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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -2 -8 BOX 22 l ar 1 rLj- ■ • I'L. i f ' I I f- � - 02567 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OV ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE MENT SYSTEM PCHD CONSTRUCTION PERMIT # ` ff l/ —D L ...:_ - ��;��� 1a3 Located at Owner/Applicant Namer> Formerly_. Mailing Address 141�%�� -�?r; Town or Village Tax Map Lot Subdivision Namer Subbd. Lo t # Cy/l�ldf1 74%1,�>r/ A y Zip J rs� � Date Constriction Permit Issued by PCHD a Separate Sewerage System built by !�W � cam"-' AddressG�r9 Consisting of 1,0'0161 Gallon Septic Tank and Other Requu.-ements: Water Sup m� 4: Public Supply From. Address or: ''' Private Supply Drilled by su %' Building Type : ���'? G' Has erosion control been completed? - Number of Bedrooms Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as show plans (copies of which are attached), in accordance with the issued PCHD Construction Permit plAve�, plans and the standard rules and regulations of the Putnam County Department of Health. " "r Date: Ce P.E. �''� R.A. by�P PpNCis Design Professional) Address a--- /0 77 2— —b_ ��` License # LU Any persodoccupying pre b ve system(s) shall promptly take such action as may be necessary to secure the correction of z e ditions resulting from such usage. Approval of the separate sewage treatment system shall become.` d 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 revoca on, codification or change is necessary. �j By: ! -- Title: Date: Z /% —0 Z— White copy - HD ile; to copy - Building Inspector; Pink copy - ner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH (DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well L6gation - Street A ess: p o illage: Tax Grid'# Map S2, Block Z Lot(s) Well Owner: Name:F � Address: �- � .� io.� Use of Well: 1- primary 2- secondary �� Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment _ZG Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length 2i ft. Length below grade Oyit. Diameter (' in. Weight per foot /l0 lb /ft.. Materials: X Steel Plastic _ Other Joints: _ Welded ?<' Threaded _ Other Seal: 4_ Cement grout _ Bentonite Other Drive shoe: 7f Yes _ No Liner _ Yes 7c No Screen Details Diameter (in) Slot *Size Length(ft) Depth to Screen (ft) Developed? First _ Yes No Hours Second Well Yield Test _ Bailed _ Pumped 24�, Compressed Air Hours I Yield /U gpm Depth Data Measure from land surface- static (specify ft) 361 During yield test(ft) Depth of completed well in feet S'o0 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 q .v " If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type _40, c, Capacity 5' Depth Model 6' 07 -i Voltage a 30 HP Tank TypeW?d Y Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) i r NOTE: Exact location of well with distances to at least two permanept landmarks to be provided on a separate sheet/plan. Well Driller's Namec 17��% n- o vL Address /dam ° j� �,.. . Signature: �� l Date: 161 P11 Y White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97, Public �i f., , - LC)RE,TfA MOLINARI R.N., M.S.N. PuWk- Health''DirWor PaUvic Services DEEPA.R-I'ME."N'T" OF 1-TEAL"TH I Ucawva Road Bremsia, Nov York t0509 I:uvivvumuiiud lkalLh 1,914)278-000 kuu (91,l) 278 - 7921 Nursing Servim (914)276-058 - I IIIC (914) 2 78 - 66 18 I-•ax (914) 2M - 608S EM-ly 111EN-YI•1117U11 (914)218-014 Preschuu) (914).178-6082 Fax (914)278-6648 NiAT NL11Y143ER-. AMA.1 u% ss: Ad!T1108J1;ED T01,11N OP'. .............. 7f- Courity Duqw.i-fiaeut of Uc�,1101 I-Vill 110t iSSLIL' 11 CeL'tiffUte Of -(I by all a 1.1 ffic) rized (ol-vi.] o tficial. 'I'llis form is to be submitted w0il applicatiolo for �j C(-,'rt1•1c;11-e of C"0121phance. ! i .,., i -] ( I P �.I) 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL .HEALTH SERVICES GUARANTEE OF SUBSUP, FACE SE aVA G E TREATMENT SYSTEM Owri;,-r or Purcaaser of Building Tax Map Block Lot Building Z& _6:)_n:;_tn_icted by Tom nNillage Locall'on - Street Sul ......... Name Building T,pe S*livision Lot # I represent tiat I am wholly a.)-ij (:oinpleil :Jy rc•spol,sibi: for the location, workmanship, material, construction end drainage of thQ sewage ti,k:atmei.t stiswni sl.,rving tht above-described property, and that is has been constructed as shown on Lilt appiovcd pian l approved amendment thereto, and in accordance w-,th the standards, r-,.des and rCUL1.1ationi oftfiv.1"umain County Department of Health, and hereby guarantee to the owner, fds 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 treatmmt 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 I of the building utilizing the system. The undersigned further agrees to accept as conclusive the Bete: mination of the Public Health Director of the Patnarn County Department of Health as to whether'or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month Day Year 02-- Signature: ,6/)222 &— — —Ger—nx—al E_o_nt_r_actor (Owner) - Signature Corporation Name (if corporation) Address: State L-ip Title: Corporation Name (if corporation) Address: 4&,6V S t a t LO 61 Form OS-97 rj YML ENVIRONMENTAL SERVICES ' 321 Kear Street Yorktown Heights, N.Y. 10598 ��s`����' _�. � .(914) 245�2�0�' �'-��~�--~�� �^-~' - , Albert H. Padovani, Director LAB #: 32.207913 CLIENT #: 56048 NON STAT PROC PAGE KHAN, BRIAN FAIZUL DATE/TIME TAKEN: 10/23/02 10:00A 3239 LEXINGTON AVE DATE/TIME REC'D: 10/23/02 02:20P MOHEGAN LAKE, NY 10547 REPORT DATE: 10/31/02 PHONE: (914)-490-5750 SAMPLING SITE: 157 OSCAWANA HEIGHTS RD. PUTNAM VALLEY SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE COL'D BY: BRIAN KHAN TEMPERATURE..: < 4C NOTES...: RUN OFF HOSE COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE RESULT NORMAL - RANGE PUTNAM CNTY PROFILE 10/23/02 MF T. COLIFORM ABSENT /100 ML ABSENT 10/23/02 LEAD (IMS) <1 ppb 0-15 ppb 10/23/02 NITRATE NITROG <0.2 MG/L O - 10 10/23/02 NITRITE NITROG <0.01 MG/L N/A 10/23/02 IRON (Fe) <0.060 MG/L 0-0.3 mg/1 10/23/02 MANGANESE (Mn) 0i023 MG/L 0-0.3 mg/1 10/23/02 SODIUM (Na) 3.87 MG/L N/A 10/23/02 pH 6.9 UNITS 6.5-8.5 10/23/02 HABDNESS,TOTAL 48.0 MG/L N/A 10/23/02 ALKALINITY (AS 34.0 MG/L N/A 10/2310EL � 'TURBIDITY (TUR _ -/_<1NTU^_~ ' '-^..