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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.10 -2 -44 BOX 20 ., 1, I'm . ILI L% i r #; Vuk .r 02326 SHERLITA AMLER, MD, MS, FAAP Commissioner of Hea_Ith .,, LORETTA MOLINARI, RN, MSN Associate Commissioner of Health ROBERT J. BONDI - - ,.�:; :County'Executive - ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ADDITION APPLICATION RESIDENTIAL ONLY �__& STREET Hi b l 0_5 �ye�t WN TO YlawVc C TAX MA P# — NAME Renta H_U tot%lr rAt, PHONE C11 l.Lgt(.Lt - 171,6 PCHD# a r� MAILING n ADDRESS � . �e� d A c DESCRIPTION OF ADDITION -�F— i vi 17bk t-ke- c of -'v �r no w-.e— rao r"\ NUMBER OF EXISTING BEDROOMS a PROPOSED # OF BEDROOMS 3 (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to.Putn_ am County Health Dept.; 1 Ge.neva,Rd,. V :Brewster; -N'Y 10509, Phone: (845) 278- 6130. �/1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. Two sets of proposed floor plan (drawn to scale with name, street and tax map #) *Non- professional sketches are acceptable `4. Copy of survey showing well and septic locations to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet J of the property line. Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification Irom Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS M Environmental Health (845) 278 -6130 Fax (845) 278 -7921 r Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 ri SHERLITA AMLER, MD, MS, F'AAP Commissioner of Health... LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Renta Hutabarat 18 Clark Street Winchester, MA 01890 Dear Ms. Hutabarat: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 July 21, 2008 Re: Addition- A- 131 -08 No Increase in Number of Bedrooms 15 Holly Street (T) Putnam Valley, T.M. # 41.10 -2 -44 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated July 21, 2008. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system and its expansion area must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets etc. 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not obtained proper approvals Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you have any questions, please contact me at (845) 278 -6130, ext. 2261. Sincerely, Gene D. Reed Senior Engineering Aide GDR:kly cc: BI, (T) Putnam Valley Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 .f PUT TNAM `COUNTY DEPARTMENT OF HEALTH ENVIRONMENTAL CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT: SYSTEM PCHD .CONSTRUCTION 'PERMIT # / - y! 1 &/—. Located at Village Owner /Applicatht Name J, 1,frl * b; /o Tax Ma //d Block_ Lot_ Al nhv4 Formerly: Subdivision Name �Ci' /y e Subd. Lot # Mailing Address r A. 0'r h ,P - Zip Date Construction Permit Issued by PCHD..-, ZJ I Separate Sewerage System built by (, eey / Address ,f 4,�Af •P f ,i ��i� Consisting: of 0 d U Gallon Septic Tank and Other, Requirements: 3_ r r-r 49 /G /C e- a er Supply: Public Supply From Address or: ` !/Private Supply Drilled by A/-/x 7) Address PflIeiri f 0t*'' _..� ._� id g `t'yp'e` _ �"r/ 4'� /r' f :° /� �► _11as-erosion'control been completed? .' 'd' _. _.......r _.. -..._ Number of Bedrooms Has garbage grinder been installed? I certify that the system (s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of t44utnarn County Department of Health. Date: �� G �" Certified by P.E. 4---R.A. / Addr (Df / ess -Z 3, License -r ,�' "!5' License #VY� Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available..; Such approvals. are subject to modification or change when, in the judgment of the Public Health P*tor,; such revocatio modification change is necessary. B �l.� Title: Date: By: Z White copy - HD File; llo copy - Building Inspector; Pink copy caner; Orange copy,- Design Professional Form CC -97 CERTIFICATE OF COMPLIANCEHOCCUPANCY CERTIFICATE NO.: 2002 -23 PERMIT NO.: 2001- 343 TM#: 41.10 -2 -44 DATE: FEBRUARY 9, 2002 LOCATION: 15 HOLLY STREET ISSUED TO: J.A.V. BUILDERS INC This certificate covers the construction of: One Family Residence; Two Car Garage; Side Deck;. Rear Deck;. Three Bedrooms; Unfinished Basement. The applicant having heretofore filed an application for a building permit pursuant to the Town Code, Sanitary Code, the Uniform Building & Fire Code and the Laws in effect in the Town of Putnam Valley, Putnam County, NY, having paid the required fee therefor and the undersigned having by personal inspection ascertained that the applicant has subsequently proceeded with the erection or improvement of the proposed structure in compliance with the requirements of the- laws_..as.aforementioned; that the said work and materials met every requirement of the laws as aforementioned; and that the premises have now been fully completed and are ready for occupancy pursuant to the provisions of law. Now, therefore, this certificate of compliance /occupancy is hereby issued under the seal of the Town of Putnam Valley. TOWN OF PUTNAM VALLEY, N. Y. CODE ENFORCEMENT OFFICE e -- - -_- . . SHERLiTA AMLER, MOMSF A A1?.-:. -� ,- Commissioner ojHealth 'LORETTA MOLINARI, RN, MSN Associate Commissioner of Health. DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 Town Legal Bedroom Count Re: HUTABARAT Tax Map #: 41,10 -2 -44 Address: 15 Holly Street Town: Putnam Valley Year Built: .2002 (Owner's Name) According to records maintained by the Town, the above noted dwelling, is xx in compliance with Town Code. County Executive is not in compliance with Town Code. The Legal Bedroom Count is: 8 This information has been obtained from: Certificate of Occupancy: #2002-21 Other: �- 5/22/08 As s i s tBuilding Inspector John W. Allen Date Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 46' -11 112" DEPLH TUB 04 • 60 0 m HATH 2 Cv 48 1 2" I 28'-1 1/2" 112" 27'-7 112" E3R 3 0 M Ivv r — — — — — 'A -2-2crx22' ML j 7 UTNAM COUWY &EPARTMENT OF HEALTH IV , —r_— , WWY 4 1/2" -5 'k i4t-� 17'-0 112". rPLANS APPRINVED FOR BEDROOM COUNT ONLY A- (31 - -9 U) I 00 -11 112" ALL SUBSEQUENT RIEW11WA17ERATIONS TO THESE HOUSE PLANS MUST BE SUHWTTED TO THE PCOOH FOR APPROVAL 7 Z7 O IX IR8 12 H BE I SIGNATURE & TITLE OATE FILL L POVO&IML I A (OPEN 1P BELOW) ao '-7" 17'-3 112" �A 3 v 4257 4257 4257 4257 4257 OUTED TO ®R Ap", L JON 20--2" qUILT PORT 48'-0" 16'-0" 6'-0 MAY 8 Z001 39 -, vl[-5� I I i Pr F; PH �� 3A ffl'ff ", Ll I H c I (v3 lu�. V" ��Wo the best of my knowledge. bellef and bUILDiNG DEPT- 0 cuam FEY" 1. lNs Home (FMH) plan has been PREmIERB MMR �'-ITSTE� from system t of FMH lam preygig".pe,�,,V by 01 UILDERS ation No. 1387, Me tion factrers No. 13 DATE -Il.r. 5-5-00, which has 2t been modified in my Mal"Ir. SIDEWALL= 2x6 Aa &x 337 -MM. Ps ffm - M546-m MARR WRLL= 2x3 2- the anerm portlony of this F- plan lhas..been prnV TRIPLE-M / HUTRBARRT IL 54 N � State Energy :. 1,001— X—L(q Part 5 of or -atl n Ug." CLG HGT= 8'-0" (Energy Code) and In full compkaknce with the Energy PERMIT NO. 2 STY FLOOR PLIll') W1 DUCT PUN 5V low m: oars scnc owe no: I MINCE 5-16-01 -0 4# is DINING RM CIMP. SfRrf, -5t. rz� DAIL 4-SIGNAT&SE 8 TITLE �211't -7 1 2" II II FOYER (OPM TO PBOVE) 38'-4 q 28' -6 1/4" T is,l 112" IFNEEEiEiiial 4257 4257 44'-11 112" "Z33!zT _112' 112" 34' -11/2" 20'-2" tL 48'-0" 38'-0" 27'-0" 16'-0" i 3037 +25 7 72VINYL To the bast of my knoviedge, ballef and professional YA90mOnt 'MRRR WRLL= 2x4 1. this Factory Manufactured Home tFMH) plan has been BPPrOvsd from a system set of FMH plans previously dper..,,v:d by DHM No. 1387, Manufacturer's No. 13$7. tion �o CLG HGT= 8'-0" v'"eue (ct4Tq-e Ulcation 5-5-W, which has not been modified In any manner. I DATE RDDTL BSMT COL tA '&ezN.�I,1F ex 4v 2. prepared using the werL Portion of this FM plan has been pT Part 5 of Now yc,k State Energy Conservation Construction Code. -LABEL -C-1 — -,25A��V (Energy Code) and is In fiA compliance Ath the Energy Code'. Gftroa b�p JL w3mo 'I I W363D:`_ c,DEST.= CRRMEL, NY 23 *- 1 W Ow 9'-7 112" 1/2" WF1 `V All zo 1 0 () 0 C:3 -NOOK 4i (13 Li KLICBEU 5-5 1/2" 2'-0" y t M z 4-SWS -4- R V. 3 q ism ---------- GAaaUE 8' 9" 3-7" 4' -3 1/2 � Z X-7" 2 5'-4 2 S' -P' — C3 V30 n4glw Colo= up b HOUSE PLANS APPROVED FOR OM COUNT ONLY H1. OD U, 09 � � BEDROOMS 7,-m A 2,�P- �IbNS TO THESE HOUSE SUBSEQUENT REVISION,'ALT E' W ALL , ---DOH FOR APPROVAL Ti� lk ik -1 co PLANS MUST BE SUBMITTED DINING RM CIMP. SfRrf, -5t. rz� DAIL 4-SIGNAT&SE 8 TITLE �211't -7 1 2" mI 425 pp AL LPtITED TO C;T�)S' titij PORTIO &IP-TP Sr_�E� MAI 1. 