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Home My WebLink About2464DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -30 BOX 21 02464 &A -. -1 - -r lLr ir �W; 16 ,I J' R tj Ak' , 02464 f PUTNAM COUNTY DEPARTMENT OF HEALTH MF:,�.� , FJF L.1_H_SERVTC: �:._..,..gin. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEW NT SYSTEM PCHD CONSTRUCTION PERMIT # Located at /,;&, Town or Village Owner /Applicant NameVy ona Tax Map -:0 Block I Lot 30 Formerly Subdivision Name Subd. Lot # 6i Mailing Address /ly z p�o y' I Date Construction Permit Issued by PCHD �� Ole Separate Sewerage System built by V,0W kW Address `oeAX� /o�, eiA®A-' AP Consisting of 2 t1 Gallon Septic Tank and e0 Other Requirements: %�G �� /� �� Cry �Oir� c r %47 Water Supply: Public Supply From Address or: Private Supply Drilled by �� _ Address /w % Build' T e... C mg - yp � !�. �_�.- --.-- Has- erosroireontrol�beencompletzd?--_... �. ��.-__... _..,_._..__...__._......._ - -... Number of Bedrooms 4 Has garbage grinder been installed? All 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 t1County Department of Health. Date: �' o _ Certified by is P.E. ✓ R.A. Address %/� f'�'�'�l g ` a License # ?4895 Any pe on occ pying premises erved by a v� s all promptly take such action as may be necessary to secure the correction of any unsanitary conditio 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 revocatiorhmodific on c an is necessary. 1 4 By: Title: Date: 71 1 -7t.) 0 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 IPUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT. ,. Well Location Street Address: L I "151 1&// �� Town/Village: 'di p'\. A11C Tax Grid # Map ,$"1 Block / Lot(s) 30 Well Owner: - Name: (,,Pv.4- a #o Address: Use of Well: 1- primary 2- secondary J7 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 67 ft. Length below grade , 5 ft. Diameter 7 in. Weight per foot lb /ft. Materials: _L/ Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: -Cement grout _ Bentonite Y Other Drive shoe: Y Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours _ Yield 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-analyses.... are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation ][Description ft. ft. Land Surface O I If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ' Capacity /() Depth v0 Model /0 6-509 Voltage 9,j 0 HP � Tank Type &d Volume 65� 6C,1 I , Date Well ompleted Putnam County Cert ification No. 067 Date of Report 7 l Well Driller (signature) N )E: E act location of well with distances to at least two permanen landm ks to be provided on gVeparate sheet/plan. f Well Driller's Name /' �j fit. �j � A. Address: A0A( 81'- 9// A II&I /v t Signature: C/ Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 NE LABS REPORT TO: NORTHEAST LABORATORY of DANBURY �N ACC0,9 19 -MILL PLAiN -ROAD - . DANBUR_Y, CT.. 0681.1.._4C.T.Cert:_.PRA404 �� . ...pw..:>.a- :.:m»u .+..s '-N'.:-- ;.,... r. +ro <a. ».Mnv.:. -. :x:o...- ur..w. :,r.�+n:✓m�v: -nv.rs� _�.u..le...r.r� 203) 748 -7903 -FAX (203) 748 -0652 NY Cert: 11471 v U 1A - LABORATORY REPORT D.E.W. CONSTRUCTION DATE SAMPLE COLLECTED: 6/25/2001 P.O. BOX 420 TIME COLLECTED: 3:30 P.M. PATTERSON, N.Y. 12563 COLLECTED BY: DANNY F24NEY DATE RECEIVED @ LAB: 6/25/2001 TESTED BY: LAB #11471 LAB I.D. # NY -71 REPORT DATE: 6/29/2001 SAMPLE SITE: LOT #8, BELL HOLLOW ROAD, PUTNAM VALLEY, N.Y. SAMPLE POINT: KITCHEN SOURCE: WELL -NEW TREATMENT: NONE MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR STANDARD BACTERIAL: • Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml PHYSICALS: • Color (Apparent) 0 - EPA 110.2 15 • Odor ND - - 3 Units • pH 6.27 - EPA 150.1 No designated limits • Turbidity 0.82 NTUs EPA 180.1 5 NTUs CHEMISTRY: _...__�. ....•,...