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HomeMy WebLinkAbout2489DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -50.6 BOX 21 x;l NQ , ri JL " urn "M Jti 1 �'• PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT WeIlLocation- . Street Address:- 7-1 vA \A Town/Village: . - A.�- 4M Tax Grid.#-. 5 G) Map Block Lot(a) (P Well Owner: INa e: Address: NANCIt, &M-C77" Use of Well: -prima 2- secondary -secondary 2-secondj 'X Residential Public Supply Air cond/heat pump _Irrigation Business Farm Test/monitoring Other(specify). Industrial Institutional Standby Drilling Equipment Rotary _ Cable percussion __y Compressed air percussion Other (specify) Well Type Screened _ Open end casing Open hole in bedrock Other Casing Details Total length L Lq_ft. Length below grade I. ft. Diameter & in. Weight per foot _I _7_lb/ft. Materials: _X Steel Plastic Other Joints: Welded _X Threaded Other Seal: _& Cement grout Bentonite Other Drive shoe: _)(Yes No ILiner: Yes No Screen Details Diameter (in) Slot Size ILength(ft) Depth to Screen (ft) Developed? First I — Yes No Hours Second I Well Yield Test Bailed _Pumped _X Compressed Air Hours Yield ;Ed gpm Depth Data Measure from land surface-static (specify ft) During yield test(ft) Depth of completed well in feet 3 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 3 13 1A 3314 rJ11,4W 4 0Q/jfrs gleA,4 arAtv(Zfy ........... . A, C, 64 11 S 22 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Info rrrWion 6 Pump Type Capacity _43 Depth .110 Model 7 G —Sto Voltage 3a HP Tank Typ"JALITINLVolume 64 Date Well Completed �311 10-1 Putnam County Certification No. 1 Date of Report 1114110-7 Well 15rill r (signature) . : 21, :Z�- NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Drill 9 d qL- Sd o-S Address: 4110 x4t, AAJ Signature: Date: // tg Lo -7 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 `l da Ei �1 p I i _"AD iITA 4 5 4 •E� 1�e •� 1 I F1 F1 ' Ob CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM[ PCHD CONSTRUCTION PERMIT # 5 Vy O q- 0 Z Located at T M 5 E R L I iJ G DV P-T Town or Village PV T d AM VA L L EY Owner /Applicant Name I Mae 2 L A EE ,Uc�l�reTax Map Block I Lot 50.6 Formerly Subdivision NameTJ M taJ E R L I N E &STATES Subd. Lot # Mailing Address l IpAoyrr� MIr Kl�6P, NY Zip IOS Date Construction Permit Issued by PCHD D ZCo D� Se2arate Sewerage System built by LEA — Ro M E � Address Z I PEEKS Ki LL PV it Consisting of I ®O' Gallon Septic Tank and (v 30 L. F 2 OF 1Nto� I�OD��L. co�lc. PUP�%1� Plryv��1� DA��yERFl�ov� s Other Requirements: ?i t De E,P C D 13. F I L- L �C-GTI Water SUPP11: Public Supply From Address ore %C Private Supply Drilled by To I� L15d �eS)O�S Address &W a.l �. - - Btiilding3'ype �-t�A'm I Ly R C� l ODE Has erosion control been completed? Number of Bedrooms I V C Has garbage grinder been installed? I� O 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 accordan ued PCHD Construction Permit and approved plans and the standards, rules and regulatio of epartment of Health. y Date: I Z aj D Certified by ° P.E. R.A. RALP es Address �j Pove G01J G License # D 5449 Any person occupying premises served by the abov 4 9 1`romp take such action as may be necessary to secure the correction of any unsanitary conditions re3 9ffi m_' such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocatio , modificati -on or ge i— s�necessary. i By ��� Title: Date: / copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 RALPH G. MASTROMONACO, P,E., P,C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 _ - : Fax-, i, ..— ..- ..- .r., -,.... ..... ........n,�.r. .. —r_n ... ,. .,r. -.... �. .,.� �...— us.... -..�. ... .�... rx. .. ,� ..,.. w... r.,.» ..- .;.:.v.r.�. a.._- ....,. .,.... -.�.w ._...... ...+.,,.r..r c:,crv= ,.wna... Mr. Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Health Dept. 1 Geneva Road Brewster, NY 10509 Re: SSTS As -Built Timberline Associates, LLC 31 Timberline Court, Putnam Valley, NY (TM #51 -1 -50.6) R.S. Lot 6 Dear Joe: November 29, 2007 Enclosed please find five (5) signed and sealed copies of the SSTS As -Built R.S. Lot 6, Timberline Estates (Sec 51, Block 1, Lot 50.6) Prepared For Timberline Associates LLC, Located at Timberline Court, Town of Putnam Valley, NY, dated November 29, 2007 We are requesting your review and approval of the submitted materials. Please call if you have any questions. Sincerely,,:_ _ ... -.- V Ralph G. Mastromonaco MD /jl Enclosures PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheetiplan. Well Drill er's am A r2 �-9 P-V �- S®A/-S Address: ®N Signature: Date: / D White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 i lit Ta Grid ,._:.... _,.. Map '5 1 Block I Lot(&) Well Owner: N �- �y Address: �i B ill �° - � � 1l_ Use of Well: - prima 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling ]Equipment Rotary Cable percussion _.)L Compressed air percussion Other (specify) Well Type Screened Open end casing P Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter in. Weight per foot alb /ft. Materials: _X Steel Plastic —Other Joints: _ Welded _X Threaded _ Other Seal: -X Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped _X Compressed Air Hours Yield 9C1 gpm Depth Data Measure from land surface - static (specify ft) psi , During yield test(ft) 3✓ o Depth of completed well in feet J ��. Well Log If more detailed information descriptions or sieve analyses ... _:_ .....: are available,.'.__.. please attach. Depth Fro rrr Surface Water Bearing Well Diameter(in) (Formation Description ft. ft. Land Surface 3� 3 6A 1/16^ Ota/7f9'S ! B _ � % ' . - . afCA4 Q=rA -Vf -€' ._ .�.,�- ,�f�S� _ -e✓o ,, '�/�- l�fZ�NtT -Q If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth 410 Mode17SfO Voltage -60 BP / Tank Typ h fi- Volume Date Well Completed 16 10-1 Putnam County Certification No. Date of Report Well rill r (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheetiplan. Well Drill er's am A r2 �-9 P-V �- S®A/-S Address: ®N Signature: Date: / D White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 i BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278.6678 Fax (845) 278.6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: J AUTHORIZED TOWN OFFICIAL: (Sign ure) DATE: llaio7 The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. 9 (E911 verfrm) PUTNAM COUNTY DEPARTMENT OF HEALTH GUARANTEE OIL SUBSURFACE SE WAGE TREATMENT SYSTEM EM 50. � Owner or Purchaser of Building Tax Map Block Lot Building Constructed by 31 TIti.6V- •�Le �, � Location - Street Building Vpe -?Q, � G% Town/Village TlM�erII nle- Subdivision Name 6--- 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. Dat . Mon I Day Z6 Yea 00 -J� General Cont ctor ( wner) - Si are Lt - 40 e.' TNc_ . Corporation Name (if corporation) Address: 2 I "t U e i a �L P V State Zip 1 os� I Signature: Title: —7jA4 v\O &-t SQ C (46-J-j. Corporation Name (if corporation) Address: � State �{T k- �s, Zip two Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 _ 4- Albert H. Padovan, Director LAB #: 1.705861 CLIENT #: 114 NON STAT PROC PAGE: l of 2 TORLISH & SONS DATE /TIME TAKEN: 10/22/07 10:45 BOX 271, 45 MAPLE AVE. DATE /TIME RECD: 10/22/07 02:12 ATTENTION: DWAYNE TORLISH REPORT DATE: 10/30/07 ARMONK, NY 10504 PHONE: (914)- 273 -3448 SAMPLING SITE: TIMBERLINE ESTATES LOT 6 SAMPLE TYPE..: POTABLE : TANK TM.t 5I- I- 5o•% PRESERVATIVES:-NONE COLD BY: D. TORLISH TEMPERATURE..: < 4C NOTES...: COLIFQRM METH: MF' DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 10/22/07 MF T.•COLIFORM ABSENT /10,0 ML ABSENT SM 18 -20 9222B 10/24/07 LEAD (IMS) 1'.2 ppb 0- 15.ppb SM 18 -19 3113B 10/26/07 NITRATE NITROG <0'.2 MG /L 0 10 •SM18- 204500NO3 10/24/07 'NITRITE NITROG <0.01 MG /L 1.'0•MG /L• SM18- 20450ONO2 10/26/07 IRON (Fe) <0.060 MG /L 0 -0.3 mg /l SM 18 -20 3111B 1.0/26/07 'MANGANESE (Mn)­ <0.01 MG /L 0 -0.3 mg /l SM 18 -20 3111B 1-0/26/07 SODIUM (Na) 4:41-MG /L N/A SM 18 -20 3111B 10/22/07 pH 6.9 UNITS 6.5 -8.5 SM18 -20 4500HB 10/29/07 HARDNESS,TOTAL 150 MG /L N/A SM 18 -20 2340C 10/29/07 ALKALINITY (AS 134 MG /L N/A SM.18 -•20 2320B 10/29/07 TURBIDITY (TUR <1 NTU 0 -5 NTU SM 18 (2130B) COMMENTS: MFTC THESE RESULTS INDICATE THAT THE WATE (WAS) WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p• EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ablic 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'-are proscribed. Suggested guidelines state: .that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 Albert H. Padovani,�Director LAB #: 1.705861 CLIENT #: 114 NON STAT PROC PAGE: 2 of 2 TORLISH & SONS BOX 271, 45 MAPLE AVE. ATTENTION: DWAYNE TORLISH ARMONK, NY 10504 DATE /TIME TAKEN: 10/22/07 10:45 DATE /TIME RECD: 10/22/07 02:12 REPORT DATE: 10/30/07 PHONE: (914)- 273 -3448 SAMPLING SITE: TIMBERLINE ESTATES LOT 6 SAMPLE TYPE..: POTABLE : TANK PRESERVATIVES: NONE COLD BY: D. TORLISH TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF ----------- - ------- ------ ~~ ---- ~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER:.0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD --WATER.;- 70- 140- -MG /L, s MG /L MILLIGRAM PER--L1-TER. HARD WATER: 14+0 -300 MG %L^ (1 grain /gallon = 17.2 MG /L)..,..__.__ ' _....._.._.,. _.. SUBMITTED BY: 1 vv _11\ Albert H. dovani, M.T.(ASCP Director ELAP# 10323 11/27/2007 15:37 6664547621 NY BOARD OF FIRE UND PAGE 02 BY THIS 'dltRTIFICATE OF. CONtPL1ANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by BACCARI ELECTRIC BITTMAN bEV. TIMBERLINE ASSOC. PO BOX 243 118N. BEDFORD RD., STE 102 MILLWOOD, NY 10546. MT. KISCO, NY 10548 Located at 31 TIMBERLINE CT PUTNAM VALLEY. NY 10578 Application Number: 3036272 Certificate Number: 3036272 Section: 51 Block: 1 Lot: 50.6 Building Permit:2007.48 BDC: W106 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located inion the premises at- Basement, First Floor, Second Floor, Attached Garage, Outside, Attic, A visual inspection of the premises electrical system. limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and /or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 21st Day of November, 2007. a M Rate C' cu' Dig DUMBWAITER BY OTHERS REMOVED 11/21: DID NOT CONFORM Alarm and Emergency Equipment Sensor Sensor Panel Board Appliances and Accessories GPCI (Faceless) Exhaust Fen Oven Air Handler Air Conditioner Electric Heater Unit Electric Heater Unit Panels 1 0 CarMo"moke I I 0 Smoke 1 0 SEPTIC Alarm 4 0 20 Amps 6 0 F.H.P. 1 0 g KW 4 0 F.11.P, 4 D 20 Maps 4 0 'TOWEL 4 0 M1RRO 1 200 40 1 100 20 Continued on Ncxt Page 1 of 3 seat This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 11/27/2007 15:37 8664547621 W BOARD OF FIRE UND PAGE 03 BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORE(, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by BACCARI ELECTRIC BITTMAN DEV. TIMBERLINE ASSOC. PO BOX 243 116 N. BEDFORD RD., STE 102 MILLWOOD, NY 10546, MT. KISCO, NY 10549 Located at 31 TIMBERLINE CT PUTNAM VALLEY. NY 10579 Application Number; 3036272 Certificate Number: 3036272 Section: 31 Block; 1 Lot; 50.6 Building Permit200749 BDC: W106 Described as a occupancy, wherein the premises electrical system consisting of electricai devices and wiring, described below, located in /on the premises at: Basement, First Floor, Second Floor, Attacbed Garage, Outside, Attic, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein. was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 21st Day of November, 2007. Continued on Next Page 2 of 3 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. Raring 60 Ir1& Wiring and Devices Receptacle 116 0 General Purpose Receptacle 10 0 GPCI Receptacle 1 0 SEPTIC Special Motor Control Center 1 0 SEPTIC Special Switch 117 0 General Purpose ,Fixture 153 0 Incandescent Fixture 9 0 underca Incandescent Receptacle 1 0 30 A tract Appliance Receptacle 1 0 30A Dryer Receptacle 6 D 20 A Appliance Switch 1 0 WELL Motor Control Service I Phase 3W Service stating 400 Amperes Service Disconnect, 2 200 CA Meters: I seal Continued on Next Page 2 of 3 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 11/27/2007 15:37 8664547621 W BOARD OF FIRE UND PAGE 04 ® • BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET — NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by BACCARI tLECTRIC BITTMAN DEV. TIMBERLINE ASSOC. PO BOX 243 118 N. BEDFORD RD.. STE 102 MILLWOOD, NY 10546, MT. KISCO, NY 10549 Located at 31 TIMBERLINE CT PUTNAM VALLEY, NY 10579 Application Number: 3036272 Certificate Number: 3036272 Section: 51 Block: 1 Lot: 50.6 Building Permit :2007-49 BDC: W146 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Resement, Furst Floor, Second Floor, Attached Garage, Outside, Attic, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 21st Day of November, 2007. Name- MY Rate 811101 Circuit I= seal 3 of 3 this certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. SHERILITA AMl_.ER, MD, ISIS, FAAP Commissioner of Health LORE'1 rA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Mike Doebbler Ralph Mastromonaco 13 Dove Court Croton -on- Hudson, NY 10520 Dear Mr. Doebbler: R®HERT J. H®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health November 29, 2007 Re: Cosntruction Compliance — Timerline Associates 31 Timerline Court (T) Putnam Valley, TM# 51 -1 -50.6 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. The house is to be survey located with respect to the property lines. 