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HomeMy WebLinkAbout2684DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -1 -39 BOX 23 1 •..I LIM .� L 1 •..I PUTNAM COUNTY DEPARTMENT OF HEALTH _ ON-,OF ENVIRONMENTAL.IHEALTH:.SERVICES CERTIFICATE OF CONSTRUCTIOppN COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Q � Located at G S—v N Sfr-�"" H IU, Town or Village P" 0*1--t —T Owner /Applicant Name D Cif Tax Map 6 r Block Lot Formerly Mailing Address _I go S-4-4- H((, Subdivision Name Subd. Lot # 4 " Pv-rNft*A VA- Zip r 6Y-7 -P Date Construction Permit Issued by PCHD Q Separate Sewerage System built by 1j--,u b ytr" 4x Address L (LtZ iO� Consisting of TEA15r Gallon Septic Tank and SGcS L - 1cr_ 40 r 2P, et l a w- Other Requirements: Water Supply: Public Supply From. Address or_ , (Private Supply Drilled by JE 6-1� �• Address ---° -- Building -F yp e- - 4- 4X- � ­Has erosion cont rol ttol been completed" Number of Bedrooms Has garbage grinder been installed? aR I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations a Putnam County Department of Health. Date: lO /6 G Certified by P.E. /� R.A. Address License # 0`7 6 7q3 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY HEALTH DEPARTMENT o ; DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO Internal Use Only — v�J ❑ Repair Permit issued in last 5 years ❑ N In Watershed — �✓ El / Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated El Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION S;467Zr /� %GC fi�J TM # OWNER'S NAME l3go C SC PHONE # (-) S2-6-21033 MAILING ADDRESS Svn/S4 7- d I&C (Le) 4,�Q APPLICANT �T-F_P yrau �ok' Name & Relationship (i.e., owner, tenant, contractor) DATE Y 1�3 0 Q FACILITY TYPE PCHD CQMPLAINT # PROPOSED INSTALLER GG PHONE# S2 ' 2c-, 3 3 ADDRESS REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. /r S,e D-Z I, as owner, or re ed age owner agree to the conditions stated on this form SIGNATURE TITLE DATE Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions. Proposal Approved Proposal Denied , pector's re &l Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P� Subd. Lot # Tax Map 4-l- Block Lot Located at Sy v 1--1/4,0 rL_e__)t4r) Town or Village Subdivision name Date Subdivision Approved Owner /Applicant Name (3 CAS 1f Renewal Revision Date of Previous Approval Mailing Address I&-'-) �-�t"" P lC� Zip _ Amount of Fee Enclosed g -G Building Type Lot Area, 6 hr4oNo. of Bedrooms -5'- Design Flow GPD tOOO Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of c.�fLtC tSi.Jallon septic tank and 24 w� b� AGSa fd-r7cN Other Requirements: To be constructed by % 6P— Address Water Supply: Public Supply Fr Address or: Private Supply Drilled by X S N __ Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment s, sy tem 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: P.E. K. R.A. Date Address ().C). (�>O X t 0 �7 K)C-f O ( t_" Ci 01f 7 7- 6License # , 767!F3 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. By: Title: Date: White copy - HD i e; 'ellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL .HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR ..;A 'WASTEWATER Tlt' AT1igE'NT- 'S'YS�EM • — un -r:,.,_. -" .... 1. Name and address of applicant: CffsE AAQ 2. Name of project: ckc 4. Design Professional: 5r-e fH -rd 1 iA"- { 04 6. Drainage Basin: 111V osar1 QN/Er2 7. Tvne of Proiect: 3. Location uE 5. Address: P.0. B ©x /0 Loy /11Eo✓/1�Z4'f'0IV cam— Dg; -r -zd 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)? Type Status (check one) ....................... ............................... Type I Exempt k( Type II Unlisted . 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 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 ordmances� W......_..�.;... ..:.... . e•,..... .,..:::'.....................,. »:.:.......r ._....... _..._ ._. 