��'�0�5,NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDl�S���THE 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. iblic 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 is suggested. METHOD 1008 9101 9139 9146 2037 2037 9043 --~ -' -' _ YML ENVIRONMENTAL SERVICES � 321 Kear Street Yorktown Hei N����10�98. (914) 245-2800 Albert H. Padovani, Director LAB #: 32.207913 CLIENT #: 56048 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ KHAN, BRIAN FAIZUL 3239 LEXINGTON AVE MOHEGAN LAKE, NY 10547 DATE/TIME TAKEN: 10/23/02 10:00A DATE/TIME REr'D: 10/23/02 02:20'' REPORT DATE: 10/31/02 PHONE: (914)-490-5750 SAMPLING SITE: 157 OSCAWANA HEIGHTS RD. PUTNAM VALLEY SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE COL'D BY: BRIAN KHAN TEMPERATURE'.: < 4C NOTES... : RUN OFF HOSE ' COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 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 O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L ,.'�MODERATELY-JHABD'�WATER: 70-140 MG/L MG/L��]�ILL�GRAM'F�3�,�ITER - --- - -`' HARD SUBMITTED BY: Director ELAP# 103R3 BRUCE` R: FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH. 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 September 16, 2002 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 M Dear Mr. Sullivan: Field Inspection - ahn (T) Putnam Valley, TM# 52 -2 -8 A site inspection was made for the above referenced project on 9/16/02. The following comments must be corrected in the field. 1. Although a fax was sent in stating the system was complete, the system has not yet been completed. The trenches are in but it appears the septic tank and curtain drain have not -been installed.. Please verify_ and- let-this Department- know. when the entire system - has been installed. 2. There needs to be silt fence downgrade from the SSTS area. 3. Please provide this Department with a copy of the trench plan (sheet 2 of 2). If you have any further questions, please contact me at (845) 278 -6130 ext. 2157. JSP:cj Sincerely, Joseph S..Paravati, Jr. Assistant Public Health Engineer w ?;F - _ Sheet of * * PUTNAM BOUNTY DEPARTMENT.OF I3EALTH DIVISION OT ENVIIRONMENTAL HEATLH URVICES ,street TovGn State z Zip " PERSON TN CIiAR'GE sj t nvTFF� vrF,XA Harp 4 Name d.Title =� -1 11L TYPE O SFACILITY �� +7c � �� � ' � � $k� ���� H C �(s� 1•'i { ,. �z�i- �?s.g ,� w"�"``��` "� GGl'x'.! �� `��s �•�" � J `` k�- ``...� (�'[�'`' -�1 p •� r s 7 r '` cJl /(I S`�z"v a.'+'?.' �ti s w* �� �y � •F'Ca „G a� � � � �: -3'z � '°� 3 �,'�' -»v'�' ^=� "'£ tea„€ � +sue } u; +� �`.,. 5,7�,. z. S � � ''{t�+�.5 f r�'i "�qs �•tvs+, i.L, `� 's'>^ - `Y'- '�'-S— �•'� �. ,�`r�wps 'x '�"d .'"` �'�. 3^>� -- t � �'1'r'.. e¢'3 .�,ti..g �� � ,, ,a .¢ � r•�; rte- .� - ,>- � .4�-'�: "c'� � `� _ ✓-�.� .tom '.� ,�,�"`.t :, m �'"` ; ^+y $ �' -'�•� �� _-L`ix _ yi„�. �'ax.,� c� �i"c'� ' a ,ate �. o,.? Ar ,y. K.k T- r '��;a �.s s`°� �F�'� -- 3 -k '�"` �,�. �'���'�� .'�- � s s �.�:r"'��yy.,,F',� w{M .�� 1 7�- sf0�° y.T�•i' � 4 S _ �«.✓ r, r�-' S<,^ �.�5"k- ,�.z, � � � m� z �. d >" �� �':m �t'�- ��;4'- ���.Y.3�» { ,� .. s „ s,� i � �*� � � c `.��✓rT��+' �.'�.� ,� � }$. t E 1' Y - R _ � •yam �'��'S' �.. R�. -A t+ K§� f, f 'S'�'^`�J -.. i F� '� � - s>+_ ax �, •'•` �' xa-ro rt �Y � ay � �� �, �. ti .ry � `�" g.. sR �:. � �",�y, - rc,�s �r :_ r '.� '�' q; N' S w 3� "'f�.,_ F+cx.•,- "`'- r y t. vv v i .t c ✓§` �. sr a$' T' r r �""vr -. 2 e`r 't e �,.3L.x.^. F fr r `� v 15x z ���soi±`r'�k���rt""' �.�''.�a�?:.�`• k'F� -:,. «a>< 0, .., 96 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRON IEN TAL HEALTH SERVICES . FINAL SITE MPECTION Date: '� ��� Street Location ,/ Owner Town Permit # �` TM # " Subdivision Lot # 1. Sewage System Area a. STS area located as per approved plans .......... .......] ...:.. b. Fill section = date of placement 3:1 barrier Lgth. Z4 Width Avg.Dpth c. Natural soil not stripped ........ ............................... d., Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course /wetlands ............... II. SeN!aae System , a.�eptic� tank size - 1,000 .......... ................ 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 Bo - properly set ........... ............................... f. renc es T.—L—eng--th required Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft: foundations.......... 6. Depth of trench <30 inches from surface ........ :......... 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 -1' /Z" diameter clean .................... - Depth -of gravel in -trench 12" miniFnum........ ...:.:..::.� 10. Pipe ends capped ........................ ............................... g. Pumo or Dosed Systems Size ot pump c am er ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ............................ ............. ..........:........ 6. Cycle witnessed by H.D.estimated flow /cycle.......:... III. House/Building a. house located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... . IV. Well a: Well located as per approved plans . ............................... b. Distance from STS area measured ' ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box . ............................... d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.' f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............:.. h. Surface water protection adequate ... :.............................. COMMENTS 0B/07/2002 14:29 9149624248 JOSEPH SULLIVAN PAGE 01 FU7WAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATrENTION ❑ ADAM GEn REQj1E3rEQRnNALM=1QN For: Fill All information must be hilly completed prior to any Tmaches ksp*Wom being made.. PCHD Construction Permit Owner /Applicant Name: A J BIO& -Z Lot Or Subdivision Name: Subdivision Lot #---- Is system 1511 completed? Date: A- is "am complete? Date: Is system imustructed as per plains? Is well drilled? Date: Is well located as per plans? Are erosion control mft,wra in place? 