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HomeMy WebLinkAbout1816DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -5 -38.6 BOX 16 I loom oom"i IA A '� I ' ' 1 :tor 1 �' lu 1' 1 10 go f r -� ` I . -I- Wool PUTNAM COUNTY DEPARTMENT OF HE 5 DIVISION OF ENVIRONMENTAL HEALTH SERVICES 13 o CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at '3h 6y" I A DA P-1-O W WA-1r Owner /Applicant Name Tlff i ,F-�OW G� 4 Formerly Town or Village Tax Map '? 6 Subdivision Name Subd. Lot # PArTc X50H Block 5 Lot 'U 'G ,!o FAP-E5� 61 Mailing Address '` R-106r -014 �-oa1) pAT'f 0-60iq 1 i4` Zip R� -5b�j Date Construction Permit Issued by PCHD Separate Sewerage System built by TKE� 04-L-VA C Of-?• Address )2 DP-, t'\6TVNF- R ?A10-6o4 t,3? MV) Consisting of Gallon Septic Tank and 0)'16 1-f' AeA, ' T 9LFHGH Other Requirements: Water Supply: Public Supply From Address. or• X Private Supply Drilled by TO-VtH- WELL, 994WN( Address Building Type �� Has erosion control been completed? J Number of Bedrooms Has garbage grinder been installed? N0 I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam C ty D artment of Health. Date: �q ado I I Certified by �."&' P .E. X R.A. Address f ' o' �0� �61 Professional) V IQ,So� 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 revocation, modification A change is gecessary. A � LEM White copy - HD Title; Inspector;. Date: "" - Design Professional Form CC -97 A-%�) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Tow /Village: Tax Map # GPS" Map Block Lot(&) tl� Well Owner: N e: Address: Well Type _Screened _Open end casing X Open hole in bedrock _Other Total Length Mat erials: Steel Plastic Other Casing Details Length below grat�ftt f. Joints: Welded =XThreaded Other Diameter in. Seal: ) Cement grout Bentonite Other Weight per foot /I_lb /ft Drive shoe: Yes _ No Liner: _Yes No Diameter (in) Slot Size Length (ft) IDeotto Screen ft Developed? __.._._. a'J Ccf i � (1ivl.� ruc Ler �-4 saN Al Well Yield Test Use of Well: __Residential _Public Supply Air cond /heat pump Depth -Prima Business Farm _Irrigation Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Drilling Equipment Rotary Cable percussion )(Compressed air percussion Other(specify) Well Type _Screened _Open end casing X Open hole in bedrock _Other Total Length Mat erials: Steel Plastic Other Casing Details Length below grat�ftt f. Joints: Welded =XThreaded Other Diameter in. Seal: ) Cement grout Bentonite Other Weight per foot /I_lb /ft Drive shoe: Yes _ No Liner: _Yes No Diameter (in) Slot Size Length (ft) IDeotto Screen ft Developed? __.._._. Screen Details First Second Well Yield Test _Bailed Depth Date Measure from I; Well Log If more detailed information desc, ptions or sieve analyses are available, please attach. Depth ft. Land Surface L#j If yield was tested at different depths during drilling list: Pumped A, Compressed Air Hours _ irfac - static (specify ft) During yiel m Surface Well Dia ft. Water Bearing in ns Per Minute Pump Type Depths 6 D Voltage Tank Tvoe to Yield _Yes _No Hours Descrio e Tank Information Capacity Model 6 HP II I &_ Volume NOTE: Exact Location of well with distances to at least two Ormanent landmarks to be provided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 _... —11 u7. zio d4t$d /lilblIS PATTERSON PLANNING MAY -35 -2613, 12:20 PM RRY W NICHOL6 'PI-4 `fi 4557 Sherlita Amler, ,MD, MS, FAAP G 4 Commiarlow orhfsalth , )Robert Morris, PEE <..... Director ofEw(msmentat Health Department of Health 1 Cweva Road, Brewster, NY 10509 OWWMVS NAM r�ti Cap . TAX MAP NUMBER: E911 ADDRESS: VwiA &#,Ll,.w WOW PAGE 01/01 P. 02 Robert J. Bondi county Executive TOWN- PWTTtg'AP H AORIZEb TORN Oli'FICIAL: � • (Signature) DATF: l The Patnem County Department of Health will not issue a Certificate of Construction' Compliance unless the above forth. is. tompleted, Le.; a legal E911 addrar is, assijiied'by an - guthoditid'5t oiwn ofticlal. This form k to be submitted with the appticetion for a Certtf Bate of CoustimcOm Compliance. EyWrOnmentat Rsalth (845) 273.6130 Pax (M)279-7921 Water Supply Section (845)22$-5136 Fax (844225-3418 Nursing Servo ea (345) A78.6553 Fax (845) 478.6026 Nuratng / Rome Can Ageaey (84S) 273 -6085 WIC (845) 278.6678 Early Intervention /Preschool (845)228 -2247 Fax (8dS)225 -1580 -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH- SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Tf4f- .8kp -1 ow C,04`- Owner or Purchaser of Building Tax Map Block Lot Building Constructed by TownNillage ; `,i' l k Ib P4.QV4 W XY 1 �� Location - Street Subdivision Name Building Type. ` S.ibdiv -ision Lot # I represent that I..am wholly and cbrhpletely'responsible for the location, workmanship, material, constnrt;tiori and "diainage of the sewage freatment system serving the'above- describect 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 '-s-gstem coiT51ructed 1537 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 thefailure of the system to operate was caused by the willful or negligent act of the occupant of the building utiPThw,, the system. - _ .1 C f Dated: Month 01 Day '�o Year ©1 Signa General Contractor (Owner) - signature Corporation Name (if corporation) Title: Corporation Name (if corporation) Address: t r �cs�� Address: State ?