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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -50.2 BOX 21 02485 r 6 X 6 16 61 x� ., Nis Ir 02485 C ` PUTNAM COUNTY DEPARTMENT OF HEAL .�' ° • DIY�SgON"-OE Ei�Y�RO� ME�T'�'AL HEALTH SER CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATIV PCHD CONSTRUCTION PERMIT # v'_. -D A — Located t`' / ���U�� GT Town r Village Owner /Applicant Name / 11k_e l%i4'4 Tax Map yT--/ Block �_ Lot 0, 2 Formerly SubdivisionName� Subd. Lot # Z Mailing Address �lg <-e G ��` �G d'-I-- Zip ,� Date Construction Permit Issued by PCHD Separate Sewerage System built by Address _ v Consisting of Gallon Septic Tank and A � D Other Requirements: Water Supply: Public Supply From Address or:_ Private Supply Drilled byJ/ �I tf f'I Address�+'t.�r! Building Type / �1i GG�= i`as erosion control been completed? Number of Bedrooms Has garbage grinder been installed? X w 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 th am County Dealth. �. D ate: l y Certified by P.E. - R.A. ign P ession) Addess /� n ., � x r 4 G ."1 7 License # � k/ W Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well' Street Address: /yY]L r LjNf eST(PS Town/VillaQg�e:" "` u1%VIaM 1l���G Tax Grid #�' Map S1 Block 6 Lot() Well Owner: M"e--sh nn Address: e 3 NST' Use of Well: prima 2- secondary Re idential 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�4 Open hole in bedrock Other Casing ](Details Total length eft. Length below grade _400 ft. Diameter (_in. Weight per foot __�Mlb/ft. Materialv Steel _ Plastic _ Other Joints: _ Welded---j_ Threaded _ Other Sealer Cement grout _ Bentonite Other Drive shoes 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) 37 During yield test(ft) (Ooo Depth of completed well in feet 700 Well Log If more detailed information descriptions or sieve x s .:anal ses.,- �.,:_.:-_ are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description fft. ft. Land Surface g.n/ G-r& '1m _ If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type SO& Capacity .5 Depth 600 Model /,5� Voltage x,50 HP / X. Tank TypeUjLv7ldaLVolume Date Well Completed Putnam County Certification No. 0a5 Date of Report -Zla4 Well ille (signature ) NUTIK: Exact location of well witn distances to at least two permanent ianamarxs to De proviaea on a separate sneeuptan. Well Driller's N e fd7L14C' SOn/S Address: A.,,,k. Signature: Date: Z14,FL04 White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM K& 1"Iuc. -s ey I lti Owner or Purchaser of Building M 6eC/I A j r ko c -�-S L_G Building Constructed by JM6_JINE CXU4 Location - Street ildihi Type 5 I S a, 2 Tax Map Block Lot —PLA-LA-H 2� TownNillage 1 1 H 60P I/ A) � E447k, S Subdivision Name Lot VZ 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"onttyj_ Day A Ye General Condrdc—tor (Owner) - Si&,atdr'e I-e.A- -F N Corporation Name (if co lIrpora l C� tiolnl ) Address: 7 1 9w vc_ �_1 I \ A I ow 9� State pUfk p,M U J e4 `' Zip � 05 49 J' r,0 Corporation Name (if corporation) Address: State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street �������� —' 245��8�0 - � Albert H. Padovani, Director � LAB #: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 32.407828 CLIENT #: 114 NON STAT FYU]C ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE: 1 TORLISH & SONS DATE/TAE TAKEN: 10/29/04 09:3OA BOX 271, 45 MAPLE AVE. DATE/TIME REC'D: 10/29/04 l2:00P ATTENTION: DWAYNE TORLISH REPORT DATE: 11/05/04 ARMONK; NY 10504 PHONE: (914)-273-3448 MG/L SAMPLING SITE: TIMBERLINE ESTATES : LOT #2 PUTNAM VALLEY COL'D BY: D. TORLISH ___ NOTES...: TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 10/29/04 MF T. COLIFORM ABSENT /100 ML 10/29/04 LEAD (INS) 9.3 ppb 10/29/04 NITRAT NITROG 1"34 MG/L 10/29/04 NITRITE NITROG <0.01 MG/L 10/29/04 IRON (Fe) 1.16 MG/L 10/29/04 MANGANESE (Mn) 0.022 MG/L 10/29/04 SODIUM (Na) 14.0 MG/L 10/29/04 pH ' 6.9 UNITS 10/29/04 HARDNESS,TDTAL 100 MG/L 10/29/04 ALKALINITY (AS 98.0 MG/L 10/R9104 '~' TURBIDITY (TUR 11.0 NTU ABSENT O-15 ppb O - 10 N/A 0-0.3 mg/1 0-0.3 mg/l N/A 6.5-8,5 N/A N/A /0'5 NTU'''-� COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD I 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. ublic 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 If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium that for people on a contain no more than moderately restricte' is suggested. are proscribed. Suggested guidelines state sodium restri�cted diet,the water should 20-mgAL .of.Sodium. For those on a � diet, '101064'of 270 mg/L of Sodium 10O8 9101 9139 2037 2037 OEMN YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktb�n Hei .Y. '10598 ' ��� �' .- -' -` ' _��������=��'��` �� �(914) 245�280{7 ' ' Albert H. PaVqyaRi, Director .`'� LAB #: 32.407828 CLIENT #: 114 NON STAT PROC PAGE: 2 TORLISH & SONS DATE/TIME TAKEN: 10/29/04 09:30A BOX 271, 45 MAPLE AVE. DATE/TIME REC'D: 10/29/04 12:00P ATTENTION: DWAYNE TORLISH REPORT DATE: 11/05/04 ARMONK, NY 10504 PHONE: (914)-273-3448 SAMPLING SITE: TIMBERLINE ESTATES : LOT #2 PUTNAM VALLEY COL'D BY: D. TORLISH NOTES...: TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C 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 A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 80. 