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 Dqmlumt of HOWL Dee: &..o- Catified PE RA Design ProfaslozW # commW Form FIR -99 Public Health Director - , ...... - iAk>✓T"l A 11�CSY,TAfAftl 'R 144 M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 20, 2002 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Re: Khan, Oscawana Heights Road (T) Putnam Valley Lot # 1, TM# 52. -2 -8 Dear Mr. Sullivan: An inspection of the fill pad at the above referenced project has been completed. 1. Additional fill is required in order to maintain a three on one slope. 2. Measures must be taken to ensure the well maintains a 100 foot setback to the toe of fill. Please note that field measurements by s Department-in-no. Way. _suggests the. e, a ctsl7e,_�e�th:..._�:� - . _.._ _. ...... -- .._. ..... s ..- . ... _.... --. and location of the fill pad. r If you have any further questions, please contact me at ( 845)- 278 -6130 ext. 2261: Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj fill pad SENDING CONFIRMATION DATE : AUG-21 -2002 WED 08:36 NAME . PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845- 278 -7921 PHONE : 919149624248 *51 PAGES : 0/1 START TIME : AUG-21 08:35 ELAPSED TIME : 00'001, MODE : ECM RESULTS : NO ANSWER FIRST PAGE OF RECENT DOCUMENT FAILED TO SEND FULLY... a e. BRUCB R. FO1.BY WRB7TA MOIOWU R.N., M.9N. F.Mb rRaW Amax 'i AnmWM P%W AWM Daacas D&-- qr latlewl Ss.r,v DEPARTIVNT OF HEALTH 1 Genova Road, Bm A.. New York 10509 i B.m4 -ftl ROM (945)273.6130 Fax(945)278-Mi Naniat 6AMM (945)273.6556 WIC (945)273.6671 ft(BMM -6013 I+" latrrrroac,Jprncawl (143)271.6014 Yaa(64$)273 -6613 August 20, 2002 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heightq New Yoric 10599 Re: Khan, Oscawana Heights Road (T) Putnam Valley Lot 0 1, TM# 52. -2 -8 Dear Mr. Sullivan: An inspection of the fill pad at the above referenced piojcct has been completed. 1. Additional fill is required in order to maintain a three on one slope. 2. Measures must be taken to enure the Weil maintains a 100 foot setback to the toe of 611. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the 511 pad. If you have any firther questions. please contact me at (845 )-278-6130 ext. 2261. Sincerely, vJ Gene D. Read Environmental Health Engineering Aide G.DR:cj fill pad 09/11/2002 09:10 9149624248 . JOSEPH SULLIVAN PAGE 01 ]PUTNAM CQVM DEPARTbUM OF MAM ONION OF ZKVMONMMAL RtALTR =AV= ATMNTION ADAM P(Gtn For: FM AU idormtion =m be Mly wm*W prior tb anY Troadm kspectiou bW4 made. PCHDC=anw"a Penn nh# 4. w � v 2– 0, —WV ZW woow, 1, 1) (v) t ld*l hChd LA for Oww/Appbm, lion: –A& polmoy. Is system fin complaw? v2u two- Is qs= complso? Date: b quam commuted to par PIM? Ys is vrou 6ow? volt;$ Dam: well loaf W at per PIM? Idle Are erosion control numa in Ou"? I WO that the syAwX#j is UA4 at the abm premise: bow bm oamawM nd I bm kopWAd and vaMed *sk compWou W &=dim vb ft brjW PM CONOWIM Pwk Wd approved plus wad the Studardsi, Wo wA RmpWkm of do Fvl■ss#► Carty DqPAMM Of S J-- AddreS9: i -t ' 0 E& Z -- - A; pomplk-99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL :piease priiit-or type PCHD Permit# Well Location: Street Address: Town/Village Tax Grid # 0': C VV A AJ A 46' I S Iii J- V, -F y�,it Map SZ Block Z Lot(s) 2, Well Owner: Name: Address: T6. �`_ e -1— G's c d w« n a I- , ke IT J- . P. v< tv Use of Weal: _/Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondairy Industrial Institutional Standby Amount of Use Yield Sought `;' gpm # People Served ,G-, Est. of Daily Usage ,5 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type i/` Drilled Driven Gravel Other Is well site subject to flooding ............ Yes No Is well located in a realty subdivision? ...................................... ............................... Yes ✓ No Name of subdivision s L, a.:; ra E-- Lot No. I Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes Nov-- Name of Public Water Supply: Town/Village — Distance to property from nearest water main: - M i . ) Proposed viell location & sources of contamination to be provided on separate sheet/plan. Date: i-af"-4,7 1 _l Applicant Signature:. PERMIT TO CONSTRUCT A WATER WELL This permiit 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 Permit Issuing O ial: Date of Expiration Title: ,�� Permit is Non- Transferra le White copy •- HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 -BRUCE --R1.---F0L-E-Y-- .:�.._ ... _ Public Health Director DEPARTNIENT 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 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER NAME:. J act. R_ O R SITE LOCATION: 11Y.-Us STAFF PRESENT: MCL Rk I SPECIFIC WAVIER REQUEST: � DQ �} ��� • p� �j a�� s/ �j I'�•�XX.� C/ . G� DOES THE PROPOSED' VARIANCE REQUEST POSE A HEALTH HAZARD OX ENVIRONMENTAL CONTAMINATION PROBLEM? YES NO WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP? YES NO DISCUSSION REQUEST APPROVAL OR DENIED - APPROVED REASON FOPWENIAL DIRECT R O P LIC HEALTH (SPECWAIVER) DENIED DATE: 3-,7 --[) 2, NEW YORK STATE DEPARTMENT OF HEALTH Specific Waives' Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75 -A, IONYCRR for Individual Household Sewage Treatment Systems Name of Applicant No. Street L.Wxcwn State ZP Address No Street Gry/rowq State LD . Site Location "c'- �� p RWAUMDO. NOT • 1. Reason why she does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)): Separation distance cannot be achieved. Excessive slope. High groundwater. inadequate depth to bedrock or impermeable layer. Soil unsuitable. Other (explain) .. ....... ` .. ...... � ..... ...`1.. .... 1 �....... r .........G ...���...........1 a.......... � .....................� -�.............. ........ .�o.. ........... r .......... ............ ........... ___ ....................................................... .........._............_.._.... 2. Proposed design or conditions of waiver: . . . . .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . .. .. . . . . . . . . .. . . . . . . . . . . .. . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : ...................................... . ........................................... ......................................... ....................... .......................................................................................................................................... :................... .............._ f ....................................... ..._ .................................................................................................... .___...._........................................................................................ 3. The proposed design may have the following limitations (check appropriate box(es)): Increased risk of well or spring contamination. t ^j Increased risk of surface water contamination. Expected design life of the system will be diminished. 0 Operation of sewage system is subject to mechanical problems. `• 0 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 t ' suing official for a change in conditions for which this waiver was granted. Fi_PaESENTATI ORIGINAL - Local Health Agency G � COPY - Applicant/Design Professional oArE...�o .. ................................... ............................... DOH -1326 (7192) (GEN -152) S (A _0y -L)z .. 13.16.3 (2187) —Text 12 PROJECT I.D. NUM3ER 617.21 • SEAR " env " x�ndlC Review V w - -Ouality SHORT ENVIRONMENTAL ASSESSMENT FORM. f �z For UNLISTED ACTIONS Only. PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME - r , ��- .5 3. PROJECT LOCATION: _ Municipality /-'a" WJ" /,/ &11,e V County / 01 —W 3. PRECISE 7LOCATION (Streit address and road intersections,11ominent landmarks, etc, or provide map) %�h /fjd O, L/ i`' •i li�iO�,�C�° �j'�a�%� /�fJ�G' �Q',a�����L .� ` Gerf t7� 5. IS PROPOSED A'eTION: A-ex 0 Expansion 0 Mcdificationlalteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LA%0 "FECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTI04 COMPLY WiTH EXISTING ZONiN OR OTHER EXISTING LAND USE RESTRICTIONS? `Yes C! No If No, describe briefly 9. WHAT IS PRESE: r LAND USE IN VICINITY OF PROJECT? ARi31dentia! 0Industrial ❑ Commercial ❑ACr.:utture , __ 0 ParklForest)'O;en spa -ae _..... ✓ Des ibex- - -" .....__ OOther .:. 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOVI OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAL)? es 0 No If yes, list agency(s) and permitlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY .VAUD PERMIT OR APPROVAL? Yes ONO - It yes, list agency name and permitlapprovat 12. AS A RESULT OF PROPOSED ACTION WiLL EXISTING PERMiTiAPPROVAL REQUIRE MODIFICATION? 0 Yes �6LNo i CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Appliea .tlsponsor name: U�? Signature: Date, i , rr• If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this as'ses'sment PART Ii-- ENVIRONMENTAL ASSESSMENT (To be completed by kgency) A. DOES ACTION EXCEED ANY TYPE t THRESHOLD IN .6 NYCRN PART 617.127 It yes, coordinate the taview process and use the FULL EAF. ❑Yes. QNo - - , ._._ ...,._.... ........ B. WILL ACTION-R ,CELVE :COORD(NATEO NYCRR, PART 617.6? it No, a negative declaration 7syay'6e superseded by another involved agency.. . ❑ Yes Nb '• ' , C. COULD ACTIO RESULT,IN 'ANY ADVERSE EFFECTS ASSOCIATED WrrH THE FOLLOWING: (Answers may be handwritten, it 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 briefly - -.., C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: - s C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be lnduced•by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. C7. Other impacts (Including changes in use of either quantity or type of energy)? Explain briefly. A �J� - D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes It 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 ettect should be assessed in connection with Its.(a) setting (i.e. urban or.rura%.(b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or•significant adverse impacts which MAY occur. Then proceed directly to the FULL F-AF 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 attach me is as�nnecessary, the reasons supporting this determination: 91 .r if l 1 } Print or tpe-tcacne of Responsible O Tide of Respon sible O iicer ignature of Preparer it different from responsible officer) G� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM 2 PERMIT # .S l�✓ y— d 2 "�; Located at !9SCa e An A �g �oo owri or Village Subdivision;.2ame 1 4 cY o Subd. Lot # Tax Map ,5�:—'-�' Block 2- Lot Date Subdivision Approved 9` �� Renewal Revision Owner/Applicant Name /40r- Date of Previous Approval Mailing Address 41 Amount of Fee Enclosed Zip Building Type Lot Area /3 No. of Bedrooms 3 Design Flow GPD !O'P tP Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of �e ° ° gallon septic tank and v!'o o 1 Other Requirements: To be constricted by y ,c/'° Address Water Suoaly Public Supply From Address or• ✓' Privafe Supply�illed by JYmri�lAi� 1�'�l !�-:5 o Address's 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: d' Address P.E. R.A. Date e License # j/v�/Y/Iolrl - r APPROVF,III FOR CONSTRU al expires two years from the date issued unless construction of the sewage treatment system has been ected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by - . is Health Director. Any revision or alteration of the approved plan requires a new permit. Approved or discharge of domestic sanitary ewage only. By: r� �r � Title: Date: White copy - HD ile; Ye to copy - Building Inspector; Pink copy - 4ei:,-64�ige copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type v ... PCHD PerlTllt Well Location: Street Address: Town/Village Tax Grid # 6,7 C 'nl'ow'4 Z�4 H d 0r y Map 5'� 2- Block :? Lot(s) Well Owner: Name: l 0i -%O�J Aqo Address: '/�%J Use of Well: V_/Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _ '" gpm #People Served Est. of Daily Usage X16 fl gal. Reason for Replace Existing Supply. Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type _ /brilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes ✓' No Name of subdivision Lot No. / Water Well Contractor: /V'. Address: `'� Ar7 �a /��• Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village --� Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: v:. P . - Applicant Signature: - ez'4 ''? J :....::: - �°- -+tee 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. /f e , Date of Issue 6 — —0 Z Permi Date of Expiration & — 7 —0 4 Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller P Form WP -97 JOSEPH F. SULLIVAN, P.E. 2972 FERNICREST DRIVE: YORKTOWN HEIGHTS, N.Y. 10598 (914) 962-4248 6 If Al -5r7 %-mot: UI r ; s �'G?