- Nitrite.Nitrogen_. -._. <0.005 .- mg/L:as.N: - _...» _EPA.354.1 .:_a_ • Nitrate Nitrogen 0.74 mg/L as N SM 4500D 10 mg/L • Alkalinity 20.0 mg/L SM 2320B No defined limits • Hardness 34.0 mg/L EPA 130.2 No defined limits • Iron <0.03 mg/L EPA 236.1 0.30 mg/L • Manganese <0.01 mg/L EPA 243.1 0.50 mg/L Combined limit for Iron plus Manganese = 0.50 mg/L • Sodium 4.1 mg/L EPA 273.1 20.0 mg/L ** • Lead 0.014 mg/L EPA 239.2 0.015 mg/L * ** ml= milliliter mg/L--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level ** *Action Level COMMENTS: -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MPOTABLE or ONOT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 6/25/2001 �r Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 P IUTNAM COUNTY DEPARTMENT Off' HEALTH ri DIVISION ®F N ZRONMENT'A L REAL '. .; SER v-rc LETTER OF AUTHORIZATION RE: Property of 4/j 'a Located at /�eJl 4 ` %l e Gl/' /fie J 1. /.V �er��_ �'a,� 1V1��p # - ----- 131ock Lot -3 t t „ SubdiVi31011 Of Subdivision Lot # _ SF __ __ filed Map # ____ Date Filed Geritlenlen: �'lais letter is to authorize _ _ g� 0g _ �/� 04 a duly 11=11;td Professional Lngimer or Registered hrchitect -.to apply for the required wastewater treatment andlor watel- sllppl / pelll_IIt(s) to serve the above -noted property in accordance with tl�e. standards, rules or regulations as promulgated by the Public health Director of the Putnam COLI[Ity 1-1ea1t1.1 I)epal- tllleIlt, and to sign all necessary papers oa my behaff in connection with this IlMtter a.1'ld to SLIPCI-111se the conslIZ1cl7on of sald waste atcl' t1'f;tlnc 111 and /or water scrpp(y systems in conformity with the provisions ol'Article 145 anolor 147 ol' the: Education Law, the.Public.Health L c 4v, arrcl illh l'wtnalii cbLih -ty, S,,'r. -nary Code. - - , ._ ..... _ ......_ . Very truly yours, CotIFItel'signed: Signed: _ h •L•, 1�_<•, 11 (owner of Property) P p NE 4V yo - Mauling Addr _ '� �_ iilCi2S� ,++ail ing Address: State -- - -- sS Ip /O State . �1 Zip /a �'elephone`. Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION, OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM V.,' 0.-7,0 4F r" a n des Owner or Purchaser of Building . Building Constructed by Location - Street Building Type a Tax Map Block Lot e/l e- TownNillage "P,// 4W Subdi'Vi'sion Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Date • nth, D� d ar el General Co a _r (Owner) - Signature Corporation Name (if corporation) Address: %�® ��X 7,0 Signature: Title: eAt/ /, ;-e, r Corporation Name (if corporation) Address: A�, 4'' State 4��c o ky Al V Zip . i a s' State Are -40X ?1 Zip` o0 sal Form GS -97 LORETTA MOLTNARJ R.N,,- M.S.N. Public 7 -N Director of' Patient Services OF 111"3AL'.11-1 I Gic.neva Road HCUWSu�Y, New York 1.0.509 I kuikh V)14) 2,19 - 6170 V ax X9 1 'I 1 7921 Nursing Services I V1 C' (91-4) 2,7,Y - 60AV Fax (!)/-/) 378 -6085 a I. l y I I I t c v v V, I I k i .0 11 (`)14) 2 oi) I !,, prescjiut)l Fax(914)21t-664% 1 1. 1 ADDfM-SS VERIFICAJJWLI-'i�( '1111A.P N U N1.13 E'R: 1l;9 i 1A 1) 1.) R, E, S S: TTMA.dZEDT(.A1/N Vuhlaut C"ottafy 1.)epartfuclit of HUC-thh, Will 110t ISSUe a Certificate of lmsit uc boll is CS, 1SS1011ed by an Ifuthorized (owri oCtic"'.11'. I .111is krin is to be Submitted �j Certli hL,:1 ie of C,00S 1*111cli oil ("0111phlifice. Ine applicatiall I'm -FUTNAM 'COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES. FINAL SITE INSPECTION Street Location spected by: 4., 7, T) To%Nm -py;uA1AA t1 A L j_ r_ y Permit 4 -P v.- r G- 0 TMr .0 l- 5 I •- / - mo := Subdivision Lot 4 -R 1. _Sewage Systein Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil, not s'tnpp d...... ............................................. d. Stone, brush, e tc.,.. ater than 15' from STS area.......... 