8 2001 I mr, 09a" %mm smas NmERBUILDERS AOL SW 307 -kM. Pa , OM)546-M rnantxwmoraer TRIPLE-M / HUTRBRRRT 5 I C', F- W/ r-�j ir--. "" 'o-, I FLOOR L"N 1 7 II II FOYER (OPM TO PBOVE) IFNEEEiEiiial 4257 4257 36SL1 IT- 4257 34' -11/2" 20'-2" tL 48'-0" 38'-0" 27'-0" 16'-0" i Me, York Note: SIDEWALL= 2x6 To the bast of my knoviedge, ballef and professional YA90mOnt 'MRRR WRLL= 2x4 1. this Factory Manufactured Home tFMH) plan has been BPPrOvsd from a system set of FMH plans previously dper..,,v:d by DHM No. 1387, Manufacturer's No. 13$7. tion �o CLG HGT= 8'-0" v'"eue (ct4Tq-e Ulcation 5-5-W, which has not been modified In any manner. I DATE RDDTL BSMT COL tA '&ezN.�I,1F ex 4v 2. prepared using the werL Portion of this FM plan has been pT Part 5 of Now yc,k State Energy Conservation Construction Code. -LABEL -C-1 — -,25A��V (Energy Code) and is In fiA compliance Ath the Energy Code'. Gftroa DE516N SNOW LORD= 4,0 ROOF= 5112 24"oc PERMIT NO, c,DEST.= CRRMEL, NY W mI 425 pp AL LPtITED TO C;T�)S' titij PORTIO &IP-TP Sr_�E� MAI 1. 8 2001 I mr, 09a" %mm smas NmERBUILDERS AOL SW 307 -kM. Pa , OM)546-M rnantxwmoraer TRIPLE-M / HUTRBRRRT 5 I C', F- W/ r-�j ir--. "" 'o-, I FLOOR L"N 1 7 r' x ar 1. 2.1 2' 20' .01' - ; 61' 0 ' f1 ��;±{ 12' Pressure Treated Wo�den Deck with 2' Canq, e'ver {r 9 1 Smoke Detector Mounted on Garage Ceiling. Garage Door ` s' I I (2) 2x10 Header over Garage Doors -- 7_$- -� 6' 6. 3' -6" E J- Garage Door Stud bearing wall with 5/8" fire rated wallboard (2) 2x10 Header on both sides. over Garage Doors 1 3a 10, - �f { 3. 1 ho' c re r self clo' 1 PUTNAM COUNTY DEPARTMENT OF HEALTH t HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY BEDROOMS A- ' ALL SUBSEQUENT REVISION /ALTERATIONS TO THESE HOUS4 PLANS MUST BE SUBMITTED TO THE POUCH FOR APPROVAgj 4 It or Expansion Joint to control cracking. Smoke Detector Mounted on door. )Basement Ceiling. 3'I' 1' Hand Railings 22'- Up TITLE t1 DATE rJ PO ?05 71] rlNlSf'�2� 3h'SEMEIJ7T 42" x windows (5) 10' k{ 1' I. i 1 ai 5' 6' 4 3 3� 27' -6" I v\ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.. HEALT_ _ t ,.$ CES w .,...u.. .. ..- .r _..-.. .1 .. t.zyc- ;- Je.:+w.rJ►. -a.X.: •. -...�. ..i ...ac .. a,.♦ -- J_�Y .... - \. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # &I'1 `e- Located at (Town Village Owner /Applicant Name �,' "r b; �o Tax MafP Block - Lot Gl ,V i Ac -P?W 4 - Formerly Mailing Address Subdivision Name Subd. Lot # � lF % j a'y Zip Date Construction Permit Issued by PCHD Separate Sewerage System built by s 14 ecv 4. 5 `� Address J 4' Consisting of Gallon Septic Tank and 0"4 G' Other, Requirements: 3-. r %% ()/ Jel 9 t Water Supply: Public Supply From Address or: t-f"-Private Supply Drilled by Address -.- -Building =Type S'i/ - GW-: ,/, _z "7 Has- erosion_contral' *be —*'-' ipleted7 Number of Bedrooms Has garbage grinder been installed? J certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of utnam County Department of Health. Date: f /� �' Certified by P.E. l -----R.A. o�� P �(Desig�► na�� Address ��5, License # �� ���' ��i � ,�" e •�`' �- Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocatio , modification o change is necessary. J1 By: P Title: Date: White copy - HD File; Y 110 copy -Building Inspector; Pink copy er; Orange copy -Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT �N ell.Location -- Ereet res5:.._ .: - - , . d 1 To�wn/Viilage: :� Tax "G rd # Lots) Well Owner: Name: Address: Use of Well: 1- primary 2- secondary _.j _ Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type, Screened Open end casing V Open hole in bedrock Other Casing Details Total length ft. Length below grade Cl ft. Diameter 7 in. °' Weight per foot lb/ft. Materials: Steel _ plastic _ Other Joints: _ Welded _ Threaded _ Other Seal: Cement grout Bentonite Other Drive shoe: Yes No _ Liner Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped —Y Compressed Air Hours Yield L�5 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 es are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface [i f If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information -6' '' Pump Typeft'/ /4apacity L Depth oZ(0 Model 4&2gZs?A s Voltage,,�� HP� Tank Type ,� Volume /off, F� —1k) Date Well Completed 1l Cj Putnam County Certification No- 00-7 Date of Rep rt ��� e Well Driller (signature) 40ti � NO Exact location of well with distances to at least two perman provided on a separate et/plan. Well Driller's Name " 012 11var, Signature: Address: Ie '' /r "o 0e, ke, C -St"'a Date: r White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 I -I =- BRUCE, R.. FOLEY. ... . : _. -' .__ -.. _ _ Public Health Director LORETT& MOLINARI 1L -N„ -M:s N: -.: Associate Public Health Director - Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914),218 -.6130 Fax (914) 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 OWNERS NAME: TAX MAP NUNIBER: E911 ADDRESS: TOWN: V J C GPI 1 Z? 2 - A,T X ,41 � d % ZI L, L )l AUTHORIZED TOWN OFFICIAL: (Signature) j % -14- o0/ DATE: 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 VERF M) YML ENVIRONMENTAL SERVICES 321 Kear Street (914) 245-2800 Albert H. Padovani, Director LAB #: 32.108655 CLIENT #: 11705 NON STAT PROC PAGE 1 ------------ mm--Mmm ��������������������������������������� MIRABILIO, JOHN 1 RICHMOND RD. JAV BUILDERS, INC POUGHKEBPSIE, NY 12603 DATE/TIME TAKEN: 12/12/01 00:00A DATE/TIME REC'D: 12/12101 02:05 REPORT DATE: 12/21/01 PHONE: (914)-471-5199 SAMPLING SITE: HOLLY RD SAMPLE TYPE..: POTABLE : PUTNAM VALLEY ` PRESERVATIVES: NONE COL'D BY: JOHN TEMPERATURE..: NOTES...: CDLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 12/12/01 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 12/12/01 LEAD (IMS) <1 ppb 0-15 ppb 9101 12/12/01 NITRATE NITROG 0.41 MG/L O - 10 9139 12112101 NITRITE NITROG <0.01 MG/L N/A 9146 12712/01 IRON (Fe) <0.060 MG/L 0-0.3 mg/1 2037 1 5/12101 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037 12/12/01 SODIUM (Na) 3.58 MG/L N/A 12/12/01 pH 5.8 UNITS 6.5-8.5 9043 12/12/01 HARDNESS,TOTAL 38.0 MG/L N/A 12/12/01 ALKALINITY (AS 32.0 MG/L N/A C MENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SAIISFAOTORY SANITARY QUALITY ACCORD HE: NEW YORK STATE AND�EPA 'FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS � 4ESTEDIIAT THE TIME OF COLLECTION. Pb/CuLEAD limits for public schools are set at 15 ppb. EP��Le\�� & Copper Rule for Public Systems requires that no more —� 1��{ of their distribution points have a LEAD value of more ' -- ppb and a COPPER value of 1.3 mg/L, else water trkOtment must be undertaken to reduce the waters corrosive � potential. Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street ./�o � y��� W41040=6 Albert H. Padovani, Director LAB #: 32.108655 CLIENT #: 11705 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MIRABILIO, JOHN 1 RICHMOND RD. JAV BUILDERS, INC POUGHKEEPSIE, NY 12603 DATE/TIME TAKEN: 12/12/01 00:00A OATE/TIME REC'D: 12/12/01 02:05 REPORT DATE: . 12/21/01 PHONE: (914)-471-5199 SAMPLING SITE: HOLLY RD SAMPLE TYPE..: POTABLE : PUTNAM VALLEY PRESERVATIVES: NONE COL'D BY: JOHN TEMPERATURE..: NOTES...: COLIFORM METH: Ml::' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 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 SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 30. MG/L � MODERATELY HARD WATE& 707140 MG/L MG/L = MILLIG ---� P ---^--^--`----�-^--- SUBMITTED BY: Albert H. Padovani. M.TA Director ELAP# 10323 DIVISION t SERVICES GUARANTEE EE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building �G Constructed by - Street Tax Map Block Lot owe illa /ge Subdivision Name I- /'/veL44, ��l`� 0i t%r Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the 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 bui lgjutilizing the system. Day , _ Year, &4 �-- ) - Signature Corporation Name (if corporation) Signature: Title: Corporation Name (if corporation) Address: J /P � � ,!