� ,��� .��' ( 54e ,,7r )7A! e,7 INAM_UNTY DEPARTMENT OF HEALTH CO SERVICES i(l,'N DATA SHEET - S UBSURFACE SEWAGE TRAATMENT SYSTEM Owner Address . ... ... ... . ..... . ... .. Located ai. tf Tax Nlap r r,Z Block 7— Lot (inckate nearest u0s", Sirlee-t) M Wa(ershed e��e_ unicip �i 1; SOIL PERCOLATfON TEST DATA Date of.*." ;.,�,,:-s(-,,�t.;,,,.!"II ell Date of'Percolation Test Depth to Water Water ITO in Ground -Level P-OrO '44,941. j �r5 VU . Nia N.. kole A4 t0 Start 01 es j C7 T /1112 �w 1>1 3e Ae2 ........... .. . . . . . . . . ... .. 4 NOTES: e rep m is to b repeated at sae depth untilapproximately equal percolation rates are obtained at each p;�rcolatjon test hole. (i.e. ,, I inii-i for 1.30 min /inept, ; 2 min for 31-60 min/inch) All data to be for review, 1_'e P � *1 $i measure made to be ade from top of hole, Form DD-97 G.L. 0.51 1.01 1.51 2.0' 25 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.o, 7.0' 7.5' 8ff 8.5, 9.01 9'._5 lo.(,), 1EST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTE R_11:1) IN TEST HOLES DOLE NO. HOLE NO._ HOLE NO. I - Indicaic levcl at which joOUiidivater is ericotiatered Indiclaa., at which mottling I is observed Ind ilevc,! to which water level rises after being en•OUritered DeeI-) hoic, obserwitions made by: 40' Date i! Pridi% 7 W 0 0 1 U L I CL aIM.. Addu:s,,: ... .... ... Design Professional's Seal OPT NEyy�� - - -- - __ m00% --- - - - %Y- -- -- ]_�_ 4_7 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 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Frank Sullivan 2972 Ferncrest Drive Yorktown Heights, NY 10598 Dear Mr. Sullivan: January 16, 2002 Re: Proposed SSTS: Pepper Oscawana Heights Road (T) Putnam Valley TM #52. -2 -8 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.. Please show all footing and gutter drain water discharging from solid pipe to a point 20' or more below the expansion area. A cut is shown in the southerly corner of the SSTS area, please revise so that no cuts are •.shown... _. Show the expansion trenches 66 the plan witK—theif4engths provided. > �� A-- ll is to extend 10' horizontally past the end of all trenches and then slope on a 3:1 grade. "Show a minimum 100' separation distance from the well to the SSTS. el "Curtain drain discharge to be shown a minimum of 20' down gradient of the expansion area trenches. Cross out any information not relevant to this submission such as the pump notes, pump design, etc. Current codes require the construction of a SSTS on slopes s 15% with <_3.5 feet of ROB fill. The proposed action will need waivers from each of these requirements. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Shawn Rogan Public Health Technician SR/jp 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 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 January 16, 2002 Frank Sullivan 2972 Femcrest Drive Yorktown Heights, NY 10598 Re: Proposed SSTS: Pepper Oscawana Heights Road (T) Putnam Valley TM #52. -2 -8 Dear Mr. Sullivan: 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. Please show all footing and gutter drain water discharging from solid pipe to a point 20' or more below the expansion area. 2. A cut is shown in the southerly corner of the SSTS area, please revise so that no cuts are shown.:_ y - 3. Show the expansion trenches on the plan with their lengths provided. . s 4. Fill is to extend 10' horizontally past the end of all trenches and then slope on a 3:1 grade. 5. Show a minimum 100' separation distance from the well to the SSTS. 6. Curtain drain discharge to be shown a minimum of 20' down gradient of the expansion area trenches. 7. Cross out any information not relevant to this submission such as the pump notes, pump design, etc. 8. Current codes require the construction of a SSTS on slopes s 15% with _ <3.5 feet of ROB fill. The proposed action will need waivers from each of these requirements. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Shawn Rogan Public Health Technician SR/jp PuTNAit COUNTY DEPARTZNIEN-r OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH L-N-DIVIDUAL NVATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION IMIT NAME OF Olvvl. STREET LOCATION: CAAAP?%-t-- REVIEWED BY: IZ4\L GR, AS&ATE: AX NtkP' : (CONFIRMED) eD�:- pocumlrugs *Y N (REQUIRED DETAILS ON PLANS CONT'D PERMIT APPLICATION CZLJHOUSE SEWER -'/." FT. 4"0'; TYPE PIPE CAST IRON NVELL PERINUT OR PWS LETTER (��)L NO BENDS; -NLMXAENDS 45- W/CLEANOUT PER, ,T_E. _T PC-97 WALS LETTER Of AUTHORIZATION (-)L-)SITE NOTE (NO C DESIGN DATA SHEET (DDS) ��TILL `Rsv s T "EN I S `CORPORATE RESOLUTION 10"H RIZI PAST TRENCH SLOPES 3:1 TO GRADE SHORT EAr C :5 N-S-71MUE SETS C_)FILL SPECS/ FILL NOTES 1-5 (,)HOUST PLANS - TWO SETS C._,l _JFILL PROFILE& ",� (ZL_)FILL IN EXPANSION AREA (,,::�yVAP4kN`CE REQUEST FILL GREATER ,N?'2.FEET SUBDIVISIO L_)EFCLk B. R I - B C�J�LEGALSUBDIVISION ILL ICATIONNOTE L L,:5r SUBDIVISION APPROVAL CHECKED C_JL_)DE AGES JPERCR.A.rE P?-% C_j VO ON -4 FOR R.O.B., UNCLASSIFIED & ENIPE-RVIOUS RR� Ljc--lfmL REQUIRED _ DEPTH- 91 kRATI0,N DISTANCE FROM TOE OF SLOPE J-(.