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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -2 -25 BOX 22 L , T� ,' , , i -rims :1 I LLim o i o. L F �jq r r 1 o F. 11 I Ar �, �� 02581 PUTNAM COUNTY DEPARTMENT OF HEALTH lY OF._E 1IV1R-ON-MEN-TAL,I3EAL:TH .SERVICES-:_:.: _ CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR S ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # — 3S —Do Located at E7 �SCAwANA N&a b till 4g AZ Town or Village T I�AGu4- Owner/Applicant Name 4LJ. ,1_vvNPi ffoggf /AIC. Tax Map SZ Block Z Lot ZS" T Formerly_ Subdivision Name 9'SGAoVA -'0'4 Aj Oagx Mailing Address Subd. Lot # 7 Date Construction Permit Issued by PCHD 9 7 p o Separate Sewerage System built by li rW ecf- 6wS7-y(ycT/ #J Address Consisting of I Z S O Gallon Septic Tank and 610c- Other Requirements: Water Sup UI : Public Supply From. Address Zip 5- or: _ Private Supply Drilled by F WC, Address 1/ Pd "`*"v0'* *f ._ - ... - Buildin -T r g ype - - .. �3 L -Has- erosion control been completed ?. /61 Number of Bedrooms �" Has garbage grinder been installed? �r/o .b I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulation §Athe Putnam Coupty Department of Health. Date: Certified by P.E. R.A. (Design Profess(oval) Address License # 0-7 &O Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocati , modification or change is necessary. i B -� Title: 14& I-�A �� � t� C ✓ � By:. Date: 0 Wh copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Oscawana Heights Road TO illage: Putnam Valley Tax Grid # Map 52 Block 2 Lot(s) 25 Well Owner: Name: Address: Catucci Construction, P. 0. Box 453, Shrub Oak, NY 10588 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 52 ft. Length below grade 51 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner: Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 24' During yield test(ft) 440' Depth of completed well in feet 550' Well Log If more detailed information descriptions or s'jot analyses _ : -... are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 37 Drilling in over urden clay and boulders Hit rock at 37' ....._37 " '- 52 Drill n -in oc a -ca ou ed . 52 550 Drillin in rock ranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5crpm Depth 460, Model 5GS10412r. Voltage 230 HP 1 Tank Type WX250 Volume 44 gallons Date Well Completed 8/26/02 Putnam County Certification No. 001 Date of Report 5/6/03 Well ler (signature) isto her Beal NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Drillees Name P. F. Bea Address: 4 Putrtam Ave., dasher, NY 10509 Signature: Date: 5/6/03 tTifistopher Beal White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 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 (914),219 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6559 WIC (914) 279 —6678 Fax (914) 278 - 6095 Early Intervention (914) 278 - 6014 Preschool (914) 278-6082 Fax (914) 279 - 6649 OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OF (Signature) DATE: Cd X117` LC( )9 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. (E91 I NUUM PUTNAM COUNTY DEPARTMENT OF HEALTH -.: - DKVISION: OF ENVIR ONMEN�'�: EALTH.S]ERVICES. GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM .� '46M-F lb6 Owner or Purc6aser of Builhing Tax Map Block Lot Building Constructed by To- n/ illage Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant.of the building utilizing the _ . system:......._ The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the buildin ilizin e system. Dated: Moo Day-457- Year 1 -003 General'Contractor (Owner) = Signature X4 Corporation Name (if corporation) Address: State _J IJ Zip. 14Q 6116 Signature: Title: 1_l _trl-; cC, �' Corporation Name (if corporation) Address: State Zip v Form GS -97 JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET M $ STAMFORD, CONNECTICUT o6905 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Name: PF Beal 8, Sons Address: 4 Putnam Ave City: Brewster State: NY Telephone: 845 -279 -2460 Sample's Information: Client: Catucci Const. Zip: 10509 Fax: 845 - 279 -6613 Collector's Information: Name: Chris Beal Address of site: 64 Oscawana Hts Rd City: Putnam Valley State: NY Zip: Telephone: Site: kitchen tap Date Collected: 5/7/03 Date Received: 5/8/03 Preservative: HNO3 Time Collected: 14:30 Time Received: 12:15 Temperature: -;4C Lab No.: J032950 Date Analyzed Test Name Result MCL Method 5/8/03.15:00 Total Coliform Absent 5/8/03 Chlorine Free Residual <0.1 mg /L 5/9/03 Color ND 5/9/03 Odor ND 5/9/03 Iron 0.031 mg /L 5/9/03 Manganese <0.01 mg /L 5/9/03 Sodium 33.4 mg /L 5/9/03 Chloride 181 mg /L 5/9/03 Hardness 52 mg /L .. _. <._. 