():AeiS0 x-j Zip 1-7, K Stateq eJ zip 2 - Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director z a.. u... ._..... : ** TEST-REPORT LAB #: 1.303356 CLIENT #: 63799 NON STAT PROC PAGE: 1 of 2 THE BARLOW CORP 32 SYLVIA BARLOW WAY BREWSTER, NY 10501 DATE /TIME TAKEN: 09/06/13 01:00 DATE /TIME RECD: 09/06/13 02:00 REPORT DATE: 09/13/13 PHONE: (845)- 319 -3155 SAMPLING SITE: 32 SYLVIA BARLOW WAY, BREWSTER, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: HNO3 COLD BY: JOSEPH A FARESE TEMPERATURE..: < 4C NOTES...: COLIFORM.METH.: MF -------------------------------- ~--------------------------------------------------------------- START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 09/06/13 0430 09/07/13 0430 MF T. COLIFOR ABSENT /100 ML ABSENT SM 18 -20 9222B 09/10/13 LEAD (IMS) 1.3 ppb 0 -15 ppb SM 18 -19 3113B 09/06/13 0345 09/06/13 0415 NITRATE NITRO 0.75 MG /L 0 - 10 SM18- 204500903 09/06/13 0330 09/06/13 0400 NITRITE NITRO <0.01 MG /L 1.0 MG /L SM18- 20450ONO2 09/09/13 IRON (Fe) <0.06 MG /L 0 -0.3 mg /l SM 18 -20 3111B 09/11/13 MANGANESE (Mn <0.01 MG /L 0 -0.3 mg /l SM 18 -20 3111B 09/09/13 SODIUM (Na) 5.66 MG /L N/A SM 18 -20 3111B 09/06/13 0945 09/06/13 0948 * pH 7.1 UNITS 6.5 -8.5 SM18 -20 4500HB 09/10/13 HARDNESS,TOTA 80 MG /L N/A SM 18 -20 2340C 09/13/13 ALKALINITY (A 82 MG /L N/A SM 18 -20 2320B 09/06/13 0300 09/06/13 0302 TURBIDITY (TU <1 NTU 0 -5 NTU SM 18 (2130B) COMMENTS c :_ _ .. , , - :.: • -- ....v..: ._.. _ _..._.. ._ - - _.. _....... .. ._ , ...__ - ......... � �. MFTC otal Coliform = This result indicates that the water (was) (was not) of a satisfactory sanitary quality according to ew York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. Pb /Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than lot of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg /L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT) NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER RUNNING FOR 10 -15 MINUTES MINIMUM) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director_ - ** TEST REPORT ** LAB #: 1.303356 CLIENT #: 63799 NON STAT PROC . PAGE: 2 of 2 THE BARLOW CORP 32 SYLVIA BARLOW WAY BREWSTER, NY 10501 DATE /TIME TAKEN: 09/06/13 01:00 DATE /TIME RECD: 09/06/13 02:00 REPORT DATE: 09/13/13 PHONE: (845)- 319 -3155 SAMPLING SITE: 32 SYLVIA BARLOW WAY, BREWSTER, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: HNO3 COL'D BY: JOSEPH A FARESE TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium is suggested. * pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. pH IS A FIELD MEASUREMENT AND IS TESTED OUTSIDE THE HOLDING TIME. pH REPORTED FOR REFERENCE ONLY. Iid TOTAL HARDNESS-•IS`DEF'INED"AS•THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD WATER: 70 -140 MG /L MG /L = MILLIGRAM PER LITER HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) ALK (ALKALINITY REPORTED AT pH 4.5) IMS IMS = IMMEDIATE METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINUMUM OF 6 HOURS OR OVERNIGHT) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE ONLY TO TRESE SAMPLES RECEIVED BY THE LAB SUBMITTED BY: , M. T. (AS METHOD DirectoV ELAP# 10323 Harry W. Nichols Jr., P.E. P.O. Box 252 ..,..._ .., Tel. (845) 279 -4727 Fax (845) 279 -4728 y Septbmber 30, 2013 Michael J. Budzinski, P.E. Director of Engineering Putnam County Health Department 1 Geneva Road Brewster, New York 10509 RE: Individual SSTS Compliance - Barlow Corporation 32 Sylvia Barlow Way Patterson, NY T. M. # 35. -5 -38.6 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of Drawing. S -6, "As -Built SSTS ", dated 09/30/13. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 09/30/13. - 3. - -Three (3) copies of "Guarantee of Subsurfac6 Sewage _11(eatment System" Dated 09/30/13. 4. Laboratory Report, dated 09/13/13 - . 5. "Well Completion Report", dated 09/26/13 6`. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 05/21/13. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni Is Jr., P.E. HWN:jdm 10 -016.6 ALLEN BEALS, M.D., J.D. Commissioner ofHealth .-ROBERTILMORRIS, P.E.,..MPH- Director ofEnvironmental Health November 6, 2013 Harry Nichols, P.E. PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road,. Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Eacecuave Re: Field Inspection 6 Sylvia Barlow Way (T) Patterson, TM 35. -5 -38.6 A re- inspection at the above referenced lot has been completed and the revised basemen plan has been received by this Department. There are no further comments to be addressed in reference to this Department's open work inspection. If you have any further questions, please contact.me =at {845) 808 -1390, yext, 43261 Sincerely, Gene "D. Reed Principal Environmental Engineering Aide GDR: cm]. ALLEN BEAL.9, M.D., J.D. Of Reafth MARYELLENODPJ L ' ROBERT MORRiB, P.E. D;reft0f _ DEP. R ' ENT*OF HEALTH' ~.....,. 1 Geneva R04 Brewster, New. York 10509 Telephone; (845) 808 -1390; Fax; (845) 278 -7921 0 November 7, 2012 ' Harry Nichols, P.E. PO Box 252 Brewster, NY 10509 Re: Field Inspection 6 Sylvia Barlow Way (T) Patterson, TM-35. -5 -38.6 Dear Mr. Nichols: An inspection at the above referenced lot has been completed. A bedroom count needs to be performed by this Department upon completion of construction. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. _ _...... __._. Sincerely, .__.. . . Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw ��� ®d �iiL ©��[ `� m P71 Ila n' / etll Y/A 14� , " '0'rt ,, - 1411 lgnivl k-u WN t Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONAIENTAL BMALTH SERVICES FINAL SITE WSPECTION / / /-7 //2 Date: /e 1;-'12 Inspected by Street Location 1 u; arl�� %�/ ;, Owner _ 77,e- t3 low _G���� ermrt Town zo. cY'sov r - - � - . P. # -co s - lU TM # �� •� — �" — � � , � Subdivision Lot # !p 1: Se a 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 .:.... ............................... II. Sewage S vstem a. Septic tank size- 1,000 ...: 1,25 .......other.......... b. "Septic tank iiistalled-level .......... ............................... c. 10' minimum from foundation ....................... ............: d. Distribaiion Box 1. AlY outlets at same elevation- water.tested.... .............. 2-. Protected below frost ................................................. 3 Minimum 2 ft. Original soil between box & trenches e. Junction Boa properly set .......... ............................ .... 6. �ren_e_s 1. Length required 3 '715 Length installed 3 76 2. Distance to watercourse measured -t (a ° Ft.......... 3. Installed according to plan ....:.... ............................... 4. Slope of trench acceptable 1116 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7, Room allowed for expansion, 100% ......... :............... 8. Size of gravel 3/4 1'le diameter clear .................... 9. Depth of gravel in 12" m,n,mY,m ................... 10. Pipe ends.capped........................................................ g.. -Puma or...Dosed Systems .. Size of pump chamber ................................................. 2. Overflow tack ......................... .............. .................. .3. -aim, visual / audio ................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First b6iX baffled....* I.. ................ .. . . . 6. Cycle witnessed by H.D.estimated flow /cycle........... HL Hause/Bw7dinQ a. douse located . er approved plans ............................ b. Number of bedPooms. Well located as per approved plans . ......:........................ b. Distance from STS area measured /dv' ft........... c. casing. 18" above grade ............... ............................... d. Surface drainage around well acceptable .....:............. V. Qverall Worlonanshia . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box .. ............................... d. Bac1-511 material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfill protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate... .... :.......................... i. Erosion control provided ................. ............................... Rev. 2/02 COMMENTS See ra ; f � sy`Ce Fill pad located per the approved plan A"00 D 4 Fill Pad Length � U Required Length 7/ L �� 8 6 .� 11- Z 1, Fill Pad Width Required Width /o v I oo , Fill Pad Depth _ �� Required Depth , 5 y ` Run -of -Bank Fill Quality 0/,/ Slope from Top to Toe Impervious Layer Installed yei!�, Erosion Control Installed �� S Sieve Test Results (if applicable) Additional Comments: _ z, _. -✓i �{%`- e� �._._. f . CO k j M�,e.�ts C t�if� w�eti�ts 8 Reserved for Field Sketch if Annlisable ALLEN BEALS, M D., J& Commlissianer ofHealth ROBERT MORRL% P.E. Director of EnvironmcotM Health November 7, 2012 ' Harry Nichols, P.E. PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: • MARYELLRN OMLL County Emotive DEPART'MEN'T"0F' HEALTH. 1 Geneva Road, Brewster, Now York 10509 Telephone: (845) 808 -1390, Fax: (845) 278 -7921 Re: Field Inspection 6 Sylvia Barlow Way (T) Patterson, TM-35. -5 -38.6 An inspection at the above referenced lot has been completed. A bedroom count needs to be performed by this Department upon completion of construction. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw ALLEN BEALS, M.D., J.D. Commissioner ofHma ROBERT MORRIS, P.E. DirectorofEnvi vnmeitdHeahh MARYELI,EN WkU County Executive _ � �.._.M ..__._...�..._. _ .._.... _ DEPARTMENT OF HEALTH:� - 1 Geneva Road, Brewster, New York 10509 Telephone: (845) 808 -1390; Fax: (845) 278-7921 November 7, 2012 Patterson Town Hall Mr. Nick Lamberti, Building Inspector Building Department PO Box 470 Patterson, NY 12563 Re: House Plan Approval for 6 Sylvia Barlow Way (T) Patterson, TM 35. -5 -38.6 Dear Mr. L amberti: It has come to this Department's attention that a set of house plans have been approved by the Town of Patterson Building Department without first being approved by the Putnam County Department of Health. Please be advised that, as part of this Department's construction permit approval process, house plans must be. submitted_ to this Departomt for betlroom.count_pri& to seeking final approval by local municipalities within Putnam County. This Office would like this letter to serve as clarification of the Health Department's regulations and requirements. 3 Thank you for your understanding in this matter. If you have any further questions, please contact me at ext. 43261 if any questions arise. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:cw 1 !d PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,.:.GONSTRU4CTION -- PERMIT FOR- SEWAGE-TREATMENT SYSTEM::..