-)CURTXlNDRAMREQUIREt) S DRENCH GENERAL 6(_JLF TRENCH PROVIDED S-&E) 60FTMAX. (-)(-_)LOC)KEDriNYC,TjAZER:SHED C /)C_JPARALLEL TO CONTOURS (-Y-_)PLAISSIt� ----F.DTODFP - L-) _)DE iPCHDD NE OR WASHED GRAVEL FPAI., Pp _)LJDETAII.JDUST FREE CRUSHED STONE (-J(, EP APPROVAL, Q'D , 0� V C/)(__JGEOTEXTILE COVER (/J-LJDEEP 7EST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSIS -(_,/)(_)PERCSTOBEWITNESSED (U U10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 16- APPROVAL SSDS ADJ, LOTS C/j(_j2D' TO FOUNDATION WALLS –f!!5'�V-ETL,'LNDS(TOW,N/DECPF,P,l�nTRIEQ'D?) C QW: __)C– -0 _-T-Q-WR-b N DLOD, 150'TO PITS LZL_)DAT,k ON DDS PLANS & PERNITIT SAME IT 200'h. j .9 (f --ffl 100'TOSTREAM,WATERCOURSEI,A C=expan) jrRE169NEIGHBORNOTIFICATION ( �50'TO CATCH BASIN, 35'STORrYIDRAIN, PIPED WATER LJC TO WATER LINE (pits - 20) O:rT'ERBTJZBA W/1 2 0,- IM-M'--FEGOD'EL-EV,kT'ION 0 50'INTERl ENT 'RAlNXGE'COURSE'- ( _-Y,,-)SOlL'TESTIN, G LOTS>10 YEARS OLD C,15V-J, 200'1500'RESERVOER, ETC. 150' GALLEY SYSTENIS REQUIRED DETAILS ON PLANS C TO LEDGE OUTCROP C.JC SEWAGE SYSTEM PLAN-(NORTH ARROW) SEPTIC:[ ANK SSDS HYDRAULIC PROFILE �10' FROM FOUNDATION; 50' TO WELL ff(-_)GiwvrrY FLOW WELL C,!!j(__)co,N:srRucriON NOTES 1-15 MENSIONS TO PROPERTY LINES- C of&-)DESIGN DATA- PERC & DEEP RismiLIS (L-)C__)DIl 'LOCAnoN OF SERVICE CONNECTION (.o:o( NTOURS.E)a2lXG & PROPOSED X 15' TO PROPERTY LINE _j2'CO* (_)ML ) DRIVEWAY & SLOPES, CUT _)DP SL92F, (-JC--)F00tWG/GUTTERlCURTAIN DRAINS. 9 ((_)USDA SOIL TYPE BOUNDARIES' (-�)-LJSLOPE IN SSTS AREAaa(:r20 /6) (!,.-fC (ej(---)TrrLE BLOCK, OWNERS NAM ADDRESS j _)REGRADED TO 15%, IF REQUIRED TNI,-.!,PE/RA;NAblE, ADDRESS, PHONE,�' (_)C_JPLrNl? NO ES DOSE/PUKP` SYSTEMS 75 p JDATE OF DRAWING/REVISION C_)(_JDOSE N % VE E VOLUME/DOSE VOLUME NOTED ' 5, S (,6(_JDATn, I REFERENCE 5 IL F, _)LJDETrAlL F F CE MAIN, (PIPE TYPE, ETC.) Ce___)LOC&TIONL OF WATERCOURSES, PONDS C-J( B -)PIT -B SHOWN & DETAILED LAKES,WITLANDS WITHIN 200' OF Pl, Ay STORAGE (,-"J(__JPRIOPOSED FINISH FLOOR AND _JLJI D ORAGEABOVE ALARM BASENIENT ELEVATIONS STANDPIPES, DRAIN & SSDSIS WM 200' )(�)STA ES, 51 BOTH SIDES, DETAIL ->5%,2014%,251-3%,351-1%, 1000/----I% (,/J(_JPR,OPEP,IY METES BOUNDS )15' MIN to CDS —A2Pm.cD-Dis smV/mwith 182 cons day discharge e __)10'MlN to NON-PERFORATED PIPE D Ys/ -1- J 3, CONINIENTS: eev- /s 6 y - 1 Yd- 1,-5opt- ' UX013 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL. HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of T, `) Pe— Located at L AW t4 TN��,��rrl �. I C. Tax Map # 5 z Block z. Lot Subdivision of Subdivision Lot # I Filed Map # 21 1 a Date Filed Gentlemen: This letter is to authorize 4 d `5 �v � l\iV a duly licensed Professional Engineer V & Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with `the provisions of Article. _145 and/or. 1.47 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: P. E., P, A?, # Z 9 `% s' 6 � `i F Very truly yours, Signed: (Owner of Property) Mailing Address: f l .'- OS c,A `ry k State Zip I o-5_7 T Telephone: .5 —1, 33 e7 I Form LA -97 BRUCE R. F'OLEY 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 (945)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 December 21, 2001 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Frank Sullivan, PE MEE D 2972 Ferncrest Drive R-/ Yorktown Heights, New York 10598 Re: Pepper, Oscawana Heights Road (T) Putnam Valley, TM# 52 -2 -8 Dear Mr. Sullivan: 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. ocurnents Letter of Authorization: a. Subdivision of ............. must be completed. v b. Filed Map # ................. must be completed. c:.: ..Dtetled_:.x.,..,...:..•.._.., �r>us be completed,. Short Form EAF is required to be submitted. ,i`3. Well permit states "Oscawana Lake Road ", the property is on Oscawana Heights Road. Please re- execute a new WP -97 application form. Plan 1. Plan (1 " =25') is not legible!! ContOUrS stop. Grading does not tie back in. Plan is to small for amount of information provided - re -do at V =20'. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, OL Adam B. Stiebeling Assistant Public Health Engineer ABS: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 December 21, 2001 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Dear Mr. Sullivan: COPY Re: Pepper, Oscawana Heights Road (T) Putnam Valley, TM# 52 -2 -8 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. Documents 1. Letter of Authorization: a. Subdivision of ............. must be completed. b. Filed Map # ................. must be completed. C. D- fle.:.::.:...:.:::: d . :: .must be- ctnnhleted. 2. Short Form EAF is required to be submitted. 3. Well permit states " Oscawana Lake Road ", the property is on Oscawana Heights Road. Please re- execute a new. WP -97 application form. Plan 1. Plan (1 " =25') is not legible!! — Contours stop. — Grading does not tie back in. — Plan is to small for amount of information provided - re -do at 1 " =20'. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF Pt S'FOR` z':; - A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: el- � UU .17 Or Al 2. Name of project: J� 3. Location T/V: X�a7 hyk 4. Design Professional: 5. Address: �Z7 2 6. Drainage Basin: I �1� e,aW, 0 4-4e v ai 7. Tie of Pro ect: A Private/Residential Food Service Commercial Apartments ' Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? ll/v Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft ]Environmental Impact Statement (DEIS) required? .............&!k :.... 10. Has DEIS been completed and found acceptable by Lead Agency? ....... :..... 11. Name of Lead Agency ._ 12: -`Is'this project in an area under the control of local - .planning; zoning, _or other officials, ordinances? ........ ............................... , 13. If so, have plans been submitted to such authorities? :.. ............. 14. Has preliminary approval been granted by such authorities ?Y 'Vate granted: 15. Type of 'I' )ewage Treatment System Discharge ................. surface water 1/' groundwater 16. If surface water discharge, what is the stream class designation? .................... A//14 17. Waters index number (surface) ................................ :......................................... 18. Is project located near a public water supply system? ....... ............................... �d 19. If yes, name of water supply -.-P Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ �y 21. Name of sewage system Distance to sewage system A6`/% `� 22. Date test holes observed 23. Name of Health Inspector 417 24. Project design flow (gallons per day) ................................. ................... ............. o0 25. Is State, Pollutant Discharge Elimination System (SPDES) Permit required ?. .-. 