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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 50.16 -1 -6 BOX 21 lirs W. 'A% :4 r � � MAN me i � 7 ' r- I ol 02417 ALLEN BEALS, MD., J.D. Commissioner ofhfealth ROBERT MORRIS,, P.E.,•MPH Director ofEnvironmental Health DEPARTMENT OF HEALTH November 27, 2013. 1 Geneva Road,. Brewster, New York 10509 Robert &Vivian Whitman Phone # (845) 808 -1390 Fax # (845) 278 -7921 344 Dennytown Road Putnam Valley, NY, 10579 MARYELLEN ODELL County Executive Re: Addition— Approval —A-136-13 No Increase in Number of Bedrooms 344 Dennytown Road (T) Putnam Valley, T.M. 50.16 -1 -6 Dear Mr. & Mrs. Whitman: This Department has 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 November 27, 2013. The addition is approved with the following conditions: 1. Due to the recent change in design flow (150 gpd per bedroom), the current 3- bedroom SSTS is now large enough to accommodate four potential bedrooms with the exception of the septic tank. 2. A secondary; septic tank needs to be installed to gain 1,250 gallon capacity or greater. The installation of this tank requires a repair permit from this Department. No Certificate of Occupancy may be issued until such time as the tank has been installed and inspected by this Department. 3:... The total ruithber,of bedrooms- tnustyeM4in. -al four without-prior approval. by this. pe�acimegt..__ 4. The area of the existing sewage disposal system and its expansion area must be maintained. 5. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc .: . 6. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having jurisdiction. 7. This approval is valid for two (2) years and expires on November 27, 2013. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43157. Respectfully, Gene D. Reed Principal Engineering Aide GDR:cw cc: BI (T) Putnam Valley .kLLEN BF.AIS, MD., I D. Commissioner of rieahl, ROBERT MORRIS, RE, - Director o, f Emir ortAwwal Health ROLE Cott7�� Erecze:n.B DEPARIV.-ENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 Phone # (845) 808 -31390 AI} 17rI TI N - USMEN i ,JAL 2 16 Owner's dame: o et % r v, Phone #: Site Addm$J 6�� Tovv k Tax map # So . /01- Owner's 31affiq Owner's Signatt Description of Proposed Addition: 4)'n)'. -7 % 4tooi- *Number ofeslsting bedrooms: Total number of bedrooms (emoting +proposed): l3 * (FiDii CERT. OF OCCUPANCY OR CERTNIC-ATION FONT BL'ILUNG INSPECTOR) *° Arty addfti- -in whkIi is con idered a bodroolnrequa-es formal appro-%-1 ofpbm (Colnttw:bnpmnk) prepared by a PmfessionalEngiineer or Registered Arciftect in accordance with applicable sections of tic PutmmCounty Sammy Code. Please subunit the t mand the followitlg to PutnamCottnty, DqxrtrwI ofHeahh. 1 Geneva Rd, Brewster, NY 10509, Phone: (845) SOS 71390. 1. Certified check or money order for S100.00. 2. Tvvv sets ofsi-ttches of =zing floor pbn (drawn to scab all thing siva including basement, v to be shown and ditrt Wowd and use of each room zpecffrzdj (see Section 3.c ofBuaeria HA -1) 3. Two sets ofproposed floor pions (drawn to scale - w- ith xntne- street "tax rnap ¢} ✓ * :ion- professional sletehese are acceptable and preferred. (See Section 3.d ofBuiietar HA -1) 4. Copyofsurteygm-itlg allwellan d septic locations an dr subject pmpertyto the best ofyour knowledge. Comaet this office �i ith airy questions. 5. copy of Cate ofOccupancy fromthe Town or CertftatiDn firm the But Ita Departrmnt v with legal bedroom cou t ofdwe&-g OFFICE USE CONIINMN-°rs Rer. July, 2013 5. fj)d 1 SHERLITA AMLER,.MD,INIS, FAAP Commissioner o Ne&ith LORETTA MOLINARI, RN; MSN Associate Commissioner of Health. F• ... .- .. , ROBERT L BONDI . . ... ... - Coii►i[j�'7;zec'utive�" ,.... _ . _.... DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York' 10509 Town Leeal Bedroom Count Re 1, W 4 I I to A N (Owner's Name) Tax Map #: Address: 3 '� NN Y '16:>\-J N R'D Town: PUJ -rNA M V.A'LL ,� Year Built: According to records maintained by the Town, the above noted dwelling, is i n compliance with Town Code. is not in compliance with Town Code. The Legal Bedroom Count is: Z 'This information has been obtained om: i Certificate of Occupancy: Other: 3 30 Building Inspector Dat 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 r C aj a F� i ` atkf . t o tp C �' • Q N "y ' Nik' n � {�O J i � ' 1 1r�•y4�It}�•i.. tl 1 � Q � K•`T{'` I y A � yl?i �. �' � +�_ - "R �'�3 �� �.; t � � � �? �. i�{•JI� � rf� - �',r,�.