'J� u'r . e. 100' fromavaier� S�/wetlands ... 9A.' II. Sewage System a. Septic tank siz -1000 .... 6th ........ ..... b. Septic tank installed level ........................... ............ .... c. 10' minimum from foundation .............................. F ...... d. istributibn Box 1. All outlet,; at same elevation-water tested ............. . 2. Protected below frost ........................................... 3. Minimum 2 ft.Original soil between box & tren e. Junction Box -properly set... ......... .. ..................... ...... f. Trenches 1 . Len required Yo 49 Length installed 2. Distance to watercourse measured.+ i 19'C' ) Ft ...... 3. Installed according to plan ............................. . .... 4. Slope of trench acceptable 1/16 - 1/32"/foot .... . .. s ....... . 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!/2" diameter clean .................... -9.- Depth of gravel- in trench 12" 10. Pipe ends capped ................................... ; .................... g. PumR or Dosed Systems I . Size ot 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 ........... M. House/Building - a. House located per approved plans.. .. .. b. Number of bedrooms ....................... IV. Well a. Well located as per approved plans ................................ b. Distance from STS area measured I o 6 ft........... c. Casing 18" above grade .................. ............................... . . d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted .................................................. b. All pipes partially backfilled .......................................... c. All pipes flush with inside of box ................................... d. Backfill material.contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .................................. COMMENTS 7PI-T�-b-S116f 6, >1 I Ae)01-mc �- 1� V 1 41 BRUCE --R.. EOLEY. Public Health Health - director LORETTA A! OJJNARITRN�.:.NT-S.N Associate Public Health Director Director of Patient Services DEPARTWIENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date: To: ERINK 6ULtlVdAl ]Fax #: ate, -P14 zi�jr- ZZ:IM 1,4 No. ]Pages C8C-6L got4D& 712W, P TAV,4Ai V4¢Cjv -1 (Including cover sheet) ]From: Gene D. Reed ]Putnam County Department of Health y inforaiIatiou....: ]P.lease Despond.__ —z For, -for:. out - _ ._._._ For your review Attached as requested As discussed ]Please call Notes/Messages S K L FZZ 14N he In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. 05/10/2001 10:37 9149624248 JOSEPH SULLIVAN PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION XADAM 13 GENE UQLMCT FOR FINAL TNSPEC?ION For: Fill r All information must be fully completed prior to any Trenches inspections being made. PAGE 01 PCHD Constructs Permit # Located: 44'ad (T) (V) �jjjg».J )4,111e-i . Omer/Applicant. Name: TM 52 . Block _L Lot 30 Formerly: Ag!;Yza' /m Grj4 Subdivision Na ow Subdivision Lot # Is system fill completed? Date: /tee Is system complete? Date: ' Is system constructed as per plans. Is well drilled? V Date: Is well located as per plans? A _ Are erosion control measures in pla e? yt I certify that the system(s), as listed, at the above premises has been constructed and I have inspected . and verified their completion in accordance with the issued PCHD Construction Permit quad approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Dates: a o- Certified by: PE_ !'