- w r . PERMIT # Pa l.0 4 t G Located at 'LV ik PyI�R -LoW Poe Town or Village PA-rU P- 60H Subdivision name Subd. Lot # & Date Subdivision Approved o %7 / I.- I / �a Tax Map '��• Block r Lot Renewal Revision Owner /Applicant Name x'1+0 bNP --WV4 fi 9-?- Date of Previous Approval Mailing Address 19- &-1H 07-r0HlE 9-0. PAT1-159-60H , W Amount of Fee Enclosed �9kti� P(�o�IhL j Zip 111 (01� Building Type RV 10i;1-4C4 Lot Areal) oldbI No. of Bedrooms Design Flow GPD Co GO Fill Section Only Depth Volume PCHD NOTIFICATION IS REOIIIREI) WHEN FILL IS CnMPi.F.TFD Separate Sewerage System to consist of 1').4'0 gallon septic tank and IM 1-f - AZ6 Other Requirements: R Q 1 l� . 1%t t•t, To be constructed by Ti5p Address Water Supply: Public Supply From or:. Private Supply, Drilled by Address 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 treatmentsystem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Director /Commissioner will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: _ n Address P a 4 ,V , XL� 0 P.E. j(' R.A. L o 4, v 0 License # Date 0910r:71I� 5;6 12 ' 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 Ihen considered ne essary by the Director /Commm —over. ny revision or alteration of the approved plan requires anew pe it. Ap roved f ischarge of domestic sanitary sews only. By: ... Title: Date: q-- /G -7 ?.-- White copy - HD Fil Yello cop - Building Inspector; Pink copy - Owner; rang c py - Design Professional Form CP -97 pq 191 y u L i/A R TMENT 0 F HEA LTH A o S APPROVED FOR, ec BEDPoCpjqo FIRST FLOOR ALL SUBSEQUFAlT u T ONS TO AL I'EIRA I I ALA t.s P.4►z :.. -:�;!—'-- - 'USE ST BE.3j G E Hl, HE'TOTHEPCDOHFORAPPROVAL SIG&TURE & TI E 44 ,,DATEe- T Nw A pq 191 y u L i/A R TMENT 0 F HEA LTH A o S APPROVED FOR, ec BEDPoCpjqo FIRST FLOOR ALL SUBSEQUFAlT u T ONS TO AL I'EIRA I I ALA t.s P.4►z :.. -:�;!—'-- - 'USE ST BE.3j G E Hl, HE'TOTHEPCDOHFORAPPROVAL SIG&TURE & TI E 44 ,,DATEe- T Nw d ,e 1 I- �d .1 \Bath __— rrr.� -,— IJ , Bedroom #2 0� 15' -4., x 12' -9" I rBed - -- - CI CI om #3 15; -1,. - -- i - I. I I open to below I t I I SECOND FLOOR t 3132° y 1'= o° h d�� I r. O 0 Harry W. Nichols Jr., P.E P.O. Box 252 — - Brewste _. ,..... . ....... >v _ _.._ __ .. Tel. (845) 279 -4727 Fax (845) 279 -4728 September 5, 2012 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Michael J. Budzinski, P.E. Re: Individual SSTS- Trench Permit for P -05-10 The Barlow Corporation Farese Subdivision- Lot 6 6 Sylvia Barlow Way Town of Patt erson T.M. # 35. -5 -38.6 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of SS -6 "Proposed SSTS" dated 09/05/12. 2. "Construction Permit for Sewage Disposal System ", dated 09/05/12. 3. "Design Data Sheet" (for percolation tests in fill pad) dated 09105/12. .. _. ,.. _._... _..._..:._..Wr�vuouJbd appre�.iate -year- review, approval- and- issuance -of the= £onsfrizction�Perrrlic at_ your earliest convenience. Very truly yours, Harry �W.hols ., P.E. HWN:jdm 10 -016.6 PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner THf— CAOIDP+-fl OH Address 12 04H s�14 qM10-604,q 1%6$ Lot 50 Co � Located at (Street) 9,pph Tax Map 56- Block '5 — (indicate nearest cross street) Municipality ?A-1TflL/WH Watershed SOIL PERCOLATION TEST DATA Depth t ;]From 5 N UTE 6: 1. 1 ests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. --5 1 min for 1-36 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 . ........... . . . . . . . . . loll IOU 15/1 2 102' loll' (51 3 4 5 2 100 3 61W I 4 5 s 2 3- 5 N UTE 6: 1. 1 ests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. --5 1 min for 1-36 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 ALLEN BEALS, M.D., J.D. Commissioner of Health .ROBERT _MORRIS,, x Director of Environmental Health August 6, 2012 DEPARTI�J[ENT' OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Harry Nichols, P.E. PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: MARYELLEN ODELL County Executive Re: Field Inspection — Joseph Farese 6 Sylvia Barlow Way (T) Patterson, TM 35.-5-38.6 An inspection of the f ll pad at the above referenced project has been completed. The following comment needs to be addressed: • It appears the fill pad width and length is short by 20 feet. Trench permit and plans must be submitted to this Department for final approval of construction prior to the installation :. `. ::.. _Of the. separaw. sewage treatment'system� _ti_ _..._........- If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, MAP- Gene D: Reed Sr. Environmental Health Engineering Aide GDR:cw 914 279 4567 P. 01 ,�O ib � -7 w a- j PUTNArii- COUNTY DMlEtTMENT'OF HEALTH DMSTON OF ENVIRONMENTAL HEALTH SERVICES For: Fill Date: Trenches PCHD Construction Permit # '` � � /0 Located: (T) ia� r- g 0 Owner /Applicant Name: j sr�; TM -36'+ Block T Lot 3814 Formerly: Subdivision Name: );Fr Subdivision Lot -# is system fill completed? - Date: 71 2of/ I's system complete? Date. Is system constricted as per plans? Is well drilled? NO Date: Is well located as per plans? _._. Are erosion control measures in place? T certiiy that. the system($), 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: -7 1 — Certified by: , pg RA Address: (S 66Y w ro^ Lic. J Comments, FOR: D Al]AM 11 GEl + kc, 3,Pd=,,.s k / Form FIR -99 f PUTNAM COUNTY DEPARTMENT OF HEALTH ti DIVISION OF ENVIRONMENTAL HEALTH SERVICES - ....