�.�+t a ,� »yye�t. `rj b:. :.`�'; nt : ♦ 6 ° t, 7}* fi•''^ k Sa `j. 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I I DulE�ma.r -o' I 1 L -.._J L -1_ J L_._J , 1 1'- - T•- --i T.I' � ` i' -O f/4• D''D ____.- D'.b• _ !'.4 V{• I e 1 1 1 I � vtr L.YLT CO"" RlTH 12JOT \�sypmvE ; r1oTe, ' ' 1 I I PANT SET ON 31• r !.• • 12' COW- PAD � , I THE fOUI T1Y,a1 PL, N104N Ib NOT PROVIDED Dt MI'REX I N 1 n4rx163�a11E AND THSOMDAT1ON DETAILS INDICATED ARE NOT I' A . _0 AJO AT AAND Mb4 SUP- 1 A S FOR IC V M NALS O FO CN Q, THE MEASUREMEN -1 -S ON ThIS FUi�ivi::: PORT "A"'E` i87/LY �. FOLACAT POTAILSARE 1107 A ®g4DW. DESIGN AND APR , TO; 4 T ION PLAN ARE SUBJECT TO CHANGE-- REFci' SEER U*146 0el'�ATE F0,NDATIOI14 MT e�AC4CEP"i'.°' I I J Al" TO IbIOMCR BULK HEAP EXITS ARE OAMPACTORY -� TO THE CONFIRMING ORDER AND PRINT. I bo -1.. + 711eY a4FOW 0114 THE MMMAL RwPORT 1 IT' CON70M�LO ca�ta POOTNG CRITERI. PR4N RIFMD. - _ 1 gB10%20=0 AS REWIRED BY LOCAL B" OHO t 1 1 OPPIGALS OR OITIF CCHO"I" I1- 1 �'------- ----._ - ------ -------------- a--^ - -- -.-- --; ^ --- --..:..- �.,..---- ------------- 1 I ------------------ 4 ----------- ____.___- ------------ _.____.. ----------------- I 1 1 I it '/Niar) 7, �OCvI7 I - �1�7�Q, l� - i 1 SHERLITAAMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health May'/, 2009 DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health 0 Robert and Vivian Whitman 344 Dennytown Road Putnam Valley, NY 10579 Dear Mr. & Mrs. Whitman: Re: Addition- A7063 -09 No Increase in Number of Bedrooms 344 Dennytown Road (T) Putnam Valley, T.M. # 50.16 -1 -6 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 M, 6, 2009. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. I 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... Please be advised that this Department's records show that the above referenced lot and its.septic'system is approved for three (3) bedrooms. Therefore this.Department has no objection to the addition of the proposed third bedroom. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you haN e 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax. (845) 225 -1580 SHERLITA AMLER,.M D, NIS, FAAP . Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health. DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 :.: ,.- .,._'._ROBERT J. -BONDI .: County Executive Town Legal Bedroom Count Re: W H 1! O A N (Owner's Name) Tax Map #: 5 ) Address:— 344 _1)�_: NN `% 1 ©al N Town: I vl -FN A M V ,A L L-F— �( Year Built:�j _ According1 to records maintained by the Town, the above noted dwelling, Is y in compliance with Town Code. is not in compliance with Town Code... The Legal Bedroom Count is: Z This information has been obtained om: Certificate of Occupancy: Other: 3 30 � Building Inspector Dat 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 Interventioa/Preschool (845) 278 -6014 Fax'(845) 278 -6648 AM COUNTY DEPARTMENT OF HEALTH N. OF._E.NVIRCIN FN'T.,A --- :: A-LTI-I . ERVICES.....�..:., CE IEICATE OF CONSTRUCTIO COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PC FII I NSTRUCTION PERMIT .#- J Located at r7 ,7 G / ��'�'J Town or Village Owner /Applicant Name Tax Map -5`e- /Z Block f Lot Formerly Subdivision Name 6?,J Subd. Lot # Mailing Address - / , sir o � T r� ,y� � Ile V % %' y Zip Date Construction Permit Issued by PCHD,r ? %1� Separate Sewerage System built by a FV /V Address Consisting of � 6, ci 6 Gallon Septic Tank and Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by � h /-7 Address Rdildiffg Type e" Has erosion control -been completed? Number of Bedrooms Has garbage grinder been installed? &V I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which.are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: Certified by 4 0 "''>�""� P.E. R.A. rte' (Desr n'F fessiona] Address' �%"� 6 -y'y -� %r� ��� lW k`�ice e # Any person occupying premises served by the abovel ystem(s),shall,�)rar'omptly take such action as may be necessary 7 to secure the correction of any unsanitary conditions fesiu%tng fforij•Such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall.become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is, necessary. I: White copy - HD Title: ,���e,�c --0 ,1 Vr H i, Date Yel11-w co y - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 e IRV SEVELOWITf Code Enforcement Officer JOHN W. ALLEN Deputy Zoning Inspector 'I3A�RICIA A. S�il•T H::.. -, w .::...,..