2.. The plan is to note the.source of the survey. 3." The well is to be locafed f bm two fixed points. This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. JSP/kly Very truly yours, oseph S. Paravati, Jr. Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 RALPH G. MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 Mr. Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Health Dept. 1 Geneva Road Brewster, NY 10509 Re: SSTS As -Built Timberline Associates, LLC 31 Timberline Court, Putnam Valley, NY (TM #51 -1 -50.6) R.S. Lot 6 Dear Joe: Enclosed please find the following materials: November 28, 2007 1. Four (4)) signed and sealed copies of the SSTS As -Built R. S. Lot 6, Timberline Estates (Sec 51, Block 1, Lot 50.6) Prepared For Timberline Associates LLC, Located at Timberline Court, Town of Putnam Valley, NY, dated November 29, 2007 2. Four (4) signed and sealed copies of the Certificate of Construction Compliance form 3. Four (4) signed copies of the Well Completion Report 4. Two (2) copies of the Well Water Analysis Report 5. Two (2) copies of the Electrical Underwriters Certificate 6. Three (3) signed copies of the Guarantee of Subsurface Sewage Treatment 7. Two (2) copies of the E911 Address Verification Form . :..8: One-04- bank check, #423160277 -4, payable: to the Putnam. County_.:Dept. of. Health. in the amount of $300. We are requesting your review and approval of the submitted materials. Please call if you have any questions. incerely, Iph G. Mastromonaco MD /jl Enclosures SHERLI'TA AMLER, MD, MS, FAAP Commissioner of Health LORE7TA MOLINARI, RN, MSN Associate Commissioner of Health November 29, 2007 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Ralph Mastromonaco 13 Dove Court Croton -on- Hudson, NY 10520 Attn: Mike Doebbler Dear Mr. Doebbler: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Field Inspection — Timberline Assoc. Timberline Court (T) Putnam Valley, T.M. # 51 -1 -50.6 The results of todays pump test were satisfactory. A bedroom count was also performed. There are no further concerns or comments at this time. If you have any further questions, please contact me at (845) 278 -6130. JD:kly Sincerely, t 1� J ph Digit Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool(845)278 -6014 Fax(845)278 -6648 Nov -28 -07 03:59P Ralph G. Mastromonaco PE 914 271 4762 P.01 PUTNA.M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REM rF ST FOR FINAL INSP .0 ITOW For: PU M P Tas-r Date: _ 11 12810 Trenches PCHD Construction Permit # SW 0 "0 2 Located: Tl MBERL! NE C, ou 9. (T) (V) P��-tIAR VaLLEY Owner /Applicant NameT M MP-LI F- Assocl AM TM S 1 Block �_ Lot 5�• �O Formerly: Subdivision Name: I MBEELWE E51,�,JES Subdivision Lot # Is system fill completed? Date: Co O-:� Is system complete? Date: 14 0-7 Is system constructed as per plans? `(FES Is well drilled? YES Date: -710-7 Is well located as per plans? _ it--$ Are erosion control measures in place? YEFS 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 and approved plans. and the Standards, Rules and Regulations of the Putnam County Department of Health. _Date: Y. I ^1 ZO D , .. . Certified by: RA esign Professional Address: 1 _"_'> QeJ 6 C' e01bN -0 N - AQ0So N Lic. # S 44`1 e M I$) 144 M ., • o ' r • • , .►! ' t* 914.2_71- FOR ❑ ADAM XCIENE O (NAME) Form FIR-99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION /6 0 Date: Inspected by: [own VirsNA f U&..t✓E y Permit # SW— ocl - o 2- [M # 51 _ 1 _ .fin m ( Subdivision Lot. # 6 0 L. Sewage Svstem 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., greater than 15' from STS area........:. e. 100' from water course / wetlands ...... ............ .................... ®L. Sewage System d a: Septic tank size - 1,000 .......... 1250......... other..0 .... b. Septic'tank installed level ............................................... c. 10' minimum from foundation ........... ............................... 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. r1' enches �.. 1. Length required �O �J Length installed 2. Distance to watercourse measured Ft......t;O 3. Installed-according to plan ................:. 4. Slope of trench acceptable 1/16 - 1/32 "50ot ............. 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 - 1112" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... :....:, 1fl. Pipe ends ca ed ......... ................::............. ........ �._ . g:._ . _.._ I'umn or Dose ystems j OCA1 1. Size of pump chamber ..................... /......................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ........:........... ..............................: 4. Pump easily accessible, manhole to grade ................. 5. First box ba$ led .......................... ............................... 6. Cycle witnessed by H.D.estirnated flow /cycle........... III.IEI ®raseBuildia� a. House located per approved plans .................. b. Number of bedrooms ....................... ............................... IV. Well Well located as per approved plans ....... <....... ....;,..�.. b. Distance from STS area measured* ft........... c. Casing 18" above grade ................ ............. ................... d. Seace drainage around well acceptable .........:............. V. Overdl Workmanship . a. Boxes properly grouted ................... ............................... b. Al pipes partially backf lied ........... ............................... c. A pipes flush with inside of box ... ............................... d. B 4kfill material contains stones <4" diameter .............. . e. Certain drain & standpipes installed according to plan.. f. Crtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :.......................... i. Erosion control provided ............... ............................... Rev. 12/02 D IT" -DlW' (191- li,, RAFM MAE I� A WV V D IT" -DlW' (191- li,, sw_ oR- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION Or ENVIRONMENTAL_IIEATLII SERV.I,. -• ,.;, ;: -, ;�:.,:;,�,:._- �,..;,.:,.: ACTIVITY REPORT MAX4F, r✓F Cvv,(- PbQvt VA Street Town State Zip PERSON IN CHARGE QR TNTFRVM.WPT): T1atP i TEST 0— . zj DOSE TEST REQUIRED GALLONS ,,C$� C7XiC. OOSE' 3„ , 00 5", 00 o� 0.0- EL START EL. STOP L� 91v Signature and I acknowledge receipt of this report: SIGNATURE: 02/96 Title: r` Ida B3 Isoo 1U,00 o 0 om 0— . zj DOSE TEST REQUIRED GALLONS ,,C$� C7XiC. OOSE' 3„ , 00 5", 00 o� 0.0- EL START EL. STOP L� 91v Signature and I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Nov -28 -07 04:OOP Ralph G. Mastromonaco PE 314 271 4762 11/27/2007 15:37 8664547621 NY BOARD OF FIRE UND PAGE 03 BY 'rail$ CERTIFICATE OF COMPL.IMOE THE NEW YORK BOARD OF MRE UNDERWRMER SUREAU OF ELECTRIC 577 40 FULTON STREET — NEW YORK. MY I CERTIFIES THAT Upon the application of upon premises awned by BACCARI ELECTRIC BITTMAN DEV, TIMBERLINE ASSOC. PO BOX 243 146 M. BEDFORD RD., STE 102 MLLWOOD, MY 10046, VAT. KISC®, MY 10549 Located at 31 11MBERLIRIE C4 PUTNAM VALLEY. NY 10579 Application Numben 3036272 Coalgicske Numbw: 3036272 Section 51 Block: I Lot: 50.6 Building Permit200749 BDC. W106 P.03 Described as a occupancy, wherein the premises electrical System consisting of electrical devices and wiling, described below, located Won the premises at: Basemetrt, Fires Floor, Second Floor, Attacbed Garage, Outside, Attic, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein. was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 21st Day of November, 2007. _ 1 60 0 Wiring and Devices Rmptacle 116 0 General Putpase Raeeptacle 10 0 GPCI Receptacle 1 0 SEPTIC Spacial Motor Control Center 1 0 SEPTIC Special Switch 117 0 General Purpose Fixture 133 0 Ineanducent Fixture 9 0 mtderce leca idescent Receptacle 1 0 30 A vac Appliw= Receptacle l 0 30A Dryer Receptacle 6 0 20A Appfiance Switclh 1 0 WELL M for Control 1 Phase 3W Service Rating 400 Amperes Service Disconnect: 2 200 CS Not sers: 1 sea/ continued on Next Page 2 04 3 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indirAed. Nov -28 -07 03:59P Ralph G. Mastromonaco PE 914 271 4762 11/27!2007 15:37 8664547621 W HOARD OF FIRE UND PAGE 02 BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by BACCARI ELECTRIC BITTMAN DEV. TIMBERLINE ASSOC. PO BOX 243 116 N. BEDFORD Rb., STE 102 MILLWOOD, NY 10546, MT. KISCO, NY 10540 Located at 31 TIMBERLINE CT PUTNAM VALLEY. NY 10570 Application Number: 3036272 Certificate Number: 3038272 Section: 51 Block: 1 Lot: 50.6 Building Permit:2007 -49 BOC: W106 Described as a occupancy, wherein the Premises electrical system consisting of electrical devices and wiring, described below, located inlon the premises at- Basement, First Floor, Second Floor, Atte.ched Garage, Outside, Attic, A visuet inspection of the premises electrical System, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and /or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in Compliance therewith on the 21d Day of November, 2007. >,litae S?IY 8aA& _,i�n8 �It 1kR9 A91eceUanevas.... ., .... .. ...._.__. ... .. ". _._�_._..._. _ .._.,... _� ....__. ,.... �.._... _.. .. DUMBWAJTER BY OTHERS REMOVED )1/21: DID NOT CONFORM Alarm ttad Emergency Equipment Sensor 1 0 CerMoa�Snwke Selasor it 0 Stroke Panel Board t 0 SEPTIC Alarm Appliances and Accessories OF'CI (Facel03) 4 0 20 Amps Exhaust Fan 6 0 F.H.P. Oven 1 o 9 KW AirH"er 4 0 F.H.P. Air Conditioner 4 0 20 Amps Electric Heater Unit 4 0 'TOWEL Electric Heater Unit 4 0 MIXRO Panels 1 200 40 seal I too 20 Cominued on Next Page 1 of 3 This certificate may rut be altered In any way and is validated only by the presence of a raised seal at the location indicated. P.02 11/27/2007 15:37 8$64547621 W BOARD OF FIRE VNP PAGE 02 BY THIS CER'TiFICATIE OF COMI WANCE THE BUREAU OF F-LECT RICfTY 40 FIJLTON STREET q NFEW YORK. NV 1 CERTIFIES, THAT t)pon the application of BACCARI ELECTRIC PO BOX 243 MILLWOOD, NY 10546. Lmteo at 31 TIMOCRUNiE CT PUTNAM VALLEY. NY 10570 Applitatimn Number: 3036272 . -ion. 51 Qlocb: 9 upon premises owned by BrTTIAAN DEN. TIMBERLINE ASSOC. 118 N. BEDFORD W. S'TE.102 RA'T. ICISCO, NY 10b49 CAwtii'It s Number- 3036272 Lot; 50.6 000ing Permit- 2W74-0 BOO W106 t]escrib as a occupancy, Wherein the premises electrical system consisting of electrical devices and wiring, described below, located infon the premises at- $asetttent, First Floor, Second Floor, ,Attached Gorage, Qatside. Attic, A visuel inspection of the premises electrical system, limited to electrical devises and wiring to the extent detailed herein, was cond►,cted in accordance with the requlremeRts of the agpiicable code and/or standard promulgMed by the State of New York, Department of State Code Enforcement and Administration, or other authority having.jurisdiction, and found to 00 in compliance therewith on the 24st Day of November, 2007. 'DVMBWAJTER BY OTHERS i R.>rWVW I In I - DID NOT COWRM !Alwm 400 j9ioe mosey 1 SetlE4r $ 0 � Ceft�am�e�ce Soo- 11 0 S>eloica Paap) Board 1 0 S>rP`'I'IC Alam APPOnsces and Awwriea 0FCI (Faceless) 4 0 20 Amps Bxl►aust Feud b 0 IFIN.P. Oven 1 0 9 KW Air H041W 4 0 F.H.P. Air Cam_ b boner 4.0 20 Amp Electric Heater Unit 4 0 TOWEL Electric Hieakw Unit 4 0 M=0 Taub I 200 40 1 too 20 Continued on 14cm Paps t Of 3 seal this cectiticate may r� be allwed in any way and is validated only by the presence o4 a raked seal at the tacai iCk9iCated. U- 11/27/2007 15; 37 W OQUARD OF FIRE UND AAGi 03 BY THIS CERTIFICATE OF COMPLIANCE THE BUREAU OF ELECTRIC#TY 40 FULTON STROE• — NEW YORK. NY 10038 CERTIFIES THAT Upon the application of upon promises owned by BACCARI ELECTRIC SITTMAN QW. TIMBERLINE, AW)OC. PO BOX 243 110 K BEDFORD RD., STE 102 MILLWOOD, NY 10546, MT. KISCO, NY 10549 Located at 31 TIMBERLINE CT PUTNAM VALLEY. NY 10579 APP10tion Number: 3030272 Cot"Icaft Number: 3036272 Section: 51 , Block: I Lot: 50.6 Building Permit2007--49 BDC, W106 described as a occupancy, wherein toe premises electrical System tem consis ing of olect(icol devices and wiring, deseribed below, located in/On the premises at. Onmem, First Floor, SemW Flow, Attacbwl 0"o, Outside, Atli% A visual inspection of the promises electrical Wsturn.jimitoO extent detailed to electrical devices and wiring to the herein, was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of Now York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to b a f e in compliance therewith on the 21st Day November, r, zoo 7. a M wit Tx 09 I ad Devices neks 116 0 GFC1 acle 1 0 1515"Ic SPmw control c9alar 1 0 se"Ic smial 117 0 Oewal Puqx.w 153 0 lacandftcM 9 0 underca bK4ftftceW ale 1 0 30 A vac Applium MID 1 0 30 A Dryer Ack 6 0 20 A Applimm 1 0 WELL motor Control I Phaso 3W Service Raft 400 Amperes &MCO Visco=e0t: 2 200 CD Nem: I seat Caraipued an Next Page 2 of 3 This certiflCft may not be alWed in any way and is valliclateO only by the presewe of a raised seal at the location indicated. 