-s.APPUCATIO TO CONSTRUCT A °WATER °WEAL :. ,.....,... .. ,. .....,....... please print or type VGH[3e'it Well Location Street Address: Town/Village: Tax Map � A- �o 5yWlA $/�UW WIC f x -r'5 . '4 Map X17 Block Lot(s) 'ls fo Well Owner: Name: Address: Phone #:(9,4 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 54- gpm # People Served ' T Est. of Daily usage 00 gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling X 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 X No Name of subdivision r—Aa- Lot No.�_ Water Well Contractor: _r Address: Is Public Water Supply available on site? ....................................... ............................... Yes _ No Name of Public Water Supply: t-]Ar Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to rovided on separate a t/plan. r Date: ll — l7 — 16 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. `4 =The well dGlller shallabide9b afl condlt�ons of he ecmlt 5)' During allwe l dnllm o erations the welt duller shall _....:.. _ _ s[_... take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may. be amended or modified when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam Cp�nty. A _ Date of Issue I _Z0_1/ Permit Issuing Date -of Expiration / — zy — Title: Permit is Non - Transferable _ White copy - HD file; Yellow copy - Building Inspector; Pink copy - Ownaf; Orange copy - Well driller Form WP -97 Rev. 3/06 1110 W U110911 NAOMI I '&''INUT310 0"WILLWAINUMN J( Gc CONSTRUCTION PERMIT FOR--9Z WAGG,TR EA'I'I�IEI�1�'-- SY�S'I'EP� PERMIT # 1 (r=te Ai d :0 ID Located at C® -5Y 1-'J 1 A E�A,iZLo W by "kY Town or Village PAil-07¢ -may O H Subdivision name FAQ-F- 6F- Subd. Lot # Co Tax Map Block 15 Lot % Date Subdivision Approved 0-->/Z-7/98 Renewal Revision Owner /Applicant Name Mailing Address TH- 6AP -1—OW (,09-f- 11— N -1 r1A.Y-1Q Hr Amount of Fee Enclosed Building Type gt�7' 1961.>c -r- J®,0 or Date of Previous Approval FATT-ep-,50H , N.Y. Lot Area 9i ZU No. of Bedrooms 15� Design Flow GPD Zip 11-66S Fill Section Only Depth 'J-S' Volume 4100 Ca PCHDD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To be constructed by g,?.ro -*..j' 12 -v. $. r1LL TOP gallon septic tank and '�'14 Lr— A05- Address Water Supuly: Public Supply From Address _ or: Private Supply Drilled by - 71-15 P. 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. X R.A. Date 11— j 4 License # 15611 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 n9pessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pet•mit. Approved f r discharge of domestic sanitary sevAge only. By: AktA-r-L White copy - HD Y Title: Inspector; P Date: Z, OD ' j/ - Design Professional Form CP -97 January 19, 2011 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Aft: Michael J. Budzinski, P.E. Director of Engineering Re: -Proposed SSTS —Barlow Corp. 36 Sylvia Barlow Way Lot 6 Farese Subdivision Patterson, NY T.M. # 35.-5-38.6 Dear Mr. Budzinski: Harry W. Nichols Jr., P.E. P.O. Box 252 Brewster, NY 10509 Tel. (845) 279-4727 -Fix ?, 0 . / , 0 .5"` In response to your January 12, 2011 review letter, we note the following: 1. The SSTS design data chart now indicates a min. of 3.5 feet R.O.B. fill. 2. A 3:1 side slope is now provided at the southern end of the fil pad. 3. A 100% reserve system area is now provided. -Reflecting,the cibove,. enclosed- are--the, folloWing., Three (3) prints of SS-6 "Proposed SSTS", rev. 01119/11. Five (5) prints of SF-6 "Preliminary Design for Fill Placement" rev. 01/19/11. Kindly continue with your review of this Application. Very truly yours, Har W. Nich I Jr., P.E. H W N -,�Jdm 10-016- 0 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health ROBERT MORRIS, PE _ Liire4.tor. of Environ> enta.t - health • - Harry Nichols, RE PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Office (845) 808 -1390 Fax (845) 278 -7921 or (845) 808 -1937 PAUL ELDRMGE County Executive January 12, 2011 Re: Proposed SSTS for the Barlow Corp Lot # 6 — Farese Subdivision @ Sylvia Barlow Way .(T) Patterson, TM # 35 -5 -38.6 This Department has received and reviewed the revised plans for the above - mentioned project and the following comments are offered for your consideration. The SSTS Design Data Chart is to specify a minimum of 3.5 feet R.O.B. fill. 2,/ A 3:1 side slope has not been provided on the southern end of the R.O.B. fill pad. It does not appear that a 100% reserve system area has been provided. Upon completion of the above, this Department will continue its review. Kindly, advise us if .... ... _ _ .... Respectfully, 4ichael J. Bu' in , P Director of E Line MJB:cw Barlowcorp2 Harl-y W. Nichols Jr., P.E. P.O. Box 252 Brewster, NY 10509 _ Tel- .7,2.7 Fax (845) 279 -4728 January 3, 2011 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Aft: Michael J. Budzinski, P.E. Director of Engineering Re: Proposed SSTS — Barlow Corp. 36 Sylvia Barlow Way Lot 6 Farese Subdivision Patterson, NY T.M. # 35. -5 -38.6 Dear Mr. Budzinski: In response to your December 16, 2010 review letter, we note the following: 1. The toe of fill has .been revised to reflect a distance of 10 feet to the property line. 2. The toe of the fill pad has been revised to provide for a 5' separation from the ledge rock outcropping. 