� .. -.. ...... - Deputy Zoning Inspector DOREEN C. PIACENTE. May 6, 2009 Town Hall b .� 265 Oscawana Lake Road Putnam Valley, N.Y. 10579 (845) 526 -2377 =(845y52&8806 (fax) PUTNAM VALLEY BUILDING AND ZONING DEPARTMENT Putnam Count Department of Health Attn: Gene Reed e Y Re: Tax Map #50.16 -1 -6 (344 Dennytown Road) The attached plan represents the single - family dwelling as built at the above address with the approval of the Putnam Valley Building Department except that the entire second floor was unfinished and a Certificate of Occupancy was issued for the dwelling in this condition. e ards, ohn Allen Deputy Code Enforcement Officer w ?pro HAII uj m QU, ? $� .p gga3tl g � �Wm _ef'S a s����,>�eg WW � � D� � s � o s a � •° � 6 i ° Y v �. S � � p I Q = c, va'at afllvl r Q'. Oa. E1. -v n11 d_l \U rf16+.:@ e�..dJ,gg >.4 g3�y� T+�. pY���:�r..__. Li t lj II .a •'viol. �-,n u, LT' / , h m r z 14 y C I 1 I d �• 1 tu M I I 1 � ' I O I 1 I lJJ ( - I I I � 3 1 f I ` 4 I I I 1 � O I I I ° 3 fLGA nq � `,F • y 1 1 I I 1 1 .fA1 .tA ♦.L � y_� I I t 1 O \ 1 `\ I �I I 4 lu I gg ° , '• 1 lj II .a •'viol. �-,n u, LT' / , h m r z 14 y C froPer(-. v Vtvio n U-1P)t / r4on �,4/ J_-Ie an#p W, -) 1>21' 9 ry Moo I f)ve INq- a—ret ld&d P40,01,1ke p"J." #a I porole. Oa 4. o le- -st'4 of 1Vde4.p11'&" H "This is to oertify that the sewage, dii,P0841 d7st, constructed'. as indicated ed o was ins"et-ed bV me before 1b system was constructed. In aco'' ' aul ets rules and regulationa of the•j a,"Ik'oo* Health and the r6w Yor,, Stst6-�D,'ip "V VI division of Environmental Health Serviob A!, - Approved as noted for conformanoe with a plieable Rules and Regulations of tke tuam c 0' l' Depar. par tment A*6 Opt-, V I 1 4 tl31� im eras M nt of 7,77- .......... . 24 95- 1*3 ) 3 �l9 Lo -Al "This is to oertify that the sewage, dii,P0841 d7st, constructed'. as indicated ed o was ins"et-ed bV me before 1b system was constructed. In aco'' ' aul ets rules and regulationa of the•j a,"Ik'oo* Health and the r6w Yor,, Stst6-�D,'ip "V VI division of Environmental Health Serviob A!, - Approved as noted for conformanoe with a plieable Rules and Regulations of tke tuam c 0' l' Depar. par tment A*6 Opt-, V I 1 4 tl31� im eras M nt of 7,77- WWII S r vve � olra. d Idea -�, -& ,io "' tea. :: _ a ►.aS� 0 lot Ab.PDv.g ;Apo i WAj !Pq L'm.r Wo i N 1 ire na $ a: %. WWII S r vve � olra. d Idea -�, -& ,io "' tea. :: _ SHERLITA AMLER, MD, MS, FAAP :- =^ � t�tiint�rsoner of lfealti� ' - " LORETTA MOLINARI, RN, MSN Associate Commissioner of Health. DEPARTMENT OF HEALTH 1 Geneva Road,' Brewster, New York 1809 ROBERT J: BONDI . County Executive Town Legal Bedroom Count -Re: W 4 1 I INt R N (Owner's Name) Tax Map #: Address: 344 -_ANN y I °W N_. Town: Pvt -rN A M V A L_& � Year Built: �l According to records maintained by the Town, the above noted dwelling, is in compliance with Town Code. is not in compliance with Town Code. -'-.-The Legal Bedroom Count is:. This information has been obtained om: Certificate of Occupancy: Other: 3 30 Building Inspector Dat 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 "Ov Kv sus qD. ) RPT C) b 00 7i J Lot I Filed Mar) No. 21 - At, Filed in the Putn Clerk's office on 28 October, 1981 /V/F- p RRI/V f. -MAP o Robert & Situate PUTN Putnam C. .2 4 AL SCC U.1 jov 77 T To in 00 C.1 140 P, ZI < A "Ov Kv sus qD. ) RPT C) b 00 7i J Lot I Filed Mar) No. 21 - At, Filed in the Putn Clerk's office on 28 October, 1981 /V/F- p RRI/V f. -MAP o Robert & Situate PUTN Putnam C. .2 4 AL SCC U.1 jov 77 T To ., ,, \ . ♦ ii'. .,; i:: •' C,) :�;.' ; Vii: ': \:... • ,;3 / , On�' + ' ?1 � .f.. y ;rt wY r J7Kf �5 ! r 1 •'� I ��� ♦ , 'uY1 I At. 1 • ' +S Iv.L ir" I i ..,Jr - � / �! ♦ ,'' `- / ' :.,. r, L). 1 .5'� r<TrJ g4Kh : :4 . 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S � ,��►;,r��"`7�� � \` ti,s \�' ♦ A l r �:. r ' rti �; '� T ,'-` .y 4 .�+i: �, '} , 4. Y .ip�V.���+,, T•�uw j'\4r � �' ♦"" L �r• 1 /� • 7 �i � � � 1f ♦ 1 if r Z' �n�.'�,,,��'`t(J�•,;s Rjj�p• �'�::iiit 3 f,'k ♦ t• °c t ..! Ir 4♦ rip tt I t i.�:i, ,,:, ..•.;: js• � k' r a/ r ' �' !' r ' n � ,�i. °: ".r., • k' + t� ♦+ x' yI(�;J?��1,/,,.orA� • �� t n ) 1 .: \ .r ,,r r r �ti� !'�':�' ♦r.�yir` •hr1j�7 , I i !., .'' s ;� w Nr~.