/�'��a� //o J` Address s,� State Zip State Zip Form GS -97 PiloDANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS Breckenridge Road -- Mahopac, N.Y. 10541 845- 628 -7576 January 2, 2002 Putnam County Department of Health Geneva Road Brewster, N.Y. 10509 Att: A Steibling RE: As Built SSTS Property of J. Moribilo Holly Street/Arbutus Street Putnam Valley Dear Mr. Steibling: Enclosed please find: 1. Certification of Construction Compliance 2. Well Log and Bacti Results 3. Guarantee and two copies 4. Three copies of the as built plan 5. Filing fee of $200.00 to be furnished by owner 6. E911 Verification Letter Since Daniel J. Donahue, P.E. Site • Sanitary • Environmental BRUCE R.TFOLEY— = - - Public Health Director DEPARTMENT 1 Geneva Brewster, New OF HEALTH Road York 10509 LORETTA MOLINARI R.N.,4M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 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 January 8, 2002 Daniel Donahue, P. E. 120 Breckenridge road Mahopac, NY 10541 Re: Proposed SSTS Compliance Morabilo, Holly Street (T) Putnam Valley, TM #41.10 -2 -44 Dear Mr. Donahue: 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. Well completion report (original enclosed) lacks the necessary information relevant to "Pump /storage Tank Information" and "Tax Grid #." Please complete and return to this office. Upon-receipt o a submission,-revised to reflect ihe'above-coituments; this application will b& J" considered further. Very truly yours, Shawn Rogan Public Health Technician SR/jp enc. PUTNAM COUNTY DEPARTMENT OF HEALTH dC i DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ WELL COMPLETION REPORT Well Location Street Address: Town/Village: -Map Tax Grid # - Block Lot(s) Well Owner: Name: Address: Use of Well:. 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter ��in. Weight per foot lb /ft. Materials: Steel —Plastic _Other Joints: _ Welded _ Threaded _ Other Seal: Cement grout Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped —Y Compressed Air Hours _jr Yield &5' gpm Depth Data Measure from land surface - static (specify ft) 7 Lr-cj During yield test(ft) A orn Depth of completed well in feet ;295, Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(iri) Formation Description ft. ft.. Land surface M ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information L3 Pump Type Capacity Depth Model Voltage HP Tank Type Volume LIT Date Well Completed Putnam County Certification No. Do Rep /� 7 1,01 Well Driller (signature) N011: Exact location of well with distances to at ►east two permanentfianaEtarKS LO oe provioeu on a separateXeuplan. Well Driller's Name � Oh #00# Address: /6 � &T& 6S,6p IV` pal Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH c DIVISION OF ENVIRONMENTAL HEALTH SERVICES �- ! MAL SITE Iii TSPECTION — Date: Street Loc�T - n _. -1" �'-rt•�) c, �,,.� i, 1. * Town inspec e Y Owner Av& ► CO Permit # - 2 - Subdivision Lot 9J 7 / 1. SeNvage Systein Area a. STS area located as per approved plans .. ...................... b. Fill section - date of placement 3:1 barrier. Lgth. tl 8 Width_:13 Avg.Dpth 3 -6`' c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... Z) II. SeN age System a. Septic tank s - 1 ...1,250 ......... other ................ b. Septic tank insta ed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. AI outlets at same elevation -water tested .............:... 2. Protected below frost ................. ...:........................... �. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .... .. ............. .. ...................... f. 'trenches engt required 12o, op Length installed '5 06 2. Distance to watercourse measured Ft.......... �j 3. Installed according to plan .... ............................... 4. Slope of trench acceptable 1/16 =1/32 "/foot ............. d 5. 10 ft. from property line - 2D ft.= foundations.......... 6. Depth of trench <30 inches from surface :................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 - 1' /�" diameter clean........,........... 4 g ✓ - 9.�>Bepth o-f grraveHri trench" 12�' 10. Pipe ends capped ........................ ..........:.................... g. PumD or Dosed Systems 1. Size ot pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visuaVaudio .................... ............................... . 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ..............::................ 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildin� aAouse ocated per approved plans ... ..................:............ b Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans ............. . b. Distance from STS area measured cad ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship ® a. Boxes properly grouted .................. ............................... b. All pipes partially backfilled .......... ............................... c. All pipes. flush with inside of box .. ...:........................... d. Backfill material contains stones <4" diameter............. e. Curtain drain & standpipes installed according to plan f. Curtain drain outfall protected & dinto exist watercou g. Footing drains discharge away from STS area ............. h. Surface water protection adequate .......... I .................:.... i. Erosion control provided ........... :.................................. WrKAH COUNTY DEPARTMENT OF HXALTH DIVISION OF ZNVMONMWT P CHD Consmicdon Pemit 0 Lowed 66!2G± Ir ;1"IAe let Owwr/ApplicultNaUj rMaly_.....Subdivision Nun 29 Subdivision Lot # is system fill conwetw? Date is system eompleft? Is weli drilled? cr A Date 1s well WA%dss per PlAns?,1-" ....L- Are erosion 608WI MUSUM in jii�49 I car* that *c system(s), as listed. at to above premim hu been constructed and I have iwpgcu4 and verified their completion in wordsoct with the issued PCHD Cbnftiction Permit and approved plans ad ft S=duds, Rules and ReplWons of Ow Putnam County Depmumt Daft. Ccuficd by.. Dwip Professional 00, Lic Addreu -P' i, --f & - - - # Yr – c�T — � - e /! 5! h C01=0ats 1 FOIL' APADAM 0 006 %rm FIR." DEC-9-2001 SUN 12:56 TEL:845-278-7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. ! - 0 PUT NAM CQUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PERMIT i Located at �rr&-4,5, Subdivision name x Subd. Lot # 7107 f Tax Ma ,. Block -�Z Lot Date Subdivision Approved Owner /Applicant Name 1, leeIrl, 1t -14 i Renewal Revision Date of Previous Approval Mailing Address / le W At l iy O �. /�U �rGr�i6lF'�� f' / � e Zip Amount of Fee Enclosed Building Type /�i —a ,jLot Area ,��„1 No. of Bedrooms 0 Design Flow GPD_IX Fill Section Only Depth Volume PCH D NOTIFICATION IS RE UIREID WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1b u 0 gallon septic tank and Other Requirements: .3 a r Chi R o q r1 L e— e/ To be constructed by Address Water Suppjy: Public Supply From Address _ _...:.. -_ Addxe�s.�_.._.- .��.�. � -► -- -= - -- - __ .... , � _: 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 ther Signed: P.E. R.A. Date �® r Address 1-1-e' rtG -/ , l;' "tai -t 4?<�( 14*le ee. License # !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 wlKn considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p t. App o ed ischarge of domestic sanitary sewa a only. By: ` _ Title: Date: l? f.) White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pro ess nal Form CP -97 CONSULTING ✓,ENGINEERS U Daniel l- Donahue, P.E. 200 Breckenridge Road 914-628.7576 RJEUTEN TI M.(& SETTUIR. DATIL lice we ♦TTEhTf CJO J0 - WE ARE SENDING YOU V,�Attached ❑ Under separate cover via. --the following items: 0 Shop drawings 0 Copy of letter 0 Prints 0 Plans 13 SOMPISS 0 Specifications 0 Change order ❑ CONS DATE NO. DESCRIPTION Af LL THESE ARE TRANSMITTED as..checkod below:.... For approvei 0 Approved as submitted ❑ Resubmit copies for approval 0 For your use 0 Approved as noted ❑ As requested 0 Returned for corrections ❑ For review and comment r-) 0 FOR BIDS DUE 19 REMARKS * Submit copies for distribution ❑ Return -cor -ets prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO-_ SIGNED. If #"1~98 ore not as now. 41mor r4elty we 64%60. .n z Nnu- a -aa,�� U gg���,.. NTY DEPARTMENT OF �►�t ]HEALTX� �/y�+* p� /��1 _.. ddb -��y. p�g�r� �i � E��•tv �'j��(f� D T ISION Iii Z ®• `�.'."'_NTAL HEAL TV. —° SVR ♦ dq. S • _ For: Trenches_,_____,.. PCIRD Constnztion Permit # p ✓' `�- �r Located- ,Af &VAr' tO '"/4fe9,� 4 f � 'Y �� it Owner/ApplicaatName , � , �1'P TM clock Lot Formerly A t ,M Vt2 Subdivision Name /fit& Is system fill completed? j0A Is system complete? Is system constricted as per plans? Is well drilled? Is well located as per plans? Are erosion control measures in place? Subdivision Lot # Date ,I® /, jVA &/ Date Date I certify that the system(s), as listed, at the above premises has been consuvcted and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit . - --andvpproyed p1w aana _the Standards; Rules. and Regulations of the Putnam County Department of Health. - Date: 01 d / Certified by: PE A- gn Professional Address : AR, -rooe Ore Comments: it--., FDIC: ® ADAM (3 oEm lj FRT PIA:.