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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -123 BOX 16 01784 ' rm ; .. j 41 Ices `i b rK :11 . {,, 4. ' koi IL r- �� 01784 I x PUTNAM COUNTY DEPARTMENT OF HEALT. F- E, NVIR0, NMENTALIJEALTH SIERV CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATME1.. u A u A AULTA PCHD CONSTRUCTION PERMIT # P" 1'9- -04- Located at i ,4© Af Pt 5 141 U_ PAD Town or Village PA 'rl -a�L6uH Owner /Applicant Name Tax Map '/ �' Block 4 Lot Formerly Subdivision Name Subd. Lot # 4 Mailing Address $ C-DwIt0WAND p1A149!_: N� Zip 10 "M Date Construction Permit Issued by PCHD 111 i Separate Sewerage System built by 'VY'00"fil Address t=Or.t t�WM 0P - %\0 Consisting of 1 L5 u Gallon Septic Tank and A66. 'iR141m F-E A'+ `- W, Other Requirements: Water Sunnly: Public Supply From Address or: Private Supply Drilled by Bb_-4)D kK41&44 VIJE�VL� Address 10 K216W'616- t lr'fA L Has erosion control been- completed? - -- BuiIdirig TYPe � P . Number of Bedrooms 4 Has garbage grinder been installed? HP 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 regulati n of the Putnam Co un De artment of Health. U Date: 5'-2°1 °-© 5— Certified by P.E. X R.A. ( n Professi�l) Address �-f1 a 0 VL,, W � OS License # Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such , \,,evocatio , odific or change is necessary. i ,- �tGP�✓ Title: Date: 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 COMPLETION REPORT �VeIT ;ocafion "ryY.= ` StieeiAdiTress: �Lf� ,PFD' 1411, � OA-P Town/Village: Tax Grid # Map ��j Block 4 Lot(s) 10, Well Owner: Name: A dress: 94o ���.�/ ����l Use of Well: 1- primary 2- secondary LC Residential Public Supply Air cond/heat pump Imgation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _ e Compressed air percussion Other (specify) Well Type Screened Open end casing _� Open hole in bedrock Other Casing Details Total length _,O�Lft. Length below grade? ft. Diameter in. Weight per foot lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded , Threaded _ Other Seal: Cement grout — Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed Pumped Compressed Air Hour;--V Yield & gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) 4 Depth of completed well in feet 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 E, If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type � Capacity -Z 1p-\ Depth 2-00 Model SF_Sa 'I Z Voltage 2-30 HP Tank Typeiyk - 3a2 Volume 94.-, f am Date!W�ell Comple/t�/ Putnam County Certification No. Date of port Well qriller (signature) NOTE Lxact location of well with distances to at least two permanent landmarks to be providAWn a M6 114 10 Well Drille Signature: White copy: Address: Date: L Yellow copy - Building Inspector; Pink copy - Ownei; :te sheet/plan. C op - Wel" 1 driller Form WC -97 PII-41 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT ell°L- icatioii --•-"StreetAddrbss ` ° 1�" °l l`Ix� °�%ILI V P-OA -P Towri�'i3�a e`� °° •Tax•GridIt Map'�G 1 Block 4 Lot(s) Well Owner: Name: A dress: l ,aO6 Use of Well: 1- primary 2- secondary C Residential Public Supply Air condlheat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _ 6 Compressed air percussion Other (specify) Well Type Screened Open end casing _ X Open hole in bedrock Other Casing Details Total length eft. Length below grade _,;?f ft. Diameter !_in. Weight per foot lb /ft. Materials: XSteel _ Plastic _ Other Joints: _ Welded _ Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped _.�, Compressed Air Hours Yield L6 gpm Depth Data Measure from and surface- static (specify ft) During yield test(ft) 7�141 2 Depth of completed well in feet 4 0 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 10 ORO ,, ��- If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 5 . Capacity % per% Depth 2-00 Model S'F_SO�Z412 Voltage 230 HP Tank Type Wk ` 36Z Volume 6?4F 1' Date Well Complet Putnam County Certification No. Date of Oft Well Well riller(signature) NME: Exact location of well with distances to at least two permanent landmarKs to ne provia n a I p1/-, Well Drille. Signature: White copy: Address: Date: e Yellow copy - Building Inspector; Pink copy - Owne ; zngevptan. Form WC -97 9// Jun 16 05 11:47a TOWN OF PRTTERSO 845 - 878 -2019 P•4 i.GR.E -iZ'A MOL.SiARI• Ul.. NUN. Puma ffeaftA Drrec:cT `� Aj3aclau Pv6Mc Stab Dtreezor DtrsCtDT qJ' �Ql:Rnt Servt:+ee DEPARTIAV04T OF HEALTH I c'reneva Road Brewster. New York 10509 1:a�iroametral Haalth (9(4)271.8tJQ PaR(9;t) 278.792! ?l arsimt S.ry+.eu ,91a; 277 -6558 WIC (f)L4) 27E . 