•. ✓ r 't i t.,.. , ` ��t ('Ft v'tl f� 1. w „ . ♦''YY v 'r i i o?-/ 7� �' = / -� O .42901 -� '6rafj .� WPL4A `/- 717&9 l 1� -+; tr r.i PA�_,y� I 1i�>.- �! v 7.. k " "v♦tl - j:,t�7' � E�7 U 1 11 � .. Fj,/ r .- t ��,,:..i,�; :,� � � � � .� ♦� �s:. .:c`,i; r L +1 p� � �'1D.ry`��' „ '�rv'It,�."�' •rt, 3r y' •`�i, F. t � I N�.' I �: ,h 13 w:`J"�. qi �� +f+'- J..t. �l�V� �q :�. vr�!" L ; .s:T +7 � M ja 1 �� ♦��I v � '1 r Zd � V,, p r' `0 i�� :MU ` - i•�� t v �Iti ! S � ,��►;,r��"`7�� � \` ti,s \�' ♦ A l r �:. r ' rti �; '� T ,'-` .y 4 .�+i: �, '} , 4. Y .ip�V.���+,, T•�uw j'\4r � �' ♦"" L �r• 1 /� • 7 �i � � � 1f ♦ 1 if r Z' �n�.'�,,,��'`t(J�•,;s Rjj�p• �'�::iiit 3 f,'k ♦ t• °c t ..! Ir 4♦ rip tt I t i.�:i, ,,:, ..•.;: js• � k' r a/ r ' �' !' r ' n � ,�i. °: ".r., • k' + t� ♦+ x' yI(�;J?��1,/,,.orA� • �� t n ) 1 .: \ .r ,,r r r �ti� !'�':�' ♦r.�yir` •hr1j�7 , I i !., .'' s ;� w Nr~.•. ✓ r 't i t.,.. , ` ��t ('Ft v'tl f� 1. w „ . ♦''YY v 'r i i o?-/ 7� �' = / -� O .42901 -� '6rafj .� WPL4A `/- 717&9 l .0 SHERILITA AMLER, MD,'MS,1~AAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner. of Health DEPARTMENT OF HEALTH Geneva Road, Brewster, New York 10509 ROIBERT J. BOND6 County RORER! Director c ADDITION APPLICATION RESIDENTIAL ONLY STREET_ Qenl,?"a. T® Ty,.,nq TAX MAI'# 0,4 -1-6 lit .7 oier4v- XvI4,J 'HONE MAILING AIDDRESS aa rrt e. (DESCRIPTION OF ADDITION o i n.r rely s e- A' v i n. q s-znls,� . NUMBER OF EAISTING BEDROOMS PROPOSED # OF BEDR ®OMS J (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 Putnam County Health Dept., 1 Geneva Rd, - - Brewster,.NTY 10509, Phone: (84�) 2'.8' 613.0. 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 of the property line. Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS 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 1 AM COUNTY DEPARTMENT OF HEALTH 10N. ENTA.LMEALTH..SSER- ICES. w_., CE IFICATE OF CONSTRUCTIO COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD NSTRUCTION PERMIT # Located at Pel" ,-I V A1114 Town or Village Owner /Applicant Name J,���i r t.-� Tax Map 14 Block f Lot 6 Formerly Mailing Address Subdivision Name will ;)m<I Subd. Lot # A110W Aelu;/ Pw & it rV Y 6%��; ,z Zip Date Construction Permit Issued by PCHD � , Separate Sewerage System built by & dv p Address Consisting of % & d c) Gallon Septic Tank and 3 s''� Other Requirements: Water Sunnly: Public Supply From. M Address or: Private Supply Drilled by A Wn Address --- ..Building -Type . _._ _ Number of Bedrooms Has garbage grinder been installed? Ale I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: f G Certified by Address :Z97>, P.E. k,` R.A. e# Any person occupying premises served by the above =r' s),shaI1; i mptly take such action as may be necessary to secure the correction of any unsanitary conditiong..fro uch 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 revocatign, modification or change is necessary. White copy - HD File' Y TitlepFeec-ro"I Dr 4 H G Date /�- � -.-? J - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 I__— - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -. WIELL COMPLETION ➢RII+.Pf[Dl{RT Al.'(7-K Well Location Street Address: 3 Aly T illage: Vey Tax Grid # Map,: O,Alock / Lot(s) Well Owner: Name: Address: Use of We ➢ ➢: I- primary �- 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 '>C Open hole in bedrock _ Other a✓asing IlDetaills Total length ! ft. Length below grade Diameter 4"" in. Weight per foot L6_lb /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded _X Threaded _ Other Seal: ?< Cement grout _ Bentonite Other Drive shoe: k' Yes No Liner _ Yes '>-�No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second I Well Yield Test I _ Bailed Pumped Compressed Air Hours Yield ZO gpm Depth Data Measure from I'an'd surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieveanalyses are available, please attach. be th From Surface Water Bearing Well Diameter(in) (Formation Description ft. ft. Land Surface 17 1/1 " iF0 G If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model . \< Voltage HP Tank Type Volume Date Well Completed Putnam County Certification No. Mrt Well Driller (signature) i ,45u um. rxact location or wets with aistanees to at Least two permanent ianamarKs to be provided on a separate sheet/plan. Well Driller's Name �?