-j4 TF! : A45- P7R -79Pj NAMF: PI inonm .-„-.. Form FUL- 99 1 . ...... ..... ...... 3UMING ENGINEERS (017 VMS Daniel J. Donahue, P.E. 200 Breckenridge Road DATE: - r_ ,. ... ,, �..�w r .., .� �.. - ivsahopac, N.Y. 10541 914-628.7576 TO tRE I (j 41c, WE ARE SENDING YOU "Attached -3 Under separate cover via- 0 Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter 0 Change order ❑ ----the following items: 0 Samples ❑ Speclfication3 COPIES DATE No. DESCRIPTION THESE ARE 'TRANSMITTED as Decked below: ❑ For approval r,3 Approved as submitted 0 Resubmit --Copies for approval 0 For your use -j Approved as noted L 0 Submit copies for distribution 0 As requested Cj Returned for corrections ❑ Return corrected prints ❑ For review and comment 0-- 0 FOR BIDS DUE 19__ ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO-- It s�closuTOS are not as noted, kJRd#Y notify US at "Ca' Y PUTNAM C RUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of J-,ti � /i o Located at / 16 6'7vS �lP� �1G �/j Tax Map # _ Block._ Lot Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter,.is to authorizeL a duly licensed Professional Engineer 4or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health __...Law ?:and =the- Putnam County- Sanitary Code. -- Countersigned: P.E., R.A., # Mailing Address /,'z- �raL ����� W of State 'Zip Telephone: If-ger, -2 f7G Very truly y Signed: Property) A Vd State Telephone;_ Fotm LA -97 r, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .�..:..,CONSTRUCUON PERMIT FOR SEWAd3F: -TY,,—EAT3IENT SYSTElV PERMIT # Located at or Village. Subdivision name / f Subd. Lot # Tax Mapj!'ol / Block Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name 'All 1-4 �/ 40 Date of Previous Approval Mailing Address ! '6i a? JA� 4, &-e I Zip Amount of Fee Enclosed Building Type f1#4e /�f/'-� Lot Area f -!-No. of Bedrooms -3 Design Flow GPD�(�� Fill Section Only /.--' Depth Volume 1.-0& PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of a D o gallon septic tank and Other Requirements: ? r d 1° 9 Gt? To be constructed by Water Supply Public Supply From Address or: PrivateSapp1y Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatmentsystem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the 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 ffiereto. Signed: Address P.E. e� R.A. Date 2Za?= o License 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 p�e r>%i it. Appkovq4 IN dharge of domestic sanitary sewage only. r r White copy - HD File; Yellow copy - Building Inspect ; Pink copyl Owner; Orange copy - Design Professional Form C ltvw P r' PUT NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD�Perrrilt # Well Location: Street Address: To Tillage Tax Grid # 0?&•T t-f-F rS' l' ®b7W.4.-y Mapl5;,// Block Lot(s Well Owner: NZrm Address: e of Well: esidential Public Supply Air /Cond/Heat Pump Irrigation Wmary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _1_, gpm a Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling mew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Z— Is well located in a realty subdivision? ...................................... ............................... Yes No 4,— Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: X/ /,f Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to b ovid don arate sheet/plan. Date' 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. _ l� Date of Issue Permit Issuing cial: Date of Expiratio / Title: Permit is Non- Transferrals White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 i' CONSULTING ENGINEERS Cl Danicl J. Donahue, P.E. ....,.,_..,.n c.',:.v,;y.- s:- ..:.x:.,;,: s.y.. -t:.— - : � _: - s.s,n.;.,•,v w2rl0- BTG ^k,.eIlndsC:80a!1,.:.:.., i Mahopac, N.Y. 10541 914.628 -7576 TO 6 e LETTEEM Off' MUSUu"7i 07ML oATe DATE •TTEN TiO Re �lz i! -c o •� ®°ten c_� J' G ICJ. f f approval ❑ Approved as submitted Al /A? fe For your use O Approved as noted WE ARE SENDING YOU Attached O Under separate cover via ___.the following items: G Shop drawings ❑, Prints O Plans ❑ Samples ❑ Specifications O Copy of letter O Change order O COPIES DATE NO. DESCRIPTION approval ❑ Approved as submitted ❑ Resubmit copies for approval U For your use O Approved as noted O Submit copies for distribution L As requested ❑ Returned for corrections O Return corrected prints O For review and comment Cl ❑ FOR BIDS DUE _ _ 19 O PRINTS RETURNED AFTER LOAN TO US THESE ArR�E tD as' checked below: �,T�RANSMIT approval ❑ Approved as submitted ❑ Resubmit copies for approval U For your use O Approved as noted O Submit copies for distribution L As requested ❑ Returned for corrections O Return corrected prints O For review and comment Cl ❑ FOR BIDS DUE _ _ 19 O PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO - SIGNED: SIGNED: H enelosurss are not as noted, kindly notify us at once. CONSTRUCTION PERMIT FO ATMENT SYSTEM PERMIT # Located at ` /r /i�'°S �'l�° Town or Village �TP� f�") Subd. Lot # % Tax Ma Block �_ Lot Subdivision nam jz,��,� Date Subdivision Approved Renewal Revision Owner /Applicant Namek) �,_ aif Date of Previous Approval Mailing Address _z�& `/. ✓!� rffz7 � �� � �� � - Zip li j a Amount of Fee Enclosed��s ee. le Building Types dl�i Lot Area:lrj$t No. of Bedrooms T Design Flow GPD �20 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILE. IS COMPLETED Separate Sewerage System to consist of gallon septic tank and Other Requirements: To be constructed by Address __ V6�ate Sunnlv:_ __Public - Supply From Ad_ dress_ or: F'i� Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed:`' _ Address P.E. _ a, XO R.A. Date License # f— 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 dis ar a of domestic sanitary se 7�1t*l nly. By: Title: Date: 7/20/v? White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Prbfessfonal Form CP -97 a e PUTNAM COU' NTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL ;.,PCHD�Permif # Well Location: Street Address: Town/Village Tax Grid # U'V 1' #M-F U l?i Ma 4j- ( Block Lots) Well Owner: Name: Q) (, j +T" c, Address: Use of Well: 4— Residential Public Supply Air /Cond/Heat Pump Irrigation 1 rimary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm erved Est. of Daily Usage 2 L? gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason A�t P r tO y G,E for Drilling Well Type Drilled Driven Gravel Other Is wellsite subject to flooding? ................................................. ............................... Yes No Is welllocated in a realty subdivision? ...................................... ............................... Yes No l/ Name of subdivision Lot No. Water Kell Contractor: �/3 13 Address: Is Pubic Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: a 44 Town/Village Distane to property from nearest water main: Propoed well location & sources of contamination to be pro 'ded on s to sheet/plan. Date: �% d Applicant Signature:... - _ -.- PERMIT TO CONSTRUCT A WATER WELL This prmit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnm County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that Whin thirty (30) days of the completion of water well construction, the applicant or their designated represntative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requixnents of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provied by the Putnam County Health Department. During all well drilling operations, the applicant and/or well d1ler shall take appropriate action to assure that any and all water and waste products from such well d1ling operations be contained on this property and in such a manner as not to degrade or otherwise conta irate surface or groundwater. APPIDVED_FOR CONSTRUCTION: This approval expires two years from the date issued unless constction of the well has been completed and inspected by the PCHD and is revocable for cause or may be ainer;id or modified when considered necessary by the Public Health Director. Any revision or alteration of tiaepproved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam Cow. Date ilssue artze 19q. I Permit Iss 'n Official: Dates i Expiration o Title: yw Per' *is Non- Transferr le Wtziiit3epy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 -1 :1'N4YCi HALL LIVING QM el..., RD RM' 3 -. i4 t..Y , I LAKEWOOD 24'x4O' CHEN ittJ:Y:i s.l.