26. Has SIDES Application been submitted to local DEC office? ......................... Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? 29. Wetlands ID Number 29: - Is Wetlands Perrnit requir6d?` .. ............. .......................... ............................... Ale . Has application been made to Town or Local DEC office? 30. Does P require ro j q uire a DEC Stream Disturbance Permit. Ale 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No Av 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No ✓yo DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... AU 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... dU'� 35. Are any sewage treatment areas in excess of 1'5% slope? 36. Tax Map ID Number .......................... .. .............................. Map,Z Block :2 Lot S 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All applications for review and approval of.anew. SSTS.to be located within the NYC: Watershed shall � "' ::be sent to the.Degz-nent and -hec ¬ -be sent`m,duplicafe to the DEP, although the project may require DEP approval of the SSTS. prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as storm'water plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISI- ON- -OF- EhT�RONMENTAL I EA,LT�I R' CES .� .. _.:.......: INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION. A. GENERAL INFORMATION Name of Project �.� (T)(V) 1 County Site Location 01�,C MMA 4y- « kC n Building construction begun Extent Is property within NYC Watershed ? ................. F-1 Yes (–�No SECTION B. TOPOGRAPHY (Please check all appropriate ``77` at_ b� oxL –(" � � °�o I. Hilly 0 Rolling p s ope Gentle slope Flat 2k c 2. Evidence of wetlands 0 Low area subject to flooding F7 Bodies of water F7 Drainage ditches F--J Rock outcrops 3. Propert3( lines or corners evident ............................................... :...... 4. Do water courses exist on or adjoin the property? .......................... 5. Will these affect the design of the sewage system facilities ?..:.......; 6. Do watershed regulations apply in this development ?.... .. ................ 7 Will extensive grading be necessary? ................ ............................... 8. Will extensive fill be necessary for SSTS ? ............................. I......: .... 9. Do filled areas exist within the SSTS area? ....... ....................:.......... Yes No Yes io Yes �No F--]Yes ©iiQo Yes No _ V es No��� 0 Yes �tQo If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: Sand Gravel Loam � Clay 0 Hardpan Mixture 11. Observed from: F—] Borings a Bank cut ackhoe excavations f 12. Soil borings /excavations observed by L on (( Lv 13. Depth to groundwater �- on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas ...... ............................... es No I 16. Soil percolation tests made by �� on 17. Soil percolation tests witnessed by on SECTION D (on back) Form ST -1 2 SECTION Ii DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes No 19. Will groundwater or surface drainage require special consideration? ..................:.. F Yes o 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... a Yes �o SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? .............. :............................... ................... F__J Yes U' "6 Inspection data 22. Do adjacent wells and/or sewage systems exist? ... .............................:: .. E2 es 0 No 23. Additional comments 0 24. Site observer /inspector and title �a1�},1r �t;� _ -y Y'r rpm 25. Date(s) of observation(s)inspection(s) o r TEST PIT PROFILES Hole # Lot # I Hole # Lot # j Hole # Lot # 1 Depth to water Depth to water Depth to water Depth to mott th to mottling mottling Depg De th to li p _ _ - . - -• � T >jepth rock/imp. Depth to rock/imp. o: Depth to rock/imp. G.L. G.L. G.L. 0.5 1.0 2.0 3.0 6:2 � r' 3 4.0 5 5 5.0 7.0 ! 8.0 9.0 i 0.5 !I _ b rr 0.5 1.0 1.0 2.0 �o <r� �6 �� SSL. 2.0 3.0 4.0 3G" - 91 "' 5.0 6.0 7.0 8.0-///,/ °7T M 10.0 10.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... .........:... : APPL`ICA'IbN FOR APPROVAL OF PLANS FOR 1. A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 2. Name of project: :S' 3 T� 3. Location 4. Design Professional:« 5. Address: Z y z. --• •� ��3A 6. Drainage Basin: Z� r A_ 7. Type of Pr,&ct: _ /$rivate/Residential . Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Al' Type Status (check one) ...................................................... Type I Exempt Type II. Unlisted 9. Is a Draft. Environmental Impact Statement (DEIS) required? .. .............. ...... Ala 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency this :project ui an -:area under-• the - control- of- local -planning; zoning; --or other _..._...._........_.__a :._ . ..._..:..._._. ___ officials, ordinances? ............. 13. If so, have plans been submitted to such authorities? 14. Has preliminary approval been granted by such authorities& Date granted: /fi'p'z 15. Type of Sewage Treatment System Discharge ................. surface water y' groundwater 16. If surface water discharge, what is the stream class designation? ..............:::... 17. Waters index number ( surface) ......................................... ............................... 18. Is project located near a public water supply system? ....... ............................... We, 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A/4 21. Name of sewage system Distance to sewage system /°IJ /mss 22. Date test holes observed G 23. Name of Health Inspector ,fro 24. Project design flow (gallons per day) ......... z el 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.:. A/"' 26. Has SPIES Application been submitted to local DEC office? — 0' 27. Is any portion of this project located within a designated Town or State wetland? /4f© 28. Wetlands ID Number u' 29 Is`"Wetlands Permit required? ............................................. ............................... q Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit ?�' 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................. Yes/No /y 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No J✓ U DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ............:............ Al-, 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of r5% % o slope? .......... . � .............. 36. Tax Map ID Number .......................... ............................... Maps 2 Block 2 Lot 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.AIIapplications for review and approval of anew SSTS to be-loeated within thel�YCWaferslied shall - be s�nf to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the.watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those. forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.43 of the Penal Law. SIGNATURES & OFFICIAL TITLES. Mailing Address :. `..... 7 7 Z BRUCE.. R FOLEY::: ,.. Public Health Director r - LORETTA MOLINARI - RN.,= M:S:N, .- - Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 REQUEST FOR FIELD TESTING ATTENTION: ADAM STIEBELING ❑ GENE REED All information below must be ul v completed prior to any scheduling. DATE: �� o ENGINEER OR FIRM: oT �y i'tl�sJ PHONE #: 9X2- REASON:. — - -- — - -= - DEEPS: ❑ PERCS: �C PUMP TEST: ❑ ROAD /STREET:. TOWN: _ %�c� TAXMAP#: ��• °' �` g SUBDIVISION: LOT#• OWNER: NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES NO - - - -= - = - =- - - _..... __ . _._ ..... - .. ❑ Al- Proposed.SSTS within the drainage basin of West Branch or Boyds.Corner.Reservou-s:_...:.. Proposed'SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ pJ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.. I` h ❑ 0 Proposed SSTS for a Commerical Project. - - _...--- ...._... - - - - -- 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. or Delegated)._based on the.___.__ ._ -- response. If you answered Yes to any of the questions, NYCDEP must witness the soil teshng::This __._ _ .._ _ _. 0.. Department will coordinate a mutually suitable time for field testing with the PCDOH, the.Design Professior.Lal and NYCDEP. �I 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. DATE: CON NL S: XLDTES'[) FOR COUi JW USE ONLY M E: r 14- 1 "_ (?JS?J— T4;r r 12 ,-P,FtOJ, &,SrT f C NUP64SER SEOR C Staloo Envirarovental Quality R*vWw SHORT ENVIRONMENTAL ASSESSMENT FORM For UNUISTED ACTIONS tinily PART I—PROJECT INFORMATION (Po be cornploted by Applicant or Project sponsor) 1. APPL I C ANT )5P(1NSOA 2. PROJE NAME _Te ,q�— & " 5,-:5 3 R OJECT LOCATI County A--? L4AM16pailly 4 PRECISE LOCATION (Sis"t address and road Inlersema, promInont landmarks. &1c.. of provide mapi CK)5r,4 W,.+A"A 15?el�z_-2 —PROPOSED ACTION Now 0 Expansion ❑ Modification/altatation 6. DESCRIBE PROJECT BRIEFLY- 7. MOUNT OF LAND AFFECTED; ocres thflfaLof!. $CIO's 8. WILL PW6p65EDTAC COMPLY WITH EXi&TING ZONtN OR OTHER EXISTING LAND USE RESTIR)CTIONS? Yes L_J I No If No, describe briefly 9. W,1HAT JS PRESENT AND USE IN VICINITY OF PfAOJECT7 RISidential ❑ Industrial Cl Comrnsrclol tJ Agriculture Park/For"t/Open space u Other ribs 10. DOES AC71ON INVOLVE A PERMIT APPROVAL, OR FUNUING. NOW OR ULTIMATELY FqOk ANY OTHER OOYERNMENTAL AGENCY (FET)ERAL. STATE OR L OCA L)? 5(Y es D Nc. It yen, Mel Dwcy�z) artd pamIVapptoy&;% 11. J�EIS ANY ASPEC7 OF THE ACTION HAVE A CVFIRENTLY VALID PlEAPIT OR APPAOVA' Y y No If yes, 0si ag"oy name and pwrnitiapprov&I ti AS A ESULTOF PROPOSED AMON WILL EXISTING PERMIT)APPROVAL REQUIRE MODIFICATIONS yes CERTIFY THAT THE INFORMATION PROVIDED ABOVE.IS 'RUE TO THE %EST OF M1 KtQWLEDGE e, J AppilconVaDonsor narna: SigniAtUft. —K. 81 the action Is In the Caiiiatel Arrow., and you art a stets age rot Y, compWill th* Cow4al Assessmeni Form before procceding with this assessmont 'AVER I PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ M.:,.<.__..-:...,__...__.-.. tONSTRLTCTION 'PERMIT'FOR'SEWAGE'TRE _T1VfMSYSTEAV PERMIT # _ (A) Located at �i cd w "oy A _ Subdivision name ubd. Lot # / �- Date Subdivision Approved .S'' Owner /Applicant Name Mailing Address 5--i' % e� " d L Amount of Fee Enclosed Old Tax Map Block :Z Lot 7 Renewal Revision Date of Previous Approval Zip /vim ? Building Type ,2%�. -'a4P7 ee Lot Area .)3 *4 o. of Bedrooms .,3 Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of lee e gallon septic tank and Other Requirements: j� U J�/�j Y�� •�`i�� % �� �� n �. -��'rJ To be constructed by Address Water Sunnily: Public Supply From Address Supply. Jll���YlGis'� .,Address .:..Private. Su 1 .Drilled by I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the ssparate sewage treatment 5 sy tern 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 approv Certificate of Construction Compliance of the original system or any repairs thereto. pF NEh, jo Signed: Address '2-P,72- R.A. Date License # a 9 APPROVED R CONSTRUCTION: is approval ears 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 sew e only. 't/ ;mod 1.�7 / v By: Title: Date: White copy - HD File; Ifellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION 7Z UL Located at 05 GaW-0, n A /4 C T/V✓"4 w,-*7 H e, Tax Map # 3 Block 2 Lot Subdivision of Subdivision Lot # % Gentlemen: Filed Map # �/ �— Date Filed i/ > ?-/ 9-6 This letter is to authorize �i G -� ✓0) a duly licensed Professional Engineer V or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law; and the Putnam County Sanitary Code: Countersigned: P.E., R.A., Mailing State rr1 G /�5/4 Zip % I&3_, " Very truly yours, Signed: ,� f", (Owner of Prope Mailing Address: r& &. D callwJE NM�2m/ , I State N � Zip Telephone: %I ' Gl Z Telephone: C A a �_d Form LA -97 F .L APPROVED BY RESOLUTION OF THE PLANNI> �Ca OF THE TOWN OF PUTNAM VALLEY, PUTNAM COMM ON THE DAY OF _. ANY' CHANGE.., ERASURE.. MOD I F I ;AT IO'N 0 c OF THIS PLAT, A'S APPROVED, SMALL VOID rfiF� 0 - SIGNED THIS DAY OF .._..._._._ 2 CHAIRMAN SECRETARY 9-v v . tf F }'. • ' V is ` i � i • 7Qs^ \ �� i _ �� p 4 , / J ` 1� � (,- .`,•�i i l r? f'Y5 'i' Fl A.. ! 4 :. i � 5� ` 4? t; i i JOSEPH F. SULLIVAN, P.E. eonliting �ruJL:eez .,..+•_. ... �:. .:. : +:: :.., , .. .'.' ._ ,,.:. _ ... -. , - -'.: _" �C. 29T2•FERNCRES"I. ORiVE•:. ... ..:a. : _ ._ ._ .. ... ......... .. .. .. -.. 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