5/9103. __.. ..... _ :. Nitrite:::..::_: :.:. _._._.:: _.::.. , ::1.25 mg /L•.: _.r. 5/9/03 10:00 Nitrite <0.1 mg /L 5/8/03 pH 7.01 S. U. 5/9/03 Sulfate 23.1 mg /L 5/9/03 Turbidity 0.03 NTU 5/9/03 Alkalinity 42 mg /L 5/9/03 Lead 6.95 ug /L At the time of analysis the sample was acceptable for total coliform Absent SMWW 92228 N/A SMWW 4500CIG 15 Units SMWW 2120 B 3 TONs SMWW 2150 B 0.3 mg /L SMWW 3111 B 0.3 mg /L SMWW 3111 B N/A SMWW 3111 B 250 mg /L SMWW 4500 Cl C N/A SMWW 2340 C ::10.rng /L• - -.._, .--. _._ .......Sh9WV1F 4500 NO3E. .. 1.0 mg /L SMWW 4500 NO3E 6.5 -8.5 S.U. SMWW 4500 H B 250 mg /L SMWW 4500 SO4F 5 NTUs SMWW 2130 B N/A SMWW 2320 B 15 ug /L SMWW 3113 B N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter r. Signature: State #: PH -0218 Michael Lapman ELAP M 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: a 0 3 spe In cte y: d-51° Town - vPermit # PV 3 F- a z> 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. Width . Avg.Dpth c. Natural soil not stripped ................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... 11. Sewage System / a. Septic tank size - 1,000 .......... 1 ,250 ......... other ................ . b. 'S epfic' tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box // 1. All outlets at ' vation- watq�te�ed ................. 2. Pro elow frost .................. ............................... um 2 ft.Original soil between box & trenches . Junction Box - properly set .......... ............................... 6, Trenches 1. Length required T Length installed 2116 2. Distance to watercourse 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 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends ca ed ..... ................... ,. .....,.......: ; . _.. _.. . g.- PI' b 6r'Db*sed Sviteins / 1. Size of pump chamber......... ,.,/��,- ....... 2. Overflow tank ......... ......................./// "'"'..................... 3. Alarm, visu io ................... 4. Pump y accessible, manhole to grade ................. 5. box baffled .......................... ............................... C�yycle witnessed by H.D.estimated flow /cycle........... M. oUse/Building T House located per approved plans ........................: ........ b. Number of bedrooms ......... ............................... `.......... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured -low ' - ft........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially baclfilled ........... ............................... 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 & dinto exist watercours g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... Rev. 12/02 i •_T•TJ r 0� �� , .%� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # f V1— 3d "oo Located at aCAW4"A 96,1r S 120 Subdivision name occur c-Ag aJ c� Subd. Lot # Date Subdivision Approved Owner /Applicant Name n Mailing Address 1Dr&VK:5 (Do— Amount of Fee Enclosed `j� Town or Villages Tax Map -52 Block Z Lot Renewal w"' Revision Date of Previous Approval t4,1 I ca-141dd. , Zip /m7 2.- Building Type 6L- Lot Area3 -;? No. of Bedrooms 4 Design Flow GPD -cOY c3 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1250 gallon septic tank and 2.r!