 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 conformity with the provisions of Article 145 and/or 147 of the Education Law, the- Public Health Law, and the Putnam County Sanitary Code. Very truly you Countersigned: Signed:'' P.E., R.A., # 076-793 (Owner of Property) Mailing Address 10STre4kT State G Zip O (o`T Z b Telephone: SU ---480 — 0 7 7 Mailing Address: 6 1- ZD 6015 tl�' State W, \ r Zip Telephone: T(S ` 'Z24 1 l 19 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 6�,- �arua 1Z �i� „��/LA�✓� F�y�d Ca w��� 61-40 z•v l* -5-77U67- 2. Name of project: /e 7- a-v 3. Location TN: /94' 7-711,12410'A) 4. Design Professional: Sir -,,o ,y fie-4461M 5. Address 6. Drainage Basin: og;-,41.57- 6/?v*tA 7. Type of Project: Private/Residential Food Service Apartments Institutional _ Office Building Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... ,va 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency iv v 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ................... .. ......... ..... _.. ..._._.......�.n..�,...�.:�:r.: - - _ ..tea...,__... _. 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities? r} Date granted: — 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) ..........:. - . ............................... ............................... 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? ................ oVa 21. Name of sewage system Distance to sewage system 22. Date test holes observed 91t yf° v" 23. Name of Health Inspector C,r E 4exz /zsov 24. Project design flow (gallons per day) ................................. ............................... Zoo 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... -- /'a 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 8199 2 27. Is any portion of this project located within a designated Town or State wetland? /Pv 28...Wetlands ID;Number.. .............................................. ...... .....:..I..... 29. Is Wetlands Permit required? .............................................. ............................... ,yo Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... A/o 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? ......................:..... YeE�D, 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 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? ................................ ............................... No 35. Are any sewage treatment areas in excess of 15% slope? ............................... NZ 36. Tax Map ID Number .......................... ............................... Map Block Lot 37. Approved plans are to be returned to ..... Applicant _ Design Professional - - NOT- ::Altapplications for- review and approval of anew SSTS- to be-located within the NYC Watershed- shall' - k be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans ox-the creation of W ,,t� —- impervious surfaces, and the project applicant should obtain the appropriate forms for suchcactivities 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 pray %srbn may be grounds for the rejection of any submission., cn 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 21:0.45 enal Law. SIGNATURES & OFFICIAL TITLES: r Mailing Address: ................................... /0 3 rr r r' OPEN BEDROOM #1 BEDROOM #2 B5LOW 17'8 x 18'5 13'1 x 14'11 , rr ' I CATWALK }r • J PRELIMINARY PLANS SUBJECT TO ENG. APPROVAL NOT FOR PRODUCTION r 2852 2852 R.O. FOR ANDERSEN 2852 2852 WINDOW (SIZE T8D) II 48' SECOND FLOOR LEVEL (8' CEILING HEIGHT) .1 I , v/0 i 1-�4A1 a i D r M ' I i PUTNAM COUNTY DEPARTMENT OF HEALTH 4 $OUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, r BEDROOMS ; ALL SU EQUEN P VISION JALT ZATIONS TO THESE HOUSE �L ST E BirIiTTED TO THE 284s 2421D 2846 iAUCET IDG7roN , ' nnrr9e ,'SIGNATURE &TITLE DATE BEDROOM #3 i ; ; ' r 1 WH\ BATH #1 '"� 173x 117 W.I.C. ; 15'6 X 11'7 .. HT3 x 1117 i ® i T x 11'7 ' ® i NO WALL r , 80� SHOWER` PAN Ow o 1 ABOVE3 ER PA\M\ RO.FORFUTURE PULL DOWN , UN- FINISHED STORAGE 30`INT. DOOR , ArnOSw66 , J SPACE ABOVE SITE BUILT ___ __FLUSH HEADER _________ _________ ___________ GARAGE I FLUSH HEADER , DN Jfl- rr r r' OPEN BEDROOM #1 BEDROOM #2 B5LOW 17'8 x 18'5 13'1 x 14'11 , rr ' I CATWALK }r • J PRELIMINARY PLANS SUBJECT TO ENG. APPROVAL NOT FOR PRODUCTION r 2852 2852 R.O. FOR ANDERSEN 2852 2852 WINDOW (SIZE T8D) II 48' SECOND FLOOR LEVEL (8' CEILING HEIGHT) .1 I , v/0 i 1-�4A1 a i D r M PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSFi,PLANS APPROVED FOR BEDROOM COUNT ONLY, �? BEDROOMS o ALL SUB UENT R VIS OTd�ALTLRATIONS TO THESE HOUSE o= PLANS U BE SU iTTED THE PCDOH FOR APFROVAL 2 24210 !� IN 20210 6088 VINYL FRENCH ' DOOR W/ GRILLES 2852 2852 o SIGNATURE &TITLE - - p p - z BATH 23 KITCHEN R.O. FOR FUTURE 6 X 17*6 x 1411 `• 42 FIREPLACE r� FAMILY U r !T OUNTERTOPS 22!6 x 14'11 (OM C ) ' � 2m FIRE RATED DOOR 24- X 24' SITE BUILT GARAGE ---- - - - - -- "'"°"°°�' HFADUt - - - -- __� _ -_ � -- _ -- _ (BY OTHERS) - SO ---------------- _ nN ; WA=OrAF.F. I ' DINING LIVNG TWIN 154 x 1411 OPEN 17.10 x 14'11 ABOVE i ::HEAMR 2852 2652 ��. TRAY CEILING - ,' ; , & ?AFF. ---------- - - - - -- n W ,, 2862 2852 3(0 &PANEL WITH 2852 2852 (z� sIDELIGHTs `" PRELIMINARY PL „ 48' FLOOR LEVEL (9' CEILING HEIGHT) SUBJECT TO ENG. �. APPROVAL N N 0 - F- FOR PRODUCTION o Z i '