6678 Fua (914) 274 •601: € rly IMCesreacloa 014) Z78 -6014 rmchool (914) 218 -4082 Fa (914)178•• 6648 OWNERS `AMt-. TAX MAP NUNMER: E91.1 ADDRESS: `% y� /� 11:�pdl.�Ar AUTHORIZED TOWN 0 BFI L L C -k . • .�✓� f v' ��--'` (Signature) DATE: _ !l// //a The Putnam County Department of health will not issue a Certificate of Construction Compliance unless fhe above form is completed, i.e., a legal E9,11 addressIs amignecl by an authorized town official. This form is to be submitted K4th the application for a Certificate of Construction Compliance. (E911 VMMI M; -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SLJ13SURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot m Building Constructed by Location - Street Building Type.' TownNillage o op Subdivision Name g- Subdivision Lot # I represent that I am wholly" and completely responsible for the location, workmanship, material, construction and"draina`ge of the sewage -& a&ment-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 parr--of said • nstem cori9ructed Sy" me which fails to operate fora 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 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. w _ . _ L _. . 'Is, Date : Mon 6P Day 2cl Year 0 6— fi I L, 4nefA Co ntract6F(Owner) = ignature . Signature: - r Title: \J p i L4 r151 i Corporation Name (if corporation) Corporation Name (if corporation) Address: G� � b�a� j t -t Address-1 WW 0%r o Dpi w6, State N r Zi �Q � A '1 State zip (S � - Form GS -97 SHERLITA AMLER, MD, MS, FAAP LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF. HEALTH 1 Geneva Road, Brewster, New York 10509 July 5, 2005 ROBERT J. BONDI Re: Proposed Compliance: Wyndham Homes 140 Apple Hill Road, Lot 41 (T) Patterson, TM # 35 -4 -123 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 water analysis has not been submitted. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:kly Very ly yours, Robert Morris, P.E. Senior Public Health Engineer 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 YML ENUI IAL SERVICES �i�l Kear 5treet Yorktown ight�' N,y� lO598 - (914) Albert H. Padovani, Director LAB #: 9.501231 CLIENT #: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~=~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 SAMPLING SITE: 140 APPLE HILL ROAD : PATTERSON COL'D BY: JOSE NOTES...: WELL TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY PROFILE. 06/09/05 MF T. COLIFORM 06/16/05 LEAD (INS) 06/10/05 NITRATE NITROG 06/10/05 NITRITE NITROG 06/17/05 IRON (Fe) 06/14/05 MANGANESE (Mn) 06/17/05 SODIUM (Na) 06/10/05 pH 06/17/05 HARDNESS, TOTAL 06/17/05 ALKALINITY (AS 06/14/05 TURBIDITY (TUR 06/09/05 E. COLI (CONFI DATE/TIME TAKEN: 06/09/05 01:50 DATE/TIME REC'D:' 06/09/O5 O3:30 REPORT DATE: 06/20/05 PHONE: (845)-279-2022 SAMPLE TYPE..: PDTABLE PRESERVATIVES: NONE TEMPERATURE..COLIFORM METH: N/A RESULT NORMAL - RANGE PRESNT /1O0 ML ABSENT 2.6 ppb 0-15 ppb 1.84 MG/L 0 - 10 <0.01 MG/L N/A <0.O60 MB/L 0-0.3 mg/] <0.O1O MG/L O-O.3 mg/l 10.7 MG/L N/A 6"7 UNITS 6.5-8.5 148 MG/L N/A 76.0 MG/L N/A <1 NTU 0-5 NTU ABSENT 100/NL ABSENT BACT THESE RESULTS INDICATE THAT THE WATER (WAS ISTATE SATISFACTORY SANITARY QUALITY ACCORDING TO ORAND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ICATE THAT THE WATER (WA TARY QUALITY ACCORDING TO DRINKING WATER STANDARDS, FOR THE PARAMETERS �E OF COLLECTION. * ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total Value combined 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 METHOD 1008 9003 9052 9162 9002 9002 9002 9043 ' YML ENVIRONMENTAL SERVICES . 321 Kear Street Albert H. Padovani, Director LAB #: 9.501231 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 SAMPLING SITE: 140 APPLE HILL ROAD : PATTERSON COL/D BY: JOSE NOTES...: WELL TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE DATE/TIME TAKEN: 06/09/05 0050 DATE/TIME REC'Dt 06/09/05 03:30 REPORT DATE: 06/20/05 PHONE: (845)-279-2022 SAMPLE TYPE..: POTABLE . PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY-RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE ------ tar QR1�H-`���l��'��-��� ---'---'--- SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L =MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert H � dovani, M.T.(ASCP) Director ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 _.: >.:... 