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 O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L � �MODERAIELY HARD WATER: 70_140 MG/L MG/L - jILLIGRAM PER LITER . ---HARC'-WA[ERY''140-S00' MG/t ^-'~----'TI`����/�/��I��� SUBMITTED BY: "�w C/— Director ELAP# 10323 k�t~T°e /ML ENVIRONMENTAL SERVICE� ��r-�-��» ���� � m'v �� ��_ ����� 321 Kear Street i t | Albert H. Padovani, Director | LAB #: 32.408960 CLIENT #: 57698 NON STAT PROC PAGQ 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MARFIONE, COSMO DATE/TIME TAKEN: 12/15/04 0030 1 TRAVIS RD DATE/TIME REC'D: 12/16/04 03:55 PO BOX 417 REPORT DATE: 12/17/04 | BALDWIN, NY 10505 PHONE: (914)-424-0359 SAMPLING SITE: lot 2 TIMBERLINE CT SAMPLE TYPE..: POTABLE : PUTNAM VALLEY, NY PRESERV90VES4 NONE COL'D BY: COSMO TEMPERATURE..« ---- NOTES...: TANK COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ | | DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 12/16/04 IRON (Fe) 0.233 MG/J... 0-0.3 mg/l 2037 COMME Fe/Mn If b | comb 1 3UBMITTED 1 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOL1NARi R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845)279-6130 Fax (845) 278 - 7921 Nursing Services (845)278-6558 WIC (845)278-66,78 Fax(845)278-6085 Early Intervention/Preschool (845)278-6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: S✓� d ` Z E911 ADDRESS: TOWN: AUTHC Lac, DATE: NO 0 :.(Sigliature) The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed., i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificatc of Construction Compliance. (E9I 1 verfrm) v LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 October 8, 2004 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Dear Mr. Donahue: ROBERT J. BONDI County Executive Re: Field Inspection — Timberline Associates Timberline Court, (T) Putnam Valley TM# 51.4-50.2 A site inspection was made for the above referenced project on October 7, 2004. The following comments must be corrected in the field. _.:.. _ ......... -- •• - The:dirty.gravel.was replaced with ravel that is somewhat dirty; but. it -appears. to have been washed and is cleaner than the original gravel. As to the size of the gravel, it. appears to be a mixture that contains a substantial amount of stone less than the required size of 3/4 ". However, there appears to be enough larger sized stone to make up the difference. Please be advised that the smaller stone is not acceptable and should not be used in the future. The size of gravel should be between 3/4" to 1 '` /2 ". . 2. Please provide a copy of the wetlands determination from the Town of Putnam Valley concerning the detention basin and its proximity to the expansion area. 3. The bends in the cast iron pipe don't appear to be necessary and should be removed. 4. The well needs to have a cover. 5. Although about 22 to 25 feet of expansion area has been lost, there appears to be enough room to provide 100% expansion. Please verify by showing the expansion trenches on the as- built. 6. The SDR35 between the tank and the first box needs to be inspected. 7: Comments #'s 7 and 8 from the previous letter dated September 20, 2004 need to be addressed. • "-a�u• m.,. r lueevS .. ea . Me -1 tI'��d .tv.a.�.. uvtrr .. _. .. -� •' ttrar. -. v... rcv. ua;,sc �. �Y�.. �7r Fh r'•. ♦.ia� ^+'- a.. <raa♦ c. t .w If you have any further questions, please contact me at (845) 278 -6130 ext. 2157. JSP:cj Sincerely, Joseph S. Paravati, Jr. Assistant Public Health Engineer i ®/8�df2e00 2 0:43 9149373209 TMAN r Sepwmko 28, 206 Mf, lsrfc B 1mbw3at AiaocWcs, III 1 -18 *tth Bedford RQK suite 102 ;1$omt Kim, Nm york 10549 PAW R Ma: Obvbw Ott.lAk 0 T Sa:pti¢ System ad adjaent waft" wen may IEat�: As psr Your requeK B combcod a site inspection oti 09-26-04 W as *hsthW the 2", ie system oomt eW for lot Q is withbi the repWed w*kd bafft a depidod ®o fM WOM approved aubdivIu -on spa >bamd'upon my field review, Owe 6W M appm to be MY iilmiO4 WOWW area prawns inn the vicinity of lot 0 2. It is very► likely that the dateation b;sigi u ct?mtrumd tho rom mt wetland area rhet wV rermisitt$ wag Pem, McMly altered. I ob9emet no evidence of wetland ciu setedstice to roftin in the vicinity of lot d 2. Therdom, the issue of wiMbei the 1OWibo albs selAk- system oARMOsd kr got 0 2 is witWo ttts repdtmd wetAW buf n is rro logW relevam, and stmid therefore, m be ©n ire whb the Hoihh 1 #paritnent. Mease sddim whmlw you requite sdd�ionat Wbrmation N hm arty Skf� A o ro W WN. omm " t!v I@%I m 014494-194WAX 998 -m -9Eso i OCT PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMMNTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Tb�l Street Location y: , ..... _:.. ;_ ; .;; : ✓ l pry � �... , Inspected Permit # /oy - 01 1- o a TM # _ �1. -1- S v , Subdivision Lot # - ;,- A;-4"- rdAJ-vs 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc.Areater than 15' from STS area......:... I00'��from water, course we a ... ............................... II. � a. Septic tank size - , ........1,250..x'. Ether ................ b. 'S eptic'tank installed level ................. ............................... c. 10' minimum from foundation ............ I ......... .................... d. Distribution Box 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...... .............:................: 6. Wenches 1. Length required )0 Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......... ............................... -,-�Slope of trench acceptable 1/16 - 1/32" /foot .........:... � 10, ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. oom allowed for expansion, 100 % ......................:.. 8. Size of gravel 3/4 -1' /2" diameter clean ...................: Depth of gravel in trench 12" minimum .......:........... Tipe ends ca ed ..................::..:.< ...ppp g. rnp or DosedPSystems _.__._�_.... 1. Size of pump chamb'U ....:....... 2. Overflow tank .....................:.... ............................... 3. Alarm, audio. .......:........:.. ................:.............. 