�oo 6E0 RPA P I 11 sl, n Rk, 1 BED RM °^ t BE^ RNI'3 9Y..JP 111. f1 --� 77-- - K1R fffJN 6i ;II&pARTMENT OF HEALTH VOUSE PLANS APPROVED R BEDROOM COUNT ONLY; . k r t; 1 - HnTr! 2 MNINI� �aATH�I C..1 r09.61:• '1 I _--y �HALL, i BED RM 1 i L.I` ✓It G F.M c BED RW 3 ,. I� �j FERNWOOD 24x48' 6P 1Y I ' ;�tl•.•? "." ° I r.�r UV113 RM �,�i H' I ' C;11•r:�G 9 P.94 HALL BED Rh:' c mc, RM13 'i WTCHEN .. ENGLE WOOD 2 7'x42 7'x4 PlANN LYON HOMES INC. Old Trail Road, Selinsgrove Pa. 17870 Telephone (717) 743 -0111 (�� • 1 ' ' , . II , 2. � l )• f 5 .. Y� �; � '31 +♦. 1' • '1 S t � ; PUTNA M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR �::.:.....�...._. -- A- WAS'WAT1ER TREA"i'IViEPtT SYS7CERht.. 1. Name and address of applicant: ,1. (�) �e nc i ry'C� Z"2!Z /-7- 2. Name of project: 4 STX 3. Location TN: CAMP. 4. Design Professional:DAnr L?o�vANuE,r?E 5. Address: 6. Drainage Basin: 4APiIV6 y, y, 7. L U of Project Y 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 r ., Exempt TypeJI Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Wo 10. Has DEIS been completed and found acceptable by Lead Agency? ............... /Y M 11. Name of Lead Agency 12. is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............. ..............................' 13. If so, have plans been submitted to such authorities? ........ ............................... N� 14. Has preliminary approval been granted by such authorities ?/j�d Date grimed: 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... N/? 17.1 Water; index number (surface) .......................................... ............................... 4/4 18. Is project located near a public water supply system? ....... ............................... 19. If yes"nalne of water supply %, Distance to water supply � 20. Is project site near a public sewage collection or treatment system? ................ /yo- 2 1. Name of sewage system Distance to sewage system d 22. Date test holes observed .a / � 23. Name of Health Inspector 24. Project design flow (gallons per day) ... ............ar,................ f1 .............................. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?... -.S& 26. Has SPDES Application been submitted to local DEC office? ......................... d/ff rnrm Pr -w 2 27. Is any portion of this project located within a designate own State wetland ?_ 28. Wetlands ID Number .......................................................... ............................... 29. Is Wetlands Permit required? ......................................:....... ......I........................ Has application been made 7fown r Local DEC oilice? ...... .............................o. 30. Does project require a DEC Stream Disturbance Permit? .. ............................... No 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfill' M.sludge application or industrial activity? .... ........................'Yes/No IV6 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 6Lo DESCRIBE: 33. Is there a local master plan on file with the Towns er Village? 34. Are community water; and/or sewer facilities planned to be develop��, within in or adjacent to project site? ........:...::........:....... ............................... _ 35. Are any sewage treatment areas in excess of 15% slope? . ............................... &Q 36. Tax Map ID Number .......................... ............................... Map4 Blocky_ Lot 37. Approved plans are to be returned to ..... Applicant _ _ Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwaterdplans 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 I .,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 perlary, that Information provided on thisform is true to the best of nay knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 2 of the .penal Law. :Mailing Addre$s: :.......................... 1 .e,V,A=,O A? e De r__& A? __.._.. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Ownerty_, U -7,oOJee td Address 02e, Located at (Street) Tax Map-/'// / Block Lot - (indicate nearest cross street) Municipalityfi/L �v c. �; /��`- Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking. of Percolation Test��� NOTES: 1. Tests to be-repeated of same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submittedfor, review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth to a t 'WVafer From Ground Level Percaia ot4 ti Hole No Rua No Time EIa seTime Surface nebes) Arapp In Rate Start Stop 'Ln} Start Stop Inebes M�n?Inch ; f q J 3,3 - 2 i 3 ,- ,- � 3 '�� rl" %` �y f 5 3 lo- 5 1 2 3 - x . 4 .. NOTES: 1. Tests to be-repeated of same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submittedfor, review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA °2 (DESCRIPTION OF SOILS ENCOUNTERED Ili TESL' MOLES DEPTH HALE NO. HOLE NO: G.L. 0.5' = c� So L 1.0' _ 1.5 1^4 Y 4v, 2.0' 2.5' 3.0' 3.5' 2 c`-ic 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' _ 9.0' �. - ........... -... +... • r.....s .... ..q._..r .t.. ��._c - . s. v. .�. ..- .. ...... ... —... .., w.� ... .. ......W ..-.. s .-..�� O ...... ....... __ -.a .. ... -. .... -.t v �_ r. ter.... .... _ 10.0' Indicate level at which groundwater is encountered C-N Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by:_ 6- Dated r Design Professional Name: Z)�N tW4 Jr Pe 1,11 4-4' Address: Signature: " (Design Professional's Seal fi � 16 -161 (2187) —Text 12 PROJECT I.D. NUMBER 61i.z1 SEAR Appendix C State Environmental Quality Review 1.: �. .,...�V A .. For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION {To be completed by Applicant or Project sponsor) 1. APPi.ICANT ISPONSOR Q41-A T/FiV 6 2. PRO,(ECT NAME . d j - lfw &'�Z S Dom' 3. PROJECT LOCATION: Municipality '� !� i7 LLB County a. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) S. IS PROPOSED ACTION: JON&w ❑ Expansion ❑ Modificationlalleralion B. DESCRIBE PROJECT BRIEFLY: e4iu i ?fie• o r- T /a N ®F •9 ti' Ems. Ho S r i r /vix/.1,iov'TL ,o1'nre- 7. AMOUNT OF LAND AFFECTED: Initially S acres Ultimately acres 8. Vlitl PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EX)STING.LAND USE RESTRICTIONS? Yes ❑ No 11 No, describe briefly ` 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 10Residentis! CI Industrial ❑ Commercial ❑ Agriculture ❑ Park/Fomst/Opsn space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATOR LOCAL)? / f� 4 Yes ❑ No If yes, list agency(s) and permlVapprovats G 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes 1� No It yes, list agency name and permWapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REOUIRE MODIFICATION? of ❑ Yes No a' I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Date: ` �-- Applicantisponsor name: signature: ter• It 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 If— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 817.127 If yes, coordinate the review process and use the FULL EAF. 13 yes u No e. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded b' another Involved agency. . ❑ Yes 4� fdb 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 pattems, 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: 442 . C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: n 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 \CS. Growth, subsequent development, or related activities likely to be Induced'py the proposed ae.tlon? Explain briefly. Cb. Long term, short term, cumulative, or other effects not Identified In CI-CS? Explain briefly. /A/ C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes TQN* If Yes, explain briefly PART iii — DETERMINATION OF SIGNIFICANCE (ro be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, Important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban of.rural);.(b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materlsis. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box If you have identified one or,more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL E4F 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 to any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Name ot Lead Agency Print or Type Name o Responsible Officer in lea Agency its o espo0 a icer ,r.