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HomeMy WebLinkAbout2465DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -131 BOX 21 Jlrj ' I IN I Ilr IN ■ ' 1 I M� -„ '. L L I. � � I IN 1 ' r �= � ` i '� �1 02465 Q. PUTNAM COUNTY DEPARTMENT OF HEALTH DI�I�IO� - F �NVT .�_..,,. �. }..._...�:..::::..,._..._..r .... �...� :... _..._._.:..... .._.... .,..... N A�..H.P�I��'H..�ERVICES..s .��..._..- .- ...._._ CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # )OK l %'Od Located at 1,�r7/gli// , O J/y v,/ , e d Town or Village _ loo'4am Owner /Applicant --Name r/W h (� / /�,,y� Tax Map �'� Block Lot 3J Formerly d 4,�l/� ���G �G Subdivision Name Subd. Lot # f Mailing Address U Date Construction Permit Issued by PCHD &,L00 Separate Sewerage System built by Address Zip /6��1` Consisting of & Gallon Septic Tank and '1 1?4 A r d F 0 ,� " k"." dc- Other Requirements: / / > ' f'l' a "�� Water Supply: Public Supply From. Address or: 1� Private Supply Drilled by /Vi .11on /fit /r►7 Address � e ors -- Building h=ype ,� f e-ge _ .-Has erosion control•been completed? 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 am County Department of Health. pF N Date: Certified by 9 w P.E. if R.A. all Address 9`r� A[W a License # � 9 �1�'_ 4'� v / may% 1 24895 Any pens occupying premises sefved by S s) shall promptly take such action as may be necessary to secure the correction of any unsanitary con ting 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 revocati mo 'ficat r ge is necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 / g 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 6 al� Town/Village: vet � Aal Tax Grid # Map Block t(s) Well Owner: Name: Y Address: l�Q ai , "Loci �. U Use of Well: 1- primary 12-secondary Residential Public SUPPW 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: -X Steel _ Plastic _ Other Joints: _ Welded X Threaded _ Other Seal: _ Cement grout Bentonite Other Drive shoe: Yes No Liner: Yes A 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 61 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 ]fearing Well Diameter(in) Formation Description ft. ft. Land Surface �cl If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity-1-0--- Depth 0 U Model f}- Voltage 90 0 HP Tank Typeob�,, Volume 16411164 Date WL11 ted ) Putnam County Certification No. Date of R port p Well Driller (signature) NOTA: EXacYlocation of well with distances to at least two permanenj iayamarics to de proviaea on a separaysneetipian. Re, % l0 Well Driller's Nam i !� Address: fJ% /� ► (% - I " Signature: Date: I White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 r f� NE NORTHEAST LABORATORY OF DANBURY ��0 kN ACCo'g0 39 MILL PLAIN_ ROAD - DANBURY, CT- _ .068.11 ,._ CT Cert: PH -0404. o` �� 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 U � S LABORATORY REPORT REPORT TO: MR. RICHARD DRUZO DATE SAMPLE COLLECTED: 6/29/2001 55 FOWLER AVENUE TIME COLLECTED: 2:00 P.M. CORTLAND MANOR, N.Y. 10567 COLLECTED BY: J. ORLANDO DATE RECEIVED @ LAB: 6/29/2001 TESTED BY: LAB #11471 LAB I.D. # NY -78 REPORT DATE: 7/6/2001 SAMPLE SITE: ORLAND0,152 BELL HOLLOW ROAD, PUTNAM VALLEY, N.Y. SAMPLE POINT: KITCHEN SOURCE: WELL 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 6.21 - . EPA 150.1 No designated limits • Turbidity 0.63 NTUs EPA 180.1 5 NTUs CHEMISTRY: _!.<Nitrite.NitrQgpn.. ....._..__..._ .w- 50QQSr_.rng/I.as,N. .'_.':RA.354,1'..._ -<._ • Nitrate Nitrogen 0.25 mg/L as N SM 4500D 10 mg/L • Alkalinity 18.0 mg/L SM 2320B No defined limits • Hardness. 26.0 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 iangaiiese a 0.50 mg!L • Sodium 4.0 mg/L EPA 273.1 20.0 mg/L ** • Lead 0.002 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: MOTABLE or UOT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 6/29/2001 Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 FIRLICF,' P. FOIL)"'Y Pubhc fhlairh LORETTA MOLINAR1 R.N., M.S.N. ss C iciff ­Fublic 1ealth ITirector Direcror of' Faf(ent Services DEPARI I Nffli.NT OF TTEALTH I Gc.