4. P easily accessible, manhole to grade ................. nrstbox baffled .......................... ............................... 6. C4�yycle witnessed by H.D.estimated flow /cycle........... III. House/Buildiriz a. _H9jLwdw&ted per approved plans ... ....................:.......... Number of e ms ....................... ............................... IV. e Well located as per approved plans . ......:........................ b. Distance from STS area measured fLoy * - 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 plans rt ed & dinto exist waterco�i3 drains discharge away from ......2 ...... 4.fFooting S e........ .. ...... . . ........ .... .. ... i. Erosion control provided ............................... Rev. 12/02 LORETTA MOLINARI Public Health Director DEPARTMENT ®F HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 December 21, 2004 ROBERT J. BONDI County Executive Daniel Donahue P.E. 120 Breckenridge Road Mahopac, NY 10541 Re: Construction Compliance — Timberline Associates 11 Timberline Court, (T) Putnam Valley T.M. #51 -1 -50.2 Dear Mr. Donahue: This office has received and reviewed the most recent set. of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. There appear to be inaccuracies in relocation dimensions B6 -B14 and A6 -A9 (Scaling is not matching the table measurement's)' 2. The original water sample retest for iron needs to be provided. Relocation dimensions for. the well are required. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, oseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cw pio DANIEL,J. ,RONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road Mahopac, N.Y. 10541. December 9, 2004 845- 628 -7576 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Joseph Pavarotti RE: As Built Plans Timberline Estates Lot #2 Timberline Ct. Putnam Valley Enclosed please find: 1. Certification of Construction Compliance 2. Well Log and Bacti Results 3. Guarantee and two copies 4. Three copies of the as built plan 5. Filing fee of $200.00 6. E911 Verification Letter Your prompt attention would be appreciated. Sincerel . ..D J. Donahue;.:P.E...._ _ ..... . Site - Sanitary - Environmental LORETTA MOLINARI Public Health Director ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Dan Donahue, P.E. 120 Breckinridge Road, Mahopac, NY 10541 Dear Mr. Donahue: September 20, 2004 Re: Field Inspection — Timberline Associates Timberline Court, (T) Putnam Valley TM# 51. -1 -50.2 A site inspection was made for the above referenced project on September 16, 2004 and September 17, 2004. The following comments must be corrected in the field. L,-AU � 1. It appears that the expansion area may be within 100 feet of a town wetland. Please contact the Town of Putnam Valley for a wetland determination and please provide a copy of the determination. (2'."' The gravel in the. trench is dirty and it appears the gravel was not washed as required. Please remove all gravel and replace with clean, washed dust free gravel. v'1�i y 3 The cast iron pipe, SDR -35 plastic pipe and respective trenches need to be bR . inspected prior to backfilling. (-A ie 4'� The well needs to be inspected when drilled. The well is to be drilled in the cC? location mutually agreed to in the field. 22 feet of expansion area was lost during the installation of the primary system. e '60 All end caps need to be exposed. 7 Roof leader and footing drain discharge points need to be verified. A bedroom count needs to be done when house is complete. If you have any further questions, please contact me at (845) 278 -6130, ext. 2157. Sincerely, oseph S. Paravati, Jr. Assistant Public Health Engineering JSP:km pi, DANIEL I DONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road Mahopac, N.Y. 10541 845- 628 -7576 April 6, 2004 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Joseph Pavarotti RE: SSTS Permit & Well Permit Timberline Estates Lot #2 Timberline Ct. Putnam Valley Dear Mr. Pavarotti: Enclosed herewith please find: 1. Application for permit to construct an SSTS 2. Application for a permit to construct a well. etter..o au. rorizatton:...:: 4. Three copies of construction drawings Comments: Application is for a renero fk nTname change fee filed under separate cover. Your prompt consideration would be greatly appreciated. Sincerel , eelJ.Donahue, P.E. Site • Sanitary • Environmental LETTER TER O AUTHORIZATION ON RI Located at Ov PU? jQ41M V,4kA- i'ax Map # 5 Block Lot So • 2— Subdivision of 7' / m &R i j y s 04-r ili o-' Subdivision Lot # 2, Gentlemen: Filed Map # 21AQA . Date Filed This letter is to authorize D&AI d a L 6 Al A *00 a duly licensed Professional Engineer _V or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putuam_County. Sanitary .Code. Very tru Countersigned: Signed: P.E., R.A., # (Owner of Property) / Mailing Address Mailing Address: <TWIPav D0JU_CAM6ftX U? Z?Z C�RAC.C, • S go x 1h'W*C. Pert r vow State Zip 204-4 ® State Zip IOS-75 Telephone: �,r 94 Telephone: 9 Y4- 6z8.4�6s Form LA -97 b 11 f-)\� PUTNAM COUNTY DEPARTMENT OF HEALTH " DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM i.,--�. zz PERIMIT #-� f j Located at 7-/IZROW4 N4,� / . Town o Village Subdivision name Ad,� Subd. Lot # Tax Map Block Lot Date Subdivision Approved 11111f Renewal Revision Owner /Applicant Name I Date of Previous Approval Mailing Address .161 cckw /Q 146 R Ra 0" 2*&*ydC^1fX Zip Amount of Fee Enclosed it 34 d Building Type %~ APY,, Lot Areaj a�No. of Bedrooms _!!O- Design Flow GPD_L_v Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED &Dsrate Sewerage System to consist of /alp gallon septic tank and �zyzj L != 6 r— aot-1 Ac-4 Othe Requirements: To b