HomeMy WebLinkAbout4845Q,
DAVID D. BRUEN
County Executive
DEPARTMENT OF HEALTH.
Division Of Environmental Health Services
Action Associates
Newburgh Road
Patterson, New York 12563
May 21, 1986
Re: Proposed SSDS
Action Associates
Newburgh Road
(T) Patterson
Tax Map 61 -4 -3.1
C A1143- A11521
JOHN SIMMONS. M.D.
Deputy Commissioner
Gentlemen:
Review of plans and other application materials submitted
relative to a construction permit for the above- captioned
property has been completed by the Department.
Based upon such review and pursuant to the provisions of
Article III of the Putnam County San1tary,Code and Part 75 of-,
- -the State of -New York, Code of. County .Rules and Regul.atlons, you
are hereby advised that this proposed method of providing water
supply and sewage disposal are considered inadequate for the
following reasons:
1. Based upon your engineer's soil percolation test, which
indicated a soil rate of 21 -30 minutes per inch, 1000
square feet of primary sewage area and 500 square feet
of expansion area is necessary (1500 total).
The proposal provides for only 520 square feet of primary
area and 260 square feet of expansion area (total 780).
As such approval of the proposal cannot be granted, returned
herewith are 2 copies of the plans.
If you have any questions, you can contact me at Ext.. 241.
lqrl tWy. aYta�r
JK:pt
cc:Mr. Kelly
JK
oYhW`l nNLY1 114 -�YJ. , P: E.
irector,
Environmental Health Services
MB
J H TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225-3641
PUTNAM COUNTY DEPARTMENT Pf'-HE ALTK
-,
DIVISION OF ENVIRONMENTAL H EALTU 'SERVIC
Gentlemen:
This letter is to 'authorize
a duly licensed professional engineer' .orl. g
,.ra: If'-s2tdr
(Indicate
to apply for a Construction Permit for a S1,is, ra e wts-e*a
serve the,above noted property in accordance with thp..:,;
or -regulations as promulagated by. the Commisa xio'n6r, oi-'�,
Department of Health, and to sign all necess4 y,pagaer3
connection with this matter and to supervisie .;the..,.q6n t
'system or systems' i:rraoiifarwity with pro.
147, Education Law, the Public Health Law, Andthe;..�
tary Code.
Very t Y rul 'yokii.6
A. Ke-i
Countersi
P.E. , R.A. ,
Address
A/ rj
146
Telephone
(ON
Ok
FM
F&MM 1110
ir:,cht -ec t
-b- h a lf in
i'on of said
Cauniv Sani-
PDTNAM OUNTY-:•DE]
DIVTSION:`.:OF.ENVIRONMENTAL HEALTH SERVICES
..BVILDING'. CARMEL, N.-Y.
il.b Mit, 10512
DESIGN' --SEPARATE SEWAGE' DISPOSAL SYSTEM- FILE NO.
�%l > -Address
Owne
E01 �- A/y
Located.-dt*!"".""(-,t Ar 61 Block
Lot :3,
A
Indicate'nearest cross s
treet)
Munic Watershed 042 dAl
SOIL•t§ftA-Tf0Ng TEST_.DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
OF
IME
PERCOLATION
PERCOLATION
apse
'Depth
to
Water
Water Level
Time
From Ground Surface
in Inches-
Soil Rate
Min
Start
stop.
Propjn
AT'i drop
'In
,
ches
Inches hes'
Inches
/5
zt
3
71
.4
M6. Z
4'-
Notes - 1*')-�-,�-,,-,"-�-,.I�e06"--,-.td be repeated at same depth until a roximatel eq'ua'l', s oil
rates each percolation test'hole. Ayy data ,tole submitted
_:777_77
for'.
2) Depth` °measurements to be made from top of hole.,
k'
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_., CONSTRUCTION PERIVIIT FOR SEWAGKTREATMkNT SYSTEM -
O
PERMIT #
Located at j,J 64 b /i.p Town or Village "V'Xtr6(___S0tJ
Subdivision name ' H u flW Subd. Lot # �lr� Tax Map 25 Block i Lot
p� ig {til5a
Date Subdivision Approved p3i o/ 31 is Renewal' Revision
Owner /Applicant Name h hU g g6 tj i.Qb p A I Co Date of Previous Approval
Mailing Address 405 b r-&tj ma t2 po 13"W3A-E9- N Zip (-`050 9
Amount of Fee Enclosed 0,0. 00
Building Type IVA I uE&P7l frt Lot Area No. of Bedrooms Design Flow GPD 200
Fill Section Only _ Depth 11T Volume -53'7.6
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of IQ00 gallon septic tank and 126 &E f�..k.