- wt va. V222cle s, Other Requirements: To be constructed by 769:7, Address Water SuIDVW. Public Supply From Address or: Private Su-p- upply Drilled by I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewa�.e treatment s,, stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will palace 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. Date 10 Z License # ``^QSOS ' 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 modifie hen considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new it.. pproved r discharge of domestic sanitary se ge only. By: s Title: a Date: Lo� Z White copy - HD Fi ; Yell w opy - Building Inspector; Pink copy - er; Or a copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _APPLICATION TO C®NNSTRUCT A V6!ATER WELL please print or type PCHD Permit Well Location: Street Address: TownNillage Tax Grid # 050-49 M P-p 4f -ym Map 4SZ Block Z Lots) Well Owner: Nam : Address: G1,-! 35- k5i®a— P-D u Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigati n 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 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ✓� ew Supply (new dwelling) Deepen Existing Well Detailed Reason g,„3 :SP,� for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No ✓' Is well located in a realty subdivision? ............ ............................... .......................... Yes No Name of subdivision &SCAwJ�w � A LJ Lot No. � Water Well Contractor: 17Y5 P Address: Is Public Water Supply available to site? Yes No tr-° Name of Public Water Supply: °'^ Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be providecLon separate sheet/plan. Date - i _ .. �,.., .. 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. -7 Date of Issue Date of Expiration /a Z 2 D Permit is Non - Transferrable Permi Title: White copy - HD file; Yellow copy - Building Inspector; Orange copy - Form WP -97 Located at Q SC LO a-n 7m TIV '.. 944 1 C"",n Tax Map # - Block - Subdivision of OSCA- r.,,1�..� Lot Z Subdivision Lot # Filed Map #. 223 Date Filed &I - Gentlemen: This letter is to authorizeo�/ a duly licensed Professional Engineer 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 orregulations 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 t onfornlity with the provisions -of Article 145 and/or 147 of the Education Law, the Public- Health - Law, and the Putnam County Sanitary Code. - Countersigned: &14L ( C ____ ,,�, P17, R.,A., # ' 'SOSO % Mailing; Address�� State _ l�� Zip Telephone: S16 %v 2 Very truly your Signed: _ (Ow of Property) t c� n �j G�!� Mailing Address: 3:5 tCS cow Jzp State 7 Zip 4 .- 1 Telephoner 14.16-4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C State Envlronmentel Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM., For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR LL 2. PROJECT_ NAME D je)'Dcs- u s A�l� 3. PROJECT LOCATION: ) )! l`e- Municipality ,r' V County 4. PRECISE LOCATION (Stre -et addreis and road intersections, itominent to ;dmarks, etc., or provide m* r "rrJ 52 2 -ZS� 5. IS PRO ?OS = ,_TION: Ex;anslon ❑ Medificationfalteration 6. DESCRIBE PROJECT BRIEFLY: ose 7. AMOUNT OF LAND AFFECTED: ZZ ' Initially _S acres Ultimately acres 8. WILL PRO' :D ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? No It No, describe briefly S. WHAT IS E-SEENT LAND USE IN VICINITY OF PROJECT? esidemia!, _ [Undustrial ❑ Commercial - D A;rlculture n Park/ForestlOpen space ❑ Other 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAL)? • es ❑ No If yes, list agency(s) and permlYapprovals 11. DOES ANY ASPECTF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes. {d 0 If yes, list agency name and permitiapproval 12. AS A RESULT OF PROP D ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes U es I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE C Applicantlsponscr Date: j name: Signature: , rr= II the action is in the Coastal Area, and you are a state agency, complete'the . Coastal Assessment Form before proceeding with this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION ExCAED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.127 If yes, coordlnate the review process and use the FULL EAF. ❑ Yes o -8-WILL ACTION RECEIVE COORDINATED REVIEW A5 PAOVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency.. ❑ Yes y�Nd C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Ci. 