13. If so, have plans been submitted-to such authorities? 14. Has preliminary approval been granted by such authorities? Date granted: 15. Type of Sewage Treatment System Discharge ....:............ surface water '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? ....... ...................:........... 19. If yes, name .of water. supply Distance to water supply 20. Js project site near a public sewage collection or treatment system? ................ afo 21. Name of sewage system 22. Date test holes observed Distance to sewage system 23. Name of Health Inspector T E 0i �i rf 24. Project design flow (gallons per day) t c�vo 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 'l.'D 26. Has SPDES 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? 28.._ Wetlands.ID Number..... T „, •_ .... �r. ....... .:.. ..........................: :,-. 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling; sludge application or industrial activity? ............................. Ye%S) 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes%(,� DESCRIBE: Po` 33. Is there a local master plan on file with the Town or Village.? ......................... YES 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 15% slope? .................. 36. Tax Map ID Number .......................... ............................... Map 1 Block / Lot 3P 37. Approved plans are to be returned to ..... Applicant K_ Design.Professional applications -for- review and° approval of a-new*SSTS to bd�l6cated Wiltlun fhe N 'C Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater 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 Se4i n 210.4Wthe Penal Law. SIGNATIURES & OFFICIAL TITLES.- �ftfl'43S Mailing Address:....... 520 A,-,! . `�� � :. ' ` s ;F Oef M, e.E SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LO RE`PT`A'MOL"IN"A'Rt,'kl i ,MSN Associate Commissioner of Health Stephen J. Ferreira 123 Washington Ridge Road New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health September 7, 2006 Re: SSTS Repair – Case – R- 213 -06 180 Sunset Hill Rd (T) Putnam Valley TM# 61.4-39 This office has "received and reviewed the most recent set of plans for the above - mentioned project. We would like to offer the following comments for your review and consideration. 1. Form PC -97 was not submitted. 2. House plans of existing floor plan were not submitted. S::riotaho- .:on.:plans. .0 4. Driveway not shown on plans. 5. Footing /gutter drains not shown on plans. 6. This appears to be an addition. Is this true? This office will continue its review upon consideration of the above- mentioned comments. Please feel free to contact me at est. 2163 if any questions arise. LCW/kly Very truly yours, Lawrence C. Werper Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5786 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, EAAP Commissioner of Health _ .. ,.. -- _LORE')i TA, MOLINARI', RFd;`1� N Associate Commissioner of Health October 4, 2006 Stephen J. Ferreira 123 Washington Ridge Road New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. R ®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Field Inspection — Case 180 Sunset Hill Road (T) Putnam Valley, TM # 61.4-39 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. Junction boxes remain uncovered for your inspection. If you have any further questions, please contact me at _(845). 2.7.8- 6.130.ext..21.55. JD:kly Sincere , Joseph Digit Environmental Engineering Aide Environmental health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 •PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION . Date: lO`A�,2/61 Inspected by: Street Location �v.�/SA T GL Owner S ; : ,n•• • ,- Town= Permit # —02/ O TM #— /I/ D -- 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 ...... ............................... II. Sewage System a. Septic tanLsize - 1,000 ... :... ..1,250 ......... other..