�tA _..._..:..:... __._.... Design Professional Address: % / arl�%i't� ri }'r Lic. # 00 Form FIR 99 IDEVE N OF ENWRONMIENTAL HEALTH SERVICES cCONSTRU CTffON PERMIT FOR SEWAGE TREATMENT SYSTEM PERMffT # P V / � -vQ Located at �,�iE''�� /Y "cam A? J V A � Subdivision nameless_ %fl / Subd. Lot # . Date Subdivision Approved /�4 Owner /Applicant Name e- • Town or Village //"�i, Tax Map ,6 / Block % Lot ge Renewal Revision Date of Previous Approval Mailing Address �! % �;a� - //1 -0 *0/r %r // Y. Zip Amount of Fee Enclosedt /� Building Type el Lot Area No. of Bedrooms -/, Design Flow GPD ZZ/ v Pilll Section Only Depth Volume PCH D NOTIFICATION IS REQUIRED WHEN (FILL IS COMPLETED Seigarate Sewerage _Svstem to consist of f:� s�� gallon septic tank and �• �° � Other Requirements: P" 17� ,��r �'r� i�� 1 �° ✓. �- -� °// (mss e� �i To be constructed by e Address WZter SUIDIDIV: Public Supply From Address oir: 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. NEW Signed: -t C� ��1�2 �� tN yo� R.A. Date �P s Address 2 G' 7,7 v �' Gam_ License # ,�„ �r•/��r; -rte' /f < ��' 2 AIPIPROVE OR CONSTRUCTIOI�V 'This appro ire�s48 0 om the date issued unless construction of the sewage treatment system has been completed and inspec d is revocable for cause or may be amended or modified when considered neces by the Public Health s revision or alteration of the approved plan requires anew pe Ap o dis arge of domestic sanitary sewa a only. By: Title: Date: CD White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or `type ° PCHD Permit # T" V-1 L —'Q 0 Well Location: Street Address: Town/Village Tax Grid # ` �N�t� 'f Map 5 % Block % Lot(s)S& Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 4-- Est. of Daily Usage &t< gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling 1"'New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No a✓ Is well located in a realty subdivision? ...................................... ............................... Yes A' No . Name of subdivision Lot No. Z7 Water Well Contractor: /,7,/- Address: Is Public Water Supply available to site? ................................ ....................J.......... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: /V 1r. 3 Proposed well location & sources of contamination provided on separate sheet/plan. 't'o�be Date: /f Applicant Signature. PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified y Putnam County. Date of Issue Permit Iss ' g Official: Date of Expiration Title: Permit is Non-Transferralfle White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUT'NA.M FOUNT" Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Vz i'G ello" Located at f /� 141e�llz ,I,- / Fel et Ll 7,N r4lx rr �414 j Tax Map # 51 Subdivision of �� d��✓�G.✓; Subdivision Lot # Filed Map # _ Gentlemen: Block Lot Date Filed This letter is to authorize a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and /or water supply pennit(s) to serve the above -noted property in accordance with tht standards, rules or regulations as promulgated by the Public Flealth 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_ alld the PL11`Ira11'1 -COL', ty ltf'Il'y C o(1C. to / �2 11-t �/_ Countersigned: _ P .E., R.A., #� Mailing Acl L ; el, Very truly yours, Signed: . (owner of 1'roperry) :Marling Address: ;`: ffx'w'�' State ' ipj`~� State Telephone: Telephone: �Z' n Fonn LA -97 14-16 -4 (208711—Taut It rPROJECT I.O. NUMBER SHORT 017.;t1 SEO R a Appendix C >31n4ra Enatmlntwintal ouettty Atmviaw► ENVIRONMENTAL ASSESSMENT FORM For UNUSTRC ACTIONS OWy PART I—PROJECT INFORMATION (To be completed by App0cant or Project sponsor) 1. APPLICANT )SPONSOR t. PROJECT NAME 9. PROJECT LOCATION: _ fitunlcipalitY / �i%�G� /U.-� County / i%f !!✓ ,_�_ _._ .___.._ __� _ 4 PRECISE LOCATION (SUaet address and road In a, prominent landmarks. otc.. or provlda mapl y �5. IS PROPOSED ACTION --'- - '— •— "'"— •`"'""- "—"•- __,_�..__.___._�. _..._.. �1ew 0 Expansion 0 Modlflcationlaiteratlon 6. DESCRIBE PROJECT BRIEFLY' } T. AMOUNT OF LAND AFFECTED: initiorly �.