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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 44. -3 -3.2 BOX 18 02115 AV CER PCHD C PUTNAM COUNTY DEPARTMENT OF HEALTH INISION sOF ENVIRONMENTAL HEALTH, SERN'10ES - v._ ..... ....... ." TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM IUCTION PERMIT # f -I " q8 Located at fp11' P�"e ar Town or Village Owner /Applicant Name V1411'ip+ Jr)JI Of414) Formerly r11TV i-N1A^ o F,A,T1 f:—:F=° ;DH Tax Map 44- - Block f� Lot ' J, Subdivision Name V 1io Subd. Lot # I— Mailing Address p g wX �-m NY Zip 104;)ol Date Construction Permit Issued by PCHD 5 /yI qs Separate Sewerage System built by : v-491 M PVFI� C P V 0 Address 5nLl- Consisting of 1V5 d Gallon Septic Tank and g�) OC�' v- � Af�`3 Other Requirements: Water Supply: Public Supply From Address or: Y Private Supply Drilled by ��` 0 NA' )h 1�-' Address Ira-. f wi..eq- S1- F\TO�M*V;c o Building Type - Number of Bedrooms 4- Has erosion contror been completed?" Has garbage grinder been installed? No 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 PutnamnCounty Department of Health. Date: 6 ` f I ( Certified by Address So Mjt P WH WD P.E. R.A. .10401 License # r% / N Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocat' odifica ' or change is necessary. ��^^ By: Title: Date: 11 Z White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 LAURENT ENGINEERING ASSOCIATES, P.C. j \\ MILLBROOKE OFFICE CENTRS Route 22 6 Millto —m Road -. �.. (914)278 -6108 • (F� 27a•2S5 HARRY W. NICHOLS JR., P.E. v CONSULTING SITE ENGINEERS December 18, 1998 Putnam County Health Department. 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Compliance Philip & Joy Harris Fair Street -Lot #2 Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -2 "As -Built Plan," dated 12/11/98. 2. "Certificate of Construction Compliance. for Sewage Disposal System," dated 12/15/98. 3. "Guarantee of Subsurface Sewage Disposal System," dated 12/16/98. 4. Water Quality Report, dated 12/16/98. 5. "Well Completion Report," dated 12/10/98 6. Application Fee in the amou.at of $200.00 payable to Putnam County Health Department. If there are any questions concerninCr the the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. 98060 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ WELL COMPLETION REPORT Well Location S "-Address: • Town/Village: Tax Grid # 0 Map Block n Lot(s) Well Owner: Name: Address: Use of Well: I- primary 2- secondary Residential Public Sunk Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment _ Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing < Open hole in bedrock Other Casing Details Total length / ft. Length below grade W. Diameter in. Weight per foot lb /ft. Materials: X Steel _Plastic _Other Joints: _ Welded _�< Threaded _ Other Seal: 2!� Cement grout _ Bentonite Other Drive shoe: X 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 Hour7_ Yield � gpm Depth Data Measure from land surface- static (specify ft) 36 During yield test(ft) Depth of completed well in feet d 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 " If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth _'2jPD Model SrPo5 -1-3 Voltage Y30 I'P Tank Type p Vol e Date Well Completed Putnam County Certification o. Date of Report �j ]Well Driller (signature) Nor: tact location of well wffh distances to at least two permane lan �Tmarks to be provided on a separate sheet/plan. Well Driller's Name - Address-/,Js r' Signature: t 4 Date: dZ : White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 mi PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Pl+1L4 -- JDi f1K'M Owner or Purchaser of Building Building Constructed by Location - Street 9.eb O KZ_ Building Type Tax Map Block Lot TownNillage Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent'act of the occupant of the buildin_ g utilizing the system. The undersigned further agrees to accept as co, nclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month �2 Da l� Year General Contract (0- Owner) - Signature 6)004cr Xe-k- Dioi Corporation Name (if corporation) Address: hx U State /0. . 7 Signature: Title: -A Corporation Name (if corporation) Address: Zip 1,2 � c�- State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 near Street - (914) 245-2800 Albert H. Padovani, Director PLAAE14-t.- 32.809933 T #: 7686 ~~~~~~~~~~~~~~~~~~ RTERHORSE DEV, INC 0K 0 BOX 402 RMVILLE, NY 12582 NON STAT pROC PAGE 1 �~~.r~~~.~~~.