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01521
'AM COUNTY DEPARTMENT OF HEALTH
ION".OF- ENVI[I ONMEN --TAL -HEALTH-
CERTIFICATE OF CONSTRUCTION MPLIANCIIE FOR SEWAGE TREATMENT
PCHD CONSTRUCTION PERMIT # �—q I' 6 !
q( AJOSh I cr L a�n -�..,
Located at k C-� {�(! dJ k)10 Town or Village
N d S 14 Y-0 LA. i A-VE
Owner /Applicant Name Tax Map
Formerly.
Mailing Address
Date Construction Permit Issued by PCHD
Block Lf Lot
Subdivision Name
Subd. Lot #
n
6A) Zip I Z5-&3
Separate Sewerage System built by t' wsd � Address CA-ILM 6�— AJ
Consisting of ' Z� Q Gallon Septic Tank and U �� Ci� �--�T - C, i+
D �2c9 x S
Other Requirements: `2 P. I 9,69 9 r! L.L, !' P- l A4 4.72 Y S
Water Supply:
Public Supply From
Address
or: Private Supply Drilled by C�"1. -- Address BIZ -
Building Type Has erosion control been completed?
Number of Bedrooms Has garbage grinder been 'installed? NU
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 regul ion of the tnam County De artment of Health.
Date: ��'�Z'b Certified by P.E. / R.A.
,7/� (Design Professionals n ,� T7
Address (' l� J � l v III � /�� �S Q � f I V %License #
t 7- +3
Any person occupying premises served by the above system(s) shaallf 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 'ect to odification or change when, in the judgment of the Public Health Director, such
revocation, d' cati change is necessary.
By: Title: �� Date:
.f
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
PUTNAM COUNTY (DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COi )1n1LETION-REP'ORT-- .'.::.:,:
Well Location
Street Address:
1429 Ice Pond Road
Town/Village:
Patterson
Tax Grid #
Map Block Lot(s)
Well Owner:
Name: Address:
Viktor Shkreli, 429 Ice Pond Road, Patterson, NY 12563
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
Well Type
X Rotary Cable percussion X Compressed air percussion Other (specify)
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length 31 ft.
Length below grade 30 ft.
Diameter 6 in.
Weight per foot 19 lb /ft.
Materials: X Steel _ Plastic _ Other
Joints: _ Welded X Threaded Other
Seal: X Cement grout _ Bentonite Other
Drive shoe: X Yes No
ILine r: Yes X No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed X Pumped X Compressed Air
Hours 6
Yield 30 gpm
Depth Data
Measure from land surface- static (specify ft)
30'
During yield test(ft)
140'
Depth of completed well in feet
205'
Well Log
If more detailed
information
descriptions or
sieve analyses -
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
8
Drillin
in over
urden clay-
Hit rock
- -° - -- "
8
31
Drillinalin
r
31
205
Drillinq
in rock
aranite
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type sub Capacity jLgpm
Depth 160' Model JOGS 0412
Voltage 230 HP 1
Tank Type WX302 Volume 86 gallons
Date Well Completed
10/30/03
Putnam County Certification No.
006
Date of Report
5/24/04
Well y9a (signatt
Ad L. Beal
NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sneet/pian.
Well Driller'syagie P. F. Beal & Sons Inc. Address: 4g*r'm Ave., Rm*r,+pr. W ICIrd1A
Signature: &__1111 Date: 5/24/04
Adam L. Beal
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Dec 23 04 10:31a
TOWN OF PRTTERSO
845 - 878 -2019
itUCE R. FOLEY LOWTA MOUNARi M. M.S.N. .Armen Heoffh Dkecfw Agoafofe Pabfk New Dtndor
Dtredar of Pefftaf Strvkei
DEPARTb ENT OF IEALTH
1 Geneva Road
Bmwster, New York 10509
Boolroeateatil Kt41tb (914)171.6170 FUP14) 371 -7921
Nvrstn& 9krdceo (%4)271 -6311 WIC (914)271.6671 Fu(914 271.60Es -
Carly loterveegoa (914)171 -6014 .1Prescboo1 (914)27& -M F4x(914)271.6641
E911 ADDRUM V.xJECAM NFORM
OWNERS NAME:
TAX MAP NUMBER:
E911 ADDRESS: �a5� �o �,4
�
AUTHORIZED TOWN OFFICIAL: r1 °o4'
(Signature)
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 h to be submitted
With the application for a Certificate of Construction Compliance. -
(E911 VEMM
P.1
e/Z 96ed `.Wy1C :l1 VO-CZ-39a `• L99VEZ !111 :48 lues
PUTNAM COUNTY DEPARTMENT OF HEALTH
.._ ..T ., �.� _ ... DI' SIO C►F ONMENTALM A LTH nSER ICE9S -
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building
Building Constructed by
XCI- 12OA10
Location - Street
w orso 1= 447kja
Building Type
3L4, —4— I j ► �.
Tax Map Block Lot
. P67RE-9_5 0 A)
TownNillage
CA, 51LIL&L
Subdivision Name
N
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 successorsn 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
- - -- --- operate7properly is caused by the willful or negligent act-of-the. occupant of the building utilizing the -
system.
The undersigned further agrees to accept as conclusive the determination of the Public Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing the
system.
Dated:. Month I- Day b Year �-
G eral Contractor (Owner) - Signature
Corporation Name (if corporation)
Address: PO
State ,��c .. Zip Z
J
Signature:
Title: 6-2v -
Corporation Name (if corporation)
Address:
State Zip
Form GS -97
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights; .. N : Y: ' 105,98
(914) 245 -2800
Albert H. Padovani, Director
LAB #: 93.402833 CLIENT #: 58096 NON STAT PROC PAGE: 1
------------------------ M - - - - - - - -
iANSON, JACK DATE /TIME, TAKEN: 12 /10/04 08:00
PO BOX 889 DATE /TIME RECD: 12/10/04 11 :40
BREWSTER, NY 10509 REPORT DATE: 12/21/04
PHONE' (845) -279 -8319
SAMPLING SITE: NOCH.KOLA DRIVE, PATTERSON SAMPLE TYPE..: POTABLE
WATER PRESSURE TANK PRESERVATIVES: NONE
COLD SY: JACK HANSON TEMPERATURE..: < 4C
NOTES...: COLIFORM METH: MF
--------------- - - ------ N ------ - ------ - ------ - r - - r - .. - -- N N - - - - - - - - -
DATE FLAG
PROCEDURE
RESULT
NORMAL - RANGE
METHOD
PUTNAM CNTY PROFILE
12/10/04
MF T. COLIFORM
ABSENT
/100 ML
ABSENT
1008
12/10/04
LM (IMS)
<1
ppb
0 -15 ppb
9101
12/10/04
NITRATE NITRROG
0.33
MG /L
0 - 10
9139
12/10/04
NITRITE NITROG
<0.01
MG /L
N/A
9146
12/10/04
IRON (Fe)
<0.060
MG /L
0 -0.3 mg /1
2037
12/10/04
MANGANESE (Mn)
0.017
MG /L
0 -0.3 mg /1
2037
12/10/04
SODIUM (Na)
26.4
MG/r,
N/A
12/10/04
pH
7.1
UNITS
6.5 -8.5
9043
12/10/04
HARDNESS,TOTAL
100.
MG /L
N/A
12/10/04
ALKALINITY (AS
114
MG /L
N/A
12/10/04
TURBIDITY (TUR
<1
NTU
0 -5 NTU
COMMENTS:
BACK THESE RESULTS
INDICATE THAT THE WATE
(WAS)MWAS NOT) OF A
SATISFACTORY
SANITARY QUALITY
ACCORD N . HE
NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR
THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION.
Pb /Cu LEAD limits for public schools are set at 15 ppb.
EPA Lead & Copper Rule for Public Systems requires that no more
than 10W cf 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
cotbined shall not exceed 0.5 mg /L.
Na No limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg /L of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg /L of Sodium
DEC -21 -04 TUE 04:50 PM FAX: PAGE 2
YML ENVIR=UWTAL SERVICES
321 Kear Street
�Y.
� _ .. 9
..Yorktown. i
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT. A -WATER WELL - _
please print or type PCHD Permit #� '
Well Location:
Street Address: Town/Village Tax Grid #
(; Y JJ ti fZ0 / fiA-
Sa I Map 3 Block Lot(s)
Well Owner:
Name:
Address:
5 � � � �� i
y z fee
Paso �ol%� 0 j -k I 1 Z_� 63
Use of Well:
Residential Public Supply
Air /Cond/Heat Pum Irrigation
1- primary
Business Farm
Test/Monitoring Other (specify)
2- secondary
Industrial Institutional
Standby
Amount of Use
Yield Sought S— gpm # People Served Est. of Daily Usage 200 gal.
Reason for
X Replace Existing Supply
Test/Observation Additional Supply
Drilling
New Supply (new dwelling)
Deepen Existing Well
Detailed Reason
re poi 014 ( ZEO-k V S
for Drilling
Well Type
Drilled Driven
Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ......................................
............................... Yes No L
Name of subdivision
Lot No.
Water Well Contractor:
Address:
Is Public Water Supply available to site? ..................................
............................... Yes No
Name of Public Water Supply:
Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contam;in' n
vided on separate sheet/plan.
atoe
Date:'1 (I 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 waIf well driller certified by Putnam
County. �
Date of Issue Permit
Date of Expiration Title: _
Permit is Non- Transferrab e
White copy - HD file; Yellow copy - Building Inspector; Pink copy -
- Well dri
Form WP -97
PUTNAM COUNTY DEPART,',IE \-I' OF HEALTH
DMSION OF ENVIRON, MENTAL HEALTH
UDWIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTE`IS
... -` . � REVIEN`SHEET -FOR CO \STRUCTIOY PERMIT -- _. " -' .: _., .. _ ....., ....., _ _.. -, . ;.�• ,
NAME OF OWNER: `a) O'CJ� -f STREET LOCATION: F '�
REVI "WED BY: RK OR, AS, (!PU: ` l TAX MAP': (CONFIRMED) l ~ ! S
Y N DOCUKEN ?S
(fUUPEp_mrr APPLICATION
(4(_UNtiTLL PERMIT OR PWS LETTER
UPC -97
UULETTER OF AUTHORIZATION
(-�UDESIGN DATA SHEET (DDS)
(_ -)(.ZCORPORATE RESOLUTION
OUSHORT EAF
U/ UPLA`iS -THREE SETS
WUHOUSE PLANS - TWO SETS
U(4VARiAN CE REQUEST
UULEG-AL
AL CHECXED
C__)L_�PAREQ UIRED DEPTH
U CURTAL`i DRAIN RE D
GE
(�U(_LOCATED ri NY WAT ERSHED k b"(
4UPLAIS SUBMITTED TO DEP (p
(�UUDELEGATED.TO PCHD �-
U(_ZDEP APPROVAL, IF REQ'D {
(L)UDEEP TEST HOLES OBSERVED &, 12 �^
(IJ-UPERCS TO BE WITNESSED
(U(ZEX- APPROVAL, SSDS ADJ, LOTS��
(__)(_,2iVETLANDS (TOWN/DEC PERbIIT REQ'D ?)
(QUDATA ON DDS PLANS & PERMIT SAME
( _J( 1969 NEIGHBORNOTIFICATION
(UU,{/ LET'ER.IlI/ZBA
(,Z(U100 YR. FLOOD ELEVATION WII200'
(ZUSOIL TESTING LOTS >10 YEARS OLD
REQUIRED DETAILS ON PLANS
(-/J(.J SEWAGE SYSTEM PLAN - (NORTH ARROW)
(4j(USSDS HYDRAULIC PROFILE
(4UGRAVTTY FLOW
( 4C )CONSTRUCTION NOTES 1 -15
(/i (_JDESIGN DATA: PERC & DEEP RESULTS
(Q( )2' CONTOURS.EXISTI�`�G & PROPOSED.
(fU(�DRTVEWAY & SLOPES, CUT
U(-JFOOTING /GUTTER/CURTAri DRAINS
I
(fU(_}US E BOUNDARIES
1 r T_-, -LE_ BLOC, ? WNERS NAME ADDRESS
J ; NAME, ADDRESS, PHONE
(mil ( _JDATE OF DRAWINGIREVISION
(f)(__-)DATUINi REFERENCE
(/__)(___)LOCATION OF WATERCOURSES, PONDS
LAXES,WETLANDS WITHIN 200' OF Y.L.
U(UPROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
Vj(_�JWELLS & SSDS'S W/IN 200' OF SSTS
U j��O P E RTY-iti1ETE S7SAB OUND Si
COMMENTS:
-Y. N (REQUIRED DETAILS ON PLANS CONT'D)
(,Q(___)HOUSE SEWER -%V FT. 4 "0'; TYPE PIPE CAST IRON
(_--)(__-)NO BEDS; M4X BENDS.45 °__�V /C -.L NO.UT
RENEWALS
(U�E NOTE (NO CHANGE)
FILL SYSTEMS
UU10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
(Q(�FILL SPECS/ FILL NOTES 1 -5
(_ZUFILL PROFILE & DRYIENSIONS
(/ (__)FILL Pi EXPANSION AREA
UU CLAY RRIE
C-)(—)FILL CER ATION N TE
UUDEPTH G
UU�OL. 0, PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS
UUSEPA tTION DISTANCE FROM TOE OF SLOPE
,/
TRENCH
k _J(_)LF TRENCH CH PROVIDED qAj� 60FT MAX.
(UUPAR- AI.LEL TO CONTOURS
(/J(�DETAIIJDUST FREE CRUSHED STONE OR WASHED GRAVEL
(�UGEOTEXTILE COVER
v cl) SEPARATION DISTANCES ON PLAN - FROM SSTS
U /U10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL
(1(_)20' TO FOUNDATION WALLS
(,f::�U100' TO WELL, 200' h 1 DLOD;150' TO PITS
(/ffU 100' TO STREAM, WATERCOURSE, LAKE (iuc- ezpan)
/�50' TO CATCH BASIN, 35' STORbIDRAIN, PIPED WATER
f4�nU10' TO•WATER L•M- (pits• -20')
(�U50' INTERMITTENT DRAINAGE COURSE
U200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS e(__)10' ZYM TO LEDGE OUTCROP
SEPTIC TANK
('e'cj10' FROM FOUNDATION; 50' TO WELL
WELL
(__) PENSIONS TO PROPERTY LINES _........ __ .._ ..------- ........
(,:::)(�LOCATION OF SERVICE CONNECTION
(r,UyII`i 15' TO PROPERTY LINE
SLOPE
c6( )SLOPE IN SSTS AREA (S20 0/6)
(-)(,,�RfGRADED TO 15 %, IF REQUIRED
cD S IPUMP SYSTEMS
UUPUIIP NOTES or
UUDOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
(__)(UDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
U(_JPIT AND D -BOX SHOWN & DETAILED
(__ C_)l DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
UUSTANDPIPES, 5' BOTH SIDES, DETAIL
UU15' blIi`i to CDS = >5 %, 20'4%,25'-3%,35'-l%, 100%-<1%
U(U20' MLN to CD DISCHARGE /100' with 182 cons day discharge
U(U10' b1I`1 to NON - PERFORATED PIPE
114.164 (9195) -7ext 12
PROJECT I.D. NUMBER 617.20 SEAR
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be comeletad by Annileant or Prolect soonsod
1. APPU (SPONSOR
s �& i
2. PROJECT NAME
3. PROJECT LOCATI /n1�
�� tj
MunlClpallLY /T u County J V �'V
4. PRECISE LOCATION (Street address and road Intersections prominent landmarks, etc, or provide map)
5. IS PROPOSED ACTION:
❑ New ❑ Expanslon OrModlllcatiorgaiteration
6. DESCRIBE PROJECT BRIEFLY:
Ce)A,S�c� c-r V43 � U� � �sD�� ( L
7. AMOUNT OF LAND FFECTED. J `
/
Intllally acres Ultimately acre
8. W, IIL.,L/PROPOSED ACTION COMPLY -WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑
I l2LYee No It No, describe bdetly
9. T IS PRESENT LAND USE IN VICINITY OF PROJECT?
esidentlai ❑ Industdal- ❑ Commercial ❑ Agdcutture ❑ P_ arWForet/Open apace []other
/ tie L
10. DOES AC71ON INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL), ?,,,��
❑ K110,
Yes It yes, Ilst agency(*) and pennIV8ppr0val3
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL?
❑ Yea (Rho IT yes, Ilst agency name and permlUapproral
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑Yes XNO
1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
� 2-
v l v Date:
Appiicant/sponso nafie.
i
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 II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR. PART 617.4? 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? _ It No. a negative declaration
may be superseded by another Involved agency.
❑ Yes ❑ No .
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten. if legible)
C1. Existing air quality, surface or groundwater quality or quantity.•noise levels, existing traffic pattern.% 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 briefy:
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 goats as officially adopted, or a change In use of 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.
s
C6. Long term, short term, cumulative, or other effects not Identified in C1-CS? Explain briefly.
C7. Other impacts (including changes In use of either quanthy or type of energy)? Explain briefly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑ Yes ❑ No
F-A-9 THERE, 014 IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL. IMPACTS?
❑Yes ONO 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 p,e. urban or rural); (b) probability of occurring; (c) duration; (d)
Irreversibility; (e) geographic scope; and (Q magnitude. If necessary, add attachments or reference supporting materials. Ensure'that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. If
question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action
on the environmental characteristics of the CEA
❑ Check this box it you have Identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration.
❑ Check this box if you have determined, based on the information* and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts
AND provide on'attachments as necessary, the reasons supporting this determination:
Pilot or Type Name of esponsi a Officer In Lead Agency
Signature of esponsi e Officet in Lead Agency
Name of ea Agency
Date
2
Title O tiponsi t OffKef
Signature of Ptepattr t different from resporlsi e 0 tw;
i
1
i
f
r'
I
pUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RE: Property of
Located at
TN P6
;LETTER OF AilTHORIZATION
x 4yt4/ ,-
.tce Po �J -9:a A-0
Tax Map # 3 Block `t Lot l
Subdivision of —�
Subdivision Lot # Filed Map # r--- Date Filed
Gentlemen:
This letter is to authorize
a duly licensed Professional Engineer X, or t to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and/or water supply systems in
conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
P.E., RA.,
Mailing Address
Mailing Address : - G%Z TC C /Cd /L',0 /00/1V
State Zip , s- State p
Z, � _ � zip-
Telephone:
Telephone: 8`j r-- Tcl9hone:-ffq� -
Form LA -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF- ENVIRONMENTAL -- HEALTH - SERVICES -- - - -
APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER TREATMENT SYS,T,EPM
1. Name and address of applicant: �r "�`'
r4 tftys wii Ny 17-1&'3
2. Name of project: �� HoN S-� a fil ?0 ocation TN: �� 7_11-F-95d1d C. %/
4. Design Professional: l k X5. Address: I Z'J Cv.S( Me-i,) ✓LcJA-0
6. Drainage Basin: g Ud A) �Jl to .5Z3
7. Tvve, f Project:
>_ Private/Residential Food Service Commercial
Apartments Institutional Mobile Home Park - -
Office Building Realty Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)? - - =
Type Status (check one) ........................ ............................... Type I Exempt
Type II Unlisted X*
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... A) 0—
10. Has DEIS been completed and found acceptable by Lead Agency? ...............
11. Name of Lead Agency
12. Is this project in an area under the control.of local planning, zoning, or other
-offvials,•ordinances ? ..........................................................................................
13. If so, have plans been submitted to such authorities? ........ ...............................
14. Has preliminary approval been granted by such authorities? Date granted:
15. T yp e of Sewage Treatment System surface-water _ u_-ndwater--- -: --
-
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? .......................................
...................... A)0
19. If yes, name of water supply Distance to water supply
20. Is project site near a public sewage collection or treatment system? ................
21. Name of sewage system Distance to sewage system
22. Date test holes observed . Z D 23. Name of Health Inspector � EAA ' 2&_4:'0
24. Project design flow (gallons per day) ................................. ............................... cpo 0
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... AJ 6
26. Has SPDES Application been submitted to local DEC office?
Form PC -97
Aioo
i 2
27. Is any portion of this protect located within a designated Towif r State'wetland?
28. Wetlands ID Number ........................................................... ............................... `�.._.._... _...._ -
--
..�.... _ . 29. Is Wetlands Permit required? ........................................... ............................... _ _ AJ 0
Has application been made to Town or Local DEC office?
30. Does project require a DEC Stream Disturbance Permit? .. ...............................
31. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ............................ Yes/No
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any /
other potentially known source of contamination? ............................... Yes/No ! "
DESCRIBE:'
33. Is there a local master plan on file with the Town or Village? :...:.....:.............:" - ..e` --
34. Are community water and/or sewer facilities planned to be developed within.
15 years in or adjacent to project site? ................................. ...............................
35. Are any sewage treatment areas in excess of 15% slope? . ............................... A) d
36. Tax Map ID Number ........ Map 3� Block Lot 1. ..
37. Approved plans are to be returned to ..... Applicant Design Professional
..NOTE:. All applications for review and approval of anew SSTS .to be located_within the -NYC, Watershed- shall -� --
be sent to tfie7�epartment, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department: Projects within the watershed -may also
require DEP review and approval of other aspects'of a project, such as stormwater plans or the creation.of
impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from-
_ DEP and submit those forms to DEP- for review and approval. - - - - --
If the application is signed by a person other than the, applicant shown in Item l .,the application must
be. accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
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 210.1 of t4ePenal Law. / - - - --
SIGNATURES & OFFIML TITLES.
Mailing Address: ................................... 'Pd 7' ZJ�7o
-e -yfi. 7
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERV
--ICES-
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Omer 5 Ay*` Address H ?-q Lc P o All) Ad ?4�
Located at '3� Block Lot
(Street)
Tax Map
Q+icate nearest cros s treet)
Municipality ttnS d �j Watershed
SOIL PERCOLATION TEST DATA
Date of Pre-soaking Date of Percolation Test VL�\� -ko
X 6 i
.... . .......... .
....... .
'N t ax't
. .. ....
a se Time :
;1.. b
9pt M'.7
",Xrom"Groun d
Surface nches
-ef
e q
Inches
3.6
2
3o
3 11-L6 tt-yt
z3 7-4
3o
4
5
o
L3
2 V 657 t i7l
�1►
3 III-F
4
5
F'3
3
4
5
'obtained
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are at each
percolation test hole. (i.e. :5 1 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 2
DEPTH HO NO. P
HOLE No:
0 t. ------
0.5 4A
t
2.0'
AA,
3.0
3.5' T
4.0
43
:).V
----------- V-
6.01
6.5
7.0
73
8.0 - -----------------
8.5
9.0
9.58
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:
I t Date
Design Professional Name: Z
j 'Ll 7LA,
Address: O
xpf,
A A / I
Signature:.
IS
Design Professional's Seal
W
4Cj
Ln 5
PROVE
._ �,. c__ _.__ -- ____ra._.. ,�_ _. � �._. _.._���....,
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # 19 o
Located at C6 0 �Zz Town or Village P A-T G]ZS 0 T
Subdivision name Subd. Lot # Tax Map Block Lot
Date Subdivision Approved
---- Renewal ` Revision
Owner /Applicant Name S14
K
P:e l— k , IA
Date of Previous Approval
Mailing Address Z--"1
C �� ' �d N
" 1' i�'o
�%� SO /Y IV
Zip
Amount of Fee Enclosed -R .
�.c ..
Building TypeW 00 .0 Pfl Lot Area No. of Bedrooms Design Flow GPD 4`0 -0
Fill Section Only Depth Volume
PCIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of gallon septic tank and L
2-F-1 C,L i v �o
Other Requirements: d X �' S
To be constructed by -'T. t+ ,/d Address l 4 Psj /v o /*� 6Af jrVS (L a y
Water Suooly: Public Supply From Address
or: Private Supply Drilled by a Y� Address 9 AeW 5#--r- A' "
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatments 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:
Address
P.E. %, R.A. Date jJ11101
i tj , W 6 114-6 ? License # •S � `L-7 7
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new p it. Approved discharge of domestic sanitary se T only.
By: Title: Date:
White copy - HD Fil Yell w opy - Building Inspector; Pink copy - ner; Or g copy. - Design Professional
Form Cp
i
SUREMENTS- .
THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRuamlb AS
INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT
WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH ALL
STANDARDS, RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF
HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH.
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THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRuamlb AS
INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT
WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH ALL
STANDARDS, RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF
HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH.
IZ VF