914 245 -2800 Albert H. Padovani, Director LAB #: 1.504302 CLIENT #: 57197 NON STAT PROC PAGE: 1 WYNDHAM HOMES DATE /TIME TAKEN: 06/27/05 10:45 8 COLLINWOOD DRIVE DATE /TIME RECD: 06/27/05 11:55 RALPH TEDESCO REPORT DATE: 06/29/05 BREWSTER, NY 10509 PHONE: (845)- 279 -2022 SAMPLING SITE: 140 APPLE HILL ROAD BREWSTER SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BY: JOSE TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 06/28/05 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 COMMENTS: FAX TO 845 279 2332 COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER (WAS),(WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED_, AT THE TIME_ OF COLLECTION. SUBMITTED BY: Albert H. Padovani, M.T.(ASCP) Director ELAP# 10323 June 22, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ry W. Nichols Jr., P.E. itterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 TeL•t (845) 279 -4003 Fax: (845) 279 -4567 iail: hnengineer @aol.com Re: Individual SSTS Compliance — Wyndham Homes, Inc. 140 Apple Hill Road - Lot # 41 Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-123 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -41, "As -Built SSTS ", dated 06/29/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 06/29/05. Three-(3)-copies of -" Guarantee -of Subsurface Sewage Treatment System", dated 06/29/05. 4. Laboratory Report, dated 06/20/05. 5. "Well Completion Report", dated 06/22/05. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 06/16/05. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. hols Jr., O.E. HWN:gav 03- 056.41 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: � X20 p5 Inspected by: Street Location-.. _ ,���z /� . �,�. / /.. �7�a.P Owner. &.I .: �/a - Town Permit # TM #— 3S-1 — / — / ,2 3 Subdivision Lot # -f / 1. Sewage System Area a. STS area located as per approved plans .......... ................. b. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............:.................. IL Sewaze System a. Septic tank size - 1,000 ...:.....1,250 ........other ................ b. Septic tank installed level ........................... ........... .. c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3... N inimum 2 ft. Original soil between box & trenches e. Junction Box properly set .......... ............................... 6. Trenches 1. Length required �0o Length installed Oa 2. Distance to watercourse measured f t o o 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 .................. 7. Room allowed for expansion, 100 % ......................... -� 8. Size of gravel 3A - 1' /2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ....... :........... _ 10. Pipe ends capped .......... .. ................ . ... ........ ......... .g; -Puann or -Dosed 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/Buildirig a. house located er approved plans ............. .. ms ............................... .... 8. b. Number of be roo ....... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured ®D - ft........... c. Casing. 18" above grade ............................. :.................. d. Surface drainage around well acceptable ........................ V. Overall Workmanship . a.. Boxes properly grouted ................... ............................... b' All pipes partially backfilled ........... ............................... C. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse gig. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 JUN -17 -2005 03:29 PM HARRY W NICHOLS 914 279 4567 PUTNAM COUNTY DEPARTMENT OF REAILTIR DMSION OF EN MONMENTAL HEALTH SERVICES REQUEST EM EDUr MECITON For: Fill Date: M.L1 / _ Trenches l� PCHD Constructiom Permit # P 12.1_ Located: AMI 14144 lo&% (T) f i fA EQUOA . Owner/Applicant Name: yj ,y aR M121Mss _ e _ TM _ Block Lot Formerly: `II 1� _ Subdivisoa Name: Subdivision Lot # P.01 Is system fill completed? Date: Is system complete? M Date: Al Is system constructed as per plans? Is well drilled? _ Date: �IaLj ej 64 Is well located as per plans? lts Are erosion coiatrol'measures in place? I certify that the system(s), as listed, at the above, premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date:___ :1&1 x p"t o Certified by yy� ..._ _. ..... -. �.__....,. .�. .. -..._ .. _�- .._.,.........__ .. _... ..G _.. .. ...- ,t -.. -. .. - .rte- 1. _. ._ __.. .. .___.._,._... _.. ______�- .��•�..