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 Alb C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: `7 C3. Vegetation or fauna; fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A conmunity's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain /vO C5. Growth, subsequent development, or related activities likely to be induced*b // y the proposed action? Explain briefly. � t• !vV C6. Long term, short term, cumulative, or other effects not identified In Ct•C57 Explain briefly. Yv C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. ryb D. IS THERE, OR INHERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? C3 Yes AN4 If 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 (i.e. urban or.rural);.(b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (i) 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 orsignificant adverse impacts which MAY 9? "'Check r. Then proceed directly to the FULL EAF and /or prepare a`positive declaration. 9?"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: on name or Leao Agency. rint or Type Name orint or Type Name espons�er in lead Agency lead Agency Tit e of Responsible Officer -A iNF.; 0 y, Ni Signature o Respo i O ice( in. Lead Agency Signatuteof Preparef!lf different from responsible o titer) 10 ° Da le I 'PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: ALL Ccoyc -v pt ms z, TIC _- 8 I F7/0 Por -t4d►-c tilwk� e d �! 2. Name of project: OSC4WA44 Woos - Lar? -3. Location TN: FOL6 }-m \1411e,-1 4. Desigg Professional: , cai 5. Address: PC> 86x j� "J.'% ,---- 6. Tyne of Project: ��e-lhivate/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 �l 8. Is a Draft Environmental Impact Statement (DEIS) required? .................... �46 . 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 10. Name of Lead _Agency _ 11. If this project is an area under the control of local planning, zoning, or other officials, ordinances? ............... :......................................................................... e s 12. If so, have plans been submitted to such authorities? 13. Has preliminary approval been granted by such authorities? \ Date granted: J 14. Type of Sewage Treatment System Discharge ................. surface water ✓ oundwater 15. If surface water discharge, what is the stream class designation? .................... ---, 16. Waters index number (surface) 17. Is project located near a public water supply system? ....... ............................... t-4 c. 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or treatment system? ................ � . 20. Narne of sewage system Distance to sewage system — 21. Date test holes observed 4&Z 22. Name of Health Inspector ' Form PC -97 2 23. Pro�ect.design flow�gallons_per day) :....:. �.._ ....._.... _ ..... 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ? ...O 25. Has SPDES Application been submitted to local DEC office? 26. Is any portion of this project located within a designated Town or State wetland? 27. Wetlands ID Number ............................................................ ............................... 28. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town of Local DEC office? j 29. Does project require a DEC Stream Disturbance Permit? .. ............................... 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 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ... ............................... Yes/No? DESCRIBE: 32. Is there a local master plan on file with the Town or Village? ......................... 33. Are community water and/or sewer facilities planned to be developed within _15 .years in oradjacent.to project site? ...........:....... ............................... ..... 34. Are any sewage treatment areas in excess of 15% slope? ................................. hl� 35. Tax Map ID Number .......................... ............................... Mapes Block Lot Z5 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 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: ................................... 