~~~~~~~~~~~~=~~~~~~~~~~~~~ DATE/TIME TAKEN: 12/11/98 01:00P DATE/TIME REC'D: 12/11/98 01:45P REPORT DATE: 12/17/98 PHONE: (914)-628-0971 ING SITE: LOT #2, FAIR STREET PATTERSON NY SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE 'D By? MICHAEL SPACCARELLI. TEMPERATURE..: . A0TES...: HOSE COLIFORMMETH: y1F -~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~-~~~~~~~~~~~~*~~~~~~~~~~ DATE FLAG PROCEDURE 0, 41 PUTNAM CNTY PROFILE 12/11/98 MF T. COL .. .- ��. '-- LEAD '-..- a^,� --- 12/11/98 12/11/98 12/11/98 12/11/98 12/11/98 12/11/98 12/11 /99 12/11/98 12/11/98 12/11/98 - 12/11/98 MF T. COLIFORM LEAD (IMS> NITRATE NITROG NITRITE NITROG IRON (Fe) MANGANESE (Mn) SODIUM (Na) pH HARDNESS,TOTAL ALKALINITY (AS COMMENTS: fax to 628 1035 RESULT NORMAL - RANGE METHOD ABSENT <1 1.08 <0.01 <0.060 <0"010 7.41 6.6 32.0 32`0 <1 /100 ML ppb MG /L MG /L MG /L MG/L MG /L UNITS MG /L MG/L NTU'' ABSENT 1008 0-15 ppb 9101 ` 0 - 10 9139 ` N/A 9146 0-00 mg/l 2037' - 0-0.3 mg/l :2037 N/A 6.5-8.5 9043 ' N/A ' - 'N/A 0-5 1NTU COMMENTS: THESE RESULTS INDICATE THAT THE WATE AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI�6�Z 'HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS; FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ' 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 If both iron and manganese are present, their total value combined shall not exceed 0.5.mg/L. � �\ ^ ~ i���!� YML ENVIRONMENTAL SERVICES VAQ Yorktown Heights, N.Y. 10598 ' (914) 245-2800 Albert H. Padoyani, Director B'#; 32.809933 CLIENT #: 7686 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~r~~ ]UARTERHORSE VO BOX 402 ORMVILLE, � � DEV, INC NY 12582 DATE/TIME TAKEN: 12/11/98 01:00P DATE/TIME REC'D: 12/11/98 01:45P REPORT DATE: 12/17/98 PHONE; (914)-628-0971 34MPLING SITE: LOT #2, FAIR STREET PATTERSON NY SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE ' OLID BY: MICHAEL SPACCARELLI TEMPERATURE.,: qnTES...: HOSE COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD I No limitsfor Sodium are proAribed. Suggested guideIines state that for peoplp 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 /L of Sodium �`. jH 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. __' '_' --'_- '-^_' TOTAL HARDNESS IS DEFINED AS THE SUM OF THE --CIUM —'MA GNFE�IU'�'`' '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 HAND WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 `MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-306 MG/L (1 rain/gallon = 17.2 MG/L) ITTED BY: � Director ` ` ELAP# 10323 Keceived Dec -16 -98 e2:58 12/16/1998 16:11 9142453170 from 9142453170 -- Ouarterhorse Dev. page 2 YORKTOWN MEDICAL LAB PAGE 02 r 1 - - .. _ -.� -- � ... -. . _..... __ .. y. w.. rr�,. u:- e.— e. >.+w ___ sJ ?. ara.-rnL rr. r. n.a. cr. n..•.+ti r.+�L. s.=.. rrc ,,,_..._�. ..a. �..,.. :,u.._..yMC ZKVIR() 'MENTAL SERVICES 3S1 K ar Streat Yorktown He ghta, N.Y. 10599 ( 914 cats, 28i)Cy Albert H. P d��vaani. Dlrector LAB #i 3::. $09933 CLIENT #t 7656 14IMMM V AIN.V II MNI I"Y W• ^f 'r •YYNMWNN------------ t.?UARTERHORSE DEV, INC PO BOX 400 STOFMVILLE, NY 125,32 1 NOW 6'TAT PROC PAGE •r--- ---- ----.4 NMNnr NNM .V nI Y Yrwr .Y � I i DATL /TIME TAWEN: 12/11/98 Ql t u0P DATE /TIME RECD: I E / 1 1 /98 01 14ZP REPORT DATEt 12/16/96 I PHONE t (914)-629-0971 SAMPLING SITEt LOT #2 FAIR STREET PKTTE'RSON NY SAMPLE TYPE..: POTABLE PRESERVATIVESt NONE COL'D BY: MICHAEL 5PACCARELLI TEMPERATURg..t NOTES...: HOSE CCLIFORM METHt MF NMNNM MNNI.rNN.YMM1'MIY NI.r Nl1r /y /y lV NrVNM NMNJYN/y y!.•uN .. NNv.YY••�'.v.vn+•Y.11r+.trN rYNMti'•y Y.---------- Y.•- Y-- --n•n. ... Ir MATE FLAG PROCEDURE RESULT NORMAL, - RANGE METHOD i , Na No limits -for wpdium are y p- OSC;ibed. SUgQeSte:1 L.id0.'inav state that for Peoples an a sodium re trioted diet•,the wstov Should contain no moils than Eu mg /L .3f Sodium. F p th° ;sw 4nn a moderately restricted diet, a .Aximum wf Er ?Q ,ng /L of Sodium is suggested. } PH pH SCALE IN WATER, =GANGES FROM -i4 +. MEASUREMENT OF pH :5 ONE OF THE IMPORTANT AND FrR`iEOUENTLY U Eb TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MISFIT BE L" �,SDSIVE Tu METAL Fr.PE�b AND FIXTURES. THE NORMAL RANGE OP p i+ I i3 TO Hd TOTAL HARDNESS 15 DEFINED AS CONCENTRATION, 50TH EXPRESSED HARDNESS- MAY- RANGE -FROM- 0- TO __. - ,SrucE AI�lb TFcEAMEI�'f' TO WHIf'_'H ,SOFT WATER: 0.70 MG ,'L MODERATELY HARD WATER & 70-140 HARD WATER t •140 -300 MG /L SUBMITTED SYt LW01- AiDe►rt H. Director E SUM OF THE CALCIUM & MAGNESIUM S CALCIUM CARBONATE, .1q MC /L. THE _-- z- (y.f,,Ep£z� �F,M�ia,.. REF` ENDS= N_:'�HE _- i-1fC fjATER HAS 'EsEEN SUBJECTED. VERY HAFi."', WATER: ABOVE 300 MG /L 11(}/L - MILLI(3F;AM PER LITER :1 grain/gallon = 17.2 MG /L.) Ioven i , M . T (ASC U ELAPO 10323 Received Dec -96 -98 02:58 from 12/16/1998 16:11 9142453170 921 ey r•arktown He 1914 Albert I P, 9142453170 4 Quarterhorse Bev. page 1 YORKTOWN MEDICAL LAB PACE 01 for Street i I I i Ia45 -2900 d-ovani ., Diract-or I LAB Oz 32.8()^,. 