3. The lengths of the absorption trenches have been shown. on.the.pfan.. -- ..- :...:.4..The:SSTS- design -data -chart now indicates armin. -of 3.5 feet R.O.B. fill 5. The junction box detail has been revised to show a minimum of two feet of solid pipe out of the box prior to the start of perforated pipe. 6. The access to the well now originates .from the driveway to eliminate any conflict with adjoining easements. Reflecting the above, enclosed are the following: Three (3) prints of SS-6 "Proposed SSTS ", rev. 01/03/11. Five (5) prints of SF-6 "Preliminary Design for Fill Placement" rev. 01/03/11. Kindly .continue with your review of this Application. Very my yours, Harry W. Nic s Jr., P.E. HWN:jdm 10 -016 Sherfita Amler, MI), MS, FA Commissioner of Health Robert Morris, PE __-Director ofEnvironmental Health Harry Nichols, PE. PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: Robert J. Bondi County &ecunve I Geneva Road, Brewster, NY Office (845) 80&1390 Fax (845) 808-1937 10509 December 16, 2010. Re: Proposed SSTS for the Barlow Corp Lot # 6 — Farese Subdivision @ Sylvia Barlow Way (T) Patterson, TM # 35-5-38.6 This Department has received and reviewed the submitted application and plans for the above- mentioned project and the following comments are offered for your consideration. 1. The toe of the fill pad is shown less than 10 feet to the property line which is 12. unacceptable. % I The toe of the fill p9A is shown less than 5 feet from the ledge rock outcropping which is unacceptable. The lengths of the absorption trenches are to be indicated on the trench plan. 4. The- ,SSTS Desiminimum ata Chart i to spec' fy a minimum of 3.5 feet R.O.B. fill. 1 The junction box detail is to e revised to show a irnimmiirn o two (2) of solid out of the box prior to the start of the perforated pipe. The approved subdivision plat shows the proposed well at the front of the lot and the submitted plan shows the proposed well at the rear of the lot. The proposed well access crosses lot #5 and it does not appear that a permanent access easement across lot 45 exists. Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. R.espeeMy, Michael J. I Director of MJB:kly barlowcorp Sherlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE Director of Environmental Health Harry Nichols, PE P.O. Box 252 Brewster, NY 10509 Dear Mr. Nichols: DeparttAefi f- 1 Geneva Road, Brewster, NY 10509 Office (845) 808 -1390 Fax (845) 808 -1937 Robert I Bondi County Executive December 15, 2010 RE: Farese — 6 Sylvia Barlow Way Lot #6 — Farese Subdivision (T) Patterson, TM 35 -5 -38.6 East Branch Reservoir Basin The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on December 9, 2010 is complete. The Department will notify you by January 3, 2011 of its determination. 0 The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. • The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt o f,the;'notice,:ycuix.application will be- deemed approved, wbject-tu standard °term`s aiidl"" " conditions as set forth in the regulations. - Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845)808 -1390 ext. 43148. Re pectfully, ichael J. Bud s i, PE Director of E gineering MJB:cw PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF' AUTHORIZATION RE: Property of YE �P��I.OV� GOP- �oT101� Located at Z�ii—V 1 A L�DW W PYY `T/V P�tTEP- �ao>�+ Tax Map # `b�9= Block 5 Lot , Subdivision of Subdivision Lot # 6 Filed Map # 270 Gentlemen: Date Filed This letter is to authorize HAPPY W • H I C._4lh 1 A a duly licensed Professional Engineer �_ or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health _---- Law;..and --the Putnam County ,Sanitary Code. 0 Very truly yours, • • • '7 r State py Zip Signed: ( ner Prop F � r f�Z Mailirng Address: K. 101201 State NY Telephone: Telephone: (914) Zip 9 Form LA -97 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: 1-0r , ��E Svti��yi�jt p►-�, ?'M '�jy, -- 38:� represent that I am ari officer or employee of the corporation and am authorized .to 'act for.:. ?Name of Corporation: 740'' 40 PAF-LoW &0PFoF_A�r'l ®H Having offices at: 12 �.f jMr?T-eNr Q.p, PArT —F"OH, H. Y. I?1564 Whose Officers Are: President - Name: JD© (FfI X154 Address: 12. MCI Mh'fo!ue- izfi. p,�°rr•����', � `+ � t256 � Vice President - Name: - Address: Secretary -Name: 5AMC— .. Address. Treasurer - Name: SaM� 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 the SrgnedL_ - reto. Q�aa� _._.... Title: Sworn to before me this 11 day of (mo th) (year) Notary Public i,)1A.NE M. SLIMOSSLER Corporate Seal NOTARY PUBLIC k4Y COMMISSION FW" MT, 31,201' Form CA -97 Hany W. Nichols Jr., P.E. f` P.O. Box 252 „ Brewster, NY 10509 el�($4).279.4727 .. . Fax (845) 279 -4728 _. ., ... .... November 17, 2010 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Michael J. Budzinski, P.E. Re: Individual SSTS The Barlow Corporation Farese Subdivision- Lot 6 6 Sylvia Barlow Way Town of Patterson T.M. # 35. -5 -38.6 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of SF -6, "Preliminary Design for Fill Placement Only ", dated 11/17/10. 2. Two (2) prints of SS -6 "Proposed SSTS" dated 11/17/10. 3. "Short E.A.F." dated 11/17/10. ...._«Application for App;l oval of Plans fog a Wastewater -Disposal System ": 5. "Construction Permit for Sewage Disposal System ", dated 11/17/10. 