��aU.... b. 'S eptic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Boat 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3 Minimum 2 ft.Original soil between box & trenches e. Junction Boat - properly set ...... ................................ . 6. Trenches � 1. Length 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 ...................; 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped ....................... ........ g. Puma or Dosed Systems .—T-size , of' pump chamber ................... I............................ 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 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 Workmanshiu . a. Boxes properly grouted ................... ............................... b. All pipes partially backflled ........... ............................... 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 watercours g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :.......................... i. Erosion control provided ................ ............................... Rev. 12/02 PUTNAM' COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS -: ... OR CONSTR . d .. ... - - REVIEW SHEET.F T3CTI FERI�'T + NAME OF OWNER: c /qj L STREET LOCATION: j �� V V 4,1 p7 r" 4l <<-- REVIEWED.BY: RM, GR, TSP, SRDATE: 9 Ct TAX MAP#: (CONFIRNMD) ' Y� N DOCUMENTS Y N (REQUIRED DETAILS ON PLANS CON m C_n )PERMIT APPLICATION __ // j�(�WELL PERMIT OR PWS LETTER A14 ( j LETTER ' ti TIER OF AUTHORIZATION (_}DESIGN DATA SHEET (DDS) (� CORPORA.TE RESOLUTION SHORT EAF UPLANS -lum SETS U( )HOUSE PLANS-`T-WO SETS UUV�NCE REQUEST NA % SUBDIVISION JLEGA.L SUBDIVISION BCD �a �SUBDIVISION APPROVAL PERC RATE 2-/ (�(,�ILL REQUIRED. DEPTH �)(ZCURTAIN DRAIN REQUIRED GENERAL, U( s�.O�CATED.IN NYC WATERSHED PLANS SUBMITTED TO DEP (� ELEGATED TO PCHD EP APPROVAL, IF REQ'D TEST HOLES OBSERVED , �--JPEEP E -- )(��VAL SSDS ADJ, LOSSDS ADJ, LOT WETLANDS (TOWNIDEC PERMIT REQ'D ?) ATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION )( TTFR.BIIZBA .-.•�,�� OO YR. F- OOD- MEVA.TLON W1I200* )SOIL TESTIING LOTS >10 YEARS OLD REQUIRED -DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) 5HGRAVMFLOW SSDS HYDRAULIC PROFILE CONSTRUCTIO1vI`•NOTES 1 -15 64 DESIGN DATA: PERC &DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED _)(= ?DRIVEWAY -& SLOPES, CUT ,)(r jFO0TINQ/.GUTrER/CURTAIN DRAINS USDA' SOIL- TYPE' BOUNDARIES TITLE BLOCK; OWNERS NAME ADDRESS TM#, PEIRA; NAME, ADDRESS, PHONE# LC—JDATE OF DRAWINGMVISION DATUM REFERENCE . LOCATION OF WATERCOURSES, PONDS LAKES,WETLAIBDS WITHIN 200' OF P.L. _)L�PROPOSED FINISH FLOOR AND i .�, 1 BASEMENT ELEVATIONS ,J WELLS is SSDS'S WnN 200' OF SSTS ,PROPERTY METES & BOUNDS EROSION CONTROL FOXHOUSE, WELL & STS, EROSION CONTROL NOTE S8�ET109 /01/00 ' ( °n( JHOUSE SEWER -1/d' FT. 4 "0'; TYPE PIPE. CAST IRON UUNO:BENDS; MAX.BENDS 45':W /CLEANOUT U(_,_,)SITE NOTE GE) FILL SYSTTrP1'15'z (� )10- HORIZONTAL; PAS NCH SLOPES• 3:1 TO GRADE ,U�FILLLSPECS/ OTES 1 -5 vUFILL PRO & DIMENSIONS UU�L ANSION AREA ILL GBEA TMZ ZMC12 FEE CLAY BARRIER U(.JFML'CERTIFICA NOTE UUDEPTH GAU (—J(__)VOL. ON FOR R.O.B., UNCLASSIFIED & IMPERVIOUS U,( JSEP TION DISTANCE FROM•TOE OF SLOPE TRENCH` ( rZL__)LF TRENCH PROVIDED_ 60FT MAX (.rZ(—)PARALLEL TO CONTOURS ($,11( __)100 %EXPANSION PROVIDED ' (-::� DET*UJDUST FREE CRUSHED'STONE OR WASHED GRAVEL GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN : FROM'SSTS �( ±�} 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL. 020' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,'150' TQ PiMS 100' TO STREAM, WATERCOURSE, LASE• (inc. expa fi) . (- _-)50' TO CATCH BASIN, 35!.STORIVYDRAIN,:PIPED WATER .... ` ( 50'- INTERMITTENT DRAINAGE COURSE 0200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS (, J10' &ffiNd'TO LEDGE OUTCROP SEPTIC TANK (,( -J10' FROM FOUNIDATION; 50' TO WELL YIyIEI SYONS TO PROPERTY LR, .MS U OCATIQN OF SERVICE `CONNECT.ION ' (,)MIN 15' TO'PROPERTY LINE SLOPE COLSLOPE IN SSTS AREA S20%) U(& REGRADED TO 15 %, WREQUIRED DOSXT SYSTEMS (UL—)P.UMP NOTES . C_ j(_,+. 