933 CLIENT' #1 7686 1 N N.V.ry•a•NVNNN•.•N.vX AJM NAIX IVMNWNMNA.X A:XNV N.V QUARTERHORSE DEV . I NC PC} BOX. 402 STORMVILLS, NY 12562 SAMPL I N6 S I TE c LOT #E.. FAIR STREET P T* CJL_ 'D ?Y1 MICHAEL. SPAC CARE L•L.. I NOTES...t HOSE , NA.A:V`Vn'IVNAIX NAINN.VN/Y:.'.V At N•V M•V +.'N rvr'+N •wN NN h.VM wr 1 ',ION 'STAT PfSOC PAGE 1 n•N.'v•+•JN NNVN Vf.INAtMI.•.VNNNArN NXIVX N:..•.V n.N n1MN.V N.V N.V DATE /TIME TAk.&N s 1 c/ 1 1 /98 01.00P DATE /TIME RE'C' Lis 12111/0a 01 a45P REPORT DATES 12/16/9E3 = HOhiEt {41�a�- 8ePs- :9"';. R50N 1''. SAMPLE TYPE..: POTABLE PRESERYA T I VES s NONE TfEMPERATURE . , t COLIFORM METH# MF NIV A•.V .1/A.'.•11 .a'.V .V V A.`A'1'N.V NNa•+.•n•nrNM•.'++•v +. 1 +w -N IVNXAIN A.Nn• I?AT:: FLAW PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE i 2/ l i/ 9'3 MF T. COL I FORM 12%11 /9B LEAD iIMS: 12:'1 i a9S NITRATE= NITROG 12/11 /�?E' NITRITE WITROG 12/11/99 IRON :Fe) 12/11/0S MANaANESE (Mn) 12/11 /98 SOL I'J11-1 (Na) i2 /11 198 pH 1 /11/98 HARDNESS,TCTAL 12/i 1 /?6 ALt F►LINITY {AS TURBIDITY (TUR _ . COMMENT5 t f tta 625 1 �:t3�i - _ -- COM116NTS PACT THESE RESULT'S INDICATE THAT THi WATE'n iWAC " , LWAS NOT) OF A SATISFACTORY SRN:TARY QUALITY i.CLIRCIN TnE PIEW YORK STATE AND EPA FEDERAL 6RIN1<1N3 WATER "STANDARDS, FOR THE PARAMETERS .TESTED, AT THE TIME OF COLLECT 014. Pb /CL-. LEAD limits for public %a"oIs-area spat at EPA Load 8. COPPe • Rule for Pup iC : YSIC -RME' 7Q- ZZL1Tr eS t.fzat ri:, mare than 10% of their di,etribut'iom ipc ints have a LEAL' 'value of more than 15 ppb and 'a ,COPPER valua loo 1.2 mq /L, else water treatment must be Undertaken tR reduce the wafters corrosive potential. >=e/Nn If both iron and manganese are ;Present, their total value combined shall not exceed O.W �.�L. i 1 ,ABSENT /;i :,t:: ML ABSENT 14.10E '.:i Dot' (i.. i pot 91 .,,I I 1 .0a MG /L G - 10 � 139 1-:V MG /L O -Q.3 m9i l 206" i:11 10 MGu: L 0 -0.3 mg / I 2037 7.41 MG /L. N/R , 6.�6 UNITE 6. -3.5 g045 a2.0MS /L N /,A••,, i diy.Q l e/M f'i1 /f1 i .:1 NTU 0 -5 NTU COM116NTS PACT THESE RESULT'S INDICATE THAT THi WATE'n iWAC " , LWAS NOT) OF A SATISFACTORY SRN:TARY QUALITY i.CLIRCIN TnE PIEW YORK STATE AND EPA FEDERAL 6RIN1<1N3 WATER "STANDARDS, FOR THE PARAMETERS .TESTED, AT THE TIME OF COLLECT 014. Pb /CL-. LEAD limits for public %a"oIs-area spat at EPA Load 8. COPPe • Rule for Pup iC : YSIC -RME' 7Q- ZZL1Tr eS t.fzat ri:, mare than 10% of their di,etribut'iom ipc ints have a LEAL' 'value of more than 15 ppb and 'a ,COPPER valua loo 1.2 mq /L, else water treatment must be Undertaken tR reduce the wafters corrosive potential. >=e/Nn If both iron and manganese are ;Present, their total value combined shall not exceed O.W �.�L. e PUTNAM COUNTY DEPARTMENT OF HEALTH VISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: StreetLocation Owner ZAly)ag-r� Town ..,Permit # T--7—.2'f5 T IN I r q q 3 — _Zt 1 Subdivision Lot g L. SewageaSv-ftem. rea a: STS area 'located as per approved plans ............................. b. Fill section - date of placement 3:1 barrier Lath.. 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 System a. Septic tank size - 1,000 ... (..1,250.. .....other ................. b. Septic tank- installed level ............................................... c. 10' minimum from foundation ......................................... d. Distribtuion Box 1. All out letsat same elevation-water tested ................. 2. Protected below frost ................................................. 3. Minimum 2 ft.Original soil between box & trenches Junction Box - roperly set... T-Te—na required - I — t�v Length installed z1 2. Distance to watercourse measured4-,2,00 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 -'I/-,Ir - 1'/2" diameter clean .................... 9. Depth of gravel in trench 42'.'.mini.mum ................ 'ro. Pipe"ends- Pump or Dosed Svstems ---- ER I . Size of pump c a er ......................................... . 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 ............ M. House/Building, a. House loc7ted per approved plans ........................ b. Number of bedrooms ................. �!A .. q4................... ' .5 IV. Well Y� 6-.5-M a. Well located as per approved plans ................................ b. Distance from STS area measured � I ev,:P ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted .................................................. b. All pipes partially backfilled .......................................... c. All pipes flush with inside of box .................................. d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir-to exist watercourse g. Footing drains discharge away from STS area........... h. Surface water protection adequate ................................... i. Erosion control provided ................................................ YES I NO COMMENTS a 34 ZA M X 41-5.. q PUTNAM COUNTY DEPARTMENT OF HEALTH 1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUC ION PERMIT FOR SEWAGE TREATMENT SYSTEM P PE # Located at ��, S�(�,���" Town or Village Subdivision name LA o_ T> Subd. Lot # 2, Tax Map,44 Block 0 Lot Date Subdivision Approved q -25 -1 I Renewal Revision Owner /Applicant Name 1% ITO LAhi(a Tg� Date of Previous Approval Mailing Address III AQr--O Ur—, : _PAV- U NCB fi 41 Zip ( 2 Amount of Fee Enclosed �i�p ®, Q 0 Building Type Kj95in�t�aiAL Lot Area..j_Ql, No. of Bedrooms __I_ Design Flow GPD 60 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12Gp gallon septic tank and L, �. ,SOS Other Requirements: To be constructed by _ ML2 Address Water Supply: Public Supply From Address or: _ Private Supply Diilled.by . �jjp ` - 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. A Signed: P.E. R.A. Date 2-111-90 Address License # �(� j7- Ia5im APPROVED FOR CONSTRUCTION: This approval expires two years fr m 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 Aen considered necessary by the Public Health Director. Any revision or alteration of the approved. plan requires a new p i Approve r discharge of domestic sanitary se a only. By: Title: �L Date: f _k/A'0�- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUT NAM COUNTY DEPARTMENT T OE HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL. please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # Map-14, Block 75 Lot(s) O, Well Owner: Name: Address: VITO L- 1_ V 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 &,i5 Est. of Daily Usage&OQ gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason S for Drilling Well Type C Drilled Driven -Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No _ C� Is well located in a realty subdivision? ...................................... ............................... Yes_ No Name of subdivision V1:W LA�A412 -rS Lot No. �2- Water Well Contractor: 'TO 0 Address: Is Public Water Supply available to site? .................................. ............................... Yes No iC Name of Public Water Supply: N /A Town/Village Distance to property from nearest water main: _.bJ1A Proposed well location & sources of contaminatio ii to be provided on se at sheet/plan. Date :,�2j-q -qb Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate 1 driller certified by Putnam County. A � ADate of Issue CS� � Pei�mit:�ss � , cr, Date of Expiration ?- Title-.,_. C.`. Permit is Non -Trans errable White copy - HD file; Yellow copy - Building Inspector; Pinkcopy- Owner; Orange copy - Well driller Form WP -97 LAURENT ENGINEERING ASSOCIATES, P.C. ..MILLBROOKE OFFICE CENTRE ..< Route 22 & Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS February 20, 1998 Robert Morris Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS LaMorte Subd - Lot #2 . Fair Street Town of Patterson Dear Mr. Morris: Enclosed are the following: L Five (5) prints of SS -2 "Proposed SSDS ", dated 2-17-98.. 2 "Short EAF ", dated 2- 19 -98. 3. "Application For Approval of Plans For a Wastewater Disposal System ". ..4:- Construction Permit for Sewage Disposal System , dated - -249;98.;: 5. "Application to Construct a Water Well ", dated 2- 19 -98. 6. "Design Data Sheet ". 7. "Letter of Authorization ". 8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only 9. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, PC.. arry W. Xi ols, Jr., P.E. l ` HWN:T :b 97004 i , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL: HEALTH SERVICES LETTER OF AUTHORIZATION Located at j�A1g,5-Sj2 T/V P - TTr:::�FSpj� Tax Map # �q-, Block 3 Lot 3.2 Subdivision of V j= t-,,4h&Q g."f Subdivision Lot # 2 Filed Map # 21-61-7 Date Filed Gentlemen: This letter is to authorize AIg g-�( (d N 16 N-OL -5 ig, p � a duly licensed Professional Engineer . or Registered Architect o apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems _ in conformity with.the provisions of Article; l45, and/or.l47. of-the Education -Law the Public Health _. 'L` aw; and the'Putnaiii Coro t ry Code. f%��ityn <j- Countersigned: (D R.A., # _ Mailing Address State NJ Zip iO c o_ Very truly yours, Signed: (Owner of Property) Mailing Address: I I I CQUI._ -� State Zip 12 5 Telephone: 14 - 2? 8 -Co 10 5 Telephone: Form LA -97 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 March 13, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 RE: LaMorte, Fair Street, Lot #2 (T) Patterson Reservoir Basin Croton Dear Mr. Nichols: N BRUCE R... FOLEY - -- Public ffealth Director The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 9, 1998 is complete. The Department will notify you by April 1; 1998 of its determination. 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 you filed- the application originally; and a� statement that a decision 'is sought -in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. 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 Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. Very truly yours, Robert Morris, PE RM:tn Public Health Engineer DEP PHONE (914) 742-2001 FAX (914) 742-2027 THE CnT Of NEW YORK 99PMTWff Of EWWOWKEWAL"I�nom JOEL A. NIEUE,. SP, P.E. Conuohdoner % I I\ 0 1) e r), i YAWAN.N. STASIUK, P.FPhB. March 25, 1999 Sadosky Robert Morris, P.E. F , i Ile Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re- Lamorte Subdv. Lot #2 SSTS (1) Patterson; Fair Street Middle Branch Reservoir DEP Log #7385 (Joint Review) Dear Mr. Morris: l of Water $up^ QtuRy and Pmecdon Based on our review, the following information is necessary to complete the above-referenced application: I., - Results of current percolation and deep,-ko)p tests performed in the primary and expansion areas U*thi'proposdd SSTS. 2. A current more precise delineation of the adjacent wetland and its associated buffer is required to facilitate our review of this project. In addition, we request that you kindly have the applicant contact the undersigned at (914) 742-2028 to arrange for a NYCDEP site visit to detemine the presence o� and if necessary, to flag any WaWcourn or watercourses connected with this wetland. If you have any questions regarding this matter, or decide on a date for the required soil testing, please contact the undersigned at the above - stated number. Sincerely. Matthew Giannetta Project M=W xc-: James Covey, P.E., NYSDOH 465 Columbus Avenue, Valhalla, New York 10595-1336 0 New York City �A Department of ..sP Environmental Protection OPM rIONS do WGINEMUNG 46S OOLIZAA IS A MMve so VALE AUA, JVAW rMW 10s1S FA,r FITS• e3a Aff co l lrmm it tb FAX# Nmbw Of pages- 7-- Date:. b �b find f&V Cover �beetj Tim . z aps k � -C. Qc- C.ommm": V ?HERE ARE ANY PROBLEMS REGAFtOING THM FAX PLEASE CALL 914- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES URFACt §M0 A GE TREATMENT DESIGN DATA SHEET - SUBSURFACE Owner \11,T0 Address 11 coL)i_-rt5-F, Mr-Nue fAF_V4Ll N& N-f 1296-t Located at (Street) � AjK Tax Map -+q-, Block S Lot 3.2 (indicate nearest cross street) Municipality tm_15aq Drainage Basin �QN SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test Hole No. Run No. Time Start - Stop Time Ela6y D.) Depth to Wat6r From Ground Surface (Inches) Start Stop Water Level Drop In es Indies Percolation Rate Tffln/Inch I !La.� -) 1, 4-4 21+ 2-1 16 2 '2(o' 3 4 5 12'26 3 121.2-1-12''S 3 o 14 Q'10 4 5 2 3 4 5 NOTES: I.. Tests to be repeated at same depth until approximately equal -percolation rates are obtamea at eacn percolation test hole. (i;e s, j min for 1-30,m1n/inch, s 2 min for 31-60 min/inch) All data to be 5 submitted for review. 2. Depth measurements toi-bemade from top q4ole. Form DD-97 2 TEST ]PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES Indicate level at which groundwater is encountered Indicate level at which mottling is.-observed Indicate level to which water level rises after being encountered p Deep hole 'observations made by: 4I- TCA4 r-,� l�� Date Design ' ME, 1_i Amnoo 14VNind 03AI3038 Design Professional's Seal 2. a W LU No. 56924 Op �, QOFESSO�P, DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 March 13, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 RE: LaMorte, Fair Street, Lot #2 + (T) Patterson Reservoir Basin Croton Dear Mr. Nichols: BRUCE. R. FOLEY - ° Puhlic Health Director The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 9, 1998 is complete. The Department will notify you by April 1, 1998 of its determination. 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-. w.�lLwhich..yo.ea.filed the application ..oria.inally;:'and..a st at€ nle- nt- that -a -4eeision- :stcught in - _ accordance with section 18 -23 (d) (6) of the \YC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. 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 Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. Very truly yours, Robert Morris, PE RM:tn Public Health Engineer 6T c1 %lei mvel PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner /—,AM 0� Address _/�),jz :!:,-F, Located at (Street) Tax Map 4 q Block 3 Lot �3 �2, (indicate nearest cross street) Municipality Drainage Basin 11tDz>i_0 '5XANz_H SOIL PERCOLATION TEST DATA Date of Pre-soaking � Date of Percolation Test EZ2!:2�25?0 Hole No. Run No. Time Start - Stop Else Time u.) Dv)th to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 10"// 119'-�34 Ilia !Z 3.' 150f -3 ZZ 2 I; 0 Z; hl 17 3 0 6 —Zra 0 all 4 5 1V 0 7 2 3 7. 67 4 1111q6_12:11 '17. 0 31 Cl 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtainea at eacn percolation test hole. (i.e. - I min for 1-30 min/inch, - 2 min for 31-60 min/inch) All data to'be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 .DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 April 16, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: La Morte Fair Street, Lot 42 (T) Patterson, TM# 44 -3 -3.2 Dear Mr. Nichols: BRUCE R. FOLEY Review of plans and other supporting documents submitted at this time relative to the above captioned project has been completed. Comments are offered as follows: "The construction of this sewage disposal system may be subject to local wetlands regulations. You -should, contact -local - wetlands officials in -th s-regard. "- The enclosed letter from New York City Department Environmental Protection was faxed to your office on March 27, 1998. Please notify this Department to arrange a mutually suitable time to witness deep and percolation tests. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yours, Robert Morris, PE Public Health Engineer RM:tn PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW 'SHEET FOR CONSTRUCTION PERMIT STREET LOCATION— /Ilt -i NAME OF OWNER REVIEWED BY M, GR, AS, MB, BH ) Z TAX MAP # Y N- U E T � fPERMIT APPLICATION WELL PERMIT_ PWSLETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROV CHECKED PERC RATE It t' FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL FMEQ 'SAME ION _Y N L) EROSION CONTROL:HOUSE,WELL, SSDS PERC, & DEEP HOLES LOCATED n REPRESENTATIVE OF PRIMARY & EXPANSION 7} LOCATION MAP (/ EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS (j WELLS & SSDS'S WAN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS r ► HOUSE SETBACK NECESSARY (TIGHT LOT) ROUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE ( NO BENDS; MAX.BENDS 450 W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. I-IORIZONI'AL;SLOPE 3:1 TO GRADE ff FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS >. VOLUME LL IN EXPANSION AREA R F N C II ( 7 LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS n-1 10' TO P.L., DRIVEWAY, LARGE.-TREES, TOP OF FILL !J -- 20 "TO FOUNDATION WALLS - 15 -WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS r 100' TO STREAM WATERCOURSE LAKE (inc. eapan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 2007500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -I %,100' - <1% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION A:t'PI��3V�J ; E REQ'_D -- DEEP TEST H_ OLES OBSERVED BCW TNESSED� EX- APPROVAL SSDS ADJ. LOTS E' FLAND.S.(TOWN/DEG:ERML1 DATA ON DDS PLANS & PERMIT PRE 1969Nr,- ,IGHBOR NOT] FICAT LETTER BI /ZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMIT(S) C/ 61 •• a , ;> FMEQ 'SAME ION _Y N L) EROSION CONTROL:HOUSE,WELL, SSDS PERC, & DEEP HOLES LOCATED n REPRESENTATIVE OF PRIMARY & EXPANSION 7} LOCATION MAP (/ EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS (j WELLS & SSDS'S WAN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS r ► HOUSE SETBACK NECESSARY (TIGHT LOT) ROUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE ( NO BENDS; MAX.BENDS 450 W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. I-IORIZONI'AL;SLOPE 3:1 TO GRADE ff FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS >. VOLUME LL IN EXPANSION AREA R F N C II ( 7 LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS n-1 10' TO P.L., DRIVEWAY, LARGE.-TREES, TOP OF FILL !J -- 20 "TO FOUNDATION WALLS - 15 -WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS r 100' TO STREAM WATERCOURSE LAKE (inc. eapan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING /REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE? GRAVITY FLOW CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS IT CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAiN DRAINS SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME,ADDRESS 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 2007500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -I %,100' - <1% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION 61 ;> 1 C c ( TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING /REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: '0 Inds 1._ Brw,_..._ Pond ake Car g °' Dean j i Pond L— 4 r q � ..4^• ,'�. a.F �se> r fit Rp ti. oui 1� .WI t trZ Mbham ,; ounfalr► + ; r 1 wft 52 3 .. 1. r S Raymond Hill z S —1 ►�— -- -" — Cem C 1 0512 $J el 301 �CARMEL HS t y m Count �Q 47 County OlfcenBuilding Q a / . bil Ludington onumenr 1 �,� Glenerda s Putnam wa: S.c. 5 /afYYt� \ Cem 1 $� ,�� A 32 s a ` R Wills >... w �R pv 1 Pp� g A I / � d I ' Ices. I Pond 1 r +tL.. >4 8 ! FF�id/ � $4 \� t and i ° Country.: 9 rM __ i dy e mall n � t 1 71 ' t I ,I 1 °s e I- o tj Till Foss•I Brsw,ar NoM1h 1� i ~q 51 , l J `�•,,� °�' i � Ides i Tree ■ �� s' . county 4 hr 8 I' Brewst wu 59 r; a\? ter OF PHONE CONVERSATION`;.'; Time: //1'/0 Date: 9 0) Person calling: Phone# Reason (Z ( ) Inspection: (Deeps and/o Scheduled Field Meeting Time, Date- y Tentative/to be confirmed Tax Map #: Comments: - - Z-!a= wlcrloc y= &a ' I)x �7 eZUA A q7d� dd.1 Iv-,-- ,Joe X70 — 6105 - 3,z PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'J ,....,. �� ..: __.._.....___...._._,_.__ APPLICA'T`ION FOR APPROVAL; OFTLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: V 170 j AMa9:1r—_ Ca4- 2. Name ofproject: f)g0pp$g'_b SSVS 3. Location TN: 4. Design Professional: a,w,iy �� OLS_�12 , 5. - -r 6. Drainage Basin: c&o:1ro W 7. Type of Project: Private/Residential Apartments Office Building Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? YP ( ) .......................... t Type Status check one ....................... ..... Type I Exemp Type II Unlisted'.' _ 9. Is'a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... , 11. Name of Lead Agency N ZA =.12.. Is this project_ in an area under the.control'of local -planning;_zom :or_other = - �...� ` officials, ordinances ?... ........ ................................... .................�............. 13. If so, have plans been submitted to such authorities? , 14. Has preliminary approval been granted by such authorities? "Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? ..................... N�,g 17. Waters index number (surface) ......:. fq , 18. Is project located near a public water supply system? ....... ......................... ....... 19. If yes, name of water supply N A Distance to water �supply -' Is project site near a public sewage collection or treatment system? ................ b 21. Name of sewage system A Distance to sewage syste d 22. Date test holes observed _ei '.23..1 Name of Health Inspector M K�0 � CZ 14 SK t 24. Project design flow (gallons per day) ..... ............. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... N Q 26. Has SPDES Application been submitted to local DEC office? ......................... N /4 Fir,,, vr_4'7 _2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number. .. 29. Is Wetlands Permit required? . ............................... Has application been made to Town or Local DEC office? ............................... Nom— 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? .............. ............... Yes/No b 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? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 96 35. Are any sewage.treatment areas in excess of 15% slope? .. ..............................d 36.' Tax Map ID Number .......................... ............................... Map 4+ Block 3 Lot .3.2 37. Approved plans are to be returned to ..... Applicant K Design Professional NOTE: All applications for review and _approval of eW:SSTS.to lieaocated witliii�.tl3e NYC Watershed shall "�� tie sent to `the llep'arrtment, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed. may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should 'obtain the appropriate forms for such activities, from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown. in Item l .,the. application 'must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true . to the best of my knowledge and belief. False statements made herein are punishable'as. a Class A misdemeanor pursuant to. Section 210.45. of, the.P nal aw. SIGNATURES & OFFICIAL .TITLES: (1&0� rzal r–'N41IN _4� Sen e'� - 8VW $6 Mailin r s: ... ...........:................... ►�� O���C.� C HIT SOMS 1411V3 nP 3 �,� �o ON Ind. SECOND FL`0.0R 4/82B .•1344SF KITCHEN .1 )o w.w DINING HOOM MORNING HOOM 13' 0" w 12••0•• L-Ij �- r , 0 LIVING ROOM 17•,0•• x 1 �'•O" FIRST FL00 R FAMILY ROOM 13' 0" e 17* 0- 4828 j•il i..t J. •..� r 1 0 �. BEDROOM 4 �� ` ! DRE- SSING. BEDROOM 3. WALK' 13' -0.. x 10'-0*' � _. IN CLOSET ry MASTER BEOROOM BEDROOM 2 j OPEN 17'-0 x t6'•8" 13' O' x 15'•8' _ = AMW il, . fiJ Fip i . ) MR SECOND FL`0.0R 4/82B .•1344SF KITCHEN .1 )o w.w DINING HOOM MORNING HOOM 13' 0" w 12••0•• L-Ij �- r , 0 LIVING ROOM 17•,0•• x 1 �'•O" FIRST FL00 R FAMILY ROOM 13' 0" e 17* 0- 4828 .•+rs •. _T.n .. .. .. .r ..� .w...- _+..n.�. � .. _ •.- ...._' .. �.. a F �- T'......+�. .y .riw -.`..a •.� .. �'!�b4...� ... ... .: r. - .. ."5.. t.... •es.t'ul`y^ ems. BEDROOM 4 1 \ ?• DRESSING- BEDROOM 3. WALK 13' -0" x 10' -0" IN CLOSET TOR • -•._ -ter.. . MASTER BEDROOM BEDROOM 2 — OPEN 13' O' z l5'•8' f SECOND FL0.08 /828 =.1344SF mot— •J42� . r. � 1 .l ���� •.......: i.-{• . KITCHEN � ;' .c..apMio DINING HOOM p �j MORNING AGO 13' 0– as 12'•0' 1-.- :j 1 1 LIVING ROOAA 13'•0" m 10'•0" 8 1- FIRST' FLOOR -4 -• f PENO VE v6 FAMILY ROOM 13' 0– a 17* 0" FOYER � 4828 14- 16.4 (2/87) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR v peen X ` State ty Revlew SHORT. ENVIRONMENTAL ;ASSESSMENT .FORM. For UNLISTED ACTIONS Only PART 1- PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME, \11:12 L-AMO �115 OSG SS DS 3. PROJECT LOCATION: Municipality °" County IN AM 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map). �i-� I Ie sT� C►=T .. 5. IS PROPOSED ACTION: R New ' ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 1' Oe. Reclt7r--NTIA1,. S►NdfLr-_ F,AM)L`( P1N)✓LL! NC�'t SSbS N 7. AMOUNT OF LAND AFFECTED: r ` Initially t .li 1 acres Ultimately io 1 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? © Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes ®No If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? []Yes. ®No If yes, list agency name and permitiapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes', : ©No'' I CERTIFY THAT THE INFORMATION PROVIDED 'ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /spons r a L� D le=1E Date: Signature: If the _action.1s in the Coastal Area, and you are a state agency, complete'the Coastal Assessment Form before proceeding with this assessment OVER 9 PART II— ENVIRONMENTAL ASSESSMENT (ro be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ' ED 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 b`e $iifter'9etled'tiy another Involved agency. •.. - -. - ". ❑ Yes .. r❑ No e C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Ct. 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 brieflyc . 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 )nduced oy the proposed action? Explain briefly, C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. D._ IS .THERE;- OR•IS.THERE LIKELY TO BE, CONTROVERSY RELATED TO'POTENTIAL ADVERSE _EN'JIlaONMENTA`L.IMP'ACTS? ❑ 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 Id 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 (Q magnitude. If-necessary, add attachments or reference supporiing materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. ❑ 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; he reasons supporting this,`determination:" Name of Lead Agency Print or Type Name of Responsible Officer in Lttea{d► Agenc(yy. Q �y ii,� 96 Ti a of Responsible Officer D5 •� 7 WdU Signature of Responsible Officer in Lead Agency 3. Signature of Preparer (if different from responsible officer) �..C.H. r ART �- .ln ft -.. 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