6. "Application to Construct a Water Well ", dated 11/17/10. 7. "Design Data Sheet" (2) dated 11/17/10: 8. "Letter of Authorization" 9. "Corporate Resolution" dated 11 /11 /10. 10. Two (2) copies of Residence Floor Plan(s, , for `Bedroom Count Only 11. Review Fee in the amount of $500.00 We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, #a- aAll- Harry W. Nicho Jr., P.E. - HWl,1:jdm 10 -016.6 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI. R.N.,. M.S.N. - --Associate Public' Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (91 278 - 6014 Presctiool (914) 278 -6082 Fax (914) 278 - 6648 TO: AD OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATTMENT SYSTEM PROGRAM DELEGATED 67 _ - Ir. PROTECT: [.! _ %/ 4eR:115E-.. �WIMIQAI TOWN: C SE PV DATE SUB'D_AP-PROVAL:- 3°' 2 S - . -.. NOTICE OF COMPLETE ArrLICATION )ATE: z , 2®/d PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER RE: Property of TM� f 5k�- SOW GOP-•POP -F) OH Located at % rt.)iLvIA kR-WVJ WAY 'TN Tax Map # Block 5 Lot 9 Subdivision of a 16 G Subdivision Lot # Filed Map # 270 - Date Filed 10 % ri l q 8 Gentlemen: This letter is to authorize w g_q_Y Vhf • H I CAOL"i ► ip a duly licensed Professional Engineer x or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam - County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise 'the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health _.._ .and the Putnam County Sanitary �Code. ` - - Countersigne :.Q. P.E., R.A., # �" Mailing Address a X-16� W/, T61L State P T Zip 19-501 Telephone: _045) - 2,1- -f?21 Very truly yours, Signed: ( �,rProp F Mailing Address: H JnH� p-0 • State Telephone P t -TT NY Zip I ? TL �5 C914J - GCA_ 1266 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FQK— APPROVAL OF PLANS,FOR . A WASTEWATER TREATMENT SYSTEM try + 1. 2. 4. 6. 7. Name and address of applicant: I N r— Vf r LOIN GO "Dv-pt-1 I OH PAi77e-A -070 H , N -Y , I ?h61 Name of Project: FW066 1,70 1-6 VT Cv Design Professional: H>W W, OUJO h I,@5 Drainage Basin: 15P< $ N Type of Project: Private/Residential Apartments Office Building 3. Location: TN: FATT'ML&H 5. Address: POD � %'L BJZF J - M IKo Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR) ? .............. Yes/No No Type Status (check one)............. .......................... ............................... Type I Exempt Type 11 Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/No H 0 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes/No' NA 11. Name of Lead Agency N A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............................................................. ............................... Yes/No 1�Eh 13. If so, have plans been submitted to such authorities? .. ............................... Yes/No No 14: Has pkeliminary*approval been granted by such authorities? t`4 A, Date -granted: N 15. Type of sewage treatment system discharge ........................ surface water X groundwater 16. If surface water discharge, what is the stream class designation? .......................... NA 17. Waters index number (surface) ............................................. ............................... H A 18. Is project located near a public water supply system? . ............................... Yes/No N 0 19. If yes, name of water supply MA Distance to water supply N A 20. Is project site near a public sewage collection or treatment system? .......... Yes/No N D 21. Name of sewage system N X Distance to sewage system PA 22. Date test holes observed I 1 23. Name of Health Inspector KV-6 bV02JH,6j&1, 24. Project design flow (gallons per day) ............................. ............................... 6 QO 25. Is State Pollutant Discharge Elimination system (SPDES) Permit required? ... Yes/No N 0 26. Has SPDESApplication been submitted to local DEC office? ......................... Yes/No iJ(� Rev. 11102 Fom PC -97 Pg. 1 of 2 27. Is any portion of this project located within a designated Town or State wetland ?... Yes/No N 28. Wetlands Q number ............................................................. 29. Is Wetlands Permit required? ............. .............. ............................... Yes/No Has application been made to -Town or Local DEC .............................. Yes/No N-A NO NA 30. Does project require a DEC Stream Disturbance Permit? .... .........................Yes/No 110 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 N 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 N DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .........................Yes/No Y15'6 .34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ........... .........................Yes/No N 0 35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No IJ 0 36. Tax Map ID Number .............. ............................... Map Block 5 Lot %,Cp 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 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 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 1, 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 true to the best of my knowledge and belief. False statements made herein are punishable as a Clas�2_4 misdemeanor purskantto Section 210.45 of the Penal Law. _ n /a I vz SIGNATURES & OFFIC2AL TITLES Mailing Address.: ........................... Form PC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owneir -T*1+5'-'—'ItiP4L-1:4--V-4---,-...