� <�nr— �li-,e Address:�� •°_ ► G� Signature: 2 ff �- / ,, Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 YML ENVIRONMENTAL SERVICES 321 Kear Street kt^own~-Heigh 'N�Y;���{598'-- ' (914) 245-2800 Albert H. Padovani, Direz.-tor LAB #.: 32.808352 PLIENT #: 9682 NON STAT PROC PAGE 1 WHITMAN. ROBERT ' DATE/TIME TAKEN: 0y08/98 08:00A 344 I]ENNYToOWN RD. DATE/TIME REC'D: 10/08/98 10:40A PUTNAMVALLEY, NY 10579 REPORT DATE: 10/20/98 SAMPLING SITE: SAME AS ABOVE : COL'D By: ROBERT WHITMAN NOTES...: KT ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE PUTNAM CNTY PROFILE 10/08/98 MF T. COLIFORM 10/08/98 LEAD (IMS) 10/08/98 NITRATE NITROG 10/08/98 NITRITE NITROG 10/08/98 IRON (Fe) 10y08/98 MANGANESE (Mn) 10/08/98 SODIUM (Na) 10/08/98 pH 10/08/98 HARDNESSJOTAL 1()/0.B19a'-.....�ALKALI�|IT-Y--CAS 10/08/98 TURBIDITY (TUR SAMPLE TYPE.": POTABLE PRESERVATIVES: NONE . ' TEMPERATURE..: COLIFORM METH: MF RESULT NORMAL - RANGE METHOD ABSENT /100 ML 2.9 ppb 0.51 MG/L <0.01 MG/L 0.072 MG/L 0.040 MG/L ` 13"() MG/L 6.3 UNITS 92.0 MG/L ~-48-,0'-G/[=----'- ABSENT 1008 0-15 ppb 9101 0 - 10 9139 N/A 9146 0-0.3 mg/l 2037 0-0.3 mg/l 2037 N/A 6.5-8.5 9043 N. /A -N�H-'--------^�~---~-�--'' 0-5 NTU COMMENTS: ' BACT THESE RESULTS INDICATE THAT A SATISFACTORY SANITARY QUALITY ACC8RDI HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb /CU LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment. must be potential. mblic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have-a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn Ifboth iron and manganese are present, their total value combined shall not exceed 0.5 mg/[. 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 Sod'ium + YML ENVIRONMENTAL SERVICES 321 Kear Street � (914) 245-2800 Albert H. Padovani, Director LAB #: 32.808352 CLIENT #: 9622 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WHITMAN, ROBERT 344 DENNYTOWN RD. PUTNAM VALLEY, NY 10579 SAMPLING SITE: SAME AS ABOVE : COL'D BY: RO BERT WHITMAN NOTES...: KT ~~~~~~~~~~~~~~~~~~ ~-~~~~~° DATE FLAG PROCEDURE is suggested. NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ' DATE/TIME TAKEN: 10/08/98 08:00A DATE/TIME REC'D: 10108/98 10:40A REPORT DATE: 10/20/98 PHONE: (914)_628-2963 ` SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE"": COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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 LOW pH MIGHT BE CORROSlVE 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 BEE, N..SU JEC `--VERY'i4ARD-WATER:''ABOVE-' -'- ri&/t----� 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: 'U, ., ii, ,.�i m - T - I a C z r;: - I DirVCtor ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES "Gfi7ARANTEKOF SUBSURFACE SEWAGk TIWATMENT"SYSTEM Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Town/Village Locati - Street Subdivision Name Building Type Subdi-ision 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 f the building utili ' g the system. - Dated: Month __ f Day Year �` Signature: �- General Contractgr (Owner) = Signature Corporation Name �if corporation) Address:, State Zip Title: 2W11-7 e-e- Corporation Name (if corporation) Address: State Zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAILTIJ SERVICES FINAL SITE INSPECTION Date: 9 / Street Locat' -1VCZ Owner t-nnk, Town Permit # (�T_� -� TM # s • 1 fo -1 -� Subdivision Lot ',# f 1. Sewage System Area a. STS area located as per approved plans ........................... h. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank si - 1,000 ........ 1, 250 ......... other ................ b. Septic tank in e l ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1.All out e� is at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches ,function Box - properly set ........ ............................... . ength required_ Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1' /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... P.nds_ capped. A.,.., .......:....... ...::.:. .:....:..... -T_.. g. Pump or Dosed Systems Size of pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual /audio ................................................... 4: Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildin a. ouse ocated per approved plans ... ............................... b. Number of bedrooms ....................... ............................... 3 IV. Well a. 