95% OF PIPE X10 GIE/1)OSE VOLUME-NOTED U_JDETAIL FOR F MAIN, (PIPE TYPE, ETC.) X SHOWN & DITAILD __)( PTT AND UUl D 0RAGE A dVE ALARM CURTAIN U)USTANDPIPES, 5' BOT45ftffS, DETAIL (,�U15' MIN to CD o, 20' -4 %, 15'-3%,35'-l'%, 100%-:<I% (—JU20' MIN to ISCEARGE1100' with 182 cons day discharge UU10' NON - PERFORATED PIPE xjr 11afflneeftnu IservIgen August 24, 2006 Stephen J. Ferreira, P.E. New Milford, Connecticut 06776 Joe Paravati Putnam County Health Department Division of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Repair/Replacement Mr. Brad Case Dear Mr. Paravati: Please find enclosed: 1. (3) copies of septic trench plan. 2. Construction permit application. 3. Letter of Authorization. 4. Application for approval of plans. 5. Soil Data Sheet. 6. Short environmental assessment form. 7. $150.00 Money Order. Please feel free to contact me if there are any further questions or information required. Sin ely Y s, Stephen hen J. effeira ZVI LETTER OF AUTHORIZATION Imo Property of Located at Tax Map # (0 ` , Block �^ Lot Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer 2L - or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: P. E., R. A., # _ _ CT 0713 Mailing Address (c)q--) BA t L;F0 State Cam- Zip.._ ©Qo-7 7f, Telephone: LlRoC-) 1 -?s-o rZ�cl 2 - Very truly yours, Signed: &"4'j - (Owner of Prop 4) Mailing Address: /so e0 .. r State �. %�, Zip / 0-� 77 Telephone: �� ��r) S2-9-21033 Form LA -97 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLMTED..ACTIOR�,Qnly_: ;....�.. •:_w.. '... : ::::.��.;:.�._._= PART I - PROJECT INFORMATION (To be completed by Applicant or Prolect Sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME ,$,QflVCASE C�s,E 3. PROJECT LOCATION: ////�/� Municipality P&'T,t/!f'A4I/ County A/AOL 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc.,'or provide map) SAN s E T 11 /LL 44" 5. PROPOSED ACTION IS: New E] Expansion Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OEIAND AFFECTED: • Initially _S j acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes No If No, describe briefly 9. WHA PRESENT LAND USE IN VICINITY OF PROJECT? I Residential Industrial Commercial Agriculture Park/Forest/Open Space Other Des: i0.' QOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Yes No if Yes, list agency(s) name and pennittapprovals: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes, 9'- No If Yes, list agency(s) name and permittapprovals: 12. AS A RESULT OF P OPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: J}rF�Of%Crt/ �,E �./� Date: gj '`p Signature: • If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 17 Reset' PART II - IMPACT ASSESSMENT (To he completed by Lead Ananr_vl A. DOES ACTION EX ED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAR E] Yes o 8. 1MLL RGTION RECEIVEOOORDINATEDREVIEWAS `PROVIDED FOR UNLfSTED ACTIONS IN 6 WTkR, iSAR7 617.6? If No, a negative declaration may bes6perseded by another involved agency. Yes o C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels,'existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: � d 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: 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: � V C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: d C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: 1{/ i D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? MYes o If Yes, explain briefly: E. IS THERE;.OR.IS.T RE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL' IMPACTS? . _.....— . ._. _ _..