- „ �- , r. .. . .. _._ ._ Design fessional. . Address: 2L .....ee f`�.,Ci sy y jOi Lic. # t 2� Comments: FOR:' 0 ADAM GENE .Q (NAME) Norm FEEL-99 -- I .. �_ .,� — . nAC -, -7o_ -7004 nIOMC• OI ITIJOM rnI IKITY r1GP0PTM1=NT nF P_ 1 G �UTNAM COUNTY DEPARTMENT OF HEALTH ISION OF ENVIRONMENTAL HEALTH SERVI CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEIV PERMIT # 0 12— -01 Located at A 4� mil 1e- / 0,j Subdivision name on ev-WOO � Subd. Lot # Date Subdivision Approved 1[)4 / G 2_ Owner /Applicant Name �, k �r.- k" C_s Mailing Address i II I u $- f9,4, Town or Village 110e, ' Tax Map 7 Block __I Lot / _44 Renewal Revision � Date of Previous Approval `I - 4_`1-0 Zip / 0 13,0 7 Amount of Fee Enclosed ;L00 w Building Type R"Ct_)T t j � Lot Area ., 01 a No. of Bedrooms Design Flow GPD 90C) Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and 4oa 4 Other Requirements: To be constructed by TA 1� Address Water Supply: Public Supply From Address _- Privaw- SupplyDrilled by _ T A D .Address_ ..:._. _.. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the s, eparate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original, system or any repairs thereto. Signed: Address R.A. Date /0 License # S`C (2I 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 en considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe i . Appro for dis arge of domestic sanitary sewage only. I By: Title:,_'- Date: d White c py - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 Pg. TNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT, A. WATER WELL please print or type PCHD Per in it # Well Location: Street Address: To age Tax Grid # A 9,11 /Ld Map Block J, Lot(s) 123 Well Owner: (Name: l Xh,,ij s:: j A dd s / Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served I-q Est. of Daily Usage 12ZO gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling /New Supply (new dwelling) Deepen Existing Well Detailed Reason ,GSI GQ for Drilling Well 'Type _� Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes t-� No Name of subdivision �� +tict.d Lot No. Water Well Contractor: 'Ir 131 Address: Is Public Water Supply available to site? .................................. ............................... Yes No 1/ Name of Public Water Supply: ,U A.- TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separat sheet/plan. Date% 1.6 Zrlj, �1Applicant.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. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a water County. 11 driller c A fied by Putnam Date of Issue f1 ° Permit Iss. Official: Ike- Date of Expiration I 01,61a & Title: Permit is Non-Transfifeabli White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WP -97 LO CD tpj i to 8 Plan C - Lot 41 WINDSOR WOODS The Comeg;e PATTERSON, NEW YORK nRST FLOOR PLAN WYNDHAM HOMES ... '. w.... ..... '• d AM COUNTY DEPARTMENT OF HEAL ON OF ENVIRONMENTAL HEALTH SER - .....�'-......�. eoN�TRU�T><+�l��E�M�T•FOR sEWAOE-TREATMENT sYST�ir�t� :�- .�.��.�� . PERMIT # P !;--0 Located at •4 AAle C /�j Town or Village Subdivision name l�%ev- wOcid Subd. Lot # Aj Tax Map 33 S`, Block -1 Lot 17-3 Date Subdivision Approved l G Renewal Revision Owner /Applicant Name Lt/ Date of Previous Approval Mailing Address -7 l , o - ri i, e B M ,_ —, Zip 05-0( ' cy- Amount of Fee Enclosed 2A0 Building Type ) p i e-1 tE Lot Area 1, 0 No. of Bedrooms --f�— Design Flow GPD 8 60 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of ' gallon septic tank and 4 v o /Y. e-J Other Requirements: To be constructed by 1 Address Water Supply: Public Supply From Address or: Private Supply Drilled by _ _ lei l Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the 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. /� ' Date . -,2—`j gLO57�`� -e,w' �'/ License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatm nt system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w en onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pro for dis harge of domestic sanitary sewage only. C Lis k - By: Title: 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 APPLICATION TO CONSTRUCT A WATER WELL please printor type '-' ' �" ' PCHD Permit # ' h Well Location: Street Ad ess* T wn/V' age Tax Grid # te ;41 d l i� a'4'� .