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 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 watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 I . 6 1 PUTNAM COUNTY DEPARTMENT OF HEALTH v �I DIVISION OF ENVIRONMENTAL HEALTH SERVICES �s:� ry.. rw.`R Tt -.. 'u• �.•:. V.: � -.:.�. '..+v....:. .+...r ..... .. ':.... - .. :._w:. ...�:....�C�.._ n.rt. �• v:�:.. •..•c ».+ rr.!1 •Y -. - .. -:.r' •?..�:::a.�': �t : 'r- r.,.... .�.r. ....... •.:: w. _. .. _ • - .0 '1u.��..n.v ::0 CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM �J PE # Located at /��n.� rV/! jd� a1 Town or Village 10,�eAotrl cr Subdivision name "i XmM, ro Subd. Lot # f Tax Map Sa. I Block I Lot Date Subdivision Approved // 11 Renewal Revision Owner /Applicant Name e f, v %ten h �%z» h . Date of Previous Approval Mailing Address 1-2- f� ��• -�'�, <, /�� u� C1��ti Zip 1ro��7 Amount of Fee Enclosed G U Building Type Lot Area No. of Bedrooms 3 Design Flow GPD 4vc/' Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of % el gallon septic tank and 3 -3 4- , c� ; 41 01d Other Requirements: To be constructed by Address Water Supply: Public' Supply From Address Private Supply Drilled b ss 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 t ificate of Construction Compliance of the original system or any repairs thereto. Signed: d 2e /% l J R.A. Date Address License # 2 ti q3-' APPROVED FOR CONSTRUCTION: This approval expires`.w- °eeaYs'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 it. pprove discharge of domestic sanitary sewage only By: Title: \ Date: White copy - HD F le; Yel w opy - Building Inspector; Pink cop - wner; r ge copy - Design Professional Form CP -97 Fl. � b PUTNAM COUNT Y DEPARTMENT OF HEALTH IlDffVRSff ®N OF ENVIRONMENTAL IHIIEAIL'll'IHI SIERWC ES APPLI<CATIi®IY TO CONSTRUCT A. WATER V.V EjL L please print or type U y YPCHD Permit # Wen Loesdonn: Street Address: Town/Village Tax Grid # C S- AY lmlwewl& ey Map Block / Lot(s) Wen Owmeir: Name: Address: Use of Wen: y` Residential Public Supply Air / C ond/Heat Pump Irrigation I- prnmmairy Business Farm Test/Monitoring Other (specify) 2- secoodairy Industrial Institutional Standby Ammouat of Use Yield Sought `-' gpm # People Served Est. of Daily Usage &G Qal. Resisoim ffoir Replace Existing Supply Test/Observation Additional Supply ➢Du°n➢IlnIlng t"New Supply (new dwelling) Deepen Existing Well BDetanlled Ressoim ffoir llDirfflkg Wen Type /' Drilled Driven Gravel Other Is well site subject to flooding? .... .. .................................. ............................... Yes No sue' Is well located in a realty subdivision? ...................................... ............................... Yes ,/' No Name of subdivision Lot No. / Water Well Contractor: s✓' An d !�r� v„ Address: Is Public Water Supply available to site? ....:............................. ............................... Yes No �- Name of Public Water Supply: — Town/Village Distance to property from nearest water main: 16% A Proposed well location & sources of contamination t "e provided on separate sheet/plan. f� �.Applicant:.Signature-- PIERI�HT 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. APPIRtOVIEIID.IFOR CONSTRUCTIION: 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. � . „ 17 Date of Issue 7i0 Permit Issuing Date of Expiration 1<1 ► Title: Peirmmut is Non -Trana n°rrahle White copy - HID file; Yellow copy - Building Inspector; Pink copy - Owner;' Orange copy - Well driller Form WP -97 1. U AT A A M. Sheet l of I PUTNAM COUNTY DEPARTMENT OF HEALTH ...,.. „ DJVISION,O.FENVJRON.MEIIIA1. III ,EAT.I.H. .SERVJCES ....... .� „- FIELD ACTIVITY REPORT Street PERSON IN CHARGE C>_ nR�TFR V���; �C�C Name and T TYPE OF FACILITY: FINDINGS: Town - rm.1 -4 !L �y No f , -s-N',L �Ky State Zip I AIyT1c4tWI�P �h iu�I�hb�y 3>0 1. U 1 Co 1-P _Tb I M [ i 41 ?C, -,W � &TRJA.% C7 F' fZ-&V cr-r tt as J`%STfi�?/I — AZ>o -t6 �e c�r�Sycr�fta �f�a Z� S ys'-i 7-oT L*QG�'�/?C Lop 0 U 4-Azp� y Wp — Z1� —6l Signature and Title v RF.P--ORT RFf:FTVFT) BY. I acknowledge receipt of this report: SIGNATURE: 02/96 CG ° ��� ��u +�/ f Title; Rev. IM DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914).278-7921 May 5, 1998 Joseph F. Sullivan, P.E. 2972 Ferncrest Drive Yorktown Heights NY 10598 Re: Robert Whitman Septic Dennytown Road TM# 50.16 -1 -6 (T) Putnam Valley Dear Mr. Sullivan'. (p�o� BRUCE R. FO �Y p Public Health Director 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. 