11/27/2007 15-37 05-64547621 W OWRP OF FIRE L;NV PAGE BY THIS CERTIFICATE OF COMPLIANCE rHE BUREAU OF CLACTRICITY 40 FULTON STREVT - N9W YORK, NY 10M (P79IRTIFIE4 TNAT Upon am application of 8ACCARI UECTRIC PO 00X 263 WW WO, my W.W6. W- ateo at 31 11MOERLINFE CT PVTNAM VAUEY. NY 10579 3035272 &estion: 51 Sh xk: I Upon preMiseg oWneO by PffTMAW DEV. T1141WRLIKE ASSOC. 118 W. PEDFORD RD., STE 102 my, casm-, my Iwo Cedjjioto M=b= 3036212 Lot: 60.0 Ouildin g Permit-2 001-60 80 wide Pownw- asp Occupancy, wherein the promlses electrical system consisting of el(Ktfir,al devices and wiring, desctibecl below, located in/on. the Premises ats owowwK, Fixo Flow, Second row, Amwbed GaWv, Ou"Ide. At*, A visual inspection Of the Promises eleciricol system, limited to olv trical OWC" and Wifin$ to the extent detailed herein, was conductaO in xcorOanm with the requirements of the applicable code a anclJor standard p►ornuApted lay-the State of New York, Department of Stato Code Enforooment and Administration, or other y . and found to be in complipnee therewith on the 212t Davy of No authority having jurisdiction. Da vgmber, 207. Qu an Soft Qkq* I= $041 3 Of 3 This certifi�, may not be Arow in any way and is Wldaed only by the oresence of e raised seal at ft 1000on indicated. Nov -20 -07 11:47A Ralph G. Mastromonaco PE 914 271 4762 I`T2 t FAX P.O1 v: .y.C'..�.... �r =..r.a �►.w +.:L aM.: •�..t -.r ase:..... xa.. •...a .:'[. �' r:•.!` �. a'• ��. a:";-' nr... rr: Y'.ry e.• p.< n; �anu .imn.at'. >.� »e.i.....ra...o.. '..1:.n s..w.9r+�v.. .ec.. rr .....n .'a...rCM >..•i .'a.rz.:.r- xy....�. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FINAL. INSPECTION For: f U Date: I f 2D 10 Trenches PCHD Construction Permit # SW - D°i - O 2 Located: T NBEF i -LI NE C ou ILT (T) (V) �uTtAAR VALLEY Owner /Applicant NameTl M BEQ.LIhiE Ass OGI ATV& TM 5l Block' _� Lot 50 - �0 Formerly: Subdivision Name: T msF.P- 4F- EST es Subdivision Lot # Is system fill completed? ES Date: Is system complete? Date: 8 14 0- Is system constructed as per plans? `ins Is well drilled? YES Date: Is well located as per plans? `f �S Are erosion control measures in place? E,�S I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: ` 1 1126107 Certified by:, _ RA esign Professional Address: Lic. # 5440►$ Comments: lsneEGrloo REQ��ST� -1`'09 PUL/LP T S�_ LA K - 914 -2-7 1 -47(o Z FOR: ❑ ADAM GENE (NAME) Form FIR -99 SHERLITA AMLER, MD, MS, FAAP LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 August 17, 2007 Ralph Mastromonaco 13 Dove Court Croton -on- Hudson, NY 10520 Attn: Mike Dobler ROBERT 3. BONDU ROBERT MORRIS, PE Director of Environmental Health Re: Field Inspection — Timberline Assoc. Timberline Court (T) Putnam Valley, T.M. # 51 -1 -50.6, Lot 6 Dear Mr. Dobler: 9 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. Silt fence must be erected and maintained as per the approved plan. 2. Pump test and bedroom count must be performed. Please call when ready. If you have any further questions, please contact me at (845) 278 -6130 ext. 2155. J-" :ens Sincerely, J seph Digit Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 RALPH G. MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 (914) 271;4762. (9.14) 271 -2820 Fax r �. Gene Reed Putnam County Department of Health 1 Geneva Road Brewster, NY 10509 Re: Timberline Associates, LLC Timberline Court, Putnam Valley, NY (TM #51 -1 -50.6) Lot 6 Dear Gene: August 10, 2007 As requested, please find enclosed two (2) signed and sealed copies of the drawing entitled SSTS Plan R. S. Lot 6 of Timberline Estates, Town of Putnam Valley, dated September 27, 2005. Please call if you have any questions. Sincerely, Ralph G. Mastromonaco RGM /nf Enclosures Aug -16 -07 09:20A Ralph G. Mastromonaco PE 914 271 4,762 P.01 VS5 -Z -78• -"79 Z 1 I:Ax .a.N:.•.a .'�.: '.a. c...., t. C::-.. ,sr.:4:•.- ,.ri:.ar�...l:nU:.�. w: -r. ..- t--.v..w..... .as.s.: T: n....c >r�_>. ..T «.aa:� a•,r.... .,.s -., ., -c.nu w.. � >..;r: �;ra.Paw •<:c.._:. k.-. .z.,. - -• .�-.a: e.:., _,rune ne++•�.;:a.v...._ MQIMST FOR IIP IDl� For: Fill Date: 1 85 0 Trenches PCHD Construction Permit # Located: T P4BERL9 AJE (::�pu KT (T) (V) PuTiAAV4 VALLC -- f .Owner/Applicant Name:T1 M �P-Wh e AsscG- -wvs TM �� Block �,. Lot S�•� Formerly: Subdivision Name: TI i EELA ESTATES Subdivision Lot # Is system fill completed? Is system complete? �(E5 Is system constructed as per plans? `ins Is well drilled? 'ICS Is well located as per plans? 'f ZS Are erosion control measures in place? . f Date: 6010` Date: F3114-10"T Date: -7 I certify that the systems), 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 and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. ....= w__.. ,...- "Date: . �. ^ «. .v .. ... Certified .by: .. .. _ ......... . ....... __ ....PE. RA _ .. Design Professional Address: ( -2-5 Qod 6 C-QJ li✓i CP-OMO 3 •®0- 100SO O Lic. # 5 44Pt S Comments: L J52F.CTjO0s F— %F POs- P IELD1 OiUL`(. Bane ua 1u Sm&u..� AT T�l S 7. E MIKE - q14-- 2 -71 --4 -7&z FOR-- ❑ ADAM XGENE 0 (NAIV E) Form FIR -99 t-60P-E SiAgi c . . . . . . . . . . . ... F-4p Rll� V. 784.60'1 4 20.0 L.F"". 77A. 4.. CIP 2.O% 1 MN. TANKS, 1500 GAL. CON6 DUAL COMPARTMENT SEPTIC TANK-SET-1ft . At - GRAVEL BED T50O--- GAL J=NCPUlMP CHAMBER 769.7s W1 24 DIA. TO GRADE. SET ON 3" PEA GRAVEL 70. ...-278.0 Sm -40 19AA11V W"-", AL PROPOSED 89. W 50' MIN. TO FIE 92 0 94 ja DT6 . 81 LG 000 DT3 H tP RONLED SV�_ 9 ok PH8 J1374 Z DT4 or r 3 %0' PH(), A O.C. 0 &JP! 7 PHC T PHA-- %4 BAFf�,E, - - --------- . . .... ......... . ..... . ... .. .5DS-ARIE, -9000 1. .... -THIERE -ARt.-N0 -S&FW-S-40eftTIW:- DIRECT-LINE OF-DRAWAGE AS SHOVM. PRbposEu wr=L6 LOCATION 4" PEFW.-- 15�VC - - REAR S , T C -FIRST- Q�Er-OVT'­ OAI56 �. I % _ORE LIN Ropos -B -TO-I5 -PLA - CE ENTIRE PRIMA la :�A:R ARE Ix ";VA� MY &,,EXPJ(ki; ENTIRE— S LS dK ��-SGROUP ts" S PE 'k-lUM40S OR FL N THOW-ARe-NU lW- Ef�E OF TFtE-eROPOSEO - SSTA. --- 9STS-ARE-TO BE STAK -13-Y-A ON. o2 33iE -PRMM TO IRE TAIRLOrCONSMU SUIRYIEYOR Sep -19 -05 10:27A Ralph G. rMastroenonaco PE Ill Z1 BRUCE IL . FOLFY 914 271 4762 P -01 - - - �- Assaefnte i'rablic l�fagfth Dt- riectov Dbwerar of Palfanr Sw Wccs DEP1RNT OF HEALTH I Geneva Road Brewster, Now York 10300 REQUES1 FOR I . I 'osEPF PAPAVATI ATTEN'T'ION: a ADAM YnEEELING El can MID All inforane;eioni below roust be iW11 completed prior to any scheduling. DATE: 0 ENGINEER OR ]FIRM. ��P.� �. M��QkdR PHONE #.(914) 271-- 47 2 REASOM din n iTID1 AL DF- EpTEESTt-1olES I� 114e C-).pA, Sloe AREA DEEPS: X PERCS: 13 FUW TEST: o Kt: i Aug-10-07 02:43P Ralph G. Mastvomonaco PE 914 271 4762 P.03 _ •w •.._. 4�'� S c.':, • -. .s_.__. •... ,T.'���. ••.:... .iv..� n '.`ti. � .. T- ,a c�W`i C ., .. '.4. ... ... ... Ate., Mi..._W ,..... ._ o b'.•er _K•: ' v J µ :. ................ -OF SILT F CE N >e p 'BUILDING DRAIN - DISCHARGE �$ s0 f Q 10' #AIN. TO N S 1500 'GAL. CONCRE•TE.....__.._... . DUAL COMPARTMENT PROPOSED y -19 :'_.: :+A;l;':.:S� << '•. 'SEPTIC TANK SET -.. N 3" PEA GRAVEL BED 3Zt0 DRIVEWAY :,? 4A•_P:;; ' ' S00 GAL. CONC. PUMP CHAMBER ' 789.75 ;, >ep W -'2 *......DfA. ACCESS MANHOLE �`,,.�'�.;;;.: T o GRADE. SET ON 3" PE .• , ., 1000 GALLON' CONCRETE GRAVE ' J A OVERFL4W'STORAGE .xANK :.. .:.:..:.... a A� �� ° "'SE•T'ON 3 PEA GR .. .. -.7.89.75 + SCE FORCEtdAIN 1 '20' -MIN. � ,......-y. • .. _. D � LINE O F SILT FENCE 00 '790 / r 9% 11 f ... 4... Al T 7 DT4 -�g3�. u�' ��.6 X815 72. ... Exp`jam %_ .... . I 63C� A 721 i1REAI...- DT2 ' . 1gHA:.63 yg1 •. DISTRIBUTION._ � ..., - .. ...... -_... � �, .•- p.OX •ill ._..._.... . - ' '-� 1 EATEL1 ANTfi1TT UPSI P SSpS 4REA - _ . . 5LE..IN- DIRCC1..._ 9,000.: -- f _ pF-'T13E.,pOopoSED WEtL...LQC.A_TION AS SHOWN- ... . __.,._._..... _. 4" PERF. _PVC MTH -CAPPED :kRo _ .) . T1{Ef� E_NO .EXISTING OR -PROPOSE SHELLS £S .RS 5W0 _Ff OU7 'OF ; ::...::: : -: - ' M� . - ^J.00ATEIS WITHIN 100' SL •OR.20�i`_DOWNStOPE IN .QJRE-GT t_iNE OF'DRAJ[IACE..QF" PROPOSED S5DA --. 3. FILL TO,. 9E .RtACED.OVER PRIMARY de EXPANSION' AREA: . ,...- .. -.- EtJ'TiRE SatA S`OiLS A�tE P 6—SP fIED�hB_ CHARLTON LOAM.... IXIM'ATEL`Y 7440 CY,,,REOUIREA) COMPLEX .... ...- ................ ......_......................., A -R'PDRi3C•00TC' A_60P B AS PER USD SCS SO SURVEY. ' - -' TLAN05 OR THERE-ARE 1.A�N. _...,......__.. FEET OF THE PR 5STA. ........................... ......._..._...._._...._.• ....._....- 80UNDARIES... DN. ..OR- 1MYHIN..1.00......�_....r, -- �.--- -._; -. ... _ . T�� a AND ^SSA TS E...STAKED BY A LICENSE _.._ ..- _... yEXAR PRti�O T, OF CONSTRUCTION. ROO - -... �? -t�. 06/21/2007 18;42 PAX 845 206 4376 PRE CAST CONCME 0, en—w Modd A 8 C D QT-760 ar 4' 66' 52" 551, OT-IOW 94r 0-10' 66' 52' 55" OT-1250 10' & OW SZ* 55" OT-1wo ICY-W 51-C 650 521, w GT-2000 1z 51-r 671, aw w OT-2500 VT WO 82" W 710 GT-3000 1 121 OW 933" 7V 82" 4' PoMcr, fnkft BMS em be ralowwd to Skoog 2411 Die. Cover A 1 2W* Dim, Menholo* " L 11 1 ----------- I 14002/002 Vent Pqw by okra 177= S a Walt Rldom avalle"D in r A. 12 cr 2411 haf@hta I :z: NII A Union Flost Chug C vew 0 Di k SION" amd .1 LMCOW *Wopenlnip Is Ow rrinimum roemsery ibr pump 00- S. We haw 317 and 3fr cow avaNable @S wW1 as akrfOnum ho& ckma. 3 SPECIFICATIONS Precast Concrete Sales Comparly P.O. Box 616 Valley Cottage, N.Y. 10989 Phone 0 (845) 268-4949 Fax 0 (845) 268-4376 U0/ZI./ZUUI is:%;d PAA $40 XGIJ 4a75 ME VASI ;jUN(;MKkh PRECAST CONCRETE SALES COMPANY 123 Route 303 • RO. Box 610 @ Valley CM69e, N.Y. 1 =9 (846) 208-4949 FAX #.(845) 208-4376 WEIIISITE: proca►oncmi"ahm.corn FAX TRANSMMAL SHEET Date: lir e/-LV Time.- To: 9 09-r - ? Alp Attenflon- Frorn: &tzer- messap:. I& VUI/ UU4 UTILITY STRUCTURES pipe A IqTTw08 C"77mas RETYUMNa WALLS SEOTOMLE FADWS WAIVKVORKS SWIRUL58 Totsi pages Wed (Including www sh"t.) le — A00M. if you have any dIfficulty in receiving this message, please call us immediately, *** �'', '"�. �� s ( ��' . eye � F' ��� �. a�� • . m�� � �� � � � I (/� � � � � '� � i i e _i�s.�- ..a.,:...... _.w...n.a.w. e...+a .+n...+.,.. .. .. -.e. ..i . ...,...• 'r- ,_ C..r. .�.. w.� a. ... _u��'m a: =:�-.. �...._ -W.-e. x::.o ,..n.cx. •; CONSTRUCTION PERMIT FOR SEWAGE TIBIEAT1ViIIEIN R 5V S 1 LIVII Xy PERMIT # �� Located at -F1 M DEE L I E ee,'-O V Town or Village P JT AM btu LUSY Subdivision name' ubd. Lot # (p Tax Map I Block Lot 50. Date Subdivision Approved 12.11 I9 (o Renewal Revision Owner /Applicant Name T I M BED,LI �E A5SOCIAT Date of Previous Approval Mailing Address 44-1, � R- (�l� U1��1 �T I O9,li�d �flE � �.� Zip I ®� %'� Amount of Fee Enclosed 400 Building Typ Lot Area 18.4 No. of Bedrooms Design Flow GPD _LCCX:) MIR Section Only Depth Vollu me PCH D NOTIFICATION IS ICE UIREID WHEN FILL IS COMPLETED gallon septic tank and Other Requirementsl E 9.0. 5. F I L. L • PI Nil F AM ft- oV R le LoW '�A � To be constructed by To BE ®ET E R M O E ® Address Water Sun ®�Ie: Public Supply From Address Prrvate Su Bril-led..b `tom 'pPly yam° _.. ._ . I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the s_parate 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 ce of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. -� A NOR Signed: ALP �' - r�, APIEnIB ®V]ED F ®ll� CONS ;proval expires two years from the date issued unless construction of the sewage treatment system has be inspected inspected by the PCHD and is revocable for cause or may be amended or modified w onsidered necessary yhe Public Health Director. Any revision or alteration of the approved plan requires a new pe t. pprov or discharge of domestic sanitary sewage only. By: Title: U Date: j White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 ;: 1....,......1 _ ..,. _ ,...... 11 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE APPLICATION TO CONSTRUCT- A, WATER WELL - please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # I M EW L I1 e oU IZT PUTt AMV L Map 5l Block I Lot(s)506 Well Owner: .