� �V S� 1 Map -3 " Block -' Lot(s) J2. Well Owner: Name: 3 w Address % 0, J f t " tc:aaJ Pr I U el iG t1i 11OW` Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation I- pnmary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage Q G al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling t/New Supply (new d elling) Deepen Existing Well Detailed Reason for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes 1/ No Name of subdivision Lot No. Water Well Contractor: TA D 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 containinatioa to be provided on separate sh Zt/p Date: 9 - �-G1 :0 _ Applicant Signature: . AA M 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 ce ified by Putnam County. Date of Issue Permit Issuing O 1: Date of Expiration 6 Title: Permit is Non- Transfer>l d°able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 N TNAM COUNTY DEPARTMENT OF HEALTI ION OF ENVIRONMENTAL HEALTH SERVI a CONSTRUCTIONTPERMITJFOR SEWAGE TREATMENT SYSTEM PERMIT #� -()�_ Located at Affif, RU- �q Subdivision name W�� Subd. Lot # 4-1 Date Subdivision Approved r��\ yq, Owner /Applicant Name �?� Irk-' Date of Previous Approval BWw" �jl Town or Village r 4 f r"C, -4;O 0 Tax Map `) Block A Lot )� Renewal Revision Mailing Address -1 C b 1,6kj \) oar D f -r4 � Amount of Fee Enclosed Building Type Kt-,)o15V44 Lot Area No. of Bedrooms 4 Design Flow GPD Zip) Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 0 gallon septic tank and `'I' oo L-F fti, Other Requirements: To be constructed by TK Address Water Supply: Public Supply From - ar -- Primate- Supply -Drilled by t! - Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments sy tem 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 R.A. Date of � al I D4 License # ,5 CIaA- 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 modTwco sidered ecessary by t he Public Health Director. Any revision or alteration of the approved plan requires a neroved dischar of domestic sanitary sewa only. By: Title: Date: G 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 . , picdse print 6f type, _ . ,:.........._.. _... -_. PCHD Permit # Well Location: Street Address :: Town/Village Tax Grid # 0 R U�- P FAT 0t-J Map '�5. Block 4 Lot(s) . Well Owner: Name: Address: 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 'JV gpm # People Served — Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason 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 Name of subdivision DE5WMV Lot No. 41 Water Well Contractor: T51) 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 contamination to be provided on separa she t/plan. F d � Date: �� Q� Q� 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. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a ware , 11 rill1cpffnedd by Putnam County. Date of Issue _ ,� t Permit Issuin .. cial: Date of Expiratio o 0 Title: Permit is Non- Transfe e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH ,DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA -SHEET = SUBSURFACE SEWAGE TREATMENT SYSTEM Owner -Address l C,Ot.LtnlW(} Q PNE( W&Alt, � Located at (Street) Tax Map �J4 Block 4 Lot UA (indicate nearest cro s street) ' Municipality QQ(��S4 Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :g 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 2 5 ii 1 t VI .3 �ti� bi�� — �`��� �1• 4 �1 �� �� 2b���r '10l ��� 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. :g 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 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST ROLES ,. -DEPTH. : HOLE NO.. ,_ - I. HOLE NO. HOLE NO. 0.5 " oy%iL 1.0' 1.5' 2.0' 5�� 2.5' 3.0' 3.5' 4.4' , 4.5' 5.0 (1 v4 5.5'A1_W� 6.0' L� 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' _ 10.0' Gp C'. Indicate level at which groundwater is encountered p- Indicate level. at which mottling is observed 9 4 0e Indicate level to which water level rises after being encountered' Deep hole observations made by: M jbJ9ZA0M ( Nt&J QD F Date Design Professional Name: H Address: _ ue o p Signature: 0 (05a Design Professional's Seal of NEW C C. T LU W No. 56124 �AA�FrSsi, PUTNAM COUNTY DEPARTMENT OF HEALTH -DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: L represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Havinc, offices at: Whose Officers Are: President - Name: Address: Vice President - Name: Address:.. Secr'etdry -Name: Treasurer - Name: I Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating theret +rat MVO* Signed: NOW Pub&# 566iiof 14W link Title: 11, C4 ri i-F 0 aworn to before me this day of (month) 3 (year).