00 TUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address 2-az-ii--wa C'evi-tv/ 14k".O-S, 114c" Ila Located at (street) NcAwAi-44 ae-iq 471 1?,p Tax Map -1) 2—Block 7— Lot Z (indicate nearest cros s reet) I? A Municipality Watershed 4 t24 SOIL PERCOLATION TEST DATA Date of Pre-soaking 4i 1 gi Date of Percolation Test 5 b ..... ........ ............ .... ........... .... ....... .... ...... ........ -.: I ........ I ............. ....... ....... ....... .. ... . .. ................... ......... .......... . .. - ......... .......... . ...... t t ....... ep o h' W X: ...... . . .... .......... : . . . . ..... .... .. . .................... ........ .... . ..... .................. '�eIa . ............... ... .......... - .... X....... se Time From"G.0"'.6 d ..... Surface ;eve Zwk r ..... ... . ... ...... O'd 0" N!... St a 1 12!-26 12,,50 ZC> 23 3 .. .... ...... . .... -5— 2 12 0 1: Off /S- ZXZ —3 3 /f'05' Z40 -3 Jr- 4 5 2 1:00 zo 3 1; 2D 1.46 SO l ?—*L 4 5 De5; I C --7 2 3 4 5 NOTES: - 1. - Tests to be renoated at same denth until annroximatelv eaual nercolation rates are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. • Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST DOLES DEPTH HOLE NO. HOLE NO. HOLE IVO. G.L. _ 0.5'" 1.0' _ 1.5' 2.0' 4 2.5' 3.0' t 3.5' `—► 4.0' _ 4.5' 5.0' 5.5' _ 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.5' 10.0' Indicate level at which groundwater is encounteredot -(�-- Indicate level at which mottling is observed Indicate level to which water level rises after being encountered j- 6r4fi- Deep hole observations made by: f- oajaP-A PPS. $ 4pAy, ST Date 4 !Z Design Professional Name: o Address: po 2�c Signature Design Professional's Seal a 0 XI��'_.� PW 4�A� Wo VJ491Y SKv p p-0uoo� 9MRAoddi P A a�aaauui v�atvmmu&w n 4Po���wp�A?p bl�qu C m E c m c �v h to a O -+ O L O E c C y c Z C O m m e O w m m U ca m m O m c L m O E..o ms n m y�cu 0 j..Z.�. _2.OU � o ff � � p m y ui - i. mo °cQ` ovcm E �� f• owt N U U m amLL CL 3 0 0Erc O1�m> CL La3v �� - .0 2QW O N bz� s 'e m� flao N s,rauusq ZD /92/1. 'S'd AAS 'Z voiea"V eiAV 20 1221L eNA DAM., N /4dy01/ Sool d 1ST (AdDiS OMi) NOJ.DNINN3d- ��ei 9�pr y�y y�y g�g y�y e 8 8 9 ��gg� � ➢� S�1313¢6i 0 O Bher,Br888 x x o eoc H0. �..J _ -�— O Q co 04 00: co (L CL Q Q -pv- ,3g-00 PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, _BEDROOMS ALL SUBSEQUENT REVISION JALTERATIONS TO THESE HOUSE PLANS MUST BE SUBMI7•TED TO THE PCDOH FOR APPROVAL SIGNATURE S TITLE ATE gn ��iiii.►:i r "To the best of my knowledge, belief and profess;onr.l E Judgment b7 t. This Factory Manufactured Home (FMI-I) plan has been approved from a system set of FMH S plans previously approved by Ny Slate Department of State t • Application roe; 1' fl -riai :cturer's No. M0497 Expirali, : .: ^ g: j pY :, :•, r ,; ; „vt L er, modified in any manner .. ' 2. the energy of ild: :';.:� ,,:., �-,s Leen buy prepared in accordance with the •,24p_i•,_ $eZ a New York State Energy Conservation Construction Code (see attached M.E.C. check)91 L V • N• GL/L'! NIIA VKL! � Y i�sun�wnc S !I'�(IIKW4 N•!NL nawL. HKw. hMNlYC) VMM IpGMti mMrtxw VALIiIM�VfNVVADVLGO w ♦ OUmILT GTOf fV1T01 SIMILlCO Am I14TNlIl A OIIfAf 'FR Ill iT�R AYO lOt.1L C®[i. T t • •rrdisruin n mim @EAT ROOM PLANT 4HP WTAL APPROVAL LIMITED TO FACTORY BUILT PORTION AUG 2 020 og N � NN nn Z V? Y6 N ;1WM 124 �8 Y O 1-- ti 0 3 rY zo C, -j I L� 0 z A zz z W W EL Y i PUTNAM COUNTY DEPARTMENT OF HEALTH ..._, DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM pi SECTION A. GENERAL INFORMATION Name of Project Aye 4 j U4 log5, (T)(V) ��( County Site Location OS c.yhJo4��� Building construction begun Extent �- Is property 5within NYC `atershed ? ................. [7 Yes No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. F--] Hilly F7 Rolling a Steep slope F--J Gentle slope F--J Flat 2. 0 Evidence of wetlands F-� Low area subject to flooding a Bodies of water Drainage ditches F-� Rock outcrops 3. Property lines or comers evident .................... 4. Do water courses exist on or adjoin the property? ....... 5. Will these affect the design of the sewage system facilities? ....... a Yes No i ........ Yes F. -1 No (e) iV (,A+ -vD ........ ED-?es 0 No &,opro-,q 6. Do watershed regulations apply in this development?., ..................... a Yes L &�J- No 7 Will extensive grading be necess ........... Yes No .8. Will extensive fill be necessary for SSTS? ......... ............................... a Yes �No 9. Do filled areas exist within the SSTS area ? ........................ ....... If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: E]JSand ravel F--J Loam lay F� Hardpan ixture 11. Observed from: E] Borings Bank cut ?.Backhoe excavations 12. Soil borings /excavations observed by _ t �0 -1( �� on �a q 13. Depth to groundwater a on 14. Depth to mottling t t on it 15. Are test holes representative of primary & reserve areas ...... ............................... � [_J No 16. Soil percolation tests made by -t'�ysr� �'� on 17. Soil percolation tests witnessed by u on Y SECTION D (on back) Form ST -1 2 .y cm SECTION D. DRAINAGE 18. Will proposed grading materi ally alter the natural drainage in this or adjacent areas? 0 Yes ✓ �'" 19.. Will groundwater or surface drainage require special consideration? ...................... a Yes N 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? .......................... 0 Yes No 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--,� Yes F � No Inspection data 22. Do adjacent wells and/or sewage systems exist ? .................I...... .............. Yes 0 No 23. Additional comments 24. Site observer /inspector and title 25. Date(s) of observation(s)inspection(s) TEST PIT :PROFILES Hole # Lot # % Hole # Lot T 7 Hol Depth to water v Depth to water ON Dep Depth to mottling �+4(� Depth to mottling �4m y Dep it Depth,to rock/imp... -0 - Depth to rock/imp. 7 ._. De' G.L. G.L. G.L 0.5 1.0�'�- 1.0 0.5 1.0 2.0 2.0 2.0 3.0 ' >�S �. 3.0 3.0 4.0 4.0 R f 4.0 rr 5.0 Zvi - �� lrW S4u 5.0 5.0 6.0 �Q Av-t 6.0 6.0 7.0 8.0 _ 9.0 10.0 7.0 8.0 9.0 10.0 7.0 8.0 9.0 10.0 ��� `\�t`:r�i�i\� � . Aries ,/� C INIME .� / , �� lei war �, , , 11 PUT y4..'�`:_ JAM: COUNTY DEPARTMENY OY HEALTH ,ioh dame clvsionApj A ©A4.2D tw ?i- (.`,4m VAIk- , N . � Zip.. %�$ % ur: Aapr rnvatc auppiy Aaar-ess .. :. I represent. that i aai �vholjy;and.eompletely responsible for the design and location of the proposed system(s) "and that the separate sew a treatments, em described above skill be on as shown onA6 approved, amendmeint thereto aril in ;accordance witt}.the standards; °soles and regulations: of the Putnam Cou*y .ppartmont :of Health, 'and 4hat on completion . there.4 a , Certificate of Construction :Compliance" sahsfea ry to the Public Health Director v�n7l -1 a subfiirt ed'to. the Department;, and a written,g�3arantee will be furnished tpe o�vne,,snctessors, heirs or assigns 'by the builder, that said builder will'place is gpocopecating condition any part of said sewage treatment system :during the period of two (2) years :.�mniediately follo�a+irig date of the- issuance of the: approval. of# ie Certificate of Construction Compliance: of the original system.:or•:anyre-pairs.thereto: on D� Signed. 1r. f R.A. at P. �! Address License 16j, V APPLZOVED FOR CONSTRUCTION: s proval expires two years from the datc.issued uziless constriction otctl e se n completed `and inspected by the PCHD and is revocable for. cause or may be amended or m consi �red`necessary.by tie public with Director: Any reVisioa or alteration•ofthe approved plan requires anew` a it; :.:A rov:.; d' harge of domestic sanitary ew a only, gy:, Title: Date: 2 . White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy Design Frofessi al Form CP -91 . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT TREATMENT SYSTEM PERMIT # PV - 3�-D - 7 Located at - 0 s GA y r-w -jA kt6i s o Town or Village Q 4M V4 I le- `T_ Subdivision name i7SUlW4i19 U)6wDS Subd. Lot # Date Subdivision Approved Owner /Applicant Name 1 �OJ d P�4 L Mailing Address Tax Map6-Z Block Z Lot Renewal Revision Date of Previous Approval Zip lfl Amount of Fee Enclosed. Building Type - Lot Area 3,2-11 No. of Bedrooms Design Flow GPD c3© O Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate SE- werage System to consist of I ZSD gallon septic tank and 2pr W I DT, 2AP-aae -s Other Requirements: e-. To be constructed by -rO-p Address Water Sup IX: Public Supply From Address or: __ Private Supply Drilled by C� �l� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the s, eparate sew<«e 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. Date 2 �1 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 it. A rove d harge of domestic sanitary a only. By: ,(�,,� Title: sew --- Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Protessiohal Form CP -97 P PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEN'T'AL, HEALTH SERVICES APPLICATION T® CONSTRUCT. A. WATER WELL--:- _ please print or type PCHDHPermit # Well Location: Street Address: Town/Village Tax Grid # w 14,q s ga , ri /-/ k Map, j C, Block 'Z Lot(s) ZS- Well Owner: Name: Address! -4/1 lcpotv &2M.T'A' .31 r1aP-'+V4"4 & v h*41 V4lk /4 Use of Well: Reside ial Public Supply Air /Con AleatIPurn p 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 �O gal. Reason for Replace Existing Supply Test/Observation , Additional Supply Drilling k/Rew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling f4 etJ ik is e_1 Well Type rilled Driven Gravel Other Jg L-.-, Is we site subject to flooding? ................................ ............................... ................. Yes No Is well located in a realty subdivision? ................................................ Yes�� No Name of subdivision (�$�,9t,tJ�4 �!� ICJ BUpS Lot No. Water Well Contractor: Address: 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 provide on separate sheet/pIan. ,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 dri er c rtified y Putnam County. Date of Issue 7 ® 0 Permit Issuing O icial: Date of Expiration I Title: Permit is Non- Transferrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 �c�p -21 -00 20:15 CHAPTER 144: STEPHEN W.,COLEMAN 914- 762 -5260 P.02 TOWN OF PUTNAM VALLEY Freshwater Wetlands, Watercourses and Waterbodies Ordinance of the Town of Putnam Valley, New York. The Town Wetlands Inspector, as Approval Authority, has determined that the proposed action is an Unlisted Action under SEQRA, and will not have a significant environmental impact. Thereti)re, a PERMIT WAIVER is granted subject to the conditions noted below. DATE PERMIT ISSUED: DATE PERMIT EXPIRES: APJI --L1CANT /SPONSOR: PR�DPF.RTY LOCATION: - a September 19, 2000 September 19, 2001 Vincent Pascuicco All County Homes, Inc. 81 Floradan Road Putnam Valley, NY 10579 Oscawana Heights Road TA7t MAP #: 52 -2 -24 SIZE OF PARCEL: 3.34 acres ZONING: R -3 PROPOSED ACTION: Construction of single family residence, septic system, driveway and well within wetland buffer MATERIALS REVIEWED:_ 1. Application Materials, life # WT -319. 2. Preliminary Fill Plan and Site Plan liar All County Homes, Inc., as prepared by R. Fredriksen, P.L•'., dated 06- 11 -99, last revised 09- 07 -00. CONDITIONS OF PERMIT: 1. All construction shall follow approved site plan as noted above. 2. The Wetlands inspector shall inspect construction of the driveway, and installation of mitigation plantings, and all wetland disturbance areas. Wetlands Inspector to be notified by applicant when driveway is being constructed, and plantings have been installed. final inspection once site completely stabilized required by Wetlands inspector. 3. The Building Inspector shall be notified once erosion control measures are in place and at least 48 hours prior to the initiation of any site work.. oW 10r2 Sap-21-00 20:16 STEPHEN W. COLEMAN 914- 762 -5260 P.05 ' 4: Wheti Erosion controls -arc requ they mus(&ti 'mamtatned properly throughout the construction process and remain in place until final site inspections for compliance with conditions ol'permit have been completed. 5. The Planning Board, Wetlands Inspector, and/or Building inspector, shall have the right to inspect the project from time to time. 6. The permit shall be prominently displayed at the project site during the undertaking of the activities authorized by the permit. 7. An additional escrow account in the amount of $ 300 must he established with the Town before this Permit Waiver can be considered validated. These additional escrow funds will be appropriated as required for construction monitoring purposes. Any portion of the account not used during the project monitoring period shall be returned to the applicant upon satisfactory completion of the project. Noncompliance with the conditions above will invalidate this Permit Waiver, and may result in a Notice of Violation and /or a Stop Work ®nrder_ Any questions regarding this Permit Waiver should be directed to the Town Wetlands Inspector (914) 762 -7289, or the office of the Building Inspector (914) 526 -2377. Bate Permit Waiver Prepared: September 19, 2000 CC: Applicant Building Inspector Planning Board Environmental Commission K 11gp 2 all Post -it` Fax Note w - 6&Ao4,,, Stephen W. Coleman Town Wetlands inspWtc,r I VTN AM COUNTY DEPARTMENT OF-HEALTH � fill, slloNj OF ENVIRONAITTNTAL BEAL rF11 Sj 'ItVICES ... APro1wrty of Z_ [,cw.,.I!ed at I i V PovA A l _ T 2. ax Mal) # 5. Block 2 Lot Subdivisioil of* 'Silh, 1i vision 1. tit # ..d lap # Z23(0 Date Filed -__ d Proh-s.sional Fn incer I?egistered-Auhit liccw;', 1 9 to apply for Ow required ect e shove -noted property in at(.Xordance, As. ndes or rell.1lations 1(yaled by the Public IleaPh Director ororlkl! Putnam h the si:w(Im as pronm�0 1!.!:d . Ill Dcj),�itnnent, and tip :sign all nemssmy papers.on my befiann connection With this 11);Wleanal to suro;. ll�e the (611sto!ction of said wastewater a pd/t P -OViSi V, F1, -16'a i fbrll,-�Iv-with 01":' 1' MIS. W 6f thei lhr, Puln;ml (_'oulltv Sail it w7y..Code. 4 Very truly yo rs, Signed: R. f1 (1, jier oUrgPefty) 1;illh ig Address _-Bb Ma . ifing ; Address: 9C. zzr(o j LieP, Zip. /0 'State Ziv -4 Telepli0t) 7 1 6 rl." '11 A -.01 ; T NA L) COPUNITY OF HEALTH r .1 T' E V 41,0NMENTAL HEALTH SERY-,WES A .1F'1"`JDAVJT-. 00'. RPORATE, OWNIERA,171PLICATION S Nj T 1'.1 TD TO '117.JTNAM COUNTY HEALTi-i 1-` TE�PART'%MIENT UB I(.): Pu W, Ji c 1 1,,: P1 it I i D:;,,- or In 11 ;:tatter ()JI for: _0S ' C (A 660 LA C-4- 0 o ',icer or empl! �vc e of the coq)orationa.�dam authorized to acct for: -14 Zj )L 91. EA2 ro da Al C/ 4) �1 Aflci at: 1d5 Wlins(, Are: ss: A Ad.':: Re CT AQ -S - 10Nli 1. am individually responsible for any and alt acts of the corpoi ation with respect all subs ,,Iuent acts rela!'ng therein. EDWARD KERSCHNER NOTARY PUBLIC STATE'OF NEW YORF S geed: NO: 30-0197880 QUALIFIED IN BRONX COUNTY T;: t 11 C: CO V SSI N EX %VO? De. I 'lie I (jay of (yea BRUCE R... F.OLEY. Public Health .Director LORETfA 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 (914) 278 - 6130 Fax (914) 278 - 7921 - Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 June 29, 2000 Mr.. Roy Fredriksen, PE PO Box 950 Mahopac, New York 10541 Re: Oscawana Woods Realty Subdivision TM# 52 -2 -25, R.S. Lot #7 Town of Putnam Valley Dear Mr. Fredriksen: 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 consideration. 1. Provide a Wetlands Permit to conduct proposed disturbance within 100 feet buffer of wetlands or provide a letter of permit waiver. This office will continue its review upon consideration of the above mentioned comments. Please _ .feel free to contact tia if any,.questigns arise. _,.__ Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj ►► 3 CONSTRUCTED AS PED BY ME BEFORE LCCORDANCE WITH ALL DEPARTMENT OF HEALTH i t S64 °44� 55 W 28 00; S6-/- -Zny,_ __...a-I LOCATION. A B 1 56' -0" 74' -0" 2 67- -0" 85' - -6" 3 68' - -6" 87' 0' 4 70' -0" 86' -6" 5 72'-8" 87-0" 6 51' -3" 57' - -0" 7 56-4" 63' - -4" 8 60.0" 69' - -0" 9 68' -0" 76- -8" 10 74' - -0" 82' -0" 11 76' -6" 69' - -6" 12 80' -0" 75' - -0" 13 84' -6" 80' -0" 14 89 =0" 85' -0" 15 9314" 90' -4" 16 29-3' _ _ __ .�_ ._ .. 49t-011 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THE PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. "NO GARBAGE GRINDER WAS INSTALLED"