- Name: �� Address: ZZZ G PLACE c u —S-r. Pow- I H FLEE 114 CME51 -, N.Y. ID5�3 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 I t gpm # People Served _4- Est. of Daily Usage I CX^agal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason pRoV i DE WATER S E WIG.E FO F_W R ES 1 DE F_ for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... ' Yes No Is well located in a realt subdivision? . ..................................... ............................... Yes >C' No II Name of subdivision I M 15E V-- L I N e E5-rAT ES Lot No. Water Well Contractor: T-p 8_F_ D E"T'E P-M 10 E b Address: Is Public Water Supply available to site? .................................. ............................... Yes No k Name of Public Water Supply: I A Town/Village /A Distance to property from nearest water main: 9ZE Proposed well location & sources of contamination a rovided on separate sheet/plan. - Date: 9-1 O5 Applicant gigiiature:.. P _.. , . - - - 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 revision or alteration of the approved plan requires a new permit. Well to be constructed by a wat; well r ill er cerlifled by Putnam County. I Date of Issue 1w 12,6 /or. Permit Issuin icial: I Date of Expiration , G Title: Permit is Non- Transferiabl 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 SERVICES b z r.. .x . „w � . .. r. ... '. .... .. Kr• +.'.. a.r. ....x .. t aa. i.... [ n. 'w -. ..-.nu. c� .�.c •.. ....- .....a ... .- _. .s . I.. 1a .. c .�v.+.e•....• + + o I..•..M.,.... aV : +sw a ... ♦.r .w .n�-.x rma• d fa... na�v� APPLICATION FOR APPROVAL OF PLANS FOR - A WASTEWATER TREATMENT SYSTEM 1. Name and address. of applicant: TI M BER L.I IJE AS5oo A-T55, L,LC. ZZZ G RAGE CtiURCJ4.5i'IZEET P0P—T GAESTEP— � 1JY. 10513 2. Name of project:T IMBERLWE- EgTATE5 3. Location TN: Pu-'�AM VALLE'( 4. Design Professional: RA A G . MAST90�tt,�J Address: 13 Do y E GOuizr or��otil- � 1JY.IoSZo 6. Type of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subidvision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? .................... 9. Has DEIS been completed and found acceptable by Lead Agency? ............... A 10. Name of Lead Agency 1 L. If this project is an area under the control of local planning, zoning, or other . officials, ordinances? ......................................................... .............................. ES 12. If so, have plans been submitted to such authorities? ........ ............................... A 13. Has preliminary approval been granted by such authorities? Date granted: LA 14. Type of Sewage Treatment System Discharge ................. surface water groundwater 15. If surface water discharge, what is the stream class designation? .................... A 16. Waters index number (surface) ...................... ...................... ....................... A 17. Is project located near a public water supply system? ....... ............................... ►JO 18. If yes, name of water supply l� �A Distance to water.supply 19. Is project site near a public sewage collection or treatment system? ................ 20. Name of sewage'system l IA Distance to sewage system 21. Date test holes observed 5 11-7105 221 Name of Health Inspectorfo tE VAT I Form PC -97 23. Project design flow..(gallons per day) ................................. ............................... -_..� X, c w .µ � .-• -a ca-•c ..: -: s ., -F. ^:I:.:. cf4+�, >c::. :a.r: r: -:c'F v. ' 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. 2 1 000 O 25. Has SPDES Application been submitted to local DEC office? ......................... . hVA 26. Is any portion of this project located within a designated Town or State wetland? t O 27. Wetlands ID Number ........................................................... ............................... II 28. Is Wetlands Permit requited? ....... ..........................::....:....:. ............................... f O Has application been made to Town of Local DEC office? ............................... 29. Does project"requke`a DEC Stream Disturbance Permit? .............................. O 30. Is or was project site used for agricultural activity involving application of .pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application'or industrial activity? ..................... ........ Yes/No �D 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? ... ........................... .I... Yes/No CIO DESCRIBE: 32. Is there a -local master plan on file with the Town or `Tillage? ......................... 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? . ............................... IES 35. Tax Map ID Number .......................... ............................... Map 5 l Block Lot 50. (® 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 l.,the application must be accompanied by. a Letter of Authorization (Form LA -97). Failure to comply with this oyJ ion may be grounds for the rejection of any submission. M. . . bra d hereby affirms under penalty of perjury➢ that information provided on this form isFIruC ~: `-r to the best of my knowledge and belief. False statements made herein are punisha at, 61' �v }� c a - g4ss-A misdemeanor pursuant to Section 210.4S of :the Penal Law. •. „,, of -Npe SYGNA 1'II T'�ESe RA, L Psi 6q. MASTPZO'MO�Ae-o Mailing A s _ ::.... w ........... P10\15 � U R: a o• 054��a� /ilJID��OI�`��•i• I�GO RALPH G.'MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 _.._.. :., _.::(9.14)_27.1: - X1.762.... (- 91,4);2.7..1, -2820 Fax . _ .. :.- -.- - . . . Mr. Joseph S. Paravati, Jr. September 9, 2005 Assistant Public Health Engineer Putnam County Health Dept. 1 Geneva Road Brewster, NY 10509 Re: Timberline Associates, LLC Timberline Court, Putnam Valley, NY (TM #51 -1 -50.6) R.S. Lot 6 Dear Joe: Enclosed please find the following materials: 1. Five (5) signed and sealed copies of the Site Plan Lot 6 of Timberline Estates (Sec 51, Block 1, Lot 50.6) Prepared For Timberline Associates LLC, Timberline Court, Town of Putnam Valley, NY, dated September 6, 2005 2. Four (4) signed and sealed copies of the Construction Permit For Sewage Treatment System 3. One (1) signed and sealed Letter of Authorization 4. One (1) signed and sealed Affidavit - Corporate Owner Application notarized September 9, 2005 5. Four (4) signed copies of the Application to Construct a Water Well 6: One. -(1 -) = signed and sealed copy-of the Application For.- Approval.. ..of - Plans... For :A. Wastewater Treatment System - -- ..._ 7. One (1) signed copy of the Short Environmental Assessment Form 8. One (1) signed and sealed copy of the Two Design Data Sheets 9. One (1) signed and sealed copy of t ump Design Calculations 10. One (1) copy of the pump curve 11. Check in the amount of $400.0 ayable to the Putnam County Dept. of Health 12. Two (2) sets of architectural plans for a five (5) bedroom house We are requesting your review and approval of the submitted materials. Please call if you have any questions. G. Mastromonaco RGM /jl Enclosures Rx Date /Time SEP- 01- 2005(THU) 09;41 914 271 4762 P. 002 Sep -01 -05 10:38A Ralph G. Mastromonaco PE 914 271 4762 P.02 -EI1�°N COUNTY :DEPA TMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF A UTHOIUZATROM FIE: Prol erty of T j M 13F_ !Z L I l E A66a, l A►T ES � l Locoted at _) I M DEE L f E (:� ®U V\rIS 1 NAPS VAUer Tax Map # 51 Block Lot 150• Sub [livision of 1 I M BERU �U STATES i Subdivision Lot # CC Filed Map # 2699 Date Filed 12- 13 9 Gentlem4 This letter iis to authorize RA LPd 6= , HA ATP_oM y�ACQ -a duly licensed Professional Engineer X_ or Registered Architect to apply for the required wastewatet 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 tI alth Department, and to sign all necessary papers on my behalf in connection with this matter and to- supervse,the construction of said wastewater treirnent and /or water supply_. systems. in . conformitk with the provisions of Article 1d5 and/or Id7 oiihe �ducatioii haw, the�`urc HeafYii -'� - - Law, and the Putnam CO un itary Code. of NEW AGE MASTh' Countersued: P.E., R.A. # O� '� 1 0. Mailing �ddress-'1_3 &�AIZT cl�=d - 0�- H uDseJ i�)My�o State K Zip 1 o5 Z o Very truly Signed: (Owner of Property) ao -%C-T bailing Address: 11b 1 b epfio98 9Z WWkA1JT V4SUO State Zip 1VS41 Telephone: q 14 ^ Z44- 860D X10 Form LA -97 Rx Date /Time SEP- 01- 2005(THU) 09:41 914 271 4762 P.003 Sep -01 -05 10:38A Ralph G. Mastromonaco PE 914 271 4762 P.03 i i __..._..., :__ .. OUTNAM - COUNTY _DEPARTMENT OF HEALTH DIVISION b F ENVIRONMENTAL HEALTH SERVICES i AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PER-NOT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the mat* of application for: I I MBE I. I C— E i tc- 1 10K- t-IAUS - e L LC,. represent t at I am an officer or employee of the corporation and am authorized to act for: Name of C rporation:- i m gEIZ Ll tJr-- 46G ,&T es L Lc-,. Having ofoces at: 11b N10 4TA &e0kkD 9'W % MSS K-• SQ0 • i �� President - Name: eRky' --Tyu-kL w�- I A dress: �`c �� ^ r No Vice Presi ent - Name: Address: ISecretary Name: Treasurer J Name: A -644 � Address: S la- � D00Q G and that I to the ant Sworn to Notary Publi and will be individually responsible for any and all ac corporation with respect al requested and all subsequent acts relating them o me this T (day of th) (year) I VJOLENE L�1T Nbtary Public, State of New York No. 4794758 0+ ellfied in Westchester un Cornllission Expires July 31, Form CA -9171 Signed: k" " I Title: 61 Corporate Seal 14 -164 (W)5r -Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix C State- 1= nvirbnmental�Quafitr 'R�viewi:�:._�- ^" °..�: _..,.,,..,-, �...,,..., ,..._,.�.•;.,;.,...:,.,,.�:,.., SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only . PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. AP LICANT ISPONSQR 1-leERL I C E ESTATES ECT NAME -1-1 M B R L.I t�E ESTATES 3. PROJECT LOCATI I �UT9 A M VA LI-E'f PUTid AO Municipality County 4. PRECISE LOCATION (Street address and road Intersectloas, prominent landmarks, etc., or provide, pI ApP�ox . 3c�o FeET-' EA-1T 0 TAE 0-5e-- ►w►A�A LA D�c„Ar,�+►�lA i-� E I Gi 1- �oAI� I �TEZS MCT Io iJ . S. IS PRO ED ACTION: New ❑ Expansion ❑ Modifloatlonlalteration .6'. DESCRIBE PROJECT BRIEFLY: s�o s'�'�.ucTiotJ of As11JGLE FA MILy P.GsIDF•1•�cE W I SE �G WE LL C) �I�WA"( Arlp Ass0c1ATEP G�►DI►�G. Pr _ 7. AMOUNT OF D AFFECTED: R �,/, , I `'' `� Initially rM acm Ultimately c acres 8. v!v i PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 9. 13 PRESENT LAND USE IN VICINITY OF PROJECT? M�� dential ❑ IndustrW ❑ Commerclal ❑ Agricutture ❑ ParldForast/Open space ❑ Other Describe: 10, DOES ACTION .INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE QR LOCAL)? ❑ es . No It yes. Ilst agen and Perini p s PG.D H. - 60AR00F EALTH RdAtl-- 1 � PIA141�1>�G ►P_0 -SITE DEVELo M ENT'A PpR %/AL. v AMVALI.� 11. DOES ANY ASP X= OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes No . It yes, fist agency name and permittapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ j4O Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE LP� M*T2C)MO�A60' O� Applicant/sponsor r` Data Signature: 1 If the action Is in the Coastal Area, and you are a state agency, complete the. Coastal Assessment Form before proceeding with this assessment OVER 1 PART 11-- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No - B W 1-U ACTION "RECEIVE COORbINATEO REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency, ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING; (Answers may be handwritten, if legible) 01. Existing air quality, surface or groundwater quality or quantityy, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage.or flooding problems? Explain briefly. C2 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; of community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildiife.spedes, significant habitats, or threatened or.endangered species? Exptaln briefly.. C4. A community's existing plans or goals as officially adopted, or a change In use of intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C - CS. Long term, short tent, cumulative, or other effects not identified in C1-05? Explain briefly. lip, �A C7. Other impacts (including changes in use of.elther quantity or type of energy)? Explain briefly. $ --- 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E IS THERE, OR IS THEME LIKELY TO BE, CONTROVERSY* RELATED TO PoTENTIAL-ADVEfiSE ENVIRONMENTAL' IMPACTS? ❑ Yes ❑ No H Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by- Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, Important or otherwise significant. Each effect should be assessed in connection with its (a) setting p:e, urban or rural); (b) probability of occurring; (c) duration; (d) irreversibiilty; (e) geographic scope; and (f) magnitude. It necessary, add attachments or reference supporting materials. Ensure. that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately'addressed. It .question D of Part ii was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box'if you have identified one or more potentially large or significant adverse impacts which MAY 'occur. Then proceed directly to the FULL EAF andfor prepare a positive. declaration. ❑ Check this. box if you have determined, based on the information and analysis above and any supporting documentation, that the. proposed action WILL NOT result in any significant adverse environmental impacts, AND provide on attachments as necessary, the reasons supporting this determination:. Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible O ricer Signature of Responsible Officer in Gad Agency Signature of Preparer (if diffe—mm from responsible o ker) Date 2 1 it M i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE PrIqWrSYSTEM Owner] mbE—ZLWEA Address F9 C, H 6 s r F- p— I M ENE-y- L. f -'L')P--'T- 'T Map Block Lot 5o.6 Located'at "street) h - ' " axM (indicate nearest cross street), MunidipAlity R L r A-M ,Watershed SOIL PERCOLATION TEST DATA Date of Pre-:'soaking S11-7los Date of Percolation Test E;//8/OE; PHA 1 3:10-3 30 zo Z3 3 2 20 2-0 2 7- Z. 10 3 .3'30-3:50 3 50 -4:10 ZO Zo Z Z 2 10 4 FH -3 0 20 23 3 2 3:4Z-4-: 12- 30 -20 Z Z /Z h 12 3 :15-445 30- 20 2 2 /Z Z '�2 12 4 5 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. -< I min for 1-30 min/inch, :5 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 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES ..:.. ;...:, DI✓PTx -.. r z_. �ILoT -1. -. �.. Y:_:_ . xoL No:- CQT- 2 = _ _... HOLE G.L. TO Fso L To P50 I L_ To PSo I L_ 0.5' 6Roy� LOAM... .uo M L. o,A M 1.5' 2.0 I 27" DAR.IC BPZ &W� 24° 5A LOAM OAM 2.5' PAM 50ow$d SA�p -I' LOAM 3.0' 5A�DY LOAM 3.5' 4.0' 4.5' 5.01 o��� 5.5' t� o a p_00 � PwATE �_ Rc)c, ,�1_0, 51 -61, tl o G , W. 6.0' �o 6.5' 7.0' ©, 7.5'" ran 10.0' Indicate level at which groundwater is encountered IJ o �j E Indicate level at which mottling is observed IJ D� E Indicate level to which water level rises after being encountered o Deep hole observations made by: Qp AeoZmFAJVArj Date 511-1105 OP9 V9 t4 EKV.%l Ll FF(a .) - Pr- r) Design Professional Name: P,q L Pt4 G . MAST 2O MO1Jl Address: 1J po\/E (::0up.7 Signature Design Professional's Seal PUTNAM COUNTY DEPARTMENT Of HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner,7 rtmgEQ - -L-1 E AS�DC_--1 AT-Er.' L LG ,kdd'foss 222 6 gAcg C, uecd ST > p_- r Located at (Street) RLAE( OVP-r Tax Map `51;*Block "I Lot 50.69 (indicate nearest cross street) Municipality Rfr�140 \IALL r=--r Watershed U P�—O� SOIL PERCOLATION TEST DATA ­�'- l Wie'of 'Pre= soaking 'Pre= soaking ']),ate of Percolation 'Tdk' c)5 X. .............................. ........... ....................... ......................... . ... ­ * ...... ** .; ........... ......... . . ........ :::: ­ ­ ....... ........... . . D: dot A h 0 ..... " . ........ ..... Hole. No ..... ... . .. ....... . ................. ... ............ .. .. ..... ...... .......... ... ......... . . M J... "F . ..... Ground From 4ace: nch...e. ..s.l . e V. f. Q . Rats U xn .. ....... .. . t -V to ... ....... ..... n . ..e . . .... . Pstiil Sfop . . . .......... . MiWInch ...................... ..... F, 3:18-3:45 20 2S-1 3 9 2 3*45-4:15 30 zQ'_ 2 3't 10 3 1 -4:4-5 3O 2c) Z 3 3 1 4 5 > 2 4:cc)-4:� -3o 2jo 23 3 10 3 4; •30 -5:cc 3 o Zo Z3 3 10 4 5 2 3 4 5 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, :5 2 min for 31-60 niin/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES DEPT-11- ::;:.;; GLE�NO .;.•E T'.. ......�.,DDL t: T �-cJ- ° ._... __GL - NO, ---0— - -. G.L. TO So1l. ToPsoIL 1 OPSo1 L- 0.5 : 8 S 1 LT LOAM 8" SILT LOAM X1:0' BR0W ;LOA M 1.5` 2.0' 2.5' 3.0' 3.5' - °SAIJDY LOAM MED.To FIiJE - SAt Q-f LOAM 4.01. SA .f DY LOAM .MEN. 4.5' 5.0' 5.5' f2.�G IC,s� 5-60 � 0 5 —(o I 6.5' laoGK@ 7.0 rlo 6 12.oUf PWATER. 5� Q o &r��� Cn rn 8.5' _ 9.0'c 10.0' Indicate level at which groundwater is encountered N o f E Indicate level at which mottling is observed 0I e Indicate level to which water level rises after being encountered 100 e Deep hole observations made by: RALP46. V�6rgomoo Aco ;Toe F1IzAVATi Date 5 17 OS Design Professional Name: Address: 1 '--2) vF e' Signature: Design Professional's Seal of NEyy Y y�Q'� \&GE MASr� o 4 1k: + v n � t`' yci W �0. 0544°�� pROFESSIO�A� COMPUTATION OF SYSTEM DYNAMIC HEAD LOSSES TIMBERLINE ASSOCIATES-LOT 6 DESIGN FLOW: CFS ITEM INTERNAL PIPING DIAMETER: INCHES LENGTH OF PIPE: FT HAZEN C FACTOR AREA PIPE: SF HYDRAULIC RADIUS: FT DESIGN FLOW: GPM VELOCITY:,FPS HEAD LOSS: FT BEND 90 DEGREES K VALUE VELOCITY: FPS HEAD LOSS: FT CHECK VALVE _...42. _ - _ __. _.... . NUM. PUMPS ON 0.094 VALUE 2.00 . 5 145 0.02 0.04 42.00 4.289 0.18 0.75. 4.29 0.21 FLOW:GPD 60480 HEAD LOSS COMPUTATIONS HIGH POINT PUMP ELEV. STATIC HEAD: FT DYNAMIC HEAD: FT TOTAL HEAD: FT 0.18 �p ........... 801.70 772.70 29.00 11.74 40.74 K VALUE 3 No. VELOCITY: FPS 4.29 05449 HEAD LOSS: FT 0.86 0.86 BEND 90 DEGREES K VALUE ols VELOCITY: FPS 4.29 HEAD LOSS: FT 0.21 0.21 BEND 90 DEGREES K VALUE 0.75 HEAD LOSS: FT 0.21 0.21 INCREASER INITIAL DIAMETER: IN. 1.25 INCREASE TO DIA.: IN. 1.500 K VALUE 0.46 VELOCITY 1: FPS 4.29 VELOCITY 2: FPS 2.98 HEAD LOSS: FT 0.01 0.01 FORCEMAIN PIPE DIAMETER: INCHES 2.000 LENGTH OF PIPE: FT 278 HAZEN C FACTOR 145 DESIGN FLOW: GPM 42.00 DESIGN FLOW: CFS 0.09 AREA PIPE: SF 0.02 HYDRAULIC RADIUS: FT 0.04 VELOCITY: FPS 4.289 HEAD LOSS: FT 10.05 10.05 TOTAL HEAD LOSS: FT 11.74 Details: Pump, Characteristics Performance Data Pump/Motor Unit Submersible in 1 24 Ce I8 z r °. c = =12 0 Materials of Construction Ha ndle Stainless Steel Manual Models (50) Ml M2 M3 M4 I M5 Automatic Models Al A2 I - - I - Horsepower 1/2 Full Load Aqs 15.0 17-6/7-11"All 1.6 1 1.2 Motor Type Capacitor Start R.P.M. 3450 Phase 0 10 1 30 Voltage 115 208. 230 2*2301 460 1 57S Manual Models (100) M2 M3 I M4 I M5 Automatic Models 11 A2 - I - I - Horsepower 1 Full Load Amps 13.6/12.1 6.0/51 21 1 1.9 Motor Type Capacitor Start 1 30 R.P.M. 3450 Phase 0 10 1 30 Voltage 208 -230 1208-23014.60 1 57S Hertz 60 Temperature 1401 Max Fluid Temp. HEMA Design L B Insulation Class B Disdtar a Size 2' HPT std Solids Handling 3/4" Unit Weight 58 lbs. (50) I 65 lbs. (100) Power Cord 115V,14/3, SJTW -A; 230V,1 a, 16/3 SWT -A; 30,16/4, STW -A, An ids 20' std. with 30' opt. Materials of Construction Ha ndle Stainless Steel Lubricating On Dielectric 01 Motor Housing Cast Iron Pump Casing Cast Iron Shah Stainless Steel Mechanical Shah Seal Seal Faces: Carbon /Ceramic Seal Body: Brass Spring: Stainless Steel Bellows: Bun" RMINEM■M.■. ..,,.■■.E Engineered Thermoplastic .hqder Upper Bearing Single Row Ban Bearing Lower Bearing Sin a Row Ban Bearing Bottom Plate Sin le Row Ban Bearing Fasteners Stainless Steel legs Engineered Thermoplastic 16® HYDRCMATIC® ]Pentair Pump Group USA 1840 Baney Road Ashland, Ohio 44805 Tel: 419 -289 -3042 Fax: A19- 281.4087 6 0L capacity -U.S. G.P. 0 Uter0econd 0 5 2E; 0 4 6 LIM SHEF50 SHEF100 All dimensions in Inches. Metric for international use. Component dimensions may vary 11/8 Inch. Dimensional data not for construction purpose unless certified. Dimensions and weights are approximate. On= level adjustable: We reserve the right to make revisions to our product and their specifications without notice. —your Audariud Local Dishibuw — CANADA 269 Trillium Drive Kitchener, Ontario, Canada N2G 4W5 Tel: 519-896-2163 Fax: 519- 896 -6337 Item #: W -02 -6370 12/99 1 OM EAD' I MENEM MEMO ., I RMINEM■M.■. ..,,.■■.E I M- MENIEN E OWN WOMEN FREI 11 iMMEM 0L capacity -U.S. G.P. 0 Uter0econd 0 5 2E; 0 4 6 LIM SHEF50 SHEF100 All dimensions in Inches. Metric for international use. Component dimensions may vary 11/8 Inch. Dimensional data not for construction purpose unless certified. Dimensions and weights are approximate. On= level adjustable: We reserve the right to make revisions to our product and their specifications without notice. —your Audariud Local Dishibuw — CANADA 269 Trillium Drive Kitchener, Ontario, Canada N2G 4W5 Tel: 519-896-2163 Fax: 519- 896 -6337 Item #: W -02 -6370 12/99 1 OM EAD' I ., +..*1111 J7.y7P F t�f Lkd itt41tt ►t Sr `C.1 a 7` .k}t Ir11b 9:1111911 1I }7'ri'l t 1 14'+ltrti R f.+l-r'1'iDer1�aS�tiC�ra.� t.2 1 39 1 1t r t ikW x :: L 1, tV- L4I'- tL ari,* s �ixLl.t 9i [ t to .�rM.'.r�3rt7tt'a °�tXl[ `oilJtYM tp a avat"4i"Tf +1 1791 .iS1 Im . 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Depth to rock/imp. 'Depth to p rock/im '(0 Depth to rock/imp.* rock/imp. G.L. G.L.., WO V G.L. 0.5 .....0.5 .0.5 Lo dP-1 F. 1.0 .1.0 2.0 2.0. 3.0 3.0 3.0 4.0 4.0 4.0 .5.0 5.0 0 6.0 6.0 .0 7.0 7.0 8.0 8.0 8.0' 9.0 9 .-9.0 ..20 10.0 10.0 -10.0 Hole # Lot # Hole # Lot # Hole # Lot# eptli' -Depth-tovater- toyata_ D" � - er Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. G.L. Depth to rock/imp. Depth to rock/imp. G.L.- 0.5 0.5 05., 2.0 1.0, 1.0 2.0 2.0 3.0. 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 M 6.'0 7 . .0 6.0' 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0. 10.0 10.0 5-0C -7 TEST PIT PROFILES Hole# j Lot # Depth to water De"pth to mottling Depth to rock/imp. G.L'. 0.5 1.0 2.0 /M /)refer f Hole # Lot # P Depth to water \j Depth tomottling Depth to rock/imp._ 73 '0.5 1.0 (� i 5�� 2.0 AV Hole # Lot # Depth to water, Depth to mottling A)M_ Depth to rock/imp.. G.L. '0 0.5 1.0 2.0 3.0. A 3.0 4.0 '):,A0j,1v'\ 410. .3.0 4.6 7 0502- 6.0 7.0. 7.0. 7.0 8.0 8.0. 8.0 9.0 9.0 10.0 Hole # Lot # Hole # Lot # Holt., # Lot .# De pih.to water Depth -19-water ,l --DeTth 16-� 7,7:-0/ff Depth to'iiiottling Depth to mottling Depth . jidtflijig Depth to rock/imp. Depth to -rock/imp. Depth to rock/imp. G.L.... G.L. G.L. 0.5 05. 1.0 -2.0 2.0 gly 2.0 - 3.0. 4.0 q© - -79 - 51.11�.P-c 5.0 07. 8.0 j.0 4.0 50 C..6.0) 4.0 7.0 7.0 8.0 8.0 9.0 9.0 .9.0 10.0 10.0 10.0 Od -a BRUCE R. FOLEY * LORETTA MOLINARI R.N., M.S.N. Public Health Director �+ 0 Associate Public Health Director Director of Patient Services DEPART MEIN ' OF -IAIL-rM .. r .:._..... _ :. 1 Geneva Road Brewster, New York 10509 REQUEST FOR FIELD TES ENG T0SC Pl4 PAP-AVA11 , PE. ATTENTION: ❑ ADAM STIEBELING a GENE REED All information below must be fW11 completed prior to any scheduling, DATE: zi 1o5 ENGINEER OR FJRM: K stnA L PH G . MA51R --0kO l - QPHONE N�914121 ' 7e Z REASON: DEEPS: )( PERCS: ❑ PUMP TEST: ❑ ROAD/STREET: T PA �. L I N <�,O L) TOWN.-R, -r�Am VA LL TAXMAP#: SUBDIVISION: TI M BER LW E__F= 5j,AT E5 LOT #: OWNER: a 0 0 (, -(MJMRIA FQ9 JOINT REVIEW AND WITNESSING OF SQ1L MU IN NO X Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. >( Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. X Proposed SSTS within 200 feet of a watercourse or a DEC wetland. Proposed SSTS design flow greater than 1000 gallons /dap or SPDES Permit required. ;�' ��op�s'ed- SSTS' forsc- 4' ounrceJrccal•�s��,ect:._.._.... - _.___��... It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered y_e3 to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Pref'e%lonal and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUM USE OI L-? DAM Trult: )r2dr7�a7el988�T% (FMLDTEST) RALPH G. MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 .(214) :27;1 -.4. 762;: -.214 1.2�7,:1�.2$2Q Mr. Joseph S. Paravati, Jr.. Assistant Public Health Engineer Putnam County Health Dept. 1 Geneva Road Brewster, NY 10509 Re: Request for Field Testing for Lot 6 Timberline Associates, LLC Timberline Court, Putnam Valley, NY Dear Joe: Enclosed please find the following materials: . I May 2, 2005 1. One (1) copy of the Site Plan Lot 6 of Timberline Estates Prepared For Timberline Associates LLC, Timberline Court, Town of Putnam Valley, NY, dated April 26, 2005 2. One (1) signed and sealed copy of the Letter of Authorization 3. One (1) signed copy of the Affidavit - Corporate Owner Application 4. Application fee in the amount of $400 payable to the PCDH 5. One (1) copy of the Request For Field Testing application r At this time;:.we_,.are -requesting your „office schedule a site inspection�to observe- -deep test.:.. - - holes._ �a . � _ _ .� < ... , .� Please call to schedule a meeting. T ely, Ralph G. Mastromonaco RGM /jl Enclosures (/ �& PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES •r- GTa+:..a:.mrvw..q q,'.q. u+w,... -a .. "'' - .u...,v- �a.. :...e : .... -. s•.�s. .. :• ..v�,. ;.. et�n .v...we e..._s wtrn.y.n�a. .. _ ,. r„ .tv. nq.• ;r. CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYS M ��,�y,. t� y PERMIT # LP4) '7- Located a%/e1 e mL< Xi i? e Town Villa e / �o." Uk 11e, Subdivision name. / Al Ae ?��$ Subd. Lot # Tax Map Block L t'f0 Date Subdivision Approved /�/��1�� Renewal Revision Owner /Applicant Name ! 11118 e�/1V9 4'r O C G L-c Date of Previous Approval i o Z Mailing Address- �elrcF 47 Zip Amount of Fee Enclosed Building Type tea'?/ Lot Areq/a0,,4/ No. of Bedrooms -L`4-- Design Flow GPD Fill Section Only Z.- Depth 3&P7— Volume & PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To be constructed by gallon. septic tank and l LZ- l .