-- Wi 0L TitA& S &A))' 12 x. ti?tk-
q
Other Re uirements:
To be constructed by Address
Water Supply: Public Supply From
Address
or: = jam_ Private Supply! Drilled by _ (S - _ -_ _ _ . 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: , P.E. R.A
Address
License #
_ Date � 13 v Z.
T
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
L8.3
Title:
Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
P. W. SCOTT
Engineering & Architecture, P.C.
3871 Route 6
BREWSTER, NY 10509
E -Mail: pws @bestweb -net
(914) 278 -2110 FAX (914) 278 -2166
TO Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
WE ARE SENDING YOU CXAttached ❑ Under separate cover via
❑ Shop drawings ❑ Prints Plans
❑ Copy of letter ❑ Change order —
�i �r rCr 0G -s
1 DATE JOB NO.
ATTENTION
i
RE:
U-r2.�hE-
yD
Subsurface Sewage. Treatment
System (SSTS)
❑ Samples
the following items:
Specifications
COPIES
DATE
NO.
DESCRIPTION
1
Application for Approval of Plans (PC -9.7)
I
I
Construction Permit for Sewage Treatment System (CP -97)
1
1
Letter of Authorization (LA -97)
1
2
Design Data Sheet (DD -97)
1
House _Plans _(2._.- _sets)
2
]
1
Check #Z/5q/96$' for the amount of S Ci✓, iii
1
1
Short Form EAF
THESE ARE TRANSMITTED -as "checked below:
i= For approval ❑ Approved as submitted Resubmit copies for approval
For your use ❑ Approved as noted Submit copies for distribution
As requested ❑ Returned for corrections ❑ Return corrected prints
>
For review and comment
FOR BIDS DUE _ = PRINTS RETURNED AFTER LOAN TO US
REMARKS
List Continued:
4 1 Septic Site Plan Drawings
`..OPY "0
' BRUCE R. FOLEY-
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845)278-6130 Fax(845)278-7921
Nursing Services (i45)278,6558 WIC (845)278-6678 Fax(845)278-6085
Early Intervention (845)278-6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845)228 - 6113
P.W. Scott Engineering
3871 Route 6
Brewster, NY 10509
Re: Proposed SSTS: Lobricio
8 Newburgh Road, Al 143 - Al 152
(T) Patterson, TM# 25.62 -1 -75
Dear Sir: .
April 18, 2002
Review of plans and other supporting documents submitted at this time relative to the above -
regarded project has been completed. Comments are offered as follows:
1. All SSTS within 200 feet of the property lines are to be shown. Plan notes no
SSTS's within 200 feet. This does not appear correct.
Lot line setbacks are to be shown (zoning).
3. Deep test hole F notes ledge at 4'3". The minimum of 2'9" of R.O.B. fill is to be
provided for the primary and expansion SSTS.
4. Minimum distance from the well to the property line is 15 feet.
5. Neighbor notification is required.
6. This Lot is in a Realty Subdivision and, therefore, has not legal rights whereby a
permit would have to be issued or waivers granted for approval. It does not appear
that this Lot is approvable.
The construction of this sewage disposal system may be subject to local wetlands regulations. You
should contact local wetlands officials in this regard.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Vy yo
i 'dyo
Robert Morris, P.E.
Senior Public Health Engineer
RM:tn
0521/01 12:49
.BRUCE L FOLE e .
pgwc Health Dimrar
PW SCOTT 3 19142787921
DEPARTbENT OF 1' 1
Geneva Road
Brewster, New York 0 •,
LORffffA MOLINARI RN, MS-N.
Assmioae Pubtle Health Diry aer
DIP cw of Patient Services
AT TERTIO N: ® t dDAK S'TIEDELING PAGENE REED
All iufannation below mos : be l completed prior to any scheduling. DAIM: 6
ENGINEER OR a
DEEPS: � PERCS: l P T =: o
ROB T:
TOWN: RA--1s� � TAX Rao: c75:6 L
OWNER-
A M1101 Imm MUM
yu NO
proposed S: i n within the drainage basin of West Branch or Boyds (Carver Reservoirs.
® Proposed S STS within 500 feet of a reservow, mervair stem or control IA&
® I�n°aposeef SST•S within 200 feet of a.Vvaterca a or a DES wedin a,..
. Proposed S STS design flaw greater than 1000 galloWday or S?DES Permit required.
o 9� proposed SSTS for a Commerical Project,
It is the responsibility of the design professional to provide the above information prior to soil testing.
This Department will det tratine the TYCDEP project stag (Joint or Delegated) based on the
response. If you answer 9 ;!a to any of the questions, NXCDEP most witness the sdna testing. 'This
Departanent will coordinatd a mutually suitable time for field testing with the PCDOH' the Design
Professional and NYCDEP
15 a project has been deter mined to be Delegated based an the above response ud dm subsequent
information indicates NYC ®EP is required -to witness the soil testing, it will be the sole respontsibility
of the design professional to, schedule re-witnessing of the soil testing with N CDEP.
FOR COUNTY USE ONLY
RATE;
�a�ARjAi�Ris; -
i llrW ESQ
05/21/01
10
a.
a.
MONEV99PCA
.4114
12:49 PW SCOTT 4 19142787921
X
tq
t+�E Ji
AL
7P.
�j.
Ar
si
j. ca
14�
op
(V
tl!
7s
a
ALI-
lift,
Ci
j.
;74
MEN-
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE. TREATMENT SYSTEM
Owner 57Lc:"PH0/V -5 Address Algea75 uggG 5 7i
Located at' (Stieet): &AS �Ala j7i2A,,;. Tax Ma. P15,-,ga Block I Lot
(indicate nearest cross street)
�Municipality P.*rr Watershed ag
SOIL PERCOLATION TEST DATA
Date.,of,- Pre- soaking ._. :2.1.2. 6:1 i'. Date of Percolation-Test f 10161-
6 e-..
2
A Mg-
........
... ....... .
..... ... ..
:.I...,Su..
......
S
f
io: 33.
ve
9L -3
2
3
4"7
126
73
%y
5
11 1'.17 — f
30
le
Al
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained . at each
percolation test hole. (i.e. g I min for 1-30 min/inch, g 2 min for 31-60 min/inch) All data to be
submitted for review.
2. • Depth measurements to be made from top of hole.
Form DD-97
2
f
io: 33.
ve
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained . at each
percolation test hole. (i.e. g I min for 1-30 min/inch, g 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 observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date 7 o ��
Design Professional. Name:
Address:
Signature:-
Desip-Professi® AP6 Seal ___ _
_
e
. TEST PIT DATA _..__..._
2
DESCRIPTION OF SOILS ENCOUNTERED IN $T TE �[®YL S
DEPTH
HOLE NO. A HOLE NO.
HOLE NO.
G.L.
r
t'Fr%-9L.1
1.0
r h. r, t s'
1.5'
2.0
s c
cr
25
,
3.0'
=o"
y.
_. -_
4.0
_. _ _
S-
_
Tr if �
5.0�
S.5
4/ Roe-
6.0'
65
_
8.5'
10.0''
:
Indicate level at which groundwater is encountered - - - - -- - -
Indicate_ level _at_ which - mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date 7 o ��
Design Professional. Name:
Address:
Signature:-
Desip-Professi® AP6 Seal ___ _
T signature ana iiue
,. 'T)TT►/�T]'T T)Y!%'1T^TT Yi";Tl DS >� .,. .. ... ..
I lack now ledge`receipt oft iS report SIGNATI1l
.,02/96 _ Title
77-� Y
.� 4n.s.a3s.7. ,iNa � .� �s- �° �_.1daaw.�a.x..':�y..5....«d,., sar. 4 �s7�%+:- +�,c..�.. 3#:�..� r w �
x
J
;Sheet of
RTMENT OF HEAiff,
f �
KTA,L�HEATLfi SERVICES
e� s
n-- W,*M1.(
4
+
r r StateEZIp
#y.
77-� Y
.� 4n.s.a3s.7. ,iNa � .� �s- �° �_.1daaw.�a.x..':�y..5....«d,., sar. 4 �s7�%+:- +�,c..�.. 3#:�..� r w �
f �
PUTNAM COUNTY DEPARTMENT OF HEALTH. -
D SIGN OF-EIVMR 4MENTAlL HEALTH SERVICES
INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM
SECTION A. ,GENERAL INFORMATION
'Name.of Project 5 f;5 AM-g o.✓ County 7:`07-NA17
Site Location ,V,0A✓p,&nz4 H SZ 7 x%74"` a
Building construction begun n/o Extent
Is pro erty within NYC Watershed ? ................. dye.s F--J No
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. Hilly_ Rolling _._ -,. ___.- .Steep slope Gentle slope == Flat
2. Evidence of wetlands Low area subject to flooding F-1 Bodies of water
Drainageyditches Rock outcrops
3. Property lines or comers evident ........... : ................ :...:...:.................
water courses exist on or adjom the property.? ............. ......::.......
5. Will these affect the design of the sewage system facilities ?............
6. Do watershed regulations apply -in this -development ?..- .:::::::;: •_.:.
-- 7 Will extensive grading be necess
8. Will extensive fill be necessary for SSTS? ........: ...............................
9. Do filled areas exist within the SSTS area? ........ ...............................
If yes, what. is -the condition of the fill?
:.:F] Yes
Yes No
aYes Q No'
No
0
Yes . .
1 Yes No
SECTION C. SOIL OBSE VATION -
---10: A eararice -of soil: Sand Gravel � Loam Cla F i
PP Y Hardpan Mixture
11. Observed from: 0 Borings F-1 Bank cut Backhoe excavations
12. Soil borings /excavations observed by G ; • ggp t"? c- D, Y , on 7
L
13. Depth to groundwater aoNC-= on
14. Depth to mottling ,A/:rAiX on
15. Are test holes representative of primary & reserve areas ...... ............. ...................
16. Soil percolation tests made by ?zo se T& %' 'Q� C./, Se-a on,
17. Soil percolation tests witnessed by 4, z 0 E o :B 4 -j�> i K • on
SECTION D (on back)
Q No
i
2
SECTION D. DRAINAGE
18. Will proposed grading materially alter the natural drainage in this or adjacent areas? ❑ Yes
.19. Will groundwater or surface drainage require special consideration? ...... ............... D Yes
20. Will gullies; ditches, etc., be filled and watercourses be relocated ? ......................... Yes No
SECTION E. REMARKS
21. If a common water supply is proposed, has an inspection been made of the
existing or proposed source and facilities? ..:............ ...............................
................. F_� Yes /No
Inspection data
22. Do adjacent wells and/or sewage - systems exist?::::. ::.- .- t?:.:.;._.:._._:�.- - Yes No
23. Additional comments
24. Site observer/inspector and title Soma 7Z>, Xx g j�_
_
-_ 25:� Dates) of observation(s)inspection(s) - -
TEST PIT PROFILES _.
Hole # Lot # _ .:�_ =Hole # - -- -Lot # .... - - -- _.....Hole #
Depth to water
p
6.0 6.0
6.0
7.0 7.0 7.0
8.0 8.0 8.0
9.0 9.0 9.0
10.0 10.0 10.0
Depth to water .......
Depth towater
Depth to mottling _ _
-- _ D epth -to-mottling
"Depth to mottling Y
Depth to rock/imp.
• Depth to rock/imp.
Depth to rock/imp.
G.L.
- - -G.L.
- - -G.L: -- -
-
0.5
0.5
_2.0
3.0
3.0 .
3.0
4.0
4.0
4.0
5.0
5.0
5.0
6.0 6.0
6.0
7.0 7.0 7.0
8.0 8.0 8.0
9.0 9.0 9.0
10.0 10.0 10.0
0
n
IT
Q�l
n E w
n
� - � NQI�NIN�bhl
IZ
kb
z
•'• � 'Y]ily� d� � a f
u.4u1JtIStlyvA � •. g G
O 1 \/ V r•
4m to
to
• I .'�N °� . � � � �. � M C U . ' �-1-- rte-' -• .. � i , qi
• of C� (Y1 1' •- -{� 9 �,•
7 .J ii •'I L�
i e •Y CCLlA' GICGA•• UWA •7-•C I _�•�� }•r- I •�.
a-
Li
' I � !•
' v i �l.W Wf'll I L Av � I I t'1
c Na
I -•Y I
if- N9�CiMCA1. --
m
F 3.' PROPERTY IDENTIFICATION
C s .�� OWNER: MAUREEN LOBRIACO. ;
465 DEANSBURG 'ROAD
BREWSTER, NY 10509 '
E911 #: 8 NEWBURGH ROAD
T. M. #: 25.62 -1 -75
PROPERTY 8 NEWBURGH ROAD
AnnRPCC- Q ATT FPQr)KI ni V
t .a Standard N. Y. B. T. U. Form $002 Bargain and Sale Deed..with Covenant against Grantor's Actt— Individual or Corporation (Single Sheet)
P
CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT —THIS INSTRUMENT SHOULD ®E USED BY LAWYERS ONLY.
art �
-. -- _ THIS 1NDENMRF, made the v � day of- Februaxy ,- nineteen hundred and ninety --four
BETWEEN ACTION ASSOCIATES, INC., a domestic corporation having
offices at Barnum Corners, Putnam Lake, Brewster, N.Y.
party of the first part, and MAUREEN LOBRAICO, residing at Barnum Corners,
RFD #3, Brewster, New York
party of the second part,
WITNESSEM, that the party of the first part, in consideration of ten dollars and other valuable consideration
paid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs
or successors and assigns of the party of the second part forever,
ALL that certain plot, piece or parcel of land, with the buildings and improvements thereon erected, situate,
lying and being in the Town of Patterson, County of Putnam, State of New York
bounded and described as follows: Lot Nos A1168 — A1174 inclusive,
Lot Nos A1143 - A1152 inclusive, Lot Nos. A1195 - A1199 inclusive as
design, e an e inea e map entitled "Map A, Putnam Lake, Town
of Patterson, Putnam County, New York
BEING the same premises conveyed by deed, dated 12/6/82 and recorded
1/20/83 in Liber 788 cp. 494, made by Commission of Finance of Putnam
County and parties of the first part.
TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and
roads abutting the above described premises to the center lines thereof; TOGETHER with the appurtenances
and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO
HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of
the party of the second part forever.
AND the party of the first part covenants that the party of the first part has not done or suffered anything
whereby the said pTemises have been encumbered in any way whatever, except as aforesaid.
AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that the party of
the first part will receive the consideration for this conveyance and will hold the rit?ht to receive such cnnsid-
ate'• .i
STATE OF NEW YORK, COUNTY OF ss:
On the day of 19 before me
personally came
to me known to be the individual described in and who
executed the foregoing instrument, and acknowledged that
executed the same.
STATE OF NEW YORK, COUNTY OF PUTNAM sa:
On the 8 th day of February 19 9 4 , before me
personally came MAUREEN LOBRAICO,
to me known, who, being by me duly sworn, did depose and
say that she resides at No. RFD #3 Barnum
Corners, Brewster, NY ;
STATE OF NEW YORK, COuI*Vd ''++� ` sa:
On the day of 19 before me
personally came
to me known to be the individual described in and who
executed the foregoing instrument, 'and acknowledged that
executed the same.
STATE. OF NEW YORK, COUNTY OF ss:
On the day of 19 before me
personally came
the subscribing witness 'to the foregoing instrument, with
whom I am personally acquainted, who, being by me duly
sworn, did depose and say that he. resides at No.
that she is the President
of ACTION ASSOCIATES, INC. that
, the corporation described
he knows
In and which executed the foregoing instrument; that he to be the individual
knows the seal of said corporation; that the seal affixed described in and who executed the foregoing' instrument ;
to said instrument is such corporate seal; that it was so that he, said subscribing witness, was present and saw
affixed by order of 'the board of directors of said corpora- execute the same; and that he, said witness,
tion, and that she signed'hher name' thereto by like order. at the same time subscribed h name as witness thereto.
Notary Public
40ANN MA>3OJ:TQ..
Notary Public, State of New York
No.4936338
Qualified in Putnam County [,l
Commission Expires July 5, 19
1Vargaw anb *ale Meea
wl'1'H COVENANT' ACAINS'r CRAN'rows AC's
TITLE NO.
ACTION ASSOCIATES, INC.
TO
MAUREEN V. LOBRAICO, PRES.
STANDARD FORM OF NEW YORK BOARD OF TITLE UNDERWRITERS
Distributed by
SECURITY TITLE AND GUARANTY COMPANY
CHARTERED 1829 � IK NEW YORK
Newburgh Canton
Road Drive
SECTION 25.62 a Z- �S 6 z
BLOCK 1 /
LOT 75 7 � �3
COUNTY OR TOWN of Patterson /Putnam Cc
RETURN BY MAIL TO:
RICHARD I. GOLDSAND, ESQ.
197 East Main Street
Brewster, New York 10509
Tel.: (9 14) 278 -2000
Zip No.
14 -16.4 ('J87) —Text 12
PROJECT I.D. NUMBER 617.21 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 •.
KF (ZFLV : iCO
2. PROJECT NAME.
3. PROJECT LOCATION, .. :....
Municipality County t$1�
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) .
dv vU .... P 60 �A iCiillZ��JI�% ti' y
1 �
5. IS PROPOSED ACTION:
New ❑ Expansion ❑ Modification /alteration
6. DE CRIBE PROJECT BRIEFLY:
10,00 &AL , G6 P11 C- TA f 12-6 LF ;?_4 -T ku N C4
AI 125 (.F Q65fP -ilf✓ 1' -G�'� p� -TIL4- �i%t2cJ
7. AMOUNT OF LAND AFFECTED: �1
Initially cot' 14 --acres Ultimately V. 14 acres
8. W14 PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS ?.
Yes ❑ No Ii No, describe briefly
9. W,H6T 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)?
C3 Yes NNo 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 permitlapproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑ Yes No
I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicantisponsor name: S Date: '' 0
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 01— ENVIRONMENTAL ASSESSMENT (To be completed by agency)
A. DOrES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
❑ Yes ❑ No
13 WMIL ACTION RECEIVE COORDINATED REVIEW-AS, PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? -Af 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
05. Growth, subsequent development, or related activities likely to be induced'by the proposed action? Explain briefly.
06. 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. S THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes ❑ No If. Yes, explain briefly
DAFT III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
NSTRUCTIONS: For each adverse effect Identified above, determine whether it Is substantial, large, Important or.otherwise significant.
ach effect should be assessed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
reversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
:xplanations 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, the reasons supporting this determination:
/n
Name of Lead Agency
r
flame ponsi le Officer in Lea Agency Title o Responsi e O icer
"?V! inr�r�� er in Lea Agency Signature o Preparer (I different from responsible officer)
4,�
Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print or type . PCHD F�ermltff-
Well Location:
Street Address: Town/Village Tax Grid #
. 44 -sou :�ATT'Ei Sod Map25-62.Block Lots)
Well Owner:
Name:
Ad ess:
MJ4U�� i.��,i��iCv
46' --P15A0LZUP -10 14 `eD 1 - 3P16WSTO N 0.
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 ° gpm # People Served Est. of Daily Usage /80 gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
P ip L
for Drilling
Well Type
Drilled Driven. Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision pGU'M,_ U&C dWff . A- Lot No. A 43 'ro
Water Well Contractor: Address: 4 Il S 2-
Is Public Water Supply available to site? ........ Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination be provided on separate sheet/plan.
Date: 1 Q' Applicant Signa .
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary'Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form,
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam
County.
Date of Issue
Date of Expiration
Permit is Non - Transferrable
Permit Issuing Official:
Title:
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
3,1 COU74 i R:T-Y
-ICES
SERV
=-IN TL-ALL =A=
-iRo
OF. E-NT"Y
L11.71-111A
DE.SIGN, DATA S=.-= T RI.
ddr-ss
Owne.
a p 0C:. T
(indicatenearest cross str•t•)
Nfunicipaliry PA-!MeC� . Drainage Basin F. Q A N CL+ 142
n-3r,z of
NOTIS: I
SOIL PERCOLATION TEST DATA
-771
oeaEel;
. at same
7-SZS to be re ac l-, ;-ercoi-ticn -,-,'as are cocam'!c 21� tac-
'0 :ninjinc) All d�ra
percctauon res" hole. (i.,- I rain for ;inc,- - I I .. —
? -,0 m 1. mi fc r I
min
su, for
miaed
me:IsL,,,emp--.r.s -10 be made "or" Zco 3r
Leath
/LA
pT + 1�/r {�7- 1 I T T 1
L tj �, i C V 1 q -1 �J 1 .t
D�TOi'�I ++ V?tOi'ii� 1�.�.. �i .�.T .5V ICES
DESiG % DATA 5=x
�T - S u-BSL �'.yCy Ste` GL TR� �TXEN T SY5 T Ll�i
y l
Owr, e.
h�U�-.�U ;L 6 1 Address
�ccatec at (Street) 1�,' 1,�' .;i '-+ T tifa� ��,�;LBloc'.c l Tet 7`T
(indicare nearest cross sleet)
tilcnc:pality A:F-' S,�: t �� Draita ?e 3asi' & (n C-SL '.U61( Ei
-
SOIL PE'RCLATION TEST DATA
Date of Pre- soa'.ci_? 7� i; Date of Percolation Test 71 16/(%
N�J1— .�: i, le$t5 CO oe repeater at Same Cent; nt:l aCCCOC:%:aC .! : , . C: �C� -:. --L••
percolation test hole. (i.e. ; 1 ^in er ..0 mi i,:c ,, <_ _ ,:,ir.:or 31 -, ...I iincal al cats ce
Submitted Ior review.
_. Deot t me�SL'ie. ^..e t0 ^laC2 .'cri..c^, cI 0.�.
Depth to Water i
From Ground
Water
Level' -
Percolation
Hole No. Run No.
Time Elapse Time
Start - Stop (llin.)
Surface (Inches) .
Start Stoo I
Drop In
Inches
Rate . I
l�Iin7Inch
I
C2
t
I- I I
- --
I
I i
N�J1— .�: i, le$t5 CO oe repeater at Same Cent; nt:l aCCCOC:%:aC .! : , . C: �C� -:. --L••
percolation test hole. (i.e. ; 1 ^in er ..0 mi i,:c ,, <_ _ ,:,ir.:or 31 -, ...I iincal al cats ce
Submitted Ior review.
_. Deot t me�SL'ie. ^..e t0 ^laC2 .'cri..c^, cI 0.�.
fir.
1.0'
1.5'
2.0'
4.0'
5.0'
6.0'
o.�
-7.0' -
7.5'
8.0'
8.� ,
TEST FIT D.I T.�
DESC ?PTIO�i OF SOILS E`+CGG`+T . c j Iii TEST HOLES
SOLE NO. in - i:GLE N0. H(DL.E NN 0. r±
-.r
� 1
-),/;d : Lc:�i .-\
!eeL-,e
1
Indicate level at whicl. C•OuriCwate: is encoumt. ==
indicare ievel at which rnonlinr is ooseried --
lndicate level to which water level rises after UeiilC encount -_
Deeo hole observations mane by: Ni✓ Ii;' 4 Date C% 1
DesiPn Professional pane: ( , S<OT7"
Address: 38 � I n� E � c " " ",S��r✓ N` Y
Sim. arur°: "
Desiar Pi 0'i °ssi00ci s �ec�
g�3, it p u.t j
i�F�
D E -:7 H
7
2.0'
2
r.01
A
6.0'
I.;?
7 . .5'
6
I
TES 7 °IT D 7
D E S C --- UP T 10 LN OF SOIL: Z C 0 U", -N-L R L) I 1 4 TES 7 1 z- 0 L -Z E
�ZCL= Nc.
IV,
,fiiool
A IV
c ar. lvi-ll at ;(z
d; c! at,- to wh;,c*L-1 level, .3ZS Z..-:
Deep hole obser;arions zmade 'o,/: --71
PC
Design Pzof-essional Name:
'3S
ca
PUTNAM COUNTY DEPARTMENT OF HEALTH
DMSION Of ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of H /+0 tLIE Fij L 0 VA I CO
1
TN Tax Map # 25. 62. Block _�_ Lot 75
Subdivision of M k P "A OF pk�rN Ah LA Y-
A i1 4,J io Aii5a
Subdivision Lot # W c iW-91 J c Filed Map # j q P Date Filed p 3. 2v — I q 31
Gentlemen:
this letter is to authorize SC�TI
- - - - -
:a duly licensed - Professional Engineer or Registered Arciitect - -- -to apply for the required
wastewater treatment and/or water supply permits) to serve the above -noted property in accordance
vith 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 Ai9p rovisions Qf Article 1.45,andlor ] 4.7 of the.-Education Law, -the.-Public Health
Law, and the Putnpp County Sanitary Code.