--C-pp-q--O,�L-NT-f.o.."--.'--.-------'.'A-d�d-r-'-e--s-s---I:�.-----OP-4-m- ,5--ro we­ vm-o) (indicate nearest cross street) — --_-------------- - W_ ..... ..... U� er s d SOIL PERCOLATION TEST DATA zil-I of - -1 Pf.67§6dk1n__'=_ __ __ - - ateb . _erco on-Test Form DD-97 R D me... T ou ... ro T. n f, cb Sta.f,j Sio . ...... ... .................... ... . ... [b] -------------- 5 IT H-41— 5 2 3 4 5 NOTES: I 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, :5 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 .9.5' 10.01 Indicate level at which groundwater is encountered'.' Indicate level at which mottling is observed Indicate level to which water level rises after being encountered MA Deep hole observations made-by: IWA/ W' Design Professional Name:. H" .__ W, j4ic+ 9✓� ---Address:. P5 Signature: Design Professional's Seal T ku 66124 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. PT lo HOLE NO. Pr I I ...HOLENO. -Pr G.L. 0.5' VJ OV 1.01 L-0 N4% 1.5' LOAH 2.0' 2.5' I b K0, -ia-TV IV- (A,% tAM, 5iLT? 3.0' 3.5' 4.0' (0 4.51 5.0 5.5' iZQ_U __V _6_1�i 0; L, IfE, 6.0' 6.5' 7.0': 7.5 8.01 8.5' 9.01 .9.5' 10.01 Indicate level at which groundwater is encountered'.' Indicate level at which mottling is observed Indicate level to which water level rises after being encountered MA Deep hole observations made-by: IWA/ W' Design Professional Name:. H" .__ W, j4ic+ 9✓� ---Address:. P5 Signature: Design Professional's Seal T ku 66124 PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'DESIGN DATA 'SHEET --SUBSURFACE SEWAGE TREATMENT SYSTEM (indicate nearest cross street) -- -e- r—s h —e d ------------ Vi __. :N1 : - - :.__ — Municipality_ - - - -- Wit SOIL PERCOLATION TEST DATA 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 ..0 ..... ..... ........ T j . . ro G : on MA S" . ....... .. .................. . ...... .. ari, t P I n c ------ ------- - - -------- J. ------ - -- 4 7- 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 Indicate level at which groundwater is encountered ------ Indicate level at which mottling is observ--&d.'--.-----A4Q--H- Indicate level to which water level rises after being Deep hole observations made Design Professional A d d r e s. Signature:. L Design Professional's Seal LU 56124. 4� r rSS�o 10 so TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOUt N.O--."- -------HQLE-NQ G.L. 0.5' 1.01. go 84WO 1.51 2.0' 2.5' 44' 3.0' e;h& 15it4y %4D 3.51 4.5' 5.01 5.5' 6.0' 6.5' 7.01 7.5' 8.0' 8.5' 9.01 -9.51 ... .... 10.01 Indicate level at which groundwater is encountered ------ Indicate level at which mottling is observ--&d.'--.-----A4Q--H- Indicate level to which water level rises after being Deep hole observations made Design Professional A d d r e s. Signature:. L Design Professional's Seal LU 56124. 4� r rSS�o 10 so 14 -164 (9195) —Text 12 PROJECT I.D. NUMBER .617.20 SEQR Appendix C State Environmental Quality Review - ` ""` ` SHORT-ENVIRONMENTAL= ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1. APPLICANT /SPONSOR n+6 ON9 --1-ow G04' 2. PROJECT NAME i-OT a 6A-T6 3. PROJECT LOCATION: (7 A.� �QN ��N�M Municipality I County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) G 'i YLQIAc 649- W I V*y 5. IS PPOPOSED ACTION: IgNew ❑ Expansion ❑ Modlflcation/alteratlon S. DESCRIBE PROJECT BRIEFLY: ilJpNl(hr�� ��r �ihi5, �hiD�kr -E, D�(��I�v�Y 7. AMOUNT OF LAND AFFECTED: ° % �' $ Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? JO Residential - 0 Industrial ❑ commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe. hiN(Aa FpHILs 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? SYes ❑ No if yes, list agency(s) and permitlapprovals Nuvib -t- w'46WNY Ft;p %Tt , -ruwm or ?i IT6r O -+ 11. DOES ANY A�SIPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? • C1 Yes No If yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes IgNo I CERTIFY THAT INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE �THE APPllcantlsponsor na 14A* / W' 1CA-8L5 A–, 9 M2 AfW Date: �16 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 617.4? 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? _. _, If 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 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. t—a r_3 cs C6. Long term„ short term, cumulative, or other effects not Identified in CI-05? Explain briefly. C? I = . i C7. Other impacts (including changes in use of either quantity 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 E IS THERE ,.OR- IS THERE..LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes No if Yes; explain brMe"ffy` PART III — DETERMINATION OF SIGNIFICANCE (ro 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. ❑ 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: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsi le Officer in Lead Agency Signature of. Prepa!er (i i erent from responsible officer) Date 2 a lk M OVA `o PROPOSED ?.O' k'ELr ACCESS B4S£MEN7 yam\ !!! FAVOR OF LOT 6 ' \e \� \ ':go•.z mc 1 R.�...oW WAY DIMENSION CART (ineetj Number 2 95' loll 5 ' a9' -� 1203' . • . 89.'. , "17 l0 15 . 2l Co 4'