`c 17— O N l%% Address Water Supply: Public Supply From Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address r A!d P.E � R.A. Date � / &C iec(K4 ,��f License # it 01 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 Rx Date /Time APR- 27-2005(WED) 15:48 914 271 4762 Apvr- 27 -05 04:48P Ralph G. Masty- omonaco PE 914 271 4752 TNAM COUNW DEPARTM(ENT OF HEALTH _ DIVAS ON OF ENVIRONMENTAL HEALTH SERVICES j ILZMR OF AUTHORIZATION ZA'!I ION P. 002 P.02 Subdivision Lot # Filed Map # Z 6619 Date Filed . 12 1 I � 9 (® Gentlemen 'Mis letter is to authorize RA &�!T� ® M ® �Ac_ .a a duly licensed Professional Engineer �_ or Registered Architect to apply for the required wastewater treatment and/or water supply permits) to serve the above -noted property in accordance with- the sta�dards, rules or regulations as promulgated by the Public Health Director of the Putnam County He' lth I)epartrnent, and to sign all necessary papers on my behalf in connection with this matter and o° superv' o truction of said wastewater tretment and/or water supply systems in cenformi .wl .P '_ article 145 ari dt. 147 of the-Educatioh Law; the Public `Health�� . Law, and 0 . ,,:r3 Countersi 0: o5 -�sF Afkg4� P.E., R.A.,,# ® caP� 'j .6 Availing A dress 13 O ®V 1, Cloven State l . Zip ] D5 zo (914) 2,771 -4 -16Z Very truly s, Signed: �'►rnNrr AIJWME, LL(- (Owner of Property) r- Form LA-97 Rx Date /Time APR- 27- 2005(WED) 15:48 914 271 4762 Apr -27 -05 04:48P Ralph G. Mastromonaco PE 914 271 4762 P. 003 P.03 PUTNAM COUNTY DEPARTMENT OF HEALTH :.K.. - :DIV�SION OF ENVIRONMENTAL HEALTH' SERVICESV - T I AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMI APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director I In the mattor of application for- 7j'ml3EV. Ll �s Assoc tAT- represent that I am an officer or employee of the corporation and am authorized to act for: II Name of Corporation:T j m R L I N President - I Name: Aildress: i Vice President - Name: Adddress: Secretary -Name: Address: Treasurer t Name: Address: . and that I aim and will be individually responsible for any and oacthe corporation with respect to the app oval requested and all subsequent acts relating th Signed: Title: n')t Y- LL-C. to Notary Form CA- 7 me this C` AW day of UJOLENE LENT Notary Public, State of New York No. 4794758 Corporate Seal Qualified in Westchester unty 6 Commission Expires July 31, r I of LORETTA MOLINARI Public Health Director May 18, 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 InterventiowPreschool (845) 278 - 6014 Fax (845) 278 - 6648 Dan Donahue, PE ROBERT J. BONDI County Executive 120 Breckenridge Road Mahopac, New York 10541 Re: Proposed SSTS Renewal — Timberline Associates Timberline Court, (T) Putnam Valley TM# 51.4-50.6 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 a new trench plan with- correct -owner and tax map number. - Y 2. Tax map number on the fill plan needs to be corrected. 3. Please show and clearly label all field- testing on the plan. Also, provide all field - testing from the subdivision on design data sheets. 4. It is hard to distinguish between the existing and proposed contours. Please clarify. 5. Deep tests results are greater than 10 years old. 6. It appears that a wall is being proposed by the driveway. Fill needs to toe back into natural grade, without use of a wall. Also, the driveway needs to be 10 feet from the toe of the slope. 7. Please show septic tank location on fill plan. 8. Please complete the profile for the fill or reference the fill section detail. Also, please clarify what is existing ground and what is proposed and label the section of fill that is ROB. 9. Fill needs to extend 10 feet past the end of all trenches before regrading at 1:3. 10. The cast iron pipe and the PVC pipe need to be labeled on the trench plan. Please provide size, type, and material. 11. Please provide fill volumes for ROB, unclassified and impervious layer, and fill in the blanks in note #3 (fill notes). 12. Please provide a note stating system is to be staked by a licensed land surveyor prior to any construction. M 1 'This office will continue - its review - upon` considerdtion of the - above - mentioned comments. ` Please feel free to contact me at ext. 2157 if any questions arise. JSP:cj Very truly yours, oseph S. Paravati, Jr. Assistant Public Health Engineer P,UTNAM CO -UNTY DEPARTMENT pF DIVISION OF ENVIRONMENTAL HEALTH . _.,. INI?IViDUAL.WATER SUPPLY & SUBSURFA;CE SEWAGE`TREAtMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: I � `' �. _ STREET LOCATION: • �' REVIEWED.BY: RM, GR, .A, SRDATE: l °y TAX MAN: (CONFERNW) l = ! — �D• G Y N DOCUMENTS (� PERMIT APPLICATION )WELL PERMIT OR PWS LETTER (�� PC =97 0 ( ' ILETTER OF AUTHORIZATION ,i(cCORPORATE RESOLUT10 i _ _ )SHORT 1'; . PLANS -THREE SETS - TWO SETS (_—)VARIANCE REQUEST`` •�� ```'� "`� — SION J LEGAL SUBDIVISION ' ((__)SUBDIVISION APPROVAL CHECKED UUPERC RATE (�( )FILL REQUIRED 'I" DEPTI3 ()(-,_CURTAIN DRAIN REQUIRED GENERAL (ULatOCATED.IN NYC WATERSHED L-)L 't CLANS SUBA=D TO DEP f L ELEGATED TO PCHD EP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED �(' E�RCS TO BE WITNESSED i) APPROVAL SSDS ADJ, LOTS �( �! W (ftLANDS (TOWN/DEC PERMIT REQ'D?) Lt: (� ��)DATA ON DDS-PLANS & PERMIT SAME Ljl 1969 NEIGHBgR NOTIFICATION:. . FLOOD ELEVATION WII 200'' n, LGLSX PLAN-(NORTH ARROW) HYDRAULIC PR 1� { phew (gZ (_)CONSTRUCTION NOTES 1 -15 G�DESIGN DATA: PERC & DEEP RESULTS .`K 2V CONTOURS EXISTING & PROPOSED (DRIVEWAY & SLOPES, CUT. O UOTING/GDT= L �A Il�iS USDA S -- TITLE BLOCK; OWNERS NAME ADDRESS TAI #, PE/RA; NAME, ADDRESS, PHONE# ( DATE OF DRAWING/REVISION y 1REOUIRED DETAILS ON PLANS CONT'D} • 2U OUSE SEWER- V7 FT. 4 "0'; TYPE PIPE. CAST IRON C--) NO BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS (__)SI'T'E NOTE (NO CHANGE) — ---- „FILL SYSTEMS LJ 10' HORIZONTAL• AST TRENCH SLOPES 3:1 TO GRADE jFILL SPECS / FILL NOTES 1 -5 (��AFILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA FILL GREATER TI N2 FEET ' L:f� CLAY BARRIER GAUGES (SEPARATION DISTANCE FROM. TOE OF SLOPE • LF TRENCH PROVIDED F 6j0 60FT MA.X.4 ( jf:PARALLEL TO CONTOURS U 100% EXPANSION PROVIDED ( �DETAIL/DUST FREE CRUSHED•STONE OR WASHED GRAVEL (EGEOTEXTILE COVER %S E o F St.aR<f SEPARATION DISTANCES ON PLAN. - FROM 4ffS, L- j ”' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (✓" - 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TQ PITS 100' TO STREAM, WATERCOURSE, c : l 0' T0- GAT-C'iIBASRi; 35''STORiVTDi2�6.Il�T, PIPED WATER -)10' TO WATER LINE (pits - 201) C�. 50'• INTERMn --ENT DRAINAGE COURSE `200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS (.�JU10' MIN TO LEDGE QUTCROP / SEPTIC TANK (_;,)f U10' FROM FOUNDATION, 50' TO WELL WELL � (, I�I+ISIODtS -T••A -PAP S (_) LOCATION OF SERVICE CO.NNECTI SLOPE LJ(� LOPE IN SSTS AREA (S20 %) - /9'- REGRADED TO 15 %, IF REQUIRED . D0SE/PUMP SYSTEMS -- -"" NI UUP.uA2 NOTES DATUM REFERENCE UUDOSE 75% OF PIP OSE VOLUME NOTED (�ULOCATION OF WATERCOURSES, PONDS U(--- )DETAIL' RCE'.MAIN, (PIPE TYPE, ETC.) LAKES ,WETLANDS WTTHIN200' OF P.L. U D -BOX SHOWi�i & DETADLEI? ( )PROPOSED FINISH FLOOR AND 1 DAY STORAGE ABi�VE ALARM BASEATENT ELEVATIONS CURTAIN DRAIN O r WELLS Ai SSDS'S WANT 200' OF SSTS ` L— )(— ) &7ANPPIPES, 5' BOTH SIDES A-�HwROPERTY METES & BOUNDS i_;__)(-__)15' MIN to CD ° , %,!5'-3%,35'-16%-, 100 % - <1% (,__)EROSION CONTROL FOR - HOUSE, WELL & C-- )(— •—)20' DISCHARGE/100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE MIN to NON-PERFORATED PIPE �MIVIEPITS: .. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES :....,. __.....,::_:..Y:�.�.;.�:....;.: APPLI,GATION TO CONSTRUCT.A-WATER.WE please print or type PCHD Permit # V Well Location: Street Address: illage Tax Gri (,� /� 6-r ��. �Ql% Ma Blocky Lot(s) (p Well Owner: Name: / /�YSACl//A94 Address: V7 Juse of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation r Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm ed Est. of Daily Usage a I r gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason VA- A At 4v 10-f t I)OA/d -/--- for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes_V No �%� Name of subdivision /�PriR� %�✓/z -- ! J% Lot No. 4/p_ Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No !� Name of Public Water Supply: Al 14 Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to b5,pmvided on se ra sheet/plan. s` Date, ...Applicant Signature: ... _ .. "....M.......:_ .... 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 - Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 C NSU TING 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 #6 Timberline Ct. Putnam Valley Dear Mr. Pavarotti: Enclosed herewith please find: L. Application for permit to construct an SSTS 2. Application 'for-a-permit to construct a well--,- 3. Letter of authorization 4. Three copies of construction drawings Comments: Application is for a renewal and name change fee filed under separate cover. Your prompt consideration would be greatly appreciated. Sincerely /aniel Donahue, P.E. Site o Sanitary o Environmental I� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of 'jl'���� Located at _'T. /neog J.1ly,e, /_ r OV P4) -r g4m V 4LL6rffax Map # st Block [_ Lot Subdivision of T / M OR `14 5 0d?"p'r"19`r Subdivision Lot # tU Filed Map # 2-fAq A - Date Filed 12-) Q j 10 Gentlemen: This letter is to authorize L)AW ! E L J. D O ALA if 0 J9 a duly licensed Professional Engineer j/ or Registered Architect to apply for the required wastewater treatment and/or water supply permits) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on. my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, ,the Public Health Law,. and.the:Putnam County Sanitary - Code. Countersigned: P.E., R.A., #g�/ Mailing Address leg Ngil . State N 9 Zip Z0,1-4 Telephone: g4s--4 -16, Very truly you Signed: (Owner of Property) �� -Ti ��tiF_ ASSoC'-� Mailing Address: P �rnvPov o2P polk-r urk--ble, I 'It, State Zip IUD %j Telephone: "f✓- 6Zg" �S Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM 1 Owner Address aal TA40 At Located at (Street) Tax Mai) 31. Block/ Lot t le i ica d' t Q e nearest cross street) Municipality 4-, I-lee Watershed 44 e: r e- SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test 1.01flop i'/ r 4 .5. y7 /7 2 Ir 1� *7 3 /0 30 4 5 1 - - * ... .. . - .. 1. .. Cyf,- Y2— �/ f r 3 3 Ae 4 .5. y7 /7 2 Ir 1� *7 3 /0 30 4 5 1 - - * ... .. . - .. 1. .. Cyf,- Y2— �/ f MUTES: 1. Tests to be repeated at same depth until approximately equal percolation races are ootainea at eacn percolation test hole. (i.e. -.q I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. 3 Ae 4 5 MUTES: 1. Tests to be repeated at same depth until approximately equal percolation races are ootainea at eacn percolation test hole. (i.e. -.q I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH _ HOLE NO y / : - : HOLE.NO. , - z .HOLE NO: - 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' ' 4.0' 4_?' Ste¢ . 5.0' — 5.5' 6.5' 7.5' 8.0' 9.0' 9.5' 10.0' 2 fk roc. •I -7,�vTorc I 4m.il Indicate level at which groundwater is encountered Indicate level at which mottlin g is. - - - -- - - - - - . Indicate level to which water level rises after being encountered Deep hole observations made by: J �'� /��� Date �) Design Professional Name: Address: ban1e8 Jo Donahu® 1. NY 905�1� Signature:. An- � T Design IProfesslonal' eal i PUTNAM COUNTY DEPARTMENT OF HEALTH DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM ONNmer. 2 Zf Address r Located at (Street) w 17le Tax Ma Block tl Lot 49 Municipality (indicate nearest cross street) —Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test 3//-.?/ er ............. .. .. .. .. ...... .... . .. . ....... .. .."Ela T' ':; <: j "m"'*""e*'*""'*""""*"'"' ..pse. ime.. T o ..Ho e',N, Mt. Y.tttt* .:Wrom n WK ...:Su* ffa&: ... . ...... :::Start ...... ...... e r a on ........... 20 4 .5. 4 "Zo 1? 17 2 3 3,;) .2 11Y 3 4 5. 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (Le-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. TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 5.01 Indicate level at which groundwater is encountered Indicate level at fifin­ - g*- 1-s- .observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Profession Name: -,Q wl&-. J, v,-f Address: Zal-e Signature:. Design Professional's Seal * E G,31 0 'OR 0 � 0 cc) ki 7V� /V 0. OF 6.0 VIM 1:2 �io 6.5 7.0 ----------- 7.5 8.0 C- 771CA 9.0 Indicate level at which groundwater is encountered Indicate level at fifin­ - g*- 1-s- .observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Profession Name: -,Q wl&-. J, v,-f Address: Zal-e Signature:. Design Professional's Seal * E G,31 0 'OR 0 � 0 cc) ki 7V� /V 0. OF 14.164 (2!871 —Text 12 PROJECT I.D. NUMBER 817.21 SEOR Appendix C :_..__ ......_____.__..._..._ . ... .. State Environmental ®uattt _8svlew_...... .. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICipNT/fSPONSOR ell `L'L( 2. PR ECT NAME 3. PROJECT LOCATION: � v / Xn ' `% Municipality Count y 4. PRECISE LOCATION jStreel address and road Intersections, prominent landmarks, etc., or provide map) le- 0 t -7-7 �.� .e L y, S. iS PROPOSED ACTION: 0 New ❑ Expansion ❑ Modi tic alionraltoration S. DESCRIBE PROJECT BRIEFLY: C0,4 r,/ U G ?(d A► DIG �} h! s'S f J. AMOUNT OF LAND AFFECTED: Q r J Initially j acres Ultimately ! acres S. R PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHE EXISTING LAND USE RESTRICTIONS? WILL M Yes ❑ No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? arFResidentia! 0 Industrial ❑ Commercial C3 Agriculture ❑ ParklForestlOpen apace ❑ Other Describe: 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE R LOCAL)? Yes ❑ No If yes, list agency(s) and permlUapprovals V 1t. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes LJ No It yes, list agency name and pennlVapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REOUIRE MODIFICATION? ❑ Yes 1!J No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE J, Applicantlsponsor `Yy "' d)V4 /4 up / : � name: Date: Signature: It the action Is In the Coastal Area, and you are a state agency, complete'the Coastal Assessment Form before proceeding with this assessment OVER 1 PART If— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. { ❑ Yes �.J No ., B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67. If No, a negative declaration may be superseded by another Involved agency. ❑ vas Na C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten. If legible) Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain brlofty C2. Aesthetic, agricultural, arch asological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: A/ 6 /V /S C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: /V 0 IV C4. A community's existing plans or goals as officially adoptod, or a change in use or intensity of use of land or other natural resources? Explain briefly /V /V C5. Growth, subsequent development, or related activities likely to be lnduced Qy the proposed action? Explain briefly. /haw C6. on term, short term; cumulative, or`other otfects not Idontlffed in C1C5? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE; OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? 13 Y03 ICJ No It Yes, explain briefly PART Ili — DETERMINATION OF SIGNiFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, Important or otherwise significant. Each effect should be assessed in connection With Its (a) setting (i.e. Urban or.ruret);.(b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (q magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all rolevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a'positive declaration. Check this box if you have determined, based on` the information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as nece'ssa ,the reasons supporting this determination: 4�� %� • U V/ same of Lead cY� ,4nt or pe 'ame of esponsc a Opicer in Lead Agency it o esponsi a Officer ...- ..,.:�, •..•+i. ,�, ,u nature• pOns _ �Yef. .if2g - � - - •'....r -• _ t - .a- ••..,::� _.: ure o reparer i Brent r response e a ricer L I Vale pUTNAM COUNTY DEPARTMENT OF HEALTH �F *SION OF ENVIRONMENTAL HEALTH SERVICES / CONSTRUCTION PERMIT FOR SEWAGE '..'MENT SYSTEM / .. %... - I % Located at Q Subdivision name =- Subd. Lot # Date Subdivision Approved Owner /Applicant Name I 4n do 2 2 � To r illage ✓' e•nc -1,/4, Ile Map Block / Lot 4 Renewal Revision Date of Previous Approval Mailing Address au / J�f* At ! G 4 R iv M, dQ D Al- ?. Zip Amount of Fee Enclosed�� Building Type Lot Area _jjKjLVo. of Bedrooms _,!I- Design Flow GPD Fill Section Only Depth 3,0 / Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage-S, stem to consist of gallon septic tank and Other Requirements: To be constructed by Water Supply: Public Supply From Address Address or:.. '!/ _Privati- Supply Drilled•by: _:_ i ;__._ _ ._ Address _ I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the I(se�arate 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 the to. Signed: _ P.E. L/ R.A. Date Address lob o ��s PG OG4 / �'' �� �✓ %��i% r 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 pe . Approved for discharge of domestic sanitary sewage only. By: Title: Of r j 6 ✓ Date: White copy - HD ile; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH / IIDIVESION OF ENVERONMIgNTAL HEALTH SERVICES AP11nIt,1<CA'B')I ®1� ' '�. ®1�15'�AB�J.C7C A. WAT EBB ILIi, ._. 7 _ ,._......._._ - . r.� .,...,. r _ please print or type _ PCHD Permit # Well Location: Str et Address: o illage Tax Grid # Map Block hot(s) WellOwneir: Name: Address: J" 6, 2 z,` 19.e,1 Iz 0 Use of Wen: Residential Public Supply Air /Cond/Heat Pump Irrigation 91rhmary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm gerVe Est. of Daily Usage 22T gal. Reason ffoir Replace Existing Supply Test/Observation Additional Supply gDrAlu g New Supply (new dwelling) Deepen Existing Well Detailed Reason Al ia w . #f 1® 'e-4- e/v for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No �l Is well located in a realty subdivision? ..................................... ............................... Yes li Np Name of subdivision �_i�e.��i�✓� ,��` �� Lot No. � Water Well Contractor: ER Address: - Is Public Water Supply available to site? .................................. ............................... Yes Nom Name of Public Water Supply: aI If Town/Village Distance to property from nearest water main: All !f Proposed well location & sources of contamination to provided o 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 driller certified by Putnam County. Date of Issue S '% 0 2 Permit Issuing Official: a2_4 Date of Expiration cl i 16 L Title: n, Permit is Non- TiransffeiriribRe White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 °°R: °'FOLEY° Public Health Director DEPARTMENT 1 Geneva Brewster, New . "LORETTA M0L1NAM—R.N -. -,- i:SN.'- ;::: Associate Public Health Director Director of Patient Services OF HEALTH Road 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) 228 - 6108 Fax (845) 278 - 6648 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER NAME: ADDRESS: SITE LOCATION: DATE: STAFF PRESENT: SPECIFIC WAVIER REQUEST: J as �a,� cif yes T', 6- /S* S/� DOES THE PROPOSED VARIANCE REQUEST POSE A HEALTH HAZARD OR ENVIRONMENTAL CONTAMINATION PROBLEM? YES WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP? YES DISCUSSION REQUEST APPROVAL OR DENIED -` _- REASON -FOR DENIAL DIRECTOR OF PUBLIC HEALTH (SPECWAIVER) NO NO DENIED DATE NEW YORK STATE DEPARTMENT OF HEALTH Specific Waiver .Bureau _of Com - %nity_Witatign_and, Food: Protection from R�qulrements_of Par4-75 and.Appendix -75 -A, IONYCRR - for Individual Household Sewage Treatment Systems Name of Applicant J 11'A) 's No. Street City/Town State Tip . Address No. Street Ci /Town State Zip Site-Location _rIA 4 6r y; ,P, ��,r-' �•4� �a, y /�IS�Q 1. Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)): Separation distance cannot be achieved. i ell Excessive. slope. High groundwater. Inadequate depth to bedrock or impermeable layer. Soil unsuitable. J Other (explain) ... : ....... ........................................................ ............................................................................. 2. Proposed design or conditions of waiver: ........................... ............................... ................................................................................. ............................... Cs.! :...� :........................................... a a�........ //x.....10 ....... .......,....................... -r 3. The proposed design may have the following limitations (check appropriate box(es)): J Increased risk of well or spring contamination. Increased risk of surface water contamination. - L] Expected design life of the system will be diminished. Operation of sewage system is subject to mechanical problems. Other(explain) ......................................................... ............................... Additional information attached Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. In accordance with New York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver may be revoked by the issuin9-�ficial fora change in conditions for which this waiver was granted. ...................... ............................... OF HEALTH ' ORIGINAL - Local Health Agency COPY - Applicant/Design Professional . ................. ............................... (GEN -152) V...KITCHEN'— DIN. RM. MORNING RM. II4x1219 1st Floor LAUN.:.' .,sgxloz, LIV. RM. I - . FAM. RM. 1840219 „- , I6flxl2q FOYER LI 94 x/94 L L__J9 BATH fl 2 BR* 3 I BR9� BATH I : CCLOOSSET 92 x122 -:;o �.._ .. _ HALL _ :._ _.... _....:...._....._ __ ..._... _. OPEN TO BR* I BELOW 161 x 16.1 OR 2 l ISflx1210 STUDY 12I x s 9 PUTN COUNTY DEPARTMENT, OF ]EALTH HUUS PLANS APP OVED FOR BEDROOM COUNT ONLY, 2nd Floor 1\4 I-s _L BEDROOMS 3 Y,,— / _ . 6 ALL SUBSEQUENT REVISIONIALTERATIONS TO THESE HOUSE PLAJn�MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL 1 1. , SIGWATURE &Q TIT] 7 r PENN LYON HOMES INC. Old Trail Road; Selinsgrove Pa. 17870 Telephone (717) 743 -0111 tkk �r•� BRUCE R. FOLEY Public Health Director DEPARTMENT OF ]HEALTH 1 Geneva Road Brewster, New York 10509 01 'Y"1'a Associate Public Health Director Director of Patient Services Environmental Health (845)279-6130 Fax(845)278-7921 Nursing Services (945)278-6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early intervention (845) 278 - 6014 Fax (845) 278 - 6648 March 21, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Proposed SSTS - Gizzi, Timberline Const., Lot #6 (T) Putnam Valley, TM# 34.4-6 Dear Mr. Donahue. Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: Provide the location of.all building drains. Provide the current owners name and address on the title box of the plans. '! Provide a note stating all septics and wells within 200 feet have been shown. Show the minimum 10 feet separation between the toe of the slope and property line. Provide the distance from the proposed well to two (2) property lines. Tlie- site -ma "dody.liot indicate the site location-- Three feet of fill h as not been rovided over the entire aliso lion area: - -- p 1p......._ . Provide cleanouts approximately every 50 feet between the tank and first box. Mote # 17 incorrectly lists a 1000 gallon septic tank. The plan indicates that portions of the SSTS area approach 20% slope. Current codes do not allow the ccnst- uction of a SSTS on slopes greater than 15% slope. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands, officials in this regard. Upon receipt of a submission revised to reflect the above Comments, this application will be considered further. SR:cj Sincerely, Shawn Rogan Public Health Technician ". LUN*,SvL111' IG EIeIULNEr- ., -: �� •: ,•; . , .. .. ., . _ ...__ �, Daniel.). Llonahue..P.E. _ _ e. 200 Breckenridge Road N-lahopac, N.Y. 10541 914 -628 -7576 TO�. - -- —F--- – - WE ARE SENDING YOU C Attached ELI Under separate cover via the following items: C Shop. drawings ❑ Prints C Plans ❑ Samples ❑ Specifications 0 Copy of letter ❑ Change order ❑ COPIES DATE ATTf�G — ..— ._»..�— ......— .— ._.... / Coll the following items: C Shop. drawings ❑ Prints C Plans ❑ Samples ❑ Specifications 0 Copy of letter ❑ Change order ❑ COPIES DATE No. DESCRIPTION Coll THESE ARE TRANSMITTED as checked below. For approval C Approved as submitted C Resubmit _copies for approval ❑ For your use ❑ Approved as noted ❑ Submit _ copies for distribution -- ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment CI ❑ FOR BIDS DUE 19� ^— ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS R k9 % G r F MINE If f?st / -- _- �IO'�ir IF -- • ••�'2_ COPY TO SIGNED: It onetaauraa aro not a$ noted, kindly notify us at one*. .n .�RL1C�'lt: "'FOI,BYK.a.i- .i+a.rt/e.• x-A•i -.f. -ivi" �. -�.Y Public Health Director to s. .= +•�T.�== +•a.v.�a'�+r. � Kfri-•'-- :iary -M:. t H ♦ .0 . �. �•, r. w. tt.rr.ri LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF IIEAI,TI-I 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 Fax (845) 278 - 6648 March 21, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Proposed SSTS - Gizzi, Timberline Const., Lot #6 (T) Putnam Valley, TM# 34. -1 -6 Dear Mr. Donahue: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. Provide the location of all building drains. 2. Provide the current owners name and address on the title box of the plans. 3. Provide a note stating all septics and wells within 200 feet have been shown. 