•,. _. - .,,�: -..,- .- •...ate -.r- �.e._- .�7C,. - - - -- -- - --• - -- _....._ _ .._ _ rgnatvre of Responsible Officer to Lead Agency 5 gnature *I Prepater III different from resP711le Of rice() , n } ate 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVI•RONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION - e.....a...s...y+fva•om:r. a _'o.�'i w✓eM:rw.. a..a r -..vi_ '•q .. a'�.r..x'..nr_ na-.. .,.� -... {.a.+. ... ,e .. SECTION A. GENERAL INFORMAA QN Name of Project L01 I (T)(V) County V i Site Location Viq�JP-T%g X7--0 i ];�},1L.L,-4 � l Building construction begun Extent Is property within NYC Watershed ? ................. F--] Yes [j�!rNo SECTION B-. TOPOGRAPHY (Please check all appropriate xes) 1. a Hilly F7 Rollina a Steep slope Gentle slope Flat 2. , 7 Evidence of wetlands Low area subject to flooding Drainage ditches Rock outcrops 3. Property lines or corners evident. 4. Do water courses exist on or adjoin 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 necessary-? ................. ............................... odies of water Yes a No Yes F--� No Yes F-1 No F7 Yes [20�N(o Yes Q < u 8. Will extensive fill be necessary for SSTS ? ........................................ © Yes No - 9. Do filled areas exist.within the SSTS area? ...... ............................... If yes, what is the condition of the fill? CN SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: Sand Gravel gam n Clay Hardpan ixture 11. Observed from: a Borings Bank cut i 12. Soil borings /excavations observed by 13. Depth to groundwater C•1 excavations on on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas ...... ............................... t ✓i `" Q No 16. Soil percolation tests made by on 17. Soil percolation tests witnessed by on SECTION D (on back) Form ST -1 2 SECTION D. DRAINAGE 18. -,.Will proposed -grading materially alter the natural drainage in this or adjacent areas? es No 19. Will groundwater or surface drainage require special consideration? ..................... 0 Yes 0 Ye TO 20. Will gullies, ditches, etc., be filled and watercourses be relocated? ...................... ... Yes I 10 SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................................................ Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist? .................... ............................... F-1 Yes No 23. Additional comments 2,02 24. Site observer/inspector and title ft)�w 25. Date(s) of observation(s)inspection(s) Z lim TEST PIT PROFILES* Hole � --_ -Lot't Hole # 2- Lot r Hole 9 Lot 4 Depth to water Depth to water 4 Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Pepth.to rock/imp, P rL'septh-to-rock/imp._ G.L. G.L. G.L. 0.5 0.5 r( 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0 3.0 'V�& LoPwv\, 3.0 4.0 5'( -0 4.0 4.0 ✓5.0 5.0x2 bo Avv� 5.0 Cfe 6.0 a., 6.0 3 err 6.0 1 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTiYORU TION RE: Property of J`G �'� ire L g /i Located at M Y0 1 j /J41' T ap #`, /dock. J,_ Lot Subdivision of G' TGf i r Subdivision Lot # / Filed Map # Date Filed Gentlemen: This letter is to authorize / �•�/ �j ,L � Z6* a duly licensed Professional Engineer L74--or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. ,____......_.very truly~ ours,_._._,_ . _ ... .< .._, ..._...�...._�.._..__.�....... Countersigned: Signed: P.E., R.A., # r of Property) Mailing Address (��i� State Zip /r Telephone: Mailing Address: a y OQ� X4..4_ State 'All Zip l G J/ ' / Telephone: 6/-� G a) i Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS EVIEW SHEET FOR CONSTRUCTION PER,INIIT, STREET LOCATION L%xry S a,.\j)C NAME ^OF OW ER REVIEWED BY' RV, GR, AS NIB, BH Y N Y N EROSION CONTROL:HOUSE,WELL, SSD PERC LOCATED SHORTEAF ANS - THREE SETS USE PLANS - TWO SETS RIANCE REQUEST FEE SUBDIVISION SUBDIVISION UBDIVISION APPROVAL CHECKED P C RATE F REQUIRED DEPTH C AIN DRAIN REQUIRED TANDPIPES GENERAL fD,,FTED IN NYC WATERSHED ff S SUBMITTED TO DEP GATED TO PCHD PPROVAL, IF REQ'D TEST HOLES OBSERVED TO BE WITNESSED :OW) ESS REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP % L,op p-y o Fxp. AREA; SHOWN; GRAVIYY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SH DETAILED HOUSE - NO.OF BEDROOMS , f WELLS & SSDS,S W/1N 200 O OPOSED b S. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT Y BARRIER T. T ;SLOPE 3:1 TO GRADE FILL SPECS FILL CERTIFICATION NOTE DEPTH GAUGES EIYdzRROFILE & DIMENSIONS �I FILLS XPANSION AREA I TRENCH C �° LF TRENCH PROVIDED 3100 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED O\ PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 15'W£LL TO PL l t 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits -20') 0' INTERMITTENT DRAINAGE COURSE 2007500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/o,10'- 4%,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <I% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 2O'FROM FOUNDATION; 50' TO WELL WELL IMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION 1 Mr, FWKA; NAMh AUUKtbb,Ff- iVNh;; DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: AGE��TEM PLAN - (NORTH AR.P HYDRAULIC PR FILE VI FLOW q CONSTRUCTION NOTES D�FggN DA C & DEEP RESULT 2' CO OURS EXISTR7G�c i0SEE DRIVEWAY , FOOTING /GUTTER/CURTAIN DRAINS SOIL TYPE BOUNDARIES BLOCK; OWNERS NAME,ADDR s ffA4iTITLE :OW) ESS REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP % L,op p-y o Fxp. AREA; SHOWN; GRAVIYY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SH DETAILED HOUSE - NO.OF BEDROOMS , f WELLS & SSDS,S W/1N 200 O OPOSED b S. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT Y BARRIER T. T ;SLOPE 3:1 TO GRADE FILL SPECS FILL CERTIFICATION NOTE DEPTH GAUGES EIYdzRROFILE & DIMENSIONS �I FILLS XPANSION AREA I TRENCH C �° LF TRENCH PROVIDED 3100 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED O\ PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 15'W£LL TO PL l t 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits -20') 0' INTERMITTENT DRAINAGE COURSE 2007500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/o,10'- 4%,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <I% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 2O'FROM FOUNDATION; 50' TO WELL WELL IMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION 1 Mr, FWKA; NAMh AUUKtbb,Ff- iVNh;; DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: _September. III,. 1999 Putnam County-Department zfHe 1a Geneva Road Brewster N.Y. LOM9 Att: Mr. Adam Steibling RE: SSTS Permit &Well- Permit Property of I Quintana... Arbutus Drive TM#. 41. 10-44 -Putnam Valley Dear Mr. Steibling: Enclosed is a coM-of :the permit - waiver -the to -of ?iAnm VaReyf<w 4he-or -the wetland with a driveway. I believe this answers all your concerns regarding this application. S' Daniel I Donahue, P.E. TOWN OF PU TNAM VALLEY I; k CHAPTER 144: Freshwater Wetlands, Watercourses and Waterbodies Ordinance of the Town of Putnam Valley, New York. The Town Wetlands Inspector, as Approval Authority, has determined that the proposed action will not have a significant environmental impact. Therefore, a PERMIT WAIVER is granted subject to the conditions noted below. DATE PERMIT ISSUED: DATE PERMIT EXPIRES: APPLICANTISPONSOR: PROPERTY LOCATION: September 6, 1999 September 6, 2000 John Quintano & Andrew Damia 20 St. Anthony Place Mahopac, New York 10541 Arbutus Drive TAX MAP #: 41- 10.2 -44 SIZE OF PARCEL: 4.99 acres ZONING: R -2 PROPOSED ACTION: Construction of Single Family Residence, SSDS, Wetland Crossing for Driveway MATERIALS REVIEWED: 1. Applicati6n- %tenals, filk'# WT -256, -iated'5 =28 -98 _ _._�.._...__..�._ -.. __.__......,..._. - __. 2. Proposed Site Plan for Quintano & Damia, dated 03- 19 -99, last revised 08- 30 -99, as prepared by D. Donahue, P.E. DATE OF SITE INSPECTION: August 07, 1998 CONDITIONS OF PERMIT: 1 • Construction shall be in compliance with approved site plan. All conditions as noted in above approved site plan to be implemented as shown 2• When erosion controls are required, they must be maintained properly throughout the construction process, and remain in place, until final site inspections for compliance with conditions of permit have been completed. All of the above erosion controls must be inspected by the Building Inspector prior to the onset of construction. Paw IOf2 sum a � , 3. Stream crossing to be inspected by Wetlands Inspector for compliance with approved 4. The Planning Board, Wetlands Inspector, and/or Building Inspector, shall have the right to inspect the project from time to time. 5. The permit shall be prominently displayed at the project site during the undertaking of the activities authorized by the permit. 6. Ari additional escrow account in the amount of $ 300 must be established with the Town before this Permit Waiver can be considered validated. These additional escrow funds will be appropriated as required for construction monitoring purposes. Any portion of the account not used during the project ,monitoring period shall be returned to the applicant upon satisfactory completion of the project. Noncompliance with the conditions above will invalidate this Permit Waiver, and may result in a Notice of Violation and/or a Stop Work Order. Any questions regarding this Permit Waiver should be directed to the Town Wetlands Inspector (914) 762 -7288, or the office of the Building Inspector (914) 526 -2377. Date Permit Waiver Prepared: cc: Applicant Building Inspector Planning Board -Environmental Commission September 6, 1999 Stephen W. Coleman Town Wetlands Inspector Pale 2 oft qub wwpw m,. BRUCE . R.: "FOLEY. ._ Public Health Director LORETTA MOLINE1Ri .R>`1. DI r:; Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509. Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 June 21, 1999 Early Intervention (914) 278 = 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Quintano, Arbutus Drive TM# 41.1 -2 -44, (T) Putnam Valley Dear Mr. Donahue: 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 consideration. Doeu ents T owing documents are required: Application Form WP -97 Neighbor Notification Proof of Stream Crossing Permit and /or Wetlands Permit. A Wetland Permit Waiver is required if applicable.�c ` 9I I of 4i f, qVr-t 1)_6> Fill Plan 1. Notes) on plan state 3.0'feet of ROB fill required. "Based on depth to rock, 3.5' fill is required. - 2. Please show limits of ROB fill, transition fill, top of slope and tow of slope, as shown on the "Trench" Plan 3. Dimension fill pad area. 4. Transition slope is not shown at 1:3 as labeled, please clarify. 5. Please verify that the fill area is large enough for 300 LF of trench and 300 LF for expansion (trench plan does not show 300 LF expansion). As always, comments are pursuant to Putnam County Health Department Bulletin ST -19. 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, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj - ° ` . ._- OA ' [���_____ _�- stir /.r o• - BRUCE R. FOLEY Public Health Director May 26, 1999 LORETTA MOLINARI R.N.,, M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road �frvster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Dear Mr. Donahue: IST R Re: Quintano Arbutus Drive, (T) Putnam Valley 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 consideration. lowing documents require revisions: Form CP -97 Ito o"I M ' I .--8' Form DD -97 l originals- are- at-tahedith r arks. 6. Neighbor Notification required. Plan: A copy of both fill and trench plans are enclosed. Find comments and mark- In red. This office will continue its review upoZnWslise. Vill e i ed comments. Please feel free to contact us if any qi i Attachments Very truly yours, 1 Adam B. Stiebeling Assistant Public Health Engineer BRUCE R._ FOLEY_ _ Public Health Director ' May 26, 1999 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director " Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Quintano Arbutus Drive, (T) Putnam Valley Dear Mr. Donahue: 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 consideration. Documents: .The following documents require revisions: 1. Form CP -97 2. Form PC -97 3. Form WP -97 4. Form LA -97 _ 5. Form DD -97 All originals are attached with red marks. 6. Neighbor Notification required. Plan: A copy of both fill and trench plans are enclosed. Find comments and mark -up in red. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact us if any questions arise. Very truly yours, J_". *1 4 Adam B. Stiebeling Assistant Public Health Engineer ABS:cj Attachments a 4 a 6 DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road Mahopac, N.Y. 10541 914-628 -7576 April 23, 1999 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Adam Steibling Dear Mr. Steibling: RE: SSTS Permit & Well Permit Property of J. Quintano. Arbutus Drive Putnam Valley Enclosed herewith please find the following: 1. Form PC -1 2. SSTS application 3. Well permit application 4. Design data sheet S. Letter of authorization 6. Fee in the amount of $300.00 7. Short EAF _ ...... _ ..._ 8. Three copies of construction -plans for both the trench layout and the fill pad 9. Two sets of house plans. Comments: Your prompt attention would be appreciated. Please note that I will begin the neighborhood notification process By. Daniel J. Donahue, P.E. Site . Sanitary . Environmental 'DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS Mahopac, N.Y. 10541 914-628-7576, September 13, 1999 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Adam Steibling if\NrL4E!B -4Li RE: 99T-9116fthit &IW611'Permit Property -of-J.�Quilatmo-.,...,,.I -b .:W T-W-41-10,44 Pu 'Dear Mr. Steibling: Enclosed please find three copies of the fill plan and two copies of the trench design. Along with this information are the neighborhood notification receipts and the well permit application. I hope this information meets with your approval. Sinc anief e, P.E. 1 •1. .. . V - re! ri Ir Site Sanitary Environmental 7 7 7 7 7 y - our:name:and, address on of ihiw.,�16rm 9b'thafdw4 caj�rOum this #1 reverse card to you.,�� OAttach this'form to the. ont. of the mailpisee , or on the back ffspace ".not permit. oWitteRefum Receipt Requested' on the mallpiece WVw the article number. 13The Return Recelpl will show to whom * the artide was delivered and the date C delivered. 0 -a 3. Article Addressed to: 4a. Article CL E ran A_Ie 4b. Service F-9 W 0 ❑ Registered (A A 19 - ❑. Express Mail CO) �-6 ❑ Return Race 7. Date of Derf 5. Received By: � Pdnt Name) B. Addresses and fee is , M-0181 6. Signature: A dd. = Agent) 0 1. ❑ Addre'ss'se't Address E 2. ❑ Restricted Delivery 9 � Consult postmaster for fee. 9C F-9 W 0 ❑ Registered (A A 19 - ❑. Express Mail CO) �-6 ❑ Return Race 7. Date of Derf 5. Received By: � Pdnt Name) B. Addresses and fee is , M-0181 6. Signature: A dd. = Agent) 0 PS Form 38114 - ecember 1994 102595-97-8-0179 Domestic mecum tieceipy 77 ,cars ui - --------- !!Aftich thid! torn to the front .j the mdplec6,o on the ba&O,; perm does not 0 awrite'Refurn RecsiptRequwW-on the mall be4owft article number. 6 =The Return Receipt will show to whom the article was delivered and the date C delivered 0 1 - v 3. Ard le Addre sod 0- v 4a. Artic el CL 4b. Sent 11'. ❑ AddrdsseelsMdr,6,� 2.13 Restricted Delivery Consult Postmaster for fee. 0 Registered a, 13 Express mail `7 ❑ Return Receipt for MercP cs 7. fDate of Deli"eu- 5. Received By: (Print Name) 8 Ad 8. Addressee's Address 1 1 and fee is paid) c 6. Signaturf. (fddressbe r 9. Ps Form 3811, Decem66r� 1994 102595-97-B-0179 Domestic SENDER: 13 Complete items 1, Ondfor 2 for additional services. I also wish to receive the Ta 13COmplate items 3;4a, and 4b. following services (for an c- SENDER: 0 -Print your name address on the reverse of this form so that we can return this extra fee): coomplete items./ and/or a OCOMOlete items 3, 4a, and 4b, re�4u �39 of this form so that we ran return this card to you. -tame " address on the 0 -Attach this form to.,the front of the mallplece, or on the back if space does not 1. ❑ Addressee's Address .2, 0 ciprint your i ot permit. 2: card to V66. to the front of the malipjace, or on the back if space does n oWdle'Return Rer6ipt Requested' on the mailpiece below the article number. 2. ❑ Restricted Delivery 0 oAltach this form U) -jpkx;g below the 13 The Return Receipt will show to whom the article was delivered and the date permit- kcr .. 3 article number- C delivered. rL, OWrite,p tij Receipt the date Consult postmaster for fee. , 8�jjrliclq was delivered and W aThe R -Y; • -a 3. Article Addreqsed to: 4a. Article Number r delive 4a. CIG I W. 0 a-A /4.) ^_F_ 29 C/ E 3. Article, E 4b. Service Type Ak 41 4b. SONG A r ❑ Registf 0 0 Registered 0 Certified of 0 s E - - A /V_ 1 , 0 Express Mail 0 Insured S' 4 or CWI 0 -n Ic " ❑ Expres IV, 0 Return Receipt for Merchandise 0 COD 0 Return I 2 2-Zatfiof Delivery 0 7• Date of 0 5. Received Bye. (Print Name) T.