*" Public Corporate Seal Form CA-97 PUTNAM -COUNTY DEPARTMENT OF HEALTH :: D-MSION -OF. ENVIRONMENTAL HEALTH -SERVICES....I:Z,."-., -LETTER OF AWTHORIZATION RE: Property of Located at TIV. Tax Map # Block Lot Subdivision of Subdivision Lot # A Filed Map # l -AMI, Gentlemen: . Date . Filed. '06 t vli,• This letter is to authori'ze a duly licensed Professional Engineer X or Registered Architect to a pty for the. required :.- wastewater treatment and/or water supply pen-nit(s) to serve the above- noted-property in :accordance with the standards, rules orregulations.as promulgated by the Public 14e*alffi Dire'cto*r.. County Health Department, and to sign all necessary papers on my behalf in connection with -this matter and to super-vise the construction of said wastewater tretment and/or water supply system- M conformity with the proyisions. of Article 145 and/or 147 of the Education. Law,- -the Public Health-- Law, _and- tb.0. utnam-; ary Code... -0,ountersigne P.8., R.A., # Mailing Add fil=�S State -zip, Telephone: Very truly yours, Signed: (7wner of PropcM) Mailing Address: State zib - C A j TTelephone: n Form LA -97 a September 29, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Re: Lot #41 - Deerwood Subdivision Revised House and Location Apple Hill Road Patterson, NY Dear Mr. Morris: Enclosed are the following: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279.4003— _ �� � -._ -Fax: (845) 279 -4567 :u... . Email: hnengineer@aol.com 1. "Construction Permit Application ", dated 09/29/04. 5. "Water Well Permit Application ", dated 09/29/04. 3. Five (5) prints - SS -41 "Proposed SSTS - Lot #41 ", rev. 09/29/04. 4. Three (3) sets of House Floor Plans. ._�...F.._.�.,��,_.s. _5...�,_.� ..Applacatlon�Fee,_$20.0.00, -• -- -. - - -. _ ...__._..... :.__.r �_,.._.._. _ ., _ ..,._--- _...._.- ..__.____._:......___. _..,_____ -_ Kindly review and approve the enclosed at your earliest convenience. Very truly yours, Harry W. Nich s Jr., P.E. HWN:gav 03- 056.41 July 7, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Re: Individual SSTS Deerwood Subdivision - Lot # 41 Apple Hill Road Town of Patterson T.M. # 35.4-1123 Dear Mr. Morris: Enclosed are the following: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 . Tel: (845) 279 -4003 -.FaxT(845) `279 -4367 Email: hnengineer @aol.com 1. Five (5) prints of SS -41, "Proposed SSTS ", dated 07/07/04. 2. "Short EAF ", dated 07/07/04. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System, ", dated 07/07/04. 5. "Application to Construct a Water Well ", dated 07/07/04. 6. "Design Data Sheet ". 7..: `..`Letter -of Autho_rizatioR_ &.Corporate. Resolution. ",. dated.07 /07/04. 8. Two (2) copies of Residence F ,or Plan(s), for " edroom Count Only". 9. Review Fee in the amount o $400.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Ni is Jr., P.E. HWN:gav 03- 056.41 14 =16-4 (9/95) —Text 12 PROJECT I.D. NUMBER 67.20 SEQR Appendix C __......_ __.... Statblfivironmerital Qiiafity'Revrew SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Prolect sDonsor) 1. APPLICANT /SPONSOR .I� j„ :r kU t'11) C J 2. PROJECT NAME �ni pin 04EP -( V �' � T ice!` � 'ley � 1 i 3. PROJECT LOCATION: ^ n�L�- �. t� �I"W Municipality Count y T 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) A' 141 tL GRUn1 TEAL, LAt*' 5. IS Pzew OSED ACTION: ❑ Expansion ❑ Modlfication /alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: ++ Initially F ° t7 lO acres Ultimately t acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? W'Yes ❑ No if No, describe briefly 9. WXT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture g ParklFo res pen space 0 Other Describe: - 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? t6Yes ❑ No If yes, list agency(s) and permit/approvals 11. 0ES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? pYes ❑ No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? 9No. ❑Yes 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Appilcant/sponsor name: 1 01''' "1 ``S V L' `1'Y'd� uV' t' lL ! JMG'1"L ft Date: Signature: Idyl A-S LJ V 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 I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinatethe review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6'NYCRFi, PART- 617.6? If No, a negative ai. 