4. Show the minimum 10 feet separation between the toe of the slope and property line. 5. Provide the distance from the proposed well to two,(2) property lines. -•6. The site mad does-not indicate`the site' location: 7. Three feet of fill h as not been provided over the entire absorption area. 8.. Provide cleanouts approximately every 50 feet between the tank and first box. 9. Note # 17 incorrectly lists a 1000 gallon septic tank. 10. The plan indicates that portions of the SSTS area approach 20% slope. Current codes do not allow the construction of a SSTS on slopes greater than 15% slope. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 March 21, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re: Proposed SSTS - Gizzi, Timberline Const., Lot #6 (T) Putnam Valley, TM# 34. -1 -6 Dear Mr. Donahue: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. Provide the location of all building drains. 2. Provide the current owners name and address on the title box of the plans. 3. Provide a note stating all septics and wells within 200 feet have been shown. 4. Show the minimum 10 feet separation between the toe of the slope and property line. 5.. -. Provide the distance from the proposed well to two (2)-property-lines: �.. .._._ .- - Y C The site map does not indicate the site location. 7. Three feet of fill h as not been provided over the entire absorption area. 8. Provide cleanouts approximately every 50 feet between the tank and first box. 9. Note # 17 incorrectly lists a 1000 gallon septic tank. 10. The plan indicates that portions of the SSTS area approach 20% slope. Current codes do not allow the construction of a SSTS on slopes greater than 15% slope. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj r PUTNAil COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH UNDWIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS _.' ......_ REVIE _ PER-MIT. W SHEET.FOR CO \STRUCTION ... , • -- - . ...,:. :_� :.. - .....r NAME OF 0,NI ER: � STRAFT LOCATION~ REVIE';VFD BY: R',L OR, AS, SFt ATE: _ t -TAX I IAP -: (CONF�D) 1' N DOCUtiiENTS /Y N (REQUIRED DETAILS ON PLANS CONT M UUPERti1IT APPLICATION LZ(__)WELL PERMIT OR PW S LETTER (�jLJPC -97 ( JLJLETTER OF AUTHORIZkTION (_ZL )DESIGN DATA SHEET (DDS) U( JCORPOP,kTE RESOLUTION t,6(__)SHORT EAF (Z L JPLANS -THREE SETS (jUHOUSE PLAINS - TWO SETS (_ j(,/)VARIANCE REQUEST SUBDIVISTON (f_L AE GAL SUBDIVISION (ZL_jSUBDIVISIO\ APYROVAL CHECEED V)UPERC RATE lb L�L�FMLREQUIRED. E PTE L /)CURTAIN DRAIN REQUIRED GENERAL Lj TEDLNN'YCW D (�( _)PLANS S D TO DEP UL—)DEL ^ DT 0 L .. _ ._ j(�} P APPROVAL,, IF RE UUDEEP TEST HOLES OBSERVED UUPERCS TO BE WTTN'ESSED ( .ZvEX- APPROVAL. SSDS ADJ, LOTS (j(--)WETLAN -DS (IO)VN/DEC PERbILT REQ'D ?).. ( _JLJDATA ON DDS PLANS & PERMIT SAME (—J( —JPRE 1969 NEIGHBOR NOTIFICATION (__)ULETIER BUZBA (�_J( 100 -lM FLOOR ELEVATION-W11200' Ll- C,ZLJ$OIL-TESTRiGlOTS:40 YEARS-OLD . AGE SYSTEM PLAN- (NORTH ARROW) i HYDRAULIC PROFILE VTTY FLOW ;-lL JCONSTRUCTION NOTES 1 -15 UUDESIGN DATA: PERC & DEEP RESULTS L%j(` j2' CONTOURS. EXISTING & PROPOSED (1i(__JDR[VEWAY& SLOPES, CUT U(_6MOTI;YG /,GIJ lERljMM M_DKM, SD (-/6(_)USDA SOILTYPE BOUNDARIES' (�(___)TTILE BLO Clr42QV NERS_NAlYIE ADDRESS TN19, PE/RA; NAME, ADDRESS, PHONE (_,j_JDATE OF DRAWINGIREVISION (_ZJ( _JDATUM REFERENCE (./J( _JLOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF Y.L. L� (_- _)PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (�(�WEL SSDS`S WlIC�..2,09�:O'RSSTS BOUNDS SCO .NIMENTS: p� (REVSHEET) L:n(JHOUSE SEWER -'/1' FT. 4 "0'; TYPE PIPE CAST IRON L/jUN 0 BENDS; NLAX BENDS 451 W /CLEANOUT RENEWALS LPA) (—J SITE NOTE (NO CHANGE) / ' 1 _)U FILL SYSTENTS i .A (_10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (::::�(__)FILL SPECS/ FILL NOTES 1 -5 /z�FILL PROFILE & DIMENSIONS �fi ( FILL Di EXPANSION AREA FILL GREATER MN2 FEET � �CL4Y BARRIER �VOL.CERTIFICATION NOTE DEPTH GAUGES ON PLAN FOR RO.B., UNCLASSIFIED & B PERVIOUS (,, jSEPARATION, DISTANCE FROM TOE OF SLOPE TRENCH (j - U�ULF TRENCH PROVIDED (o 60FT MAX. Le��PAR4LLEL TO CONTOURS 100% EXPANSION PROVIDED. _.. . DETAIIJDUST FREE CRUSHED STONE OR WASHED GRAVEL UUGEOTEXTILE COVER . SEPARATION 1 DISTANCES ON PLAN - FROM SSTS �AQC IO' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL UU'0' TO FOUNDATION WALLS (20100' TO WELL, 200' IN DLOD, 1-50'TO PTTS �/ U100' TO STREAM, WATERCOURSE, LAXE (Inc. ezpan) (__)50' TO CATCH BASIN, 35' STORbIDRAIN, PIPED WATER _ (10; TO WATER LIVE (pits - 20' .. _. _. ( rj(J50' iNi RMITTENT DRAINAGE COURSE ( 2( j200' /500' RESERVOIR, ETC. 150' GALLEY SYSTEMS (Z(_J10' bIIN TO LEDGE OUTCROP SEPTIC TANK (_ FROM FOUNDATION; 50' TO WELL WELL (/�( jDhMINSION SF T OPROPERTY'L -R— Gz6AION OSERVICE CONNECTION %MIN __..._. 15' TO PROPERTY LINE SLOPE (/�( SLOPE IN SSTS AREA (S20 9/6) (__ )(_JREGRADED TO 15 %, IF REQUIRED Fr E S UUPUIIP N ES UL�DOSE 75% FP /DOSE VOLUME NOTED U( JDETAIL FOR (PIPE TYPE, ETC.) UUPIT AND D-B ETAILED UUl DAY STO ARM :20'4%,25'-3%,35'.1%, T l UUSTANDPIPES, IDES, DETAIL U(__)15' MIN to CDS= °/ , 100 % - I% (x(_)20' MIN to CD D GE1100' with 182 cons day discharge ��%/�f ,'� UU10' MIN to N�ONJ ERFORATED PIPE Qj . . BR�7C� ' R. 'FOT.,EY ; �- � �� ; -� • .... , -:, . ... Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 298 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 January 28, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 m Dear Mr. Donahue:, Proposed SSTS - Gizzi, Timberline Court TM# 34. -1 -6, (T) Putnam Valley Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system maybe subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department of Environmental Protection on this lot percolation tests must be witnessed _by._a representative.of- - • this Department. . 1. The design data submitted relevant to the above referenced project is fourteen years old. Please contact Gene Reed at ext. 2261 to schedule the witnessing of percolation tests on this lot. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj DANIEL Jo DONAHUE9 RE. CONSULTING ENG� V E ERS -..120 Breckemridge Road - ;:. - Mahopac, N.Y. 10541 845- 628 -7576 December 2, 2001 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Adam Steibling RE: SSTS Permit & Well Permit Property of Gizzi Timberline Estates R. S. Lot #6 Putnam Valley Dear Mr. Steibling: 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 plans 9. Two sets of house plans By: Daniel J. Donahue, P.E. Site o Sanitary o Environmental ,I PUTNAM COUNTY DEPARTMENT OF HEALTH M SER-VICES.- - VISPON.OF ENVIRONMENTAL BE ALT LETTER OF AUTHORIZATION RE: Property. of --\Q k-0 j c(A A(Ln. t': CA vy oND 12-7-1 Xj Located at CSC W pyj (A �- as t;!'10 ye C T/V.P0 NWm Irrax Map # —Block. Lot Subdivision of-q7i)")..,,l-lk?-e- Subdivision Lot #. Filed Map # Date Filed L Gentlemen: This letter is to authorize' a duly licensed Professional Engineer jt� 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 qQgforinity. with -the.pro.,visi-lohs..of--Article 145'And/6 k. 1-47 bf the. Education -Law- -the-Public.446iltfi' • Law, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # Mailing Address P-,6 State Telephone: ,zip Very State I-) zip _Lno Telephone:.. rq (q) CM - 3GOO zj Form LA-97 r U 1 it AAA k U U A 1 Y 1)hrAK 1 AlhA l U k tihAL 11i '--, I DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR - A WASTEWATER.TREATMENT.S.Y,STEM ._ 1. Name and address of applicant: 2. Name of project: SIWg f y,ar- r 3. Locatigov: 4. Design Professional: hhw /EG 4. Z),om yu =. 5. Address: 14o 6. Drainage Basin: 7. Type of Project: Y_ Private/Residential Apartments Office Building Food Service Institutional Realty Subdivision M41'rolo -4r. d--1 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 Y 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... All f- 10. Has DEIS been completed and found acceptable by Lead Agency? ............... A//.4' 11. Name of Lead Agency N110 f 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .............:........................................... ............................... _ 13. If so, have plans been submitted to such authorities? ........ ............................... Al o 14. Has preliminary approval been granted by such authorities? Date granted: N 15. Type of Sewage Treatment System Discharge.. ............... surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... AIM 17. Waters index number (surface) ........................................... ............................... �- 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? ....... ........... /1/D 21. Name of sewage system Distance to sewage system 22. Date test holes observed A4�23. Name of Health Inspector Al-. t?,,. ` 24. Project design flow (gallons per day) . ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 46 26. Has SPDES Application been submitted to local DEC office? ......................... /V le Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number . ............................... . ............................... l'ermit'e�quited? .......... :....._: ............................. ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... �d 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes 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? ......... ................. :.... Yesto 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? ............................ :.................................. _ A a jk 35. Are any sewage treatment areas in excess of 15% slope? . ............:.................. A< 36. Tax Map ID Number ............................. ............................ Map 3`l Block_ Lot 37. Approved plans are to be returned to ..... Applicant - Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC: Watershed shall w be sendt9 theDepait4nent;:id&nn_ eed- not -he. sint in duplicate to the DEP; although-the prtjeet�dyrequire DEi� approval of the SSTS prior to final approval by the Department. Projects-within the watershed may also require DEP review and approval of other aspects. of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. 11 hereby affirm, under penalty of perjury, that information provided on this foram as true to the best of easy knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Venal Law. SIICIyATURES & ®IFpTICL4L TITLES.- Z) 4 a�►� �, d • �o�� tire' . Mailing Address: ............................... f LOT 6 804,357 s.f. 18.465 acres ,I R EXISTING WELL' 00' MIN. SETBACK ev C QS /�. •f I,r i t f P i i fC T � 1 DRYWELL� DRYWELL D.I. BUILDING iDRAIN DISCHARGE o... .TIE POINT 'A' / TIE POINT 'C' TIE POINT jB' SSDS AREA / J 10,000 s.f. \ _ ' JBg ' 4 PERF. PVC LATERALS •`• WITH CAPPED ENDS (TYPr) 1500 GAL. CONC. DUAL COMPARTMENT SEPTIC TANK 4" PVC T3 4" PVC T4 1500 GAL, CONC. PUMP TANK SDR35 WITH OVERFLOW STORAGE AND ACCESS MANHOLE 2" PVC FORCEMAIN J81 g' 7p. JBi6_ 70_ J871z - -�� ~ E�17 ASION DB' >< 'DBIW/ BAFFLE APPROX. LIMITS OF 2' DEEP R.O.B. FILL PLACED OVER ENTIRE SSTA --- ; —&Trr% %AATUlN Ir)n' nnVJNCI nPF � ; I 1 TIE POINT 'C' TIE POINT jB' SSDS AREA / J 10,000 s.f. \ _ ' JBg ' 4 PERF. PVC LATERALS •`• WITH CAPPED ENDS (TYPr) 1500 GAL. CONC. DUAL COMPARTMENT SEPTIC TANK 4" PVC T3 4" PVC T4 1500 GAL, CONC. PUMP TANK SDR35 WITH OVERFLOW STORAGE AND ACCESS MANHOLE 2" PVC FORCEMAIN J81 g' 7p. JBi6_ 70_ J871z - -�� ~ E�17 ASION DB' >< 'DBIW/ BAFFLE APPROX. LIMITS OF 2' DEEP R.O.B. FILL PLACED OVER ENTIRE SSTA --- ; —&Trr% %AATUlN Ir)n' nnVJNCI nPF TIE DISTANCES : 4 . TRENCHES ,REQUIRED =_625 L.F. ; TRENCHES PROVIDED = 630 L.F. PUMP TEST PERFORMED 11/29/07 PUMPED VOLUME = 290 GAL /CYCLE 9" DROP /CYCLE OWNER: TIMBERLINE ASSOCIATES LLC. 118 NORTH BEDFORD ROAD MT. KISCO, N.Y. 10549 SITE LOCATION: 31 TIMBERLINE COURT, PUTNAM VALLEY, N.Y. 10579 TAX MAP DATA: MAP 51; BLOCK 1; LOT 50.6; R.S. LOT 6 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY THE DESIGN ENGINEER PRIOR TO BEING BACKFILLED. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH THE RULES & REGULATIONS OF THE PCDH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. SURVEY INFORMATION SHOWN HAS BEEN PROVIDED BY DONALD DONNELLY, PLS. A B C T1 21.7' 48.3' T2 29.6' 58.1' T3 36.3' 58.9' T4 29.7' 48.7' DB1 104.9' 122.9' JB1 107.5' 123.0' J132 101.8' 117.3' JB3 95.4' 111.8' J64 89.3' 107.0' JB5 83.3' 101.9' JB6 77.0' 96.9' JB7 70.8' 92.1.' J138 64.6' 86.8' JB9 58.2' 82.1' L1 144.2' 135.8' L2 140.0' 130.4' L3 133.6' 123.6' L4 .127.4'. 117.1' L5 122.5', 1.11.4.' L6 116.6' 104.7' L7 110.4' 98.0' LS 105.1' 91.6' L9 99.6' 85.1' : 4 . TRENCHES ,REQUIRED =_625 L.F. ; TRENCHES PROVIDED = 630 L.F. PUMP TEST PERFORMED 11/29/07 PUMPED VOLUME = 290 GAL /CYCLE 9" DROP /CYCLE OWNER: TIMBERLINE ASSOCIATES LLC. 118 NORTH BEDFORD ROAD MT. KISCO, N.Y. 10549 SITE LOCATION: 31 TIMBERLINE COURT, PUTNAM VALLEY, N.Y. 10579 TAX MAP DATA: MAP 51; BLOCK 1; LOT 50.6; R.S. LOT 6 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY THE DESIGN ENGINEER PRIOR TO BEING BACKFILLED. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH THE RULES & REGULATIONS OF THE PCDH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. SURVEY INFORMATION SHOWN HAS BEEN PROVIDED BY DONALD DONNELLY, PLS.