-Addressee's Address (On 8. Addres and fee is paid) 5. Received . Received and fat Received 6 , Si goatuiciL (O W dressbrAgent) 0 Ase or 0 6. Sign- � PS Form 3811 December 1994 102595-97-8.0179 Domestic Retum Receipt 102595-97-B-01 PS FOtin 3811, ec'ember 1994 ti ❑ Certiffe ❑ Insurer m I also wish to receive the following services (for an E 1 9 � ❑ Certified 9C Insured So (A POD 0 eq , f FE PS Form 38114 - ecember 1994 102595-97-8-0179 Domestic mecum tieceipy 77 ,cars ui - --------- !!Aftich thid! torn to the front .j the mdplec6,o on the ba&O,; perm does not 0 awrite'Refurn RecsiptRequwW-on the mall be4owft article number. 6 =The Return Receipt will show to whom the article was delivered and the date C delivered 0 1 - v 3. Ard le Addre sod 0- v 4a. Artic el CL 4b. Sent 11'. ❑ AddrdsseelsMdr,6,� 2.13 Restricted Delivery Consult Postmaster for fee. 0 Registered a, 13 Express mail `7 ❑ Return Receipt for MercP cs 7. fDate of Deli"eu- 5. Received By: (Print Name) 8 Ad 8. Addressee's Address 1 1 and fee is paid) c 6. Signaturf. (fddressbe r 9. Ps Form 3811, Decem66r� 1994 102595-97-B-0179 Domestic SENDER: 13 Complete items 1, Ondfor 2 for additional services. I also wish to receive the Ta 13COmplate items 3;4a, and 4b. following services (for an c- SENDER: 0 -Print your name address on the reverse of this form so that we can return this extra fee): coomplete items./ and/or a OCOMOlete items 3, 4a, and 4b, re�4u �39 of this form so that we ran return this card to you. -tame " address on the 0 -Attach this form to.,the front of the mallplece, or on the back if space does not 1. ❑ Addressee's Address .2, 0 ciprint your i ot permit. 2: card to V66. to the front of the malipjace, or on the back if space does n oWdle'Return Rer6ipt Requested' on the mailpiece below the article number. 2. ❑ Restricted Delivery 0 oAltach this form U) -jpkx;g below the 13 The Return Receipt will show to whom the article was delivered and the date permit- kcr .. 3 article number- C delivered. rL, OWrite,p tij Receipt the date Consult postmaster for fee. , 8�jjrliclq was delivered and W aThe R -Y; • -a 3. Article Addreqsed to: 4a. Article Number r delive 4a. CIG I W. 0 a-A /4.) ^_F_ 29 C/ E 3. Article, E 4b. Service Type Ak 41 4b. SONG A r ❑ Registf 0 0 Registered 0 Certified of 0 s E - - A /V_ 1 , 0 Express Mail 0 Insured S' 4 or CWI 0 -n Ic " ❑ Expres IV, 0 Return Receipt for Merchandise 0 COD 0 Return I 2 2-Zatfiof Delivery 0 7• Date of 0 5. Received Bye. (Print Name) T.-Addressee's Address (On 8. Addres and fee is paid) 5. Received . Received and fat Received 6 , Si goatuiciL (O W dressbrAgent) 0 Ase or 0 6. Sign- � PS Form 3811 December 1994 102595-97-8.0179 Domestic Retum Receipt 102595-97-B-01 PS FOtin 3811, ec'ember 1994 ti ❑ Certiffe ❑ Insurer m I also wish to receive the following services (for an ■complete hems t and/or 2 for additional services. 0 5 I also wish to receive the ■Complete items 3, 4a, and 4b. 7.��Dyaate o Del' �� following services (for an • Prim your name and address on the reverse of this forth so that we can return this extra fee): card to you. and fee is paid) 16 ■Attach this form to the front of the meilpiece, or on the back if space does not 1. ❑ Addressee's Address permit. Receipt Requested' on the mailpiece below the amide number. ■ 2• ❑ Restricted Delivery rq ■The Return Receipt will show to whom the article was delivered and the date delivered. : i Consult postmaster for fee. S 3. Article Addressed to: pt'l ��� 4a. Article Number cc 4b. Service Type rp CC ❑ Registered ❑ Certified ,�/ , �A va `� � e' ❑ Express Mail ❑ Insured to �a��� ❑ Return Receipt for Merchandise ❑ COD (, 7 Date of pellM 5. Re e) M 8. Addressee's Address (Only If requested c =��2— Ml* and fee is paid) a. 6. Sign: (Addressee or Agent), V. i PS Korm 3811, December 1994 102595 -97- 8-0179 UOr110511C NWUm r1L-CLIP1: m SENDER: W ■Complete items t and/or 2 for additional services. I also wish to receive the ■Complete Items 3, 4a, and 4b. following services (for an ■ Print your name and address, on the reverse of this form so that we can retum this extra fee): card to you. ■ Attach this f6m► to the front of the mailpieoe, or on the back If space does not 1. ❑ Addressee's Address m■WMe Retuni'Receipt Requestsd'on the mailpiece below the article number. 2• ❑ Restricted Delivery ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. 3. Article Addressed to: 4a Ard Nu b Number � E C� 4b. Service Type 8 � � � ❑Registered ❑ Certifi ed 5. g 6. Sig a re: (Addressee or Agent) 45Wonk3ol 1, Decembig 1994 F F� c ix Y cc ❑ Express Mail ❑ Insured 0 5 ❑ Retum Receipt for Merchandise ❑ COD 7.��Dyaate o Del' �� > S. Addressee's Address (Only if requested and fee is paid) 16 102595.97 - 8-0179 Uorr SENDER: Complete items 1 and/or 2 for additional services. ■Complete items 3, 4a, and 4b. I also wish to receive the ■ Prim your name and address on the reverse of this form so that we can return this following services (for an I also wish to receive the card to you. ■Complete Rema 1 and/or 2 for additional services. d ■ ' •Complete items 3, 4a; and 4b. 9 ( m extrbi fee): follorwiri services for an > Attach this form to the from of the mailpiece, or on the badcrf space does not • Print your name and 'address on the. reverse of this form so that we can return this extra fee): 1 pent P card to you. a ■WMe'Retum Receipt Requested'on the mail e 1 13 Addressee's Address pi oe below the article number. 2. ❑ Restricted Delivery rn ■Attach this forth to the from of the mailpiece, or on the be if space does not 1 • ❑Addressee's Address ■The Return Receipt will show to whom the article was delivered and the date permit a delivered. ■Wdtewetum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery W y o Consult O _ ■The Return Receipt will show to whom the article was delivered and the date 3• Article Addressed to: Postmaster for fee. n delivered. Consult postmaster for fee. / ` 4a. Article umber 3. Article Addressed to: 4a. Article Number E � �[ �v� �! cc 3� M y� / ` /� .� �' l / P r .S'� 4b. Service Type 3 ' // 4b. Service Type m , f 13 Registered ❑ Certified �� l ! i &-,-t- ❑ Registered ❑ Certified � /� �/ ,c/ ❑ Express Mail tr ( ❑ Express Mail ❑ Insured 5 Ala " , v �l /�% ! i c� �J ,r �+ 1:1 insured a / / l J ❑Return Receipt for Merchandise ❑ COD 3 ❑ Retum Receipt for Merchandise ❑ COD of Delivery L. •° 7. Date of Delivery ieceived By: (Print Name) ligna : (d re se or A. gent) ; X �?���� Fom, 381 T, D.ecember 1994 ,Z 8. Addressee's Address (Only ff requested and fee is paid) F 102595 -97 -B -0179 L)or PS Form 381t,- ecember 1994 eceipt r 8. Addressee's Address (Only ff requested w and fee is paid) C M t- 102595 -97- 8-0179 �.f `M o ®Complete Items 1 and%r 2 for additional eeMcea I also wish to receive the ©Complete Rams 3 4a,!sM 4b followingaeMces (for an ® aP.nnt your name and address on -the reverse of this torte so that we can return this- card•to,y0u. b C y allttach thistorrn to the front of the mailpiece or on the bads if space does not _ ❑ Addrest366's Address a , i . n ® ®Write Return Receipt Requested on the mail�ece below the arfide number 2 ❑ ReStriCted Ddli, -b— ®The Retum:Receipt will show to whom the amide was delivered and the date aeltvered r Consult :postmaster for fee ; x o 9p 3 ; Add reseed to Y2 4a. Article, Number fry- _ �.f `M o ®Complete Items 1 and%r 2 for additional eeMcea I also wish to receive the ©Complete Rams 3 4a,!sM 4b followingaeMces (for an ® aP.nnt your name and address on -the reverse of this torte so that we can return this- card•to,y0u. b 3 extra fee) y allttach thistorrn to the front of the mailpiece or on the bads if space does not _ ❑ Addrest366's Address a , i . n ® ®Write Return Receipt Requested on the mail�ece below the arfide number 2 ❑ ReStriCted Ddli, -b— ®The Retum:Receipt will show to whom the amide was delivered and the date aeltvered r Consult :postmaster for fee ; x o 9p 3 ; Add reseed to Y2 4a. Article, Number fry- _ 4b service T ype p. Registered ❑ Certified /- ❑ !_iipress Mail `p Insured ?; ❑RetumReoeipttorMerchandise'❑ COD ' 7. 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