•�__ v acres Ulllmolafy 8. WILL PROPOSEEf COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Ayes 0 No If No, deseriba briefly 9. WH�}T IS PPESENT LAND USE IN VICINITY OF PROJECT? rr--.l �� esideni'41 0 Industrlol 0 Commorclal l._ Agriculture L, parklForaeUOpen space 0 Other _. Describe:•.. .. ..< ... ._ _ � _ - __...__.w_. m- ._...._._.__...... ....._. .:. - - ._ .. _ �.. - __ ... . 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNINNG, NOW OR ULTIMATELY r"slOti ANY OTHER ®OVERNMf'NTAL AGENCY (FCOEFtAI., STATE OR LOCAL)? _ fy, v "'ter! 2y a a 0 No It yeo, list opency(e) and pormlVapprovals Vi i^" . /, ��e ' 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPAOVA'? gYas ❑ No It yos, 0ol ag"ey name and permlVappproval 12 AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPAOVAL REOUIRE MODIFICATIONS �l�Yaa ^�No t CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS "RUE.TO THE BEST OF MY KNOWLEDGE ApplicanUsponsor name: _ �-� _�......... —_ Date: 1 Signature: It that motion Is in the Coastal Area, and you are as estate agency, complete th* Carla .Atsl Assessment Dorm before proceeding with this aaeeeenmnt .__._._ ,'; VAR ' , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 2. Name of project: 3. Location TN: 4. Design Professional: 5. Address: 23�'7,_,7 y; /YTJX '71 6. Type of Project: V"'Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subidvision Other (specify) 7. Is this project subject to State Enviroiunental Quality Review (SEQR)? %tire/ Type Status check one YP ( ) ....................... ............................... Type I Exempt Type II Unlisted S. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 10. Name of Lead Agency - "` If this project is an area under the control of local planning, zoning, or other officials, ordinances? .... ............................... 9/<_� 12. If so, have plans been submitted to such authorities? ........ ............................... a �� 13. Has preliminary approval been granted by such authorities? Date granted: 15� °C1 14. Type of Sewage Treatment Systerrr Discharge ................. surface water y, groundwater 15. If surface water discharge, what is the stream class designation? .................... 16. Waters index number (surface) 17. Is project located near a public water supply system? ................ I..................... A � Y. 18. If yes, name of water supply Distance to water supply Jim% t> 19 Is project site near a public sewage collection or treatment.system? ................ Distance to sewage system %`/ %fir j 20. Name of sewage system 21. Date test holes observed 22 Name of Health Inspector42.o Ilc Form PC -97 2 23. Project design flow (gallons per day) ..................... ........................................... �y 24.' 'Is State'Pollutant Discharge Elimination System ( SPDES) Permit required ?... 25. Has SPDES Application been submitted to local DEC office? ......................... 26. Is any portion of this project located within a designated Town or State wetland? AIZ1 27. Wetlands ID Number ........................................................... ............................... 28. Is Wetlands Permit required? ................................. t............ ............................... -s Has application been made to Town of Local DEC office? ............................... 29. Does project require a DEC Stream Disturbance Permits /1'� ro p J q cr 30. Is of was project site used for agricultural activity involving applickion of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination Yes/No �/� DESCRIBE: 32. Is there a local master plan on file with the Town or Village? ......................... A/4) 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................. ............................... T A'& 34. Are any sewage treatment areas in excess of 15% slope? 