constructed by Address War Supply: Public Supply From Address : or: �_A�Private-Supply Drilled by _ _ Address t I rersent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the ser M sewage treatment system described above will be constructed as shown on the approved amendment thereto and in acecdance with the standards, rules and regulations of top Putnam County Department of Health, and that on completion therof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Deprtment, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builir will place in good operating condition any part of said sewage treatment system during the period of two (2) years imrrdiately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original systui or any repairs thereto. Sig;& Adiess R.A. Date License #,�/ APROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the seNNe treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or mooed when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a air pe it. Ap roved f discharge of domestic sanitary sew a only. �P , -Z3 � By; � � Title: Date: � V,,'t copy - HD Fi ; Ye o copy - Building Inspector; Pink copy - ner; OraWe copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ENWl{8ONMENTAIL HEAIL'lI"IHi SERWCES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # a Well Location: Street Address: o illage Tax Grid # Map c`3 4�X Block Q Lot(s) Well Owner: Name: J, aQ a"RP Address: "R Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation >rimairy Business Farm Test/Monitoring Other (specify) 2- secondairy Industrial Institutional Standby It Amount of Use Yield Sought gpm d Est. of Daily Usagelftr gal. Reason for Replace Existing Supply Test/Observation Additional Supply IlDriflflung mew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes Nom Is well located in a realty subdivision? . j - ,�'&# .&Y&.a - -40 -408P ........................ Yes Cam% No Name of subdivision 7 a Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: G Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be rovided on separate sheet/plan. 4 n Date:: ��- gip_ licant Signature: ._ _ -u� ]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. APPROVIE)ID -IFOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue ��i� Permit Issuin& Official: Date of Expirations - 4 Title: Permit is Non- T>ransffe>rirabRe White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 11.161(2/87) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C .. State_ _ Enrlrr�nnApltti�l :ffil�ty�RsfrF ®w OAT ENV(RONMMENTAl. ASSESSMENT FORM For UNLISTED ACTIONS Only PART F— PROJECT INFORMATION (to be completed by ADDllcant orrProl'ect•'soonsorl 1. APPL1 ANT pI§PONSOR 2. AOJECT NAME` 3. PROJECT. LOCATION: / .Municipality / County I a7 A. PRECISE LOCATION (StrHityaddress and road Intersections, prominent landmarks, etc., or provide map) `I rr 4e e r S. IS PROPOSED ACTION: M N e•X ❑ Exp8n3i0n .• . (] ModificadoNalterstion b. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: � r, J Inittany f,�, acres Ultimately r acres 8. Vlil PaOFOSED..ACT10N COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes No It No, describe bditly S. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? n Residential 0_ Industrial 13Commercial DAgriculture ❑PaWft,esUOpen apace ❑Other Descrioe: 1C1. DOES ACTION INVOLVE A PERMIT, APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STAT,yE� R LOCAL)? J E!) Yee I�7, No It yes, list agency(s) and pormlVapprovals 11. OOPS ANY ASPECT OF THE ACTION t A A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes No It yes, list agency name And permlVapprovai L9 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERmrriAPPROVAL REQUIRE MODIFICATION? Dyes 16140 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEWE r" L•` $�' of Yv U e Date: 9 a Applicant/sponsor name: Signature: 'If the action is in the Coastal Area, and you are a state agency, compiste the Coastal Assessment Form before -proceeding with this assessment OVER 1 PART 11— ENVIRONMENTAL ASSESSMENT (To be completed by Acenevl A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN a NYCRR, PART 817.12? It yes, coordinate the review process and use the FULL EAF, ❑ Yes RjNo S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED' CTiONS IN 6 NYCRA, PART 617.67 if No, a negative declaration .may be superseded by another involved agency.... ❑ Yes ' M Na C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten. If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattems, solid waste production or disposal, potential for erosion, drainage at flooding problems? Explain briefly 47 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: /V 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. /e CS. Growth, subsequent development, or related activities likeiy.to be Induoed py the proposed action? Explain briefly. /v C6. Long term, short term, cumulative, or other effects not Identiliod In C145? Explain brieflyy. A{ o nVI:6- C7. Other impacts (including changes In use of olther quantity or type of energy)? Explain briefly. .D. IS THERE. OR IS THERE LIKELY TO 6E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes No If Yes, exploin 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 (Q) 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 reftarence 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 or more potentially large or significant - adverse Impacts which MAY occur. Then proceed dlrectly to the FULL E046dlor prepare poellive declaration: Check this box If you have determined, based on the information and..a.nalya)s.,,above and any, supporting documentation,-that