1. SSTS design submitted is for three bedroom house (334 LF fields). Set of house plans submitted show four bedroom house design, please clarify. on -all submissions please -show . all proposed trench layouts, _primary and _ .. . expansion. 3. Provide source of survey for Lot. 4. Provide erosion control around house, well and SSTS area. 5. Show all existing/proposed SSTS adjacent to property on 30 scale plan. 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, Adam B. Stiebeling ASB -tn Assistant Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS STREET LOCATION - �`�►.�Ny �cJ �� NAME OF W ER {a r wt REVIEWED BY DATE "6 TAX MAP # $O. f 6 — 1 — ©� u_ O. WIT APPLICATION .I ;LL PERMIT PWS LETTER [TER OF AUTHORIZATION SIGN DATA SHEET (DDS)�t RPORATE RESOLUTION ART EAF LANS - THREE SETS OUSE PLANS - TWO SETS ARIANCE REQUEST 11 ol, LEGAL SUBDIVISION DIVISION APPROVAL CHECKED RATE L0 REQUIRED DEPTH TAIN DRAIN REQUIRED STANDPIPES GENERAL t TED IN NYC WATERSHED S SUBMITTED TO DEP GATED TO PCHD APPROVAL, IF REQ'D P -TEST HOLES OBSERVED ti:. 5� ERCS WITNESSED, IF REQ'D E JPROVAL SSDS ADJ. LOTS ETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BUZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMIT(S) REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE_ GRAVITY FLOW CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS COMMENTS: Y. EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN 4D&TAIIED HOUSE - NO.OF BEDROOMS 912— WELLS & SSDS'S WIN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL; SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GUAGES JFILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED x,60 FT MAX;,_ . PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN -FROM SSTS f�;o` r4j-> 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'min to CDS= >5 %,10'- 4 1/o,25'- 3 %,30'- 2 0/o,35' -1 %,100' - <1% 20'min to CD discharge /1004ith 182 cons day discharge SEPTIC TANK m I0' FROM FOUNDATION; 50' TO WELL FORM ST -2 IPUTNAM COUNTY DEPARTMENT OF HEALTH DIVIiSRON OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR Ak WASTEWATER TREATMENT SYST -E- M ,- ......:. w, :...:..... . 1. Name and address of applicant: 2. Name of project: „1.S 1� 4. Design Professional: 6. Drainage Basin: 7. Type of Project: Private/Residential Apartments Office Building 3. Location TN:�� /� 5. Address: Z t7 r _ A- r��r��s�!"r Food Service Institutional Realty Subdivision Commercial While I lome Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SIQR)'? Type Status (check one) ........................................... ........... Type I -- - - -- Type I 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Exempt Unlisted Nd 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? 14. Has preliminary approval been granted by such authorities? 1-",-Date granted: 15. Type of Sewage Treatment System Discharge................. surface water k--' groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... AX0 19. If yes, name of water supply `'' Distance to water supply /!%f 20. Is project site near a public sewage collection or treatment system'? ................ 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector _ 24. Project design flow (gallons per day) .....................' 6!- 42 ............................... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required' ?... 26. Has SPDES Application been submitted to local DEC office? ......................... o.r Fomi PC -97 e 4� 2 At 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ..................... TsWetlands`Permf re uired9�� ................................... ............................... •—. q............................. ............. ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... ol/a 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No A/d 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 AI'l DESCRIBE: 33. Is there a local master plan on file with the Town or Village? 34.. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... A10 lG 36. Tax Map ID Number .......................... ............................... Map Block i Lot .4 37. Approved plans are to be returned to ..... Applicant k,' Design Professional NOTE: All applications for review and.approyal of a new SS.TS.to_be located within the NYC Watershed shall- be-sent to the Department, and need not be senfiri duplicate -to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is trite 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: ................. ... .. .............. "UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Z TA, Owner Afj/' Address Located at (Street) a 4n goy Tax Map�"'-_-*" Block J Lot (indicate nearest cross street) Municipality Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre - soaking // Date of Percolation Test Hole No. Run No. Time Start - Stop ]Ela se Time �iVlin.) Depth to water rom Ground Surface (Inches) Start Stop water Level IDro In Inc�es ]Percolation Rate Min/Inch 2 2 Lys sy, Z 3 �d 3 .'y�y� ?� �a Z-r�i J1�9 4 5 J 3 3 4 5 1 2 4 5 DUTIES: 1. Tests to be repeated at same depth until approximately equal percolation rates are omainea at eacn 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 submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 2 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' . 6.5' 7.0' 7.5' 8.0' 8.5' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. /Z� �O i ./ d ;4, Sid / l HOLE NO. Indicate level at which groundwater is encountered /(d ez Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: d !�jf,,1 /,'`*p Date Design Professional Name: <j I g Address: err z > Per n c f Signature: Design Professional's Seal I OF NEw y� y�P� ��ANCl3 y.G(�•9'f' PUTNAM COUNTY DEPARTMENT OF HEALTH DWI SION OF ENVIRONMENTAL HEALTH SERVICES ]LlET�1E�t OF AUTHORIZATION RE: Property oa L. t—a rid )I r ti M A 1 u 9171"A A2 Located at T/V % J�'% Tax Map # �c�• /G Block Lot d Subdivision of �� �� r�`Gn vi/�i % �✓ Subdivision Lot # Gentlemen: Filed Map # -2,17 �r Date Filed This, letter is to authorize t �' 1/f, rfie a duly licensed Professional Engineer _j 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 �,vlth this matter and to supervise the construction of said wastewater treatment 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: - - - - Coun" rsi' `e . Sn d: P.E., R.A., # State 2 Telephone: i/–> e Very truly yours, Signed (Owner of Property) Mailing Address: ��ajr vil 3 1S Qs2� State Gip Telephone: 6 " J, jz� Form LA -97 14.16.4 (2187) —Text 12 PROJECT I.D. NUMBER 617M SEOR Appendix C State Environmental . Why �.Review...... ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR '4;4- yr/Li i�m 2. PROJECT NAME 3. PROJECT LOCATION: 1y. Municipality Je j, a a AV, County Gr�l�OfJ�% 4. PRECISE LOCATION (Street address and road inters/ectio /, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: .,flew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: � � !/!/` � / " CG ✓'/ !/ Y.�ti %/d''d�l/ 5� -2 !%L° ��' %.� / �j i 7. 7. AMOUNT OF LAND AFFECTED: Initially �'^ acres Ultimately 2'° acres - 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Ayes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? I,Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest./Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Yes r4No If list agency(s) and permlVapprovals ,( yes, C�") J�1�' ��� y /teai�� -l✓JJ Pe��J 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes XNo If yes, list agency name and permlVapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE VAT , /G Date: Applicant/sponsor 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. PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Rgency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No :,8,; yl{ I_ ACTI,QN:A�Q IyE COOK.QtP TEp;R, /:IEW.AS PROVII)ED FOR UNLISTED ACTIONS INS NYCRR, PART 617.6? -If No, a negative declaration may be superseded by anotheF Involved agency. ❑ Yes ❑ No — C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If, legible) C1. Existing air quality, surface or groundwater quality or quantlty, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or.community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. CIO v C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. ; C _ N C., E 14 D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether it Is substantial, large, Important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one o� more potentially large or significant adverse impacts Which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box If you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency Date 2 Title of Responsible Officer Signature of Preparer (if different from responsible officer)