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 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 like) to be induced by the proposed action? Explain briefly. Cam. q P Y P P Y _v;.:.,: CIO C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. "D a° CD °r< i. N w C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. N G? D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No t tS THERE; OR-IS THER& L- IKL° L-Y -TO-BE,-CONTROVERSY-RELATEb-TO- POTENTIAL -ADVERSE ENVIR(*MENTAt',MPACTB ? -' -- ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude: If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse,impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. 0 Check this box if you have Identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation; that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting• this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Office r in Lead Agency Name of Lead Agency 2 Title of Responsible Officer Signature of Preparer (If different from responsible officer) 1 V.11`ItilYl \.VV1'111 l/L'�111ttlYtL,l`l1 UL� r7L�f'111"1"t1 - -- .. DI-VI-OF ENVIRONMENTAL -HEA LTH•.SERVIiZES` -:; - APPLICATION FOR APPROVAL OF PLANS. -FOR A- VVA STEWATER TREATMENT' SYSTElYI'; - 1. Name and address of an licant: ` 2. l Name of project: L �' Q 3. Location T. V:. 4. Design Professional: %C- 5, . Address: �PJ� • AA, _ Drainage Basin: ROB. 7. Type of Project:: X Fr vat. esidential Food Service Commeicial -, Apartments'-: - Institutional Mobile Home -P -ark . •• = Office Building Realty Subdivision _TOther (specify) 8. Js this project subject.to State Environmental Quality Review (SEAR)? T e••Status (check* one):-..' - Type I 'Exempt Type TI -" Unlistcd-� )K _ 9. Is a Draft Enviromnental'Impact Statement (DEIS) required? ......................... � 10. Has DEIS been completed and found acceptable. by Lead-Agency? ......:.:;:..... 1. Name of Lead Agency .Is this project in an -area under the control of local planning, zoning, or other officials, ordinances? ...... . ........ . .........................:.. . .................... :- - 13. If so, have plans 'been submitted to.such authorities? ........ ............................... _ D 14. H•as•preliminaryapproval been•grarited by such authorities? 00 gr _ Date � anted:.• = l�•�" • •- _ -15 Type of Sewage. Treatment- System Discharge :::............. surface �rater- �i groun�w�teY - 16. :If surface -water discli�ar e"-what is the stream class'.desi ation? ..... ... ............ ' . g � � 17. Waters index number ( surface)..... ........................ ................:... .... ......... . 1.8... Js project located near-a public water supply system? .................... :....:....... ....;.. 19.• If yes, name of dater• supply �"' Distance to wi': supply -2-0: Is .project site near a public setivage collection or tteatment system? N - '2i. Name of sewage system Distancefo_setivage'sysfem' t 22. Date.test= hol"es-observed ������ 21 Name of HeaPth.In'spector ��� u�Z ►; � 24. Fro_ject design flow (gall'ons per clay) .....:............ ......:... 25. Is State Pbllutant Discharge Elimination System. (SPDES)- Perinit.req11ire4 .: �. 26. Has SPDES Application been submitted to. local DEC office? :........... PP �.......... Form PC -97 2 2 %. Is-.a - portion: of this project Ipcaf ed "wyithin 'a designated Town or State wetland? 28. Wetlands .ID. Number..,.*......... ................................ .......::.. ........ °................ ::.... _ • ... .......:_.. 29'. ---Is Wetlands Perm "i.t requtred - ?• ...:: :.:.........:...................... • .....:...... ...,.....:....�___ �.�- ..._ . .. _ ` i. Has application been -made'to Town or Local D -EC office? ......:........................ 30. "Does project require a DEC Stream. Disturbance_Pe:rmit? ............................. y �Q 31. Is or was project site used for agricultural activity involving application, of pesticides to .orchards or other crops, solid ox . hazardous waste disposal, landfillir stud e application-or industrial activity? ........ Yes/No 32.' Is project located within 1,000 feet -.of existing or abandoned landfill, hazard ous.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? ......................... 34.. Are commuriity water and/or sewer facilities.planned to be devel6p6d:within : - 15 years in or. adjacent to project site? jJQ 35. Are any sewage treatment areas in excess of 1.5% slope ? .................................... Q 36. Tax Map ID Number _. __..... -- - -. _,._ _, ....A Map Bloc k o __:...