--- • Yes No If Yes, explain bnefly: 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 (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. If question D of Part II was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. E] Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WIL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons. supporting this determination % Name of Lead Agency D f� ptn -, �/�E�gi�.1� & 0- Print or Type Name o R ible OM cer in Lead Agency Title dt Responsible Officer Signature of Responsible Officer in %-aft /. &nRV h C OnV go Signature of Preparer (if different from responsible officer) i Reset. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ._ _.1 "DESIGN DATA SHEET '-" SUBSURFACE SWAGE TI ATIVIENT` SYSTEM Owner 91W cAff" Address Igo Located at (Street) Ej Tax Map Block l Lot (indicate nearest cross street) Municipality PLAI, A V'1�4* y Watershed /� J y►�4.�L . k. SOIL PERCOLATION TEST DATA Date of Pre - soaking 7fI Z_ f2.0v 6- Date of Percolation Test ' 11z -11Zeo6 2 same depth until approximately equal percolation rates are obtained at each (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' TEST PIT DATA IDESCRI[]PTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. --� j�i¢e, ,,v �v SkNOy d/ Z7`� _ 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Sb� /V-O V-*T- e- Indicate level to which water level rises after being encountered Deep hole observations made by: 0 ` Y Date Design Professional Name: S Address: P- G- o k C(j Y 7 e� Signature: ' rr, POWig Wofes�ional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . -. - ... _. .u..r r.....a s n .�•.4 .. � .-... �z . •.r:� ti. ... . .� ..... _. , _ ..... ... ..o .��.,rm. ,- .r._ ... _. ....s,.�a: ; :..._...a .,_ .+a.. -.., vv.w • w . •..� ... _.. • .......... ..... , .. DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT. SYSTEM Owner ?O Se Q1'/9 /-re Address 3wfrr /`//z.I- )(b Located at (Street) a ¢ �8?FK #d /Wax Map . Block Lot (i dicate nearest cross street Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 1 .. 2 3 4 5 2 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1 -30 min/inch, 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 DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES DEPTH OLE IVO. G.L. 0.5' 1.0' _ d 1.5' RD�l�� �N�i AM' �J N 51�f0 2.0' D M 2.5' /i o 3.0' �NS/<S'l►UT �� 7 3.5' at) 9 ® 1117' koAp4 4.0' al&hr6 /MpAcTeT 4.5' 5.0' 5.5' 6.0' 6.5' Z 7.0' 7.5.1 8.0' 8.5' �► 9.0' 10.0' 2 Indicate level at which groundwater is encounteredo6U,' Indicate level at which mottling is observed Indicate level to which water level rises after in ountered _ u/OIV4— Deep hole observations made by:' Date Design Professional Name: Address: Signature: Design Professional's Seal A FP - -- .01 Co ri vo "V �' /O ----- --- FA 77- Ia' I C>.t. /YON Or J�O/mGr�y ILL /CK a .- lm�. s /fuoEe in the TOWN 4F AWrN�4M MUCK P!/TNA M 00.1 N.Y. Sco% / "= 40' Moi. 26",1971 S /ON y. llm asr e - L.c. r�dsurveyo�- 1738 lloI7o✓eI- .56. V0,4 gown /W a., N. V. A. Y.J. .N° 2a4 a4 (EXISTING WELL) Baxter Land Surveying, P.C. A O. Bok 147 Mahopac, Now York 10541 Phone. (845) 284-3005 DATE: AUGUST 5,2006 LOCATIONS A B Z5-O-�l 2 3 -Z ?d 4 2W -Z 5 -Z79 6 2 7 g Y/ 7 8 3 9 32(,7' J051 10 3a,?' 11 12- 13 3-1 14 ;2 14. 15 1.6 17 a 18 2G7 Z 5-3 PUTNAM COUNTY OF HEALTH DIVISION OF ENA ONMENTA -Alm LHbAkTH SERVICES. A APPROVED AS NOTED FOR CONFORMANCE WITH �TrLI'l,"I'Ll: RULE APPLICABLE RULE.-AND REGULATIONS OF THE PUT H LTH DEPARTMENT. 19,0 Y' 'OOF' dt-NATURt�TITLE qA �TE ,,I 30 0 15 70 so 120 j ( IN FEET 1 inch = 30 ft_ i' f r �r A � _ PUTNAM "COUNTY DEPARTMENT OF HEALTH k Limsion of Environmental Healih Seivices,, Carme' %:`N Y 10512 .CERTIFICATE OF CONSTRUCTION COMPLIA"Wt jFOR SF�+U�1GE DISPQSAL SYSTEM C Qz k Town' or Village 1. Located at S V UV`'g �+ L- `_ `� Section ;�t Block €fi OwnerA' N 1D sT Lot .k'-q' Job' y'+4��.EY 'rig- N C GUE. �►fc�S p #4 .Se 'Separate Sewerage System builf` by Address Consisting ;of Gel Septