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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.07 -1 -6 BOX 20 02280 ' '� I. Lr ■, . ' =j T . 02280 PUTNAM COUNTY DEPARTMENT OF HEALTH oeI D VI ION-OF ENVIRONMENTAL: HEALTH SERVICES,,.:. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # _P V— 3 8 - 9 CA Located at 9 IRO A &601< Pp, r Town or Village PU T N lei M VA L L4�- X Owner /Applicant Name J9 0341?' - 614CLARDUCC1Tax Map Block ( Lot �o Formerly Mailing Address Subdivision Name - n)1 S e- V S y pD 1 V j S 1 a /J Subd. Lot # I 2 PRrv?6 -JK, ACI+✓ YoRK zip 105-O Date Construction Permit Issued by PCHD OC T 3O, 2,06 3 6 L_tWam- 000D Separate Sewerage System built by Uf j0E R J L L C AS I'- Address k ► T0N 6k, t1i Y O 536- Consisting of 12 5 0 Gallon Septic Tank and 400 L .1F - L' '�O- J94:M r0Q r-) TC 0 Pve V I1 11-3 " Cflp1 r4, -t?e/V C u Other Requirements: 24 �� 0 �Atii KT? y /-J Water Supply: Public Supply From. Address P in >z Etc fZ S r �2 �' fi or: X Private Supply Drilled bydoRMA/4 AN9E RSorJI �i,Ic- Address PU i ,0QA N 1IPt C it / N)% Building Type -S i N C LLf RR (-7 r L+,/ Has erosion control been completed? Number of Bedrooms roo C- Has garbage grinder been installed? I certify that the system(s), as listed, serving built plans (copies of which are attached), in plans and the standards, rules and regulatior. Date: 9 - -Z.j ._0 �- Certified by Address 2 -Z70 k /'-1 �JA L f NEW Jr constructed essentially as shown on the as- 7-th' tYilb u e PCHD Construction Permit and approved `�o D partment of Health. P.E. '%< R.A. License # ® L' Cl �N`rOFE 'S10C`' -'' Any person occupying premises served by the above YsW all,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 irevocatio ification or change is necess PTitle: 1 4,e Date: File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES�cv���i-(y. WELL COMPLETION REPORT Well. Location_ ..... Stre Addres ,( illage :'? jr � Tax Grid # Map j (3`) Block I Lot(s) Well Owner: Name: 0 Address: Use of Well: 1- primary 2- secondary � Residential Public Supply Air cond/heat pump Irri ion Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment '-P< Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length eft. Length below grade 3� �yft. Diameter fain. Weight per foot lb /ft. Materials: Y, Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: < Yes —No Liner: Yes ,.,fiio Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped _ Compressed Air Hours Yield 2 gpm Depth Data Measure from land surface- static (specify ft) SO f During yield test(ft) Depth of completed well in feet 5,0 D I 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 ly " If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 31,t� Capacity /o Depth Model %OS'o5 `j Voltage 2�3a BPI/ Tank Type L34 ✓ Volu4e 7y 2. o Date Well Completed Putnam County Certification No. Date of Report Well Diller (signature) 17'7 p�lU"7: txact location of well with distances to at least two permanent lattidmarks to be provided on a separate sheet/plan. P2 4 Well Driller's Name Address: 6 Signature: 'L-74 /'j-) Date: J White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange cop - Well driller Form WC -97 . -. BRUCE R:-- FOEY„n:a;...;,:�•:..:r.,.:... _,�„ . _. Public Health Director Associate Public Health Director Director of Patient Services DEPARTNENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914)278-6130 Fax (9.14) 278-7921 Nursing Services (914)278-6558 WIC (914)278-6678 Fax (914) 278-6085 Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fax(914)278-6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: riL���� GE{i`✓ (-.i9 V CC TAX MAP NUMBER: S C G : �' f . O % t.s LK: I Lo -r: E911 ADDRESS: q OJQIR I" '� is t?0 0 e v(:�- TOWN: Ftj vjV1 rh V Iq L LC- AUTHORIZED TOWN OFFICIAL: ✓ 3� . (Signature) i J DATE: C -� ... - .... .. .. .. .: a _�..�.. s .t ... . -... .... .. .. .. ... .. '. .. .._.— r- __....�.q. . The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRM) , YML ENVIRONMENTAL SERVICES 321 Kear Street ^ Yorktown Heights, N.Y. 10598 Albert H. Padovani, Director LAB #: 1.505459 CLIENT #: 2173 NON STAT PROC PAGE: 1 NORMAN ANDERSON INC. DATE/TIME TAKEN: 08/08/05 12:00 152 BARGER ST ` DATE/TIME REC'D: 08/08/05 12:32 PUTNAM VALLEY, NY 10579 REPORT DATE: 08/17/05 PHONE: (914)-528-1491 SAMPLING SITE: ROARING BROOK : KITCHEN TAP COLM bY: SARAH-ANDERSON NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEEDURE PUTNAM CNTY PROFILE 08/08/05 MF T. COLIFORM 08/12/05 LEAD (IMS) 08/11/05 NITRATE NITROG 08/10/05 NITRITE NITROG 08/11/05 IRON (Fe) 08/15/05 MANGANESE (Mn) 08/11/05 SODIUM (Na) 08/08/05 pH 08/15/05 HARDNESS, TOTAL 08/15/05 ALKALINITY (AS 08/12/05 TURBIDITY (TUR 08/08/05 E. COLI (CONFI SAMPLE TYPE..: POTABLE ` PRESERVATIVES: NOWE TEMPERATORE..: < 4C COL}FORM METH: MF RESULT NORMAL -- RANGI-E METHOD ~~~~~~~~~=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PRESNT /100 ML ABSENT 100B 2.0 ppb 0-15 ppb 9003 0.66 MG/L 0 - 10 90 52 <0.01 MG/L N/A 9162 0.119 MG/L 0-0.3 mg/l 9002 <0.010 MG/L 0-0.3 mg/l 9002 11.5 MG/L N/A 9002 6.4 UNITS 6.5-8.5 9043 196 MG/L N/A 72.0 MG/L N/A 9001 1.2 NTU '045 NTU ABSENT 100/11L ABSENT COMMENTS: BACT THESE RESULTS _IMDICA THAT_THE WATER (WAS) F A _ SATISFACTORY SANITARY QUALITY ACCORDING TO STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% 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 exc eed 0.5 g /L ,, ; ��� Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet�the water should � YML ENVIRONMENTAL SERVICES 321 Kear Street _ Yorktown Heights, N.Y. 10598. - `' � `'�` '-~�� � � ' `'- '- � �'(9f4)-��45-28OO .� �~. .'- '1 Albert H. Padovani, Director NORMAN ANDERSON INC. DATE/TIME TAKEN: 08/08/05 12:00 152 BARGER ST DATE/TIME REC'D: 08/08/05 12:32 PUTNAM VALLEY, NY 10579 REPORT DATE: 08/17/05 PHONE: (914)-528-1491 SAMPLING SITE: ROARING BROOK SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COL'D BY: SARAH ANDERSON TEMPERATURE..: < 4C NOTES...: ` COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE ` RESULT NORMAL - RANGE METHOD contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE -- -' - 'SQURCE -ANb-T` NFNT.TO-WH!CH�THE WAT k HAS BEEN- SLQB ' ' ' .1�2—''���-�'����'�~-�` SOFT WATER: 0-70 MG/L VERY HARD WATER: ABYVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY:. A ��r ' ''' ' ---'-''-` '''''`--' ' � ELAP# 103223 1, YML ENVIRONMENTAL SERVICES 321 Kear Street (914) 245-2800 Albert H. Padovani, Director , LAB #: 1.506527 CLIENT #: 2173 NON STAT PROC PAGE: 1 NORMAN ANDERSON INC. DATE/TIME TAKEN: 09/22/05 03:80 152 BARGER ST DATE/TIME REC'D: 09/22/05 03:45 PUTNAM VALLEY, NY 10579 REPORT DATE: 09/24/05 PHONE: (914)-528-1491 SAMPLING SITE: 9 ROARING BROOK DRIVE SAMPLE TYPE..: POTABLE : TANK PRESERVATIVES: NONE CQL'D BY: 8ARA ANDERSON TEMPERATURE..: < 4C NOTES...: COLlFORM METH: MF ~~~~~~~~~~~~~~~*~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 09/22/05 MF T. COLIFORM ABSENT /100 ML ABSENT l00X COMMENTS: ` BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A lY SATISFACTORY SANITARY QUALITY ACCORDii��~THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. ~ SUBMITTED BY: Albert H ovani, M.T.(ASCP) � Director/ � �� ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM A i.G r2T G14E0qR D 0CC_ t Owner or Purchaser of Building Building Constructed by L-i, a� ! 6 Tax Map Block VAL-�nl Lot r PO T-NJq M To wnNillage i ROAR 10 6 2ROOK ORIVC t s1, Location - Street Subdivision Na e _Slr_16u� r-AMIL-Y Q61910clicc I Building Type Subdivision Lot r I represent that I am wholly and completely responsible for the location; workmanship, material. construction and drainage of the sewage treatment system sen-ing the above- described propem•, 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 Countv 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 building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. ' Dated: Month )T Day 4L Year 2065 Signature: A,241� Title: al Gplqk4 7 r (Owner) - Signature 1 Address: _ 16 - Aj ux State Z9,9 M a N .y . Zip o �° ILI i 1 a � �L // Corporation Name (if.cgrporation) M� State Zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH. I IVISI.ON OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM A( -GCf21- GKEL1qR)uCc t Owner or Purchaser of Building Building Constructed by 41,6-) 1 6 Tax Map Block 1 Lot (-r Po-rN,� TownNillage 9 ROAR 10 6 9ROOK ®RIv4� I ISL � Location - Street Subdivision Na e _S its 6u rAM t Ly t Building Type Subdivision Lot r 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 propem•. 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 o«-ner, 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 tvvo 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 bpetdte-properl-V Is caused by-the.willful.or . negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month _ DayL Year 2666. r (Owner) - Signature Address: _ /—. Q „ &L)c �0- State - AmoN k A Y Zip 20 -ra Signature: Title: l/ n Corporation Name (if corporation) Address: State , I Zip /O 53' Form GS -97 RONIN ENGINEERING P.E. P.C. The Li ndX Building. Suite 200, 2 John Walsh Blvd., Peekskill, New York 10566 _ a Tel. (914) 736 -3664 • Fax. (914) 736 -3693 .. r. ,. <. , .... .. . October 5, 2005 Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Department of Health Division of Environmental Services 1 Geneva Road. Brewster, N.Y. 10509 Re: SSTS Construction Compliance Albert Ghelarducci P.C.D.HPermit #PV -38 -99 9 Roaring Brook Drive Town of Putnam Valley Dear Mr. Paravati " Please find-enclossedd-1he original well completion report-and water analysis for -the above. referenced project. The report has been completed to show the required PCDH profiles. Please review at your earliest convenience. If there are any questions or if additional information is required please do not hesitate contacting me at the above number. Thank you for your assistance in this matter. Respectfully submitted, Kenneth M. Murphy Design Engineer LETTER OF TRANSMITTAL CRONIN ENGINEERING P.E., P.C. The Lindy Building; Suite 200 2 John Walsh Boulevard Peekskill, NY 10566 914 - 736 -3664 Fax 914 - 736 -3693 Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Department of Health 1 Geneva Road Brewster, N.Y. 10509 RE: ALBERT GHELARDUCCI PCDH PERMI #PV -38 -99 9 ROARING BROOK DRIVE TOWN OF PUTNAM VALLEY THESE ARE TRANSMITTED as checked below: September 22, 2005 ❑ FOR APPROVAL ❑ FOR YOUR USE ❑ AS REQUESTED ❑FOR REVIEW AIVD'cOAA -4 X PLEASE REPLY WE ARE SENDING YOU attached 1.) Three copies of as -built subsurface sewage treatment system plan 2.) Three certificate of the construction compliance. 3.) Three guaranties of SSTS 4.) Copy of survey showing foundation location 5.) E911 address verification form 6.) $300 certified check for application fee. 7.) Letter of Authorization The information enclosed is submitted for review only the water analysis and well completion report will be submitted when it is obtained from the well driller (Norman Anderson, Inc.). Should you have any questions or require additional information regarding this matter, please contact me at the above phone number. Thank you for your time and assistance in this matte. Respectfully submitted, �I 1: :4" h M. urph Design Engineer SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORET.TA MOLINARI, RN, MSN Associate Commissioner of Health July 27, 2005 DEPARTMENT OF HEALTH 1, Geneva Road, Brewster, New York 10509 Cronin Engineering Ken Murphy The Lindy Building, Ste 200 2 John Walsh Blvd. Peekskill, NY 10566 ROBERT J. BONDI County Executive Re: Field Inspection — Ghelorducci Roaring Brook Road (T) Putnam Valley, T.M. 41.07 -1 -6 Dear Mr. Murphy: A site inspection was made for the above referenced project on July 26, 2005. The. followin comments must be corrected in the field. u (� 100% expansion has not been provided. r2 ,.It is unclear as to whether 2 feet of fill has been provided in the expansion area. Please provide test holes to confirm depth. The well casing needs to be raised to 18" above finished grade. When house is completed, a bedroom count needs to be conducted. If you have any further questions, please contact me at (845) 278 -6130 ext. 2157. JSP:cw S' erely, L,Oseph S. Paravati Jr. Assistant Public Health Engineer Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax(845)278-7921 Nursing Services (845) 278 -6558 WIC(845)278-6678 Fax(845)278-6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 C-4 ru ru s �e CD .0 -q Im co ni m (A ...... ...... . 00 F ru . z . . . . . . . . . . . m 0 m m 14%W 221" IQ or, or C Res 4i 96* It 04C' a ft Cri AP LOT I AREAM4., 766 A CRES Wokl 021-V 81P.Mw 1t A 9 m CD U) Ir 5 24'OW 9 m CD U) DIVISION OF ENVIRONMENTAL HEALTH SERVICES y,u _ AhI,..18vt FINAL SITE INSPECTION . Street Location /t.2�;n Town n...- v , ;r;:; 1/F,°rt TM# W01 -1 -fo Date: ' 7 36 foy Inspected by: JSP Owner_ 0.h�Je Permit # — pv 3 e, -I �l - Subdivision Lot-# Kios (_ - coeld, 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill. section -date of placement 3.1 barrier Lgth. Width Avg.Dpth C. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area...: :.:... e. 100' from water course /wetlands..... .Z.-other: .......... I........ IL Sewase System 'a:. Septic tank size 1 000 . ............... - ...:.....1,250 b.. ' Septic tank installed level ..... :........... ........................... .... c. .10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at s el a ' ater tested .......:...::.... 2. Protected below . ............. r...................... 3.. Minimum 2 ft.Original oil between box & trenches e. Junction Box - .properly set .......... ............................... 6.. Trenches 1 Length required Length installed 2. Distance to watercourse measured 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 - IIA" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ........ . ............................... . .. . ....... _ ..,5: Pump or l2ospd..Sxsteaas_- .. _. ... .... . 1. Size of pump chamber .............. ' .......................... 2. Overflow tank .::..........L 3. Alarm, visual/audio..... ...... ...................... . 4. Pump easily accessible, ol to grade ................. 5. First box baffled ....:..................... ............................... 6: Cycle witnessed by H.D.estimated flow /cycle........... M House/Buildin$ a. House located per approved plans......... :. b: Number of bedrooms ........................B!1a? IK: Well Well located as per approved plans . ......:........................ b. Distance from STS. area measured -- ft........... . c. Casing. 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanshill >a. Boxes properly grouted... ..................................... I .......... 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 pl f.' Curtain drain outfall protected & dir.to exist watercr g... Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... . Rev. 12/02 07/15/2005 08:44 9147363693 CRONIN ENGINEERING 1 PAGE 01 PUTNAM COUNTY DEPARTMENT HEALTH DIVISION OF FINVYROXI NIENTAL HEAL H SERVICES ❑�b� ❑ VE ATTENTION AD��i�r>< GEC RR EQMT FOR FINAL INSPECTION . For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit,, Located: R"910C oftok. () (V) Owner /Applicant Name: Block Formerly: , Subdivision Nam subdivision Lot n Is system fill completed? `j —.5 '� JaA Dat : Is systen complete? `s Date- Is s45tem constructed as per plans? Is well drilled? Date: Is well located as per plazas? Vie Are erosion control measures n place? I certify that the system(s), as listed, at the above premises has beet constructed and I hi and verified their completion in accordance with the issued PCHD Construction a roved laps and. the Standards,. Rules and Regulations oft Putnam County D _.T- ...__.p_P.. ...P_ ... _..._.._._.__M,.... -_.. _ D Health- Date: 7� .d 2 cb�/ G7n1�'�l�P W � Certified by. Design Proi 6ssiowd Address: C.t° L 1 C Lic. Comments: Form FIR -99 Lot -e inspected Permit and )artment of RA T111- IS -PRAS FRT 14:AR TFL:945- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 T N m N rS UOI n O •. Yi }� m J m r ru J i �} ! Olt) f LEA IZP LOT t Ill Z4 4 7*4W A ORES �11rr sit t� 1 r . i DO; U� O ' r• c m N m � N CD Ul CD m A 00 LD w m w Un LO w IP' H Z 6 z m H D m m N i LOT t Ill Z4 4 7*4W A ORES �11rr sit t� 1 r . i DO; U� O ' r• c m N m � N CD Ul CD m A 00 LD w m w Un LO w IP' H Z 6 z m H D m m N cf2o�1Aj p PIS c w#q 12 ce z 0 z Cr3 •1Y� 4 0 /j / � w LL i AV LL 1 w z LAW LL SAW AL eor Lr Cl see ai Ann C'4 OW Lo LO � Pr � \� ti \ \, ti1'•, it �., / w� 1 � �„ . . :�;;;. wto ♦. P ^� , y �p r nay ♦ +lis _ �. 1.et *'q r ~ ~ r > 117 t G VAMP r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES. CONSTRUCTION PERMI E TREATMENT SYSTEM PERMIT # 9 g..9 QL3 IU Located at ,, a ri n s 1-5ia aj a c Town or Village IA�:e 4e�,vr Subdivision name �J_4 e,)eel Subd. Lot # / Tax Map .�/. 7 Block % Lot !y r Date Subdivision Approved /y�01 Renewal ✓ Revision Owner /Applicant Name Al-/� -V,4- 6 4G_ % ®r^ dye. Date of Previous Approval /// 071'/ Mailing Address h, Aw e "fad 4( Zip /V i ✓o. Amount of Fee Enclosed 30 C! Building Type Ce° Lot Area 4� 749o. of Bedrooms -,4 Design Flow GPD ZOO Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of `� �'G gallon septic tank and 2a'' c- Other Requirements: To be constructed by Address Water Sunaly: Public Supply From Address- or: _ Private Supply Drilled by /V ' "7 Address n A-gel If � f_..._ ..,.. ....._.. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the se_ par a� to 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. OF NZP Signed: Address R.A. Date O�'� License # ;,)' Y 5'g_ -' APYROVF9 FOR CONSTRUCTION: Thi i , o years from the date issued unless construction of the sewage treatment system has been completed and inspecte l y 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. By: `7✓y1i Title: Date: l 0 3o o copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PuTNnM couNTx DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _. APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD �erInit #� % Well Location: Street Address: Town/Village Tax Grid # - ,� �oe� -,h �re.ov /2, -�'rr, /gip �i- 4"i b'-y1 Map / 7 Block / Lot(s) � Well Owner: Name: Address: A'%, Use of Well: Aesidential 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 -�r gpm # People Served Est. of Daily Usage ©o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes 11`4 No Name of subdivision %4,ri is e le-y Lot No. Water Well Contractor: OV . W7deg-s�� Address: e,,-' i7a )L��ld Is Public Water Supply available to site? .................................. ............................... Yes No e" Name of Public Water Supply: — Town/Village -- Distance to property from nearest water main: Wf// Proposed well location & sources of contamination to be provided on separate sheet/plan. �.. ?Date: - �..:�`...�. ,.__ - :. licant 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 FOIL 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 �3,-W-0,3 Permit Issuing Official: av-oj�- Date of Expiration l c a Title: se`s ;r bIt`c 1 e� +� Permit is Mon - Transferrable a White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 LORETTA MOLINARI R.N., M.S.N. Public Health Director October 3, 2003 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Frank Sullivan 2972 Ferncrest Drive Yorktown Heights, NY 10598 Dear Mr. Sullivan: ROBERT J. BONDI County Executive C/ Re: Proposed SSTS Renewal — Ghelorducci Roaring Brook Road, (T) Putnam Valley TM# 41.07 -1 -6, Permit # PV -38 -99 This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. L--l. Based on subdivision plat, there appears there may be more SSTS and wells within 200 feet of the proposed well. Please verify and show all facilities within 200 feet of proposed well ._:,._ -_. andSSTS -- �2. The septic tank should be rotated 90° and relocated to avoid all bends in sewer and effluent line. 3. Please provide fill pad dimensions (length and width). -'4. Water service connection from well to house needs to be shown. Deep hole # 4 needs to read "5 feet to ledge" on plan. ,i6. A new well application needs to be submitted. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. . Very truly yours, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj PUTNW COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH _.;•,. _ .: ^ , :INDIVIDUAL WATER SUPPLY & SU$SURFACE SEWAGE'TREATMENT SYSTEMS-,: REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: =� '�'• 4,�� jP REVIEWED.BY: RM, GR, .45, SRDATE: � ( TAX MAP/#: (CONFIRN ED) Y N DOCUMENTS OR PWS LETTER OF AUTHORIZATION )DESIGN DATA SHEET (DDS) (�UCORPORATE RESOLUTION )SHORT EAF PLANS -THREE SETS (��OUSE PLANS - TWO SETS ARIANCE REQUEST SUBDIVISION LEGAL SUBDIVISION ' SUBDIVISION APPROVAL HECKED E92� E RATE M��� "►. `� REQUIRED DEPTH C�(�CURTAIN DRAIN REQUIRED GENERAL . ! C-j ATED.IN NYC WATERSHED (� PLANS SUBMITTED TO DEP LEGATED TO PCHD C�,� P APPROVAL, IF REQ'D U�EP TEST HOLES OBSERVED (�( /�P�RCS TO BE WITNESSED APPROVAL SSDS ADJ, LOTS ' (� ETLANDS (TOWN/DEC PERMIT REQ'D ?) UUDATA ON DDS PLANS & PERMIT SA (� U ME 1969 NEIGHBOR NOTIFICATION �W YR. FLOOD ELEVATION W1I 200' )SOIL TESTING LOTS>10 YEARS OLD REQUIRED •DETAILS ON PLANS )SEWAGE SYSTEM PLAN - (NORTH ARROW) )SSDS HYDRAULIC PROFILE )GRAVITY FLOW `)CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS C �2' CONTOURS EXISTING & PROPOSED (�UDRIVEWAY & SLOPES, CUT C _l FOOTING/GUTTER/CURTAIN DRAINS C��USDA SOIL TYPE BOUNDARIES Cr�C�TITLE BLOCK; OWNERS NAME ADDRESS / TM #, PE/RA; NAME, ADDRESS, PHONE# ✓ DATE OF DRAWING/REVISION (� DATUM REFERENCE . L . LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITffiN 200' OF P.L. UCJPROPOSED FINISH FLOOR AND 1'ti`ELEYA�IAAIS ✓WELLS & SSDS'S WAN 200' OF SST ` r �Y►ay�- PR OPERTY METES & BOUNDS - C,_ EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE :ONDIENTS: r7r' . SS 1 ij 5 L ' "► Y (REQUIRED DETAILS ON PLANS CONT'D) C-)H USE SEWER -' /.r' FT. 4 "0'; TYPE PIPE. CAST IRON BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS (�/ USITE NOTE (NO CHANGE) ,r � FILL SYSTEMS LC 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE _ CS/-FILL - NOTES 1 -5 � y y FILE & Dlli'IENSIONS� -�.'��v ✓, `'�`�.. . (U()FILL IN EXPANSION AREA FILL GREATER THAN.2 FEET A j .C—)C_) CLAY BARRIER (J( JFILL'CERTIFICATIO� NOT C-JC_JDEPTH GAUg6ES-- C--)C--)VOL. ON-PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS (_,,_L:m�SdARATION DISTANC OM'TOE OF SLOPE NCH• CJCC�LF TRENCH PROVIDE o 60FT MAX. PARALLEL TO CONTO 100% EXPANSION PROVIDED D FREE CRUSHED'STONE OR WASHED GRAVEL UGEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM*SSTS UL_ )10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 020' TO FOUNDATION WALLS IOO'TO WELL, 200' IN DLOD,150' TQ PITS C, ff .kf100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan)..... - _- _ 0! T.QxCA -TCH[ I3ASIA1,- 35�STORM DRAIN, •PIPED 'Q��ER_.° : - -. -... _.- _, -. . (_)10 TO WATER LINE (pits - 2Oa% UU50' INTERMITTENT DRAINAGE COURSE . C-j(__,)200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS (x(__)10' MIN TO LEDGE ,OUTCROP SEPTIC TANK CLfCj10' FROM FOUNDATION; 50' TO WELL ./ WELL OF SERVICE CONNECTIO �' (—ll'JUMnvT5"r0 PROPERTY LINE SLOPE CC_)SLOPE IN SSTS AREA (S20 %) C�Cf REGRADED TO 15 %, IF REQUIRED DOSE UMP SYSTEMS---' UUPUMp NOTES . IV/A' UUDOSE 75% OF PIPE V OSE VOLUME NOTED UUDETAIL FO '.MAIN, (PIPE TYPE, ETC.) UUPIT -BOX SHOWN & DETAILED C—j AY STORAGE ABOVE ALARM CURTAIN D UUSTANDPTPES, 5BOTH S S ,ETAIL �j (—JC—Jls, MIN to CD - , 0'-4 %,15' -3 %, 35' -1 %,100 % - <1% UU20' !m,! ISCHARGE400' with 182 cons day discharge CJ(,_)10' to NON- PERFORATED PIPE -...t ro i7 ► �' �'' fv e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ LETTER OF AUTHORIZATION RE: Property of /7��P/� / / ✓i' �. /d�C� Gil Located at ArriGr -i`4 ee . �/el®/f T/V Tax Map # 7 Block / Lot Subdivision of 9letla /! Subdivision Lot # / Filed Map # Date Filed Gentlemen: This letter is to authorize Ze i a duly licensed Professional Engineer 2f' or Registered Architect to apply for the required wastewater treatment and/or water supply permits) 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 nec6lsary 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 Ar -ticle 145 and/or 147 of the Education Law, the Public Health-- .- -- - Law, and the. Putnam County Sanitary Code. Countersigned: P.E., R.A., # OF NEW . Mailing State Telephone: / !:�!, 9 y Very truly Signed: �AL 440 ZO N 4/t3 State nay -Zip _j o -71 a Telephone: Form LA -97 0 ,1+ , 10 .14. PERMIT PUTNAM COUNTY DE?ARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT F inn REATMENT SYSTEM Located at 41 e ee,--I ` Subdivision name j e- e Subd. Lot # Date Subdivision Approved 1? 17 Owner /Applicant Name Cel ///a Mailing Address _ 30 el elle 4� e_e yL>i Town or Village ,4 4eyrnP, x f e 5e Tax Map 2//- 7 Block _I Lot_ Renewal Revision Date of Previous Approval Zip Amount of Fee Enclosed .3 ael, Building Type A-4 i4�w er Lot Area �_, Z No. of Bedrooms _ Design Flow GPD ''a Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of �' d e gallon septic tank and � d Z. Other Requirements: e- To be constructed by a W,17 -e-l" Address -3 ef _.Water SupVj :. _.- . :. Public Supply From Address or: Private Supply Drilled by �/'. fQ� lg c�� 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. 0 E Signed: ✓ P P� Address R.A. Date icense # Z '1 APPROVED FOR CONSTRUCTIOW This appr 'Val o? s a date issued unless construction of the sewage treatment system has been completed and inspected by evocable for cause or may be amended or modified w n consider necessa by e P lic Health Directo iston or alteration of the approved plan requires a new it. Approve for di h e o do tic sanitary sewaW1f-/r ly. By: Title: Dat e: l' £5 White copy - HD File; Yellow copy - Building Inspector; Pink cop - Owner; Orange copy - Design Pr fess onal Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH , DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type' d PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # 11 �ft Map 4e/• 7Block f Lot(s) � Well Owner: Name: �'� /� CO %f G, e G%i p r Address: j /l v 4 a /T G �/`r� �i Use of Well: esidential 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 ja o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling "ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type 75rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No d' Is well located in a realty subdivision? ...................................... ............................... Yes k' No Name of subdivision ; s e- !e y Lot No. / Water Well Contractor: Al, r- �,,,.,� ,, %',, �w a Address: %3o P� �,� �, F✓! A i Is Public Water Supply available to site? ' � .................................. ............................... Yes No Name of Public Water Supply: Town/Village -► Distance to property from nearest water main: M J /� Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: /o ..o Applicant- Signature: at 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 c rd ed y Putnam County. Date of Issue Permit Issuing Q cial: Date of Expiration l v Title: C Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISION-OF ENVIRONMEN'T'AL HEALTH SERVICES \ CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # t V " .Z / 9 Located at n 4 ��� eu o n or Villa e 1%J Subdivision name Subd. Lot # Tax Map /, `2 Block / Lot Date Subdivision Approved J 1r,;5P 7 Owner /Applicant Name r r- le? Mailing Address V Renewal Revision Date of Previous Approval i110lcai ;� Zip /o,�de ---3 Amount of Fee Enclosed Building Type A; dl rn e--e— Lot Area . 7 No. of Bedrooms -�4 Design Flow GPD Js eG Fill Section Only Depth Volume PCIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage Ustem to consist of %G''�'� gallon septic tank and *e ev - Other Requirements: To be constructed by C 'r.4- eQ ems'- Address Water Supply: Public Supply From. Address or: o,`' Private Supply Drilled b r� s� pp y y �r�d^�G .7 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: )Lw4 2d486&;:-- P.E. �' R.A. Date r Address z �.e.OV .0"e" License # :2 APPROWD FOR CONS TR a xpires two years from the date issued unless construction of the sewage treatment system has bee 1 cted by the PCHD and is revocable for cause or may be amended or modified when considered necess alth Director. Any revision or alteration of the approved plan requires a new a it. App ved r is ar c sanitary sew a only. By: Title: 4. Date: I &)Z 7 )7 t? White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr fessio al Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES :APPLICATION TO CONSTRUCT A WATER WELL_._. please print or true PCHD Permit # % Y;7 Well Location: Street Address: TownNillage Tax Grid # Ur a r; n /��� %� /�� r . ��!✓dr!'l l/�` /t ap 7 Block / Lot(s) ,60 Well Owner: Name: /-1q 1° %�; Address: Use of Well: 1,'11,'esidential 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 _ 5' gpm # People Served. !J2 Est. of Daily Usage Gov gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling I/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 A-'` Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No r/ Name of Public Water Supply: TownNillage �. Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 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 water well driller certifi d by Putnam County. Date of Issue 17. 2 Z Permit Issu' Official: Date of Expiration I ZJ I ii 1 O Title: tAVOIL Permit is Non- Transferr ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM "COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant:. 2. Name of project: �� j ,� 3. Location TN: ��, �i-1 I /�Q ),�y 4. Design Professional: S v ;T 5. Address: 7 �-�-✓n �,--g ��; �n s�/ 1 T�i•V12 /Sl��� � T7 6. Type of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subidvision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? i✓'a Type Status (check one) ..................................... I................ Type I Exempt Type II Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Ale 9. Has DEIS been completed and found acceptable by Lead Agency? ............... Name -of Lea' "Agency 11. If this project is an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... .................. .............. y�� 12. If so, have plans been submitted to such authorities? ........ ............................... 13. Has preliminary approval been granted by such authorities ? %Date granted: EZ 14. Type of Sewage Treatment System Discharge ................. surface water _groundwater 15. If surface water discharge, what is the stream class designation? .................... 16. Waters index number (surface) ........................................... ............................... 17. Is project located near a public water supply system? ....... ............................... 4,1'e 18. If yes, name of water supply Distance to water supply A`%"--, 19. Is project site near a public sewage collection or treatment system? ..... /........ Ala 20. Name of sewage system °^ Distance to sewa a stem 21. Date test holes observed J yd 22. Name of Health Inspector Iq Form PC -97 w .. b 2 23. Project ............ oject design flow (gallons ,......., _ . ? ..._lions per, day) .. .. -.. x. ,_. a .,. ,. , , 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 25. Has SPDES Application been submitted to local DEC office? ......................... 26. Is any portion of this project located within a designated Town or State wetland? A/v 27. Wetlands ID Number ........................................................... ............................... 28. Is Wetlands Permit required? .............................................. ............................... /1% Has application been made to Town of Local DEC office? ............................... 29. Does project require a DEC Stream Disturbance Permit? .................................. Ai/v 30. Is of 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 Ao 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ... ............................... Yes/No Al'a DESCRIBE: 32. Is there a local master plan on file with the Town or Village? .........................� 33. Are community water and/or sewer facilities planned to be developed within 15 years in, or adjacent to project site? .................................. ............................... _ *v,_ 34. Are any sewage treatment areas in excess of 15% slope? . ............................... A/& 35. Tax Map ID Number ........................... ............................... Map j/Z Block_/ Lot 36. Approved plans are to be returned to ..... Applicant `Design Professional 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 Penal Law. SIGNATURES & OFFICIAL TITLES. Mailing Address: ................................... 14-1 _(2/8 Text 12 P ECT I.D. NUMBER 61731 * Appendix C State Environmental Quality Review ` 7, SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1 • APPLICANT /SPONSOR it T. PROJECT NAME.,•, -- . a 3. PROJECT LOCATION: / Municipality /170 a �/ County i� ty 4. PRECISE LOCATION (Street address and road Intersoct1wis, p�ro`rninent landmarks, etc., or provide map) 1'qlee z/ S. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 6. DESCRI E PROJECT BRIEFLY: Mew Al 1_1':F-i;7 ' �_"4" ��e -e fA� 7. AMOUNT OF LAND I�FFECTED: Initially / acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Wes ❑ No It No, describe bristly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? esidential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Dear be: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE R LOCAL)? Yes ❑ No If yea, Ilat agency(e) and permlUapprovsslo 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yea DNo 11 yes, list agency name and psrmitlapproval 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/sponsor � � Oats: � ✓� .name: 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 4 c I i PUTNAM COUNTY DEPARTMENT OF HEALTH _ _ :TDIVISION OF ENVIRONMENTAL HEALTH SERVICE- $_- _�_.._._._.,_.__... DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM W, ;/e Owner ��� L- , ��' /v Address 3 v /lam ��•i'�� �''�i %mss Located at (Street) : ®� ✓��n.. �i o e-✓ Tax Map - j, Block : " :� Lot . (indicate nearest cross street) Munici 'ali 11' 1 e- y P tY � ��? Watershed . SOIL PERCOLATION TEST DATA Date of Pre - soaking yll¢ %�C4 &I /-9f q 9 Date of Percolation Test . T DFP th to �?Vater Water Time EIa se Time rom Ground}': Surface (Znces) Level propp In Percolattoa Rate e: I.o..:,.. Rug No Start StopkLn) ;Start Stop..... es , 1VlltnfInch 3 7 ` p, 3 Cora 3 //, 3 4�1 2 3 NOTES:, ``1':' Tesf's';to;be repeated at same depth until approximately equal percolation rates are obtained at each ,percolationlest 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 PUTNAM COUNTY DEPARTMENT OF HEALTH ��iD'Y�'¢'✓ DIVISION OF ENVIRONMENTAL HEALTH SERVICES -rd0 �?: /. WELL COMPLETION REPORT We11:Location:- ::.., Sere Addres ' - -_ /�/illage: AC) j , Grid # - - - M Block i Lot(s) 6 Well Owner: Name: Address: ,CJ� r Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irri ion 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 eft. Length below grade ,.; gr . Diameter 1�tn. Weight per foot �lb /ft. Materials: Steel _ Plastic _ Other Joints: Welded >< Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: � Yes _No Liner _ Yes ,<No Screen Details Diameter (in) Slot Size. Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Y Compressed Air Hours Yield 2 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve _analy_ses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ✓aU 6 _ _ _ .. G If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type �,:,a�z� Capacity /O Depth � / Model �Sos 9 Voltage Zia r/ HP / - Tank Type dad ✓ Vol e 2- o Date Well Completed p Sy Putnam County Certification No. Date of Report u� Well D filler (si nature)) r7/ yv V 1 t: Lxact location or well wttn atstances to at least two permanent lartatnarxs to be provtdea on a separate sneevplan. I Well Driller's Name Address: Signature: �]/% � _ 0,. Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 f S Y I IN WIP10582 ' IFIED TO: AL ; G%GHELARDDCG NATIONAL BANK OF LONG ISLAND T,q}/NLTS. INC. w (ACCO ItDANCR 1R'1H Tim ®4AN0 B Ol PAfCI'ICR TOA HAND SUAVDYS DOPTSD BY THE NEW YORK STATE' �OpAM OF PROPRESPONAL LAND IM {{ •/CSRTIFICATLONS SHAIL RUN ONLY TO ' THOSE DVDIVIDUAIB AND INSTITUTIONS SHORN HEREON UNDER THE TRLB i t PODCY NULEER SHORN ABOVE. SAID GREYIPICAYTONS ARE NOT lwmmE,.= of 708 COPTRIOH'Y (LTA 200h2006 '' S88ERV® UNASt7190W�dB�p pUpucA'InoN T 107 pN LOt E A VIOIA71ON OF APPLLCARIB LAYS 1 E i' ��p•W a's`s { Oa 1Gr q ouzz ' €.NOW d uNW' L�OEL Off• r -p a ♦I r. � O PREMISES SHOWN HEREON BEING LO ./ AS ON A1M ENTITLED SUBDIVISION MAP j'SHOWN ?RFPAREO FOR V[:RM d GWEN KNISLEY; jj7LED INTIiERRNAM COUNTY CLERKS, i ICEON NOVEMBER 1819SB. AS AT. NO. V� t•i• CER7@I 170119 HEREON ARE VALID RE V R YHE HAP AND COPES T �Y D SAID NAP OR COPES HEAR`THE IPD46 SEAL OP TTE SURVEYOR .� BICAATppg APPEARS eIW80N.;: 4URVEYEp d PREPARED BY Y UNAUTHOWSED ALTERATION OR ADDITION TO A SURVEY NAP BEARING A UCEN�E11 LAND 1�SUNNEYASSOCATEE ; LANG SURVEYORS •l SURYSY0WB SEAL E A VIOLATION OP BSCHON •TEOW. SUB- DMSfON 2. OF FIELDS LANE, BREWS7ER TEB NEW YOR[ 87eTE EDUCATION LAW. NEWYORW 10509 u PH.I815- 27730047 11 �/ =LOCATION OF UNDERGROUND AegOVEMNIS OR ENCROACHMENTS, IF ANY COST. ARE NOT CERTIFIED. 4 P r nm.. ANNA WAGNEP RLED AM 20. 1952 AS MAP No 662 f LOT 1 AREA= 4.766 ACRES i 1 y 214' / O SURVEY OF PRO) SITUATE IN THE TOWN OF PUTNAI PUTNAM COU) NEW YORK SCALE 1' =60 DATE PROP.IMPROVADDED: BROUGHT'TD, CERTIFICATIONS AD) D ISTANCES TO SSTS BOXES A B ✓UNCnON Bllp462' 2.5' 62' ./NC770N B55' 28' 67' ✓UNC770N B58' 34' 71.5' ✓UNC770N B 4O' 77' ✓UNCnON BOX 0 65.5' 82' ✓UNCn0N BOX 0 1 70' 87' —..r t } \ AREA OF 4D M/N BANKRUN- . f /) (SHADED AREA) �n 0 0 \ J.WCApH BOX (7)P) e. \� \ 700,T EXPAN.90N AREA —� /NPER'v10U5 BOUNDARY (Oli£R ENO p J (NA7AHEp AREA) eca � \ G� 0 + a ui�l�lvcts 1U NUMINLS'TERN ENDS OF SS A B WEST ENO OF 1ST. TENCH 23' 91' WEST END OF 2ND. TENCH 28' 94' NEST END OF 3RD. TENCH 34' 975' WEST END OF 4TH. TENCH 4O' 101' WEST END OF 57H. TENCH 1 45.5' 105" WEST END OF 6M.. TENCH 55.5' 102.5' may, 1? faa.bkm 2 ;,,•; I 1 D /STANCES TO SOU7HEAsimv ENDS OF SS A B EAST END OF IS TENCH 88.5' ¢8' EAST END OF 2ND. TENCH 90' 54' EAST END OF 3RD. TENCH 92' 60' EAST ENO OF 47F/ TENCH 94' 66' EAST END OF 5TH. TENCH 97' 72' EAST END OF 6M.. TENCH 92' 78' o �T t 1 0 j i O `1 1 TAX MAP SLIC770A co) DRAWN.• / DA7E•r„ l is A B T END OF 1ST. TRENCH 23' 91' ✓UNC770N BOX Ef 28' g¢' ✓UNC770N BOX 12 34' 97.5 ✓UNC77ON BOX / -T ¢O' M7O"87' ✓UNC770N BOX 14. 45.5' 105' ✓UNC77ON BOX 15t 55.5' 102.5' UNC77ON BOX d►6 f, • ' \ 1) AREA OF 24 " MW OF BAMMUN — (4%ADED AREA) 0 \ JJNCBON BOX (TYP) e , \° \ : i 100.1 EXPANSTOV AREA - -� / :fd i6 1 /MP£RNOUS BOJNOARY AT LONER END (NA7WED AREA) e L a:. e r C /Y(/J Ur 3,P /.!)I 16 L.F. -< 0 CAST 1RLW 1260 CALCDN CDNLWEM SEPRC TANK — 400 L-F. -410 PEW019WED PIC W 24 - GAA {EC TRENCH (ENDS ARE CAPPED) a� rye ••� !4 B laasson J"�k 1i •, C� tlra F0077NG DRAINS AND ROCF LEADERS (T)P) N i n [7 EAST END OF 1ST. 77?ENCH BB.5' 48' EAST END OF 2ND. TRENCH 90' 54 EAST END OF 3RD. TRENCH 92' 60' EAST END OF 47H. TRENCH 94' 66' EAST END OF 5TH. 7RENCH 97' 72' EAST END OF 67H. TRENCH 92' 7B' `OV to ,WVJ- 4241p 10*16 p LOT 1 Il j AREA-;z4.766 ACRES RbE c� "tea i 12.'p a•lrm� i EUSAVC ��jj r�G 2• � Q H1� LEw fi pcE waTER sERycE ��• EXTSRNC NEIL 97-gl ^` D lJZ9 K � t �woY , y ;'�i1,1,,,, k �. "' x�-� � +`. .^ `'�r���'a✓ �,,�„ -,�. t �•�� a,�. � � a z V J3 + ,_.._,41•.,1 RY .�� � 1 {� REAS01 REVS TAX MAP p[ SEC770N.• 41.0 LOr.• 6 DRAWN.• KMM DATE 9/22/ DWG FILE. S /C/ A B T END OF 1ST. TRENCH 23' 91' T END OF 2ND. 7RENCH L*ES 28' g¢' T. END OF 3RD. 7RENCH 34' 97.5 T END OF 4TH TRENCH ¢O' 101' T END OF 57H .. TRENCH 45.5' 105' WEST END OF 67H. TRENCH 55.5' 102.5' 16 L.F. -< 0 CAST 1RLW 1260 CALCDN CDNLWEM SEPRC TANK — 400 L-F. -410 PEW019WED PIC W 24 - GAA {EC TRENCH (ENDS ARE CAPPED) a� rye ••� !4 B laasson J"�k 1i •, C� tlra F0077NG DRAINS AND ROCF LEADERS (T)P) N i n [7 EAST END OF 1ST. 77?ENCH BB.5' 48' EAST END OF 2ND. TRENCH 90' 54 EAST END OF 3RD. TRENCH 92' 60' EAST END OF 47H. TRENCH 94' 66' EAST END OF 5TH. 7RENCH 97' 72' EAST END OF 67H. TRENCH 92' 7B' `OV to ,WVJ- 4241p 10*16 p LOT 1 Il j AREA-;z4.766 ACRES RbE c� "tea i 12.'p a•lrm� i EUSAVC ��jj r�G 2• � Q H1� LEw fi pcE waTER sERycE ��• EXTSRNC NEIL 97-gl ^` D lJZ9 K � t �woY , y ;'�i1,1,,,, k �. "' x�-� � +`. .^ `'�r���'a✓ �,,�„ -,�. t �•�� a,�. � � a z V J3 + ,_.._,41•.,1 RY .�� � 1 {� REAS01 REVS TAX MAP p[ SEC770N.• 41.0 LOr.• 6 DRAWN.• KMM DATE 9/22/ DWG FILE. S /C/