-.... �._ 37. Approved plans are to be- returned to ..... Applicant Design Professional \'0TE: All applications for.review and approval of a new SSTS to be located within the NYC Watershed shall ae.serit to the Department,. and need not be sent in duplicate to the DEP, although the. project may require DEP _ •approval of the -1-SS-TS prior" io final =approval by the Department. Projects- withiri..the watershed. "may also _ require DEP 'iev ew: and approval. of other aspects of a project, such as stormwater.plans_or the creaf on•of impervious•sur€aces, and the project applicant should obtain the appropriate forms. for such'. activities fromi 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 Itom I.-,the application must *be accompanied by'a Letter of Authorization (Form LA -97): Failure-to comply' with this:prov gnu may, be grounds for the rejection of any submission. C .? . I hereby.aff rm; .under penally of perjury, tlrat information pro.videtl "on lhls form. is trcr , _ to the be of my knowledge and belief False statements made herein: are punishable a C1assA•.misde'meanor. •ursuant to Section 210.45 o •-the Penal'L. SIG!YATURES -& - OFFICIAL TITLES.. , i Mailing Address: ..................................... /��Q /� --c" • ��SQ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, OR, AS, SRDATE: Y. DOCUMENTS PERMIT APPLICATION L(l 1WELLPERMIT ORPWS LETTER ER OF AUTHORIZATION 4N DATA SHEET (DDS) ORATE RESOLUTION T EAF PLANS -THREE SETS )HOUSE PLANS - TWO SETS VARIANCE REQUEST SUBDIVISION LEGAL SUBDIVISION SUBDIVISION AP 03Akl, CHECKED � PERC RATE )FILL REQUIRED EPTH (--)(_)CURTAIN D ATD GENERAL )LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP �DELEGATED TO PCHD (DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED �PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME (_)PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA �U100 YR. FLOOD ELEVATION W/I200' �)C-L�)SOIL TESTING LOTS >10 YEARS-OLD' 'AGE SYSTEM PLAN - (NORTH ARROW) HYDRAULIC PROFILE LAITY FLOW (�) CONSTRUCTION NOTES 1 -15 (_)DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED (� DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWINGAREVISION ` DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (�)( WELLS & SSDS'S WAIN 200' OF SSTS PROPERTY METES & BOUNDS (---)EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE , x1XIAM / ►iii (REVSHEET)09 /01 /00 TAX MAP #: (CONFIRMED) Y N (REQUIRED DETAILS ON PLANS CONT'D) L�L—)HOUSE SEWER -'/" FT. 4 "0'; TYPE PIPE CAST IRON (�jNO BENDS; MAX BENDS 45° W /CLEANOUT RENEWALS TE NOTE (NO CHANGE) FILL SYSTEMS �) 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (_) FILL SPECS/ FILL NOTES 1 -5 (_) FILL PROFILE & DIMENSIONS U FILL IN EXPANSION AREA FILL GREATER THAN 2 FEET CLAY BARRIER C--) FILL CERTIFICATION NOTE (_) DEPTH GAUGES L� VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS U SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH LF TRENCH PROVIDED 60FT MAX. PARALLEL TO CONTOURS ((,,)100% EXPANSION PROVIDED DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SST5 (__)5 )10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL ( 20' TO FOUNDATION WALLS •00' TO WELL, 200' IN DLOD,150' TO PITS �) 100' TO STREAM, WATERCOURSE, LAKE (inc. espan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER W �) 0' TO WATER LINE (pits - 20') (� 50' INTERMITTENT DRAINAGE COURSE �200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS 10' MIN TO LEDGE OUTCROP SEPTIC TANK C__)10' FROM FOUNDATION; 50' TO WELL WELL *L--)MIN DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION 15' TO PROPERTY LINE SLOPE L�SLOPE IN SSTS AREA (520 %) IF REQUIRED r DOSE/PUMP SYSTEMS UMP NOTES ►OSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED IRTAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) 'IT AND D -BOX SHOWN & DETAILED DAY STORAGE ABOVE ALARM CURTAIN DRAIN TANDPIPES, 5' BOTH SIDES, DETAIL 5' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %, 100 %- <1% 0' MIN to CD DISCHARGE /100' with 182 cons day discharge 0' MIN to NON - PERFORATED PIPE g� IX PROPE TAX M w', s . 29 °00'00" MPR OJ CC DIMENSION GI RT (in fe &t) Number ' >.00' $ I 2.2 15 2 l2 6i 3 76 63 4 SO 67 5 65 70 G 90 74 7 94 76 8 99 82 9 105 8� 10 131 119 I i 127 116 tZ• I24, 114 13 121 112 14 I1a 110 15 116 Io8 L= 02' If L- 39.< R =3-1 � R= 25.0 A= 90° .2' >.00' 73 r 0 M c' r r I %n I 3 N R= 25.0 A= 90°