35. Tax Map ID Number .......................... ............................... Map 3'—/ Block / Lot .?v 36. Approved plans are to be returned to ..... Applicant 4,-'� Design. Professional If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by 'a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES:'N�� /�rl�l�r Mailing Address: .... ............................... PUTNAK COUNTY DEPARTMENT OF HEALTH DWISION OF ENVIRONMENTAL HEALTH SERVICE.S DESIGN DATA SHEET-- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Al— j "144 00 e,,*,* Address Located at (Street) 15�-WAlle14' Tax Map -5-1 Block Lot (indicate nearest cross street) Municipality �Iplle_X Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test lE$9Je No R N Time X Elaose Time M Depth to Watef�:-.: F oun rom Gr' d. Surface (Inches) Start Stop' a er- .' Level V. :ro . hes .ric 'T er glipe 2 2-2— 3 >2— .4 5 2 Z9 Ad g, 3 4 5 2 3 4 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e.. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 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' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. / HOLE NO. G HOLE NO. I r r�� Indicate level at which groundwater is encountered Al,,7e Indicate level at which mottling is observed %. Indicate level to which water level rises after being encountered Deep hole observations made by: '.�/� > ",i�r' Date y' Design Professional Name: Address: Signature: Design Professional's Seal 4 'k Aj -IN 41 It lL a ZVI .7, V TT S?,7 z i� np, f, Z Avislon of: -ath-SoMoei' ipproved -as noted for bonfonmr,60- wltb Was and Ragout tolloable lows of.,us Pa Coon yartaent.. - '7. is AOL � ooaet 74 _7 TV` Is to T 7_17 y'�aoraw�:Q ill ----------- I r.. Sepa►ate.'Sewe►ag To be' cgristructe Watey Supply:" r r `.Other ReQUireme I :iepresent.,t hat: Q veimsc o to sewage; disposal system gulations.,ot -tne Putnam ommissloney, o/: Health Will Htle►, thaf!safd liuilCer .will . owing thedate-oLthe isfu p dl Re: Pro Loc (T) Sub PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Subdvo Lot # A Filed Map # Date Gentlemen: This letter is to authorize P a duly licensed professional engineer or regis eyed architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said - system or "syst- em "s -in conformity -with the' provisions of "Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tart' Code. $g VED Very Signed Countersigned: P*Eo , ReAe , Owner of Proper Address Town Telephone PUTNAM--COUNTY DEPARTMENT -.OF HEALTH:;.-,;_ DIVISION- OF- ENVIRONMENTAL'HEALTH SERVICES " __.... -._ -- COUNTY OFFICE BUILDING; -- CARMEL, N." Y. _10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.' Owner Address A�OIA- 1� Y A... ......... ---T Located at (Street) Sec. Block. Lot 8 ' :....................._..._ _.._._........ #kdate,nl4rest cross s ree ' "- Municipality 7 Watershed SOIL" PERCOLATION TES 'DATA °REQUIRED "TO BE SUBMITTED WITH APPLICATIONS `Hole Number. "._ ... ......CLOCK TIME _........._ ..._ __...- PERCOLATION _.:._..,_...:..__..... -.. PERCOLATION apse. Depth to a er Water Level No......,.._ ...............:._.........Time From'' :_Ground "Surface --"in: -'I i hes'. _..._.::.Soil Rate Start -Stop .'Min. Start Stop ..Drop n Min. /in drop Triches-_.... Inches ..., ._...._._..._..... . _..5..::.....__..__.:.:._.. _......._... ._....,:_........._......_._... �......__.... ... _ ... .. ...... ._.._..__.._. rr � :x :. 'b�►� . OF Notes: 1) Tests to be repeated at same depth until a roximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. DEPTH G.L. 6" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE'NO. HOLE NO. - DESIGN Soil Rate _.,Used(p.` Min/1 "Drop; � _S..D.. t Usable Area ,Provided600 _.. No _ of Septic-Tank Capacit ' Gals.o Type�� Absorption Area Prodded By L.F. x24" " width trench. i Other E.