the proposed action WILL NOT resutt.66 any significant adv ®rata envEronmental Impacts AND provide on attachiitants as necessary, the reasons supporting this determination: V -1 6 ..A A..e,,.., ALFt- ""-' —title o esponxciite Officer .ror ,n 1 on Anee�ty �— ,gnature o spo lrs o mparer different from responsi e officer) ey ate , -sual NMENGIN ERS X200 Brwkenftg! M4?ippac, N.Y. I V; ' To 14 We. -1 Up --the fauowft ftma: ARE KNOING YOU C Attached L AW m"rsto ww vis ❑ SW drowinp 0 PrIft . C3 Pums C) Samples 0 opwAkwm C3.C.4ft of letter 0 Cherilp ender ❑ ppnsval ❑ Approved as submitted Cl For your un 0 Approved as f*tW C Resubmit.00pla for approw 0 Satonit-copin f4w dWbabW C As roqu"W 0 rwumw for corrmlons 0 Nowm-offma" pmo C For roll o and amnwit C) — O FOR BIDS DUE 19 _ Cl PRINTS RMRNtO AMR LOAN TO US COPY TO SIGNED: 41"OAW —*dPW Mia At 00". PUTNAM COUNTY DEPARTMNT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION 0-JOSEPH MUEST FO RFINAL J NS EEC I I ON 11 GENE For: Fill All information must be fully completed prior to any Trenches -V inspections being made. PCHD Co tion Permit 62— Located:- (z r Block Owner/Applicant ist gi S.- Bk Formerly:' Subdivision .Nam: e, Subdivision Lot # Is system fill completed? C Date: Is system complete? Date:' is system constructed as per p ans? Is well drilled?-, Date. Is well located per plans? Are erosion control measures in place? I certify that the system(s), as listed - At the above premises has: b6en constructed and I have inspected and verified their comp leti n, in - accordance e with the issued PCHD Construction Permit and - . o approved plans and thi Standards, Rules and Regulations of the - Putnam 'County Department of Health. d Date: ZLILIEX Certified by: oen!!�_ PE RA Design Professional Address, Lie. # Comments: A4':;-P7A-79p1 [1AMF: . PLITNAM COUNTY DEPARTMENT OF P. ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at a, f 1-i n -1c C /0-r [7 "111A14- Subdivision name a2r Subd. Lot # .�., Date Subdivision Approved % ////5P4/0 A �� �/ Town Village y' Gar Tax Map 1 Block / Lot � r .� Renewal Revision Owner /Applicant Name / M (3 iM k /A) g 4rrd e &6 Date of Previous Approval Z Mailing Address draGc �%�u,�d�i J �°U,�flilP, %!I& Zip 6 ' Amount of Fee Enclosed—/041 r) AJt� Building Type /� w/k 6, Lot Area 3. tNo. of Bedrooms --1L Design Flow GPD_ &4kj Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Zjcz= gallon septic tank and Other Requirements: P l/ - To be constructed by Address Water Suuuly: Public Supply From Address - orc'. -g.. Private- Supply -Drilltd -by 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 th reto. Signed: P.E. R.A. Date Address �r Qv �n f a� �d /��G �` �� License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p it. Approved for discharge of domestic sanitary sewage only. By: Title: "/�� Date: 7/.; z � a White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT ®IF HEALTH H DRgSION CIF ENVIRONMENTAL HEALTH S ERW CIES AI?PLICATffON TO CONSTRUCT A WATER WELL please print or type Permit # Q WeRR Location: Street Address: o illage Tax Grid # / Map .�� Block �' Lot(s) Wen Owner: Name: /�® �i.��- Ard —'d Address: ;(y PWIe,4,A U off Wel. Residential Public Supply Air /Cond/Heat Pump Irrigation I u'uMary Business Farm Test/Monitoring Other (specify) - secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # erve Est. of Daily Usage 7Z.-V51. Reason for Replace Existing Supply Test/Observation Additional Supply IIDn°inkg New Supply (new dwelling) Deepen Existing Well IIDetafled Reason 1f d__X. 14 A11A&&,0--,of0- !,V�-.v� -� for IIDrMinng WeRR Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes �No Name of subdivision (21N IAIA. /,:�' Lot No. r� Water Well Contractor: '-7-/R P Address: Is Public Water Supply available to site? .......... /Vo ..............: ............................... Yes No Name of Public Water Supply: 6/,f TownNillage Distance to property from nearest water main: AJ Proposed well location & sources of contamination to be vided on s arat sheet/plan. Date: lieant Signature: - - -- -- .. PERNUT 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 CONSTRUCTffON: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue s Permit Issuing Official- G ?. Date of Expiration Title: S.5 Permit is Non-' . usWrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SE DESIGNDATA SHEET - SUBSURFACE SEWAGE TRtAT'MZNT ' SYST EM Owner J, Address d2 41 Located at (Street)-r/ m2ftigN& Tax Map Block,,- -"Lot -71 (indicate nearest cross street) w. Municipality PAff6j&� q jeWAgoo :f Watershed e. *V A]t wa#. 4,�. Po e SOIL PERCOLATION TEST DATA Date,of Pre-soaking Date of Percolation Test-. ;L percolation test hole. (i.e. r. I min for 1 -3u min/inch, s .2 null lu . T .71 -UV 8181lu glawaij . a. submitted for review. 2. Depth measurements to be made from top of hole. Fom DD-97 , . 0 Water be tm to -* ":: " ': Tim !�Ikl* ""ll M" ei rom Gro, 4 'oil rite ;Stop J�oe 11 AMR In Femol 0 7 As 2 AI Z 7 �g Ae.13 d 3 IQ 1 30 QdYA-.�J!�! ..1 -'/* / 4 17 2 /01 64 la a to 3 rJ6 4 2 3 4 NOTES: 5 at;; 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained ff% -!- 1-'--L% All A.#. ♦- ka percolation test hole. (i.e. r. I min for 1 -3u min/inch, s .2 null lu . T .71 -UV 8181lu glawaij . a. submitted for review. 2. Depth measurements to be made from top of hole. Fom DD-97 , . 