-neva Road BVC',vSLvr, New York L0509 Enviromucti tit I I Ica Mi (I) 14) 278 - 6130 Fzu%`t,9 H) 279 - 7921 Nursing Services (914) 278 .. 65jS IVIC (914) 27S - 66178 Fax (9 14) 278 - 6085 Early Interventiun (914)M - 6014 Preschuo) (914)238-6082 Pas (914) M - 6649 _VURIFICA-TION FORM X. kI Al NUNIBE.R': 1. Al 1) RkESS: -Ael? -J TO NY q: g. �27.Ceoll 7 e— qf TTIAORHZE'D 'I'MYN 01."PICIAL,: Publaul COURt)l De[),141111elit Of' UCI fth. Will 110t issue a Certificate o-(' U11leSS UIC above -Num Is comp'Leted, i.e., a legal E911 address "s ass "). d by 1111 I"ItIth.orized tolvil oflicial. J.'his fban is to be submitted NVII.-II the applicatioll I'm. a Certificate of, (lolls V1,11 C h Oil C1,0111phance. 0"II-;HvI.:II'H,'A,I.) 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIH a . E......... HEALTH ..- , . ... �,..4... RONMENTAL TH SERVICES • .... r... •R. ]+11.xt'il..C..� cz_. .. r ' rr•Ar'�RJA` �+CY'n a GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot JJ Building Constructed by Town/Village Location Street Subdivision Name �S �^ _ % 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 The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month _�, Day _-6- Year 0 General Contractor (Owner)--- Signature Corporation Name (if corporation) v Address: State Zip Signature: Title: Corporation Name (if corporation) ,cress: ,'7. may. State Zip Form GS -97 PUTNAM COUNTY DEPARTMEN'T OF HEALTH DIVISION OF ENVIR0AME TAL REA.LT11 PE: property of d �� LETTER OF AUTBORIZATION Located at ��/ /� / j�% / /(��✓ ��0� 17Vr;6i.�1�'c ,ax Map `c-�� _.. - - -- -Block 'Lot Subdivision of, Subdivision Lot # Gentlemen: V1111, 1: 'iled Map # Date Filed This letter is to �I.Lrtltorize tai_ /�� �a a duty UCCI.1SPCt 1'rolessional Ln >i�1e i or: 1K isteced �cW1tect to apply for the required b _ �, PP wastewater treatment and /or water s Lipp ly pennit(s) to sc;rve the above -noted property in accordance witil suvndards, rules or regulations as promulgated by [lie. Public Health Director of the Putnam County health Department, and to sign alt necessary papers on my behalf in coimection with this matter and to stlpervise the eolisti-11Ctlon ol'sald wrstetwiter tret111eut <ndlor water supply systems in conformity with the provisions of Article 145 and /or 147 of the Education Law, the Public; Real,th Law, anal 112e PLUtnam,C0UI1ty_SanitEiry- Code, -- _ Countersigned: Mailing Addr Ver)' truly yours, Signed: 'Own - of Proper y) Mailing Address: 5-Z l state / �J State % zip Telephone: > ti e� Ireleplaoric: -- ,q4 5,2P © g Form LA -97 r u 1111Ur1 UJUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROWEN"I AL HEALTH SERVICES is FINAL SITE MPECTION . - -- __ -Date: �. _. Inspecte y: Street Loc ti Owner C v� 3"o�4n V-q Permit # ^I ~ Subdivision Lot # _ (� 1. Sewage Sv_stetn Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth l- c. Natural soil not stripped... ....................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sew%gge System a. Septic tank size -1,000 .. , other ................ b. Septic tank- installed leve ............ ......................... c. 10' minimum from foundation .......... ............................... d. i t 'buti B ox 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e Junction Box - properly set ........... ............................... f. Trenches Length required Length installed 2. Distance to watercourse easured 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 314 -1 %z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .......................... ........:........:............. g. -Puma o Dosed Systems _ Size .of pump c ani6er ................ 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. ouse/Buildin 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 *001 ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted .................................. I............... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backf'ill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan. f. Curtain drain outfall protected & dirto exist watercour g. Footing drains discharge away from STS area .............. h. Surface water protection adequate .. ............................... i. Erosion control provided ................ ............................... n_.. trn-r 4 0, 05/21/2001 10:55 9149624248 1 . JOSEPH SULLIVAN PAGE 01 UtOVVYIENT OF REALTH DIVISION OF ENYWONMENTAL HEALTH SERVICES ATTENTION 9 ADAM AL INSPY;(-. All inrot-mation must be fully winI)leted pi-for to arty itispectiolis being trade, 0 CENEE Fol.: Fill Trenches PCHI.) Construction Peruijt # Ay Located- /Vot/wtv OwncriApolicant Naine: 4o-4z,0,k TM :r/ Block- Lot Subdivision Nauie. Subdivision Lot # Is System till Completed? oilte: is systein complete'? Date.. Is system constructed as per. plans? Is-well drilled? Date: Is ✓di located as per plans? Are erosion wntrol measures in plat I cep bfy that the system(s), as listed, tit the al)ove'prenu"ses has been constructed and I have inspected and -ver'fied their completion in accordance with the issued PCRD Construction Permit and approved plans atad the Standards, Rules -wid Rqgulatluns of the'Putnaw County Department of Certilled 17Y.; RA Address- A Forru FIR-99 V.I. " 1' PUTNAM COUNTY DEPARTMENT OF HEALTH !� DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # -/ 7- 03 Located at ACS/ Alle, -i -- Town or Village Subdivision name 4e s f r ) rr f; Subd. Lot # Date Subdivision Approved Owner /Applicant Name a-An 0a 'e:7"g"fi e; a a% Mailing Address �2 e 2 / l,tv�� jj _5 J %t Amount of Fee Enclosed oea Lot Area ,3 ;/1._;� No. of Bedrooms el Design Flow GPD Tax Map X/ Block / Lot 9 / Renewal Revision Date of Previous Approval j! /':<,v v `v Zip n Building Type %f7-,--�; , ee) ,,,,�;.� Fill Section Only Depth Volume. PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of ��s%' gallon septic tank andt��s� Other Requirements: To be constructed by d /,/4 e- t -, Address Water Supply: Public Supply From Address �.. - .. b;i�".`'l�'' or: P� Pri vate Supply Drilled y � ��r? 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 thereto. Signed: Address P.E. y Date law s � APPROVED FOR CO TRU ON: This approval expir1WIe a issued unless construction of the sewage treatment system has been completed and inspected by the for cause or may be amended or modified when consider necessary by Public Health Directoation of the approved plan requires a new Ap ove isc ge o omestic sanitary se age only. By: Title: Date: 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design dofelsional Form CP -97 PUTNAM COUNTY ]DEPARTMENT 07 HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _APPLICATION TO CONSTRUCT A WATER WELL n > please print or ty pe PCHD Permit # I 00 Well Location: Street Address: TownNillage Tax Grid # well ,� f/' -%� pl W, .. Map,I Block Lot(s) / Well Owner: Name: Address: � Use of Well: p Residential Public Supply Air /Cond/Heat Pump Irrigation I- prinmairy Business Farm Test/Monitoring Other (specify) 2- secondanry Industrial Institutional Standby Amount of Use Yield Sought r gpm # People Served f- Est. of Daily Usage ao gal. Reason for Replace Existing Supply Test/Observation Additional Supply IID>riIlIlinng b-' New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type j­-4 Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No t- Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. 9 Water Well Contractor: '• ,i , _ Address: �1 = =, ­i i h^l F _ Is Public Water Supply available to site? .. ......... Yes No Name of Public Water Supply: TownNillage Distance to property from nearest water main: H Proposed well location & sources of contamination to be provided on separate sheet/plan. Date:.. ���` ��� ✓ _Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED _]FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well dril r certified by Putnam A" ' County. Date of Issue 181'61 01Q Permit Issuing Official: Date of Expiration" ' 01 Z/ C27 Title: ]Permit is Non- Tiransffe>r White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 o r� :PIUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ".APP)LICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 2. Name of project: 4. Design Professional:-,,j;,,�f °fir 6. Type o ` 'ro' ct: Private/Residential Apartments Office Building �i QCs J11Z1' A d61 h Al V 3. Location TN:l/��� 5. Address: , ;W-- y' /,� FF / ///..JJ,��//J Imo• ,/ 21 Food Service Institutional Realty Subidvision Commercial Mobile Home Park Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? lVel Type Status (check one) ..................... ............................... Type I Exempt Type II Unlisted 8. Is a Drab Environmental Impact Statement (DEIS) required? ......................... A.140 9. Has D13IS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency 11. If this project is an area under the control of.local planning, zoning, or other - _...... officials, ordinances? .............................. ............................'r' 12. If so, have plans been submitted to such authorities? ........ ............................... yet> 13. Has preliminary approval been granted by such authorities? Date granted: // Me;' 14. Type of Sewage Treatment SystemDischarge ................. surface water a,/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 ?° 18. If yes, name of water supply -= Distance to water supply I /� 19. Is project site near a public sewage collection or treatment,system? ................ '.Oovej '0. 'Name of sewage system _ I— Distance to sewage system .44A/f-' Date test holes observed 22. Name of Health Inspector��jcf Form PC -97 M, F 2 23. Project design flow (gallons per day) .....•.... 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... ^ ' X�e 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?� 27. Wetlands ID Number ................. 28. Is Wetlands Permit required? Has application been made to Town of Local DEC office? ............................... 29. Does project require a DEC Stream Disturbance Permit? .. ........................•...... ll;� 30. Is of was project site used for agricultural activity involving application'of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? • .......................•.•. Yes/No Alu 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 mil DESCRIBE: 32. Is there a local master plan on file with the Town or Village? ......................... 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? '34. -Are any sewage treatment areas in excess of 15% slope? .. ..............................a 35. Tax Map ID Number ..•.•.......• ............. •........•..................... Map '% Block / Lot 31 36. Approved plans are to be returned to ..... Applicant /,-' Design Professional If the application is signed by a person other than the applicant shown in Item 1 •,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. 1 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: flailing Address:... .....•....•.......•............ lee I � O PUTNAK COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM /3, /eo Owner e e,1 Address Located at (Street) Tax Map f'l Block Lot :9/ (indicate nearest cross street) Municipality V Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Z/ e�e Date of Percolation Test �e—z �Z IIoXe Na Run X Time Start S Ejapse Time Depth to Wate r'... From Ground Surface (Inch4) Start Stop:.. t, Wa er 'Level rpp, In. S erc 014U e 2 91- 9 _9 74 P" 21 4 5 2 3 /4k 4 5 2 3 5 NOTES- 1. Tests to, be revoated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 minlinch, 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 D b 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. G'�V6 arCN C'� u HOLE NO. HOLE NO. .5 ler Indicate level at which groundwater is encountered 0 Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep We observations made by: Date Design Professional Name:` Address: '- re •�'' �);-� Ye 1�=� -- Signature: Design Professional's Seal 2 14-I8 -4 (2187)—Tout. IZ PROJECT Lo' NUMBER SEOR Appwtdw C St aft Envinmmnial Oustlity Roview SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1—'PROJEC7' INFORMATION (►o ba compfated by App0cant or Project sponsor) 1. APPLICANT )$PON PROJECT NAME J. PROJECT LOCATION.L VoL -.4 County 4 PRECISE LOCATION (811"l address and road Intsmoctionk:1 prorntneml landmar'Kt. Mo.. of PTQVld4 Map 4; 6. ISO PAQPOSEO ACTION 19taw_ 0 Expansion 0 Modificatlon/oltstatiom 6. DESCRIBE PAOJECT BRIEFLY- 7. AMOUNT OF LAND AFFECTED-. injoally 8. WILL PROPOSE[drACTION COMPLY WITH F-XlTrINC; i6�ING 014 OTHER EXISTING LAND USE RESTRICTIONS? Yea No It No, dWrlb. 151414y 9. WHAT IS PFIFSENT LAND USE IN VICINITY OF PROJECT? p6s;dOnVal 1:3 Industrial LD Cornmtrclal l J Agdoullure Park/Fvf*sVOp9n space LJ Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNLWNG, NOW OR ULTIMATELY F90X ANY OTHER OOVE.Rt4MENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Yoh C3 NO It yen, list sgomcy(o) and ponytitlapp, ovals ey 11. !ZEG—ANY AZ-PE-G'T-0—FTH-E- ACTION HAVE A CLIFIRENTLY VALID PEPWIT OR APPROVA 5dyss ❑ No tr yes. 0st agency name and po—Wapprov&I 67 12 AS A RESULT OF PPOPOSEO ACTION WILL EXISTING PERMIT)APPATVZZ67URE ODWI 'KTION) 0 yes RNo P CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS 'RUE. TO THE BEST OF MY KNOWLEDGE -711 "'Cl J e' 4v I Signature: It the awflon Is In the Coastal Ares, mod you are a singe agency, complete she Coastal Asessomeni Form before proceeding with this as"SSMOnt 10) VER el PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTA.L'HEALTH SERVICES RE: Property. of LETTER OF AUTHORIZATION a Located at ✓�//% ��`�� TIV la d`ry &xlelTax Map # ..> Block / Lot,- .� Subdivision of e-,00 /�.o ee Subdivision Lot #— Filed Map # / Date Filed Gentlemen: This letter is to authorize 4 e_:� � /� �� /� %Ila 4 a duly licensed Professional Engineer -? or Registered Architect to apply for the required wastewater treatment and /or water supply peimit(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 14.17, ot_the Education Law, the Public Health - Law;arid- the-Putnai County`SafA,'[ry 'Code:_._,........___... Countersigned: P .E., R.A., # p Mailing Addr j WISOOVOT State Zip U Telephone: I Very truly yours, Signed:' (UWnl.r of Property) �1` Aailing Address: State Al Zip r Telephone; . Zy 7. J Form LA -97 ri '� veapr� /aPk,c A, 4",xv.0 ve. 12 47, d OA A e- v- e. A? :hl J> I V1 . . . . .. .. ............................ 4 Z22� / y. vislon Of ftmirOOMBOUl RWU1�,: DvGd 68 noted for 'comet wn n V i.t, 7'.Il Hit- T Y '7 --13 7. A V1 . . . . .. .. ............................ 4 Z22� / y. vislon Of ftmirOOMBOUl RWU1�,: DvGd 68 noted for 'comet wn n V i.t, 7'.Il Hit- T Y --13 A 77t� A -7- W, MM Dartify. that 'the sewage dieVOSal 670tew as indioated an this plan and that the sp 3d by me before It was covered over. Va %-'i ionotriwted In assordance with all'stand.,-:1 illations of the Putnam County Department og he low York State Department V1 . . . . .. .. ............................ 4 Z22� / y. vislon Of ftmirOOMBOUl RWU1�,: DvGd 68 noted for 'comet wn n V i.t, 7'.Il Hit- T