CountersiA/ --__/
P.E., R.A.,
Mailing Address
Sate Zip
lelephone: � ar - 2 V - .21I o
Very truly y urs,
A
Signe
(Owner of Property)
Mailing Address: 4CO6 3)— w:5�ioac
1Ize W ;im*_
State N y Zip 10 5_0 I
Telephone: '?A-!5' 2.1 1- ZS 51
Form LA -97
a,
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- - APPLICATION FOR APPROVAL OF PLANS-FOR-
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: LU3t �a�i C�
46c la i s-Rw PO &D
2. Name of projects t4 W F0 RGN- ("D 'Stp11(3. Location TN: PAMp -So &
4. Design Professional: PW 6 Ge)T Z,pJG._ � 5. Address: 3g]l I�U�
NIZCA Po Cl
6. Drainage Basin: EA6r $QQaCat. 66&Ab1 P- Bae Srg(Z A 105-03
7. Type of Project:
_ Private/Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................... ............................... Type I Exempt
Type II Unlisted K
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 0
10. Has DEIS been completed and found acceptable by Lead Agency? ...............
11. Name of Lead Agency I!ATM9501t Ah h& ZD hRo
12. Is this project in an area under the control of local planning; zoning, or other
- officials; - ordinances'- - . ............................................................... ._.. .. ......................
13. 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 groundwater
16. If surface water discharge, what is the stream class designation? ....................
17. Waters index number (surface) .................................:........ ............................... NT
18. Is project located near a public water supply system? ....... ............................... IV 0
19. If yes, name of water supply /nl Distance to water supply 4
20. Is project site near a public sewage collection or treatment system? ................
21. Name of sewage system a f k
U.
Distance to sewage system --WA
22. Date test holes observed ,0 60C, 23. Name of Health Inspector � Q a"
24. Project design flow (gallons per day) ......:..........019E ..W-42M................ 2oo
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 0
26. Has SPDES Application been submitted to local DEC office? .........................
Fo PC -97
2
roject located within a designated Town or State wetland? A! O
27. Is any portion of this p
28. Wetlands ID Number ...:.:........:..:..............................:......... ...............................
29. Is Wetlands Permit required? ............................................... ............................... 0 11A
Has application been made to Town or Local DEC office? ............................... LJ
30. Does project require a DEC Stream Disturbance Permit? .. ...............................
N0
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? ............................ YesNo
32. Is project.located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination. Yes/No
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? ............... ...........
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ................................ ...............................
35. Are any sewage treatment areas in excess of 15% slope? .. ............................... J
36. Tax Map ID Number .......................... ............................... Map 2S'; ZBlock._L_ Lot
37. Approved plans . are to be returned to ..... Applicant k^ Design Professional
NO'fE:.All applications for.review and approval of a new SSTS to be located withiri'theNYC'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 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.
Il hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of any knowledge and belief. False statem made herein are punishable as
a Class �A misdemeanor pursuant to Section 210.�,me penal Law.
SIGNATURES & OFFIML TITTLES:
Mailing Address: ................................... 2511 90 Uri; CO
16a6wsmp- Oy t,oSo 7
RC,
'LOTS A -1175 T A -1184 (R.O. # 149H)
TAX LOT 78
200.0 '
i
i— 6 4 PT 1
�— -- ` .44 TPA I
i TP B 9<� (2
® allows p 624 �.� EXPANSIIIW
I
42 \ -
4'0 PVC
1 8 Fi MIN
D /
TP �/
4'0 PMC a 35 6�
1 /8' /Ff MIN ` P2 ` � � 2 •. .
as w&°Fm°"LOTS A -1143 Tb �A41152 0
J RVO o i� TP F IPEc O (R.O. # 149H) ' �\ O
\ O I 1 Sr4 s-e \ TAX LOT 75 I \ \ O
e z
e� K LOTS A -1133 TO A -1137 (R.O. # 149H)
C) 4b CI MIN 1 p0 \ \
1/4�/F! MIN I I TAX LOT 76
— — — — — -- 628 ROCK
1153 TO A -1157 (R.O. # 149H) 1 BEDROOM HOUSE
(1173 SF) avows \
TAX LOT 74 \ \
g ` \
FF EL.= 632.0'
BSMNT EL.= 623.0' -� I
LL SE7gACK
• 200.00' ` � '' '
NEWBURGH ROAD
PROPOSED WELL'
(TO BE LOCATED BY A SURVEYOR
PRIOR TO DRILLING)
s
PROPOSED WELL'
(TO BE LOCATED BY A SURVEYOR
PRIOR TO DRILLING)