0 DEPTH G.L. 0.51 1.01 1.5' 2.9 2.5' 3.9 3.5' 4.01 4.51 5.01 5.51 6.01 7.01 7.51 8.01 9.0 9.51 10.01 T ST PIT DATA DESCIUpTION 01F SOILS ENCOUNTERED IN TIEST HOLES HOLE No • DOLE NO. --#—L-- HULr. fN%j - --------- — Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: e )34 C4 C= Cn W LORETTA MOLINARI Public Health Director June 25, 2004 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278.7921 . Nursing Services (845) 278 -6558 ' WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early intervention/Preschool (845) 278 - 6014 Fax (845) 278-6648 ROBERT J. BONDI County Executive Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 105.41 Re: Proposed SSTS Renewal -- Timberline Associates Timberline Court, (T) Putnam. Valley TM# 51.4-50.2 Dear Mr. Donahue: This office has received and reviewed the most recent set of plans for the above - mentioned project. We would like to offer the following comments for your review and consideration. �I Please provide the following documentation: a. Construction Permit (CP -97) 4# A-04 b. Application to Construct a Water Well CWP -97 -Letter of Authorization (LA -97) ..' Please. show the i 00 -foot buffer for the detention basin/wetland boundary. a 40b%^_ Please.provide a north arrow. 44r.1 The 4" PVC label should include SDR -35 and minimum pitch of 1% (plan and profile).�ir•.- S,B!( It appears fill for grading maybe necessary. _Please verify., A4 6' -��44 Please provide correct tax map number on documents and plans. Py .7' Please provide new deep hole descriptions from field testing on May 27, 2004 (plans and design data sheet). . This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Jo4.gph S. Paravati, Jr. IV ; JSP:cj Assistant Public Health Engineer LORETTA MOLINARI Public Health Director June 25, 2004 k DEPARTMENT OF HE ALTH 1 Geneva Road, Brewster, New York 10509 Environmental health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 ROBERT J. BONDI County Executive Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Proposed SSTS Renewal — Timberline Associates Timberline Court, (T) Putnam Valley TM# 51.4-50.2 Dear Mr. Donahue: This office has received and reviewed the most recent set of plans for the above - mentioned project. We would like to offer the following comments for your review and consideration. 1. Please provide the following documentation: a. Construction Permit (CP -97) - . - b. Application to Construct a Water Well (WP -9.7.) - -. - __ __..c. Letter of Authorization (1 A -97) _._. 2. Please show the 100 -foot buffer for the detention basin/wetland boundary. 3. Please provide a north arrow. 4. The 4" PVC label should include SDR -35 and minimum pitch of 1% (plan and profile). 5. It appears fill for grading may be necessary. Please verify. 6. Please provide correct tax map number on documents and plans. 7. Please provide new deep hole descriptions from field testing on May 27, 2004 (plans and design data sheet). This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, oe,/� /C/ Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP: cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: An., 114,4 f7Jix r,% sxrr 1, v,�4-4. 4,TS ?/ft er7`• I. Bp,.t t j G represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: 7 � LLL Having offices at: 222— �»� - r Whose Officers Are: President - Name: � az, rK_ � Address: i bko - 1.p mow Gkvve Mow T>Jt j� Vice President -Name: "A3N "404�, Address: - 156 � Secretary -Name: Address:- -- Treasurer - Name: �MIMV Address.: V% CLAValtj Ak, and that I am and will be individually responsible for any and all acts to the approval requested and all subsequent acts relating thereto Signed: Title: M04W- - Sworn to before me this 13 day of _(month) 2-®® (year) Notary P is racey A. Bo -.i.IC, State of New Ydk i1o. 01805081711 Corporate Seal ..ualified in Westchester Coun Commission Eves July 079 20 .r.; Form CA -97 ,A0 tISlS ion with respect i'° l 1 '� -� � E ((�� ( "� 6 `� III ; i" •`� i'� i '� I I � I (�> I Iii •� i � i IIDRVIISION OF ]ENWRONMEN'd'AIL ffEAILB']EI[ SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT EATM1ENT SYS'I<'iEM ]PERMIT # r Located atTmt Town . illage 6k �A �l y Subdivision name Subd. Lot # Tax MapS Block / Lot 'Z� Date Subdivision Approved `! Renewal Revision Owner /Applicant Name i ing?��I-li ,UF. !f rs'o-e L Date of Previous Approval A lI Mailing Addressj.)-Z, e-, C rte` ?Ojvf ��� Sir Zip Amount of Fee Enclosed ®° Building Type`�1i rn� i y Lot Area] wf�j No. of Bedrooms_ Design Flow GPD 'd Fill Section Only Depth VoRume PCHgD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Sepairate Sewerage ftstem to consist of or )4in gallon septic tank and Other Requirements: To be constructed by Address Wgtgr SUDIDIy: Public Supply From Address ®r: Private Su 1 Drilled b ~Address PP Y Y /�_..:_: �..._. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments stem 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 o Signed: Address R.A. Date License #,� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved P)an�equ ires a new permit. Approved for discharge of domestic sanitary sewage only. �JIAA ► e By: Title: _ Dater a2 Whit copy -l/HD File; Yellow copy - Building Inspecctor; Pink copy - Owner; Orange copy - Design Professional �' ' •�'t nG�iN2 (�il:. c amt ( ��5 .1G j (1t� �i yJc'� S� l Af4o /f -9 e- S' P t J PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ ^ please print or typ e - PCHD Permit # Well Location: Street Address: <o illage Tax Grid #L-51 JZ4 /noP)iPL�uo G'%' �v' �� l/� /�� Map Block/ L o (S) 2 T Well Owner: Named " 004" ""A ddress: &S d � LGC od.) 9R4i -#_ CiY*RO.4 91- 'v% Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation Qrimary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _ gpm # tPeup Krrei7eil Est. of Daily Usage j Zrgal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason SkVk RE 40 �� for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes � No Name of subdivision %/ h 47 0W 4 i * -X FST_ Lot No. 2 Water Well Contractor: e B P Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: 1y14 Town/Village Distance to property from nearest water main: VIA Proposed well location & sources of contamination to be provided on separate sheet/plan. s Date: Q 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 by Putnam County. Date of Issue ' Date of Expiration Permit is Non -Trl Permit Issuing Official: r;p q Title: L, i ferrable �+ / f White copy - HD file; Yellow copy - Building copy - Owner; Orange copy - Well driller Form WP -97 i 01N. Rol. nu � IZ� 6e LlV. RM. " 19111$1® 711t Floor IT. h Ii 1 1 I FAM. RK R}Onl6� FOYER. . BATH 2 i 0 ... BR 04 NTH' SIT BR 8 Ila.�a 90 Kits a WILL oar to .. ORS i �g 10 U a 10.0 OR PU .1`AM COUNTY DEPAR.' ATENT F HEAI.7II STUOY t>ZaasBHOUISE PLA 'S APPROVED FOR BE. ,OUNT ONLY, BEDROOMS ind Mbar AI.:I. 5i!liSI? Till:��'T m 1 .. +� P,.EVIS:ON�AL., EIsA'.i IONS 1'0 THESE IJOIJS' PL NS MT)ST BE SUBMITTED TO 'I'IiE PGDOII FOR AWPROVA GNAT M. DATE !l IRIAN LVOM M0>IRD118 INC- LLIW010 Trail Road, Selinsgrove Ps. 17870 Telephone f717j 743 -0111 r• OATH IT. h Ii 1 1 I FAM. RK R}Onl6� FOYER. . BATH 2 i 0 ... BR 04 NTH' SIT BR 8 Ila.�a 90 Kits a WILL oar to .. ORS i �g 10 U a 10.0 OR PU .1`AM COUNTY DEPAR.' ATENT F HEAI.7II STUOY t>ZaasBHOUISE PLA 'S APPROVED FOR BE. ,OUNT ONLY, BEDROOMS ind Mbar AI.:I. 5i!liSI? Till:��'T m 1 .. +� P,.EVIS:ON�AL., EIsA'.i IONS 1'0 THESE IJOIJS' PL NS MT)ST BE SUBMITTED TO 'I'IiE PGDOII FOR AWPROVA GNAT M. DATE !l IRIAN LVOM M0>IRD118 INC- LLIW010 Trail Road, Selinsgrove Ps. 17870 Telephone f717j 743 -0111 r• PUTNAM COUNTY DEPARTMENT OF HEALTH' DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner J1 Gib I Address .2,v/ Sow Ailke- elv* Located at (Street),77 r1 Zw , e i ,, N Tax Map Block Lot (indicate nearest cross street) Municipality loriv *z Vi1s f Watershed SOIL PERCOLATION TEST DATA Date of Pre- soaking Date of Percolation Test Depth to ' t e l Tom GrOua V e F: ere t 104.. gg .117 3 As 2 3 Ra as 4 17 5 3 4 2 3 4 NOTES: I 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 rein "� LLOO 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' 7.0' (7.5' 8.0' 8.5' 9.01 9.5' 10.0' TEST PIT DATA (DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. d HOLE NO. HOLE NO. Indicate level at which groundwater is encountered.. _ Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: & �jg Date Desi P Ca 1 N gn ro essiona. ame.AZf, �, 9. AAa��S Address: /l-0. O &RAI O'® 'air R O #& ft 4 Signature: - Design Pu•dfeWoina ➢'s Seal. N PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL�' HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR ...A ASTEWATER TREATMENT SYSTEMs...,F.,...,... 1. Name and address of applicant: dgim.. as Ys-r a-c� cl�r✓.�ti�.c:.P�� ere .e�� 10V* 2. Name of proiect: Si&&,e -�A��4 r lo F r 3. Locati*.YV: 4. Design Professional: MAi4l, J. ,aoNRHve 5. Address, L40 ,81PEG.��N,p /ptl�l o 6. Drainage Basin: e4N** X ,E%e w l�/�d!t 7. Type of Proiect: Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision ~_&0, pote- AW y Commercial . Mobile Home Park Other (specify) 8. Is this.project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ........ ........................ Type ,I Exempt, Type II Unlisted_ 9. Is a. Draft Environmental Impact Statement (DEIS) required? ......................... .10. Has DEIS been completed and found acceptable b Lead A enc ? ............... P P Y g Y. IV /en# ... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ................ .............. . .................................................... ....... 1' 13. °If so, -have plans -beeinubmitted to such authorities? ........: ... .. ::.:.....:.:. 14. Has preliminary approval been granted by such authorities? Date grented: &Z4t _ 15. Type of Sewage. Treatment System Discharge ................. surface water groundwater 16. '.If surface water discharge, what is the stream class designation? ............. .:::..., All-& 17. Waters index number (surface) ................................................ ....:.....................,llrP . 18. Is project located near a public water supply system? ..................... /►!� 19.- If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? .................. A10 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector I a 24. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... �o 26. Has SPDES Application been submitted to local DEC office? ........................... Nl* Form PC -97 k� 27. Is any portion of this'project located within a designated Town or State wetland? 28. Wetlands ID Number ........................................................... ............................... 29. Is. Wetlands Permit required? .............................................. ............................... Has application been made to, Town or. Local DEC office? . ............................... \ 30. Does project require a DEC Stream Disturbance Permit? ..... ............................,�` 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? ............................ Yesop 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& 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? ................................ ............................... iV �► 35. Are any sewage treatment areas in excess of 15% slope? . ............................... IKO 36. Tax Map ID Number .......................... ............................... Mapes Block 0 Low 37. Approved plans are to be returned to ..... Applicant _ ( Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need.not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater lans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms or 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 thelejection of any submission:, I hereby affirm under penalty of perjury, that information provided on this fora is true to the best of may knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Venal Law. SIGN AYVRES & ®F'F'ICUL TITLES. ?)4xo►e c. Mailing Address: ::::::::::;::::.::: :..:::. /� o -,,e) e, rf -02 A r . DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS. 1�20.Breckenndge Road - } Mahopac, N.Y. 10541 845. 628 -7576 May 7, 2002 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Shawn Rogan RE: SSTS Permit & Well Permit Property. of Gizzi Timberline Estates R.S. Lot #2 Putnam Valley Dear Mr. Rogan: Enclosed herewith please find the following- 1. Form PC -1 2. SSTS application 3. Well permit application 4. Design data sheet 5. Letter of authorization 6. Fee in the amount of $300.00 7. Short EAF 8. Three - copies of construction.pl_aus..... _ _ .._ .._ -. •.- - -- :...._ _,:_ .r____�.__..._�::....._.�_.. - ........ . 9. Two sets of house plans AielDo ahue, P.E. Site ��itary '-""Environmental RE: Property of Located at Subdivision of .. Subdivision Lot # �' Filed Map # 9.77 X I Date Filed > ' d� 1Y Gentlemen: This letter is to authorize A a duly licensed Professional Engineer 41or Registered Architect to applyfor the: required wastewater treatment and/or water supply permit(s) to serve the above -noted propert ..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 n connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems an conformity with the provisions of Article 145 and/or 147 of the Education Law,.-Ahe. Public Health Law, and the Putnam C.ougty.- Sanitary...Code- *_.._... _ Very truly yours, s Countcrsigne Signed: P. f7., R.A., �� _� �® (Owner o roperly) Mailing AddresV Ow,4-0 d'OVMailing Address: AO) Ali zip zoxy,- AY f,-, 4: A ? 4Y State Zip /U'/01 Telephone 63' 3(0_ ``~ Form LA -97 PUTNAM' COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATME NT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT' t NAME OF OWNER: 1 STREET LOCATION: 1-6;ljiw� G� REVIEWED BY: RM, GR, AS, ATE: S a TAX MAP#: (CONFIRMED) 1 • —�- Y N DOCUMENTS Y ,N (REQUIRED DETAILS ON PLANS CONT'D) (ZUPERMIT APPLICATION (..n( HOUSE SEWER -' /." FT. 4 "0'; TYPE PIPE CAST IRON (/)(__)WELL PERMIT OR PWS LETTER NO BENDS; MAX BENDS 45' W /CLEANOUT OUPC -97 RENEWALS L/jULETTER OF AUTHORIZATION (�(�SITE NO O CHANGE) Co- (DESIGN DATA SHEET (DDS) FILL SYSTEMS (__)(- QCORPORATE RESOLUTION L_)C_)10' HO ONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (f)(_)SHORT EAF (�(—JFILL F��J ILL NOTES 1-5 PLANS -THREE SETS �FILL & DIMENSIONS UHOUSE PLANS -TWO SETS (J(�FILL SION AREA (/)VARIANCE REQUEST FILL BEATER THAN 2 FEET SUBDIVISION (�(� CLAY B (ZJ�LEGAL SUBDIVISION (___)(FILL CER 'IF CAT N NOTE ()(JSUBDIVISION APPROVAL CHECKED UUDEPTH GA E f�(___)PERC RATE _ (�UVOL. ON P FOR R.O.B., UNCLASSIFIED & IM[PERVIOUS U(�i FILL REQUIRED. DEPTH (�USEPARAT N DISTANCE FROM TOE OF SLOPE (�(�CURTAIN DRAIN REQUIRED TRENCH GENERAL (_,� LF TRENCH PROVIDED 60FT MAX. )LOCATED IN NYC WAT PARALLEL TO CONTOURS U )PLANS SUB O DEP 66100% EXPANSION PROVIDED �) D ED TO PCHD DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL DEP APPROVAL, IF REQ'D �GEOTEXTILE COVER U/ (DEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSTS (QC,JPERCS TO BE WITNESSED )10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL C—)C,- APPROVAL SSDS ADJ, LOTS _ TO FOUNDATION WALLS (�(i)WETLANDS (TOWN/DEC PERMIT REQ'D ?) 2HIN'TO WELL, 200 IN DLOD, 15 TO PITS ()(JDATA ON DDS PLANS & PERMIT SAME ("tic--)100' TO STREAM, WATERCOURSE, LAKE (inc. expan), U(_3FRE 1969 NEIGHBOR NOTIFICATION ��50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER (�LLETTER BUZBA _ (- 10. T0- ?VATER.LINE (pits -20')- _ _.. 100 YR:- FLOOD'ELEVATION'W/1'200' ' ...- (-::Jr J50' INTERMITTENT DRAINAGE COURSE A - x(_,:115'0 1, TESTING LOTS >10 YEARS OLD (=fjT- J200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS REQUIRED DETAILS ON PLANS �)10' MIN TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK SSDS HYDRAULIC PROFILE (,�10' FROM FOUNDATION; 50' TO WELL (� GRAVITY FLOW WELL (ef::�CONSTRUCTION NOTES 1 -15 ��DIMENSIONS TO PROPERTY LINES DESIGN DATA: PERC &DEEP RESULTS C, )LOCATION OF SERVICE CONNECTION �2' CONTOURS EXISTING & PROPOSED (�U� 15' TO PROPERTY LINE §j,&RIVEWAY &SLOPES, CUT SLOPE OOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES �_)SLOPE IN SSTS AREA %p 0 %) ( (TITLE BLOCK; OWNERS NAME ADDRESS (_ }(GRADED TO 15 %, IF REQUIRED TM #, PE/RA; NAME, ADDRESS, PHONE# �(�DATE OF DRAWING/REVISION (✓�DATUM REFERENCE C� LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. U(__)PROPOSED FINISH FLOOR AND // BASEMENT ELEVATIONS WELLS & SSDS'S WAN 200' OF SSTS ( 3� )PROPERTY METES & BOUNDS .(____)(-_)EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01/00 C_)C_)PUMP NOTE SE 75% PF UME/DOSE VOLUME NOTED U( )DETAIL FOIN, (PIPE TYPE, ETC.) UC�PIT AND D & DETAILED (�(__)1 DAY STO ALARM CURTAIN DRAIN C_JC_)STANDP , 5' OTH SIDES, DETAIL (_JL )15' MIN t ->5%,20'4%,15'-3%,35'-l%, 100%-<I% UU20' MIN t CD IS with 182 cons day discharge �)( )I0' MIN o NON - PERFORATED PIPE O� • o�J ,\ c junction box rt q t andl�eptk 1 Ol D r r 4 E3 LP septic tank E ;" o UJ f WD Cn w,Q 0 CO junction C] `O box t LZ Z vv6L L 140. u: Oho 682.0 682.0 f t SEP � IC AREA TIE LOCATIONS NO. LETTER DISTANCE N0: LETTER DISTANCE I A 77.5 2 A 98.0 1 8 95.0 2 8 35.5 1 C 108.3 2 C 51.0 1 D 103' 2. D 51.5 1 E 63.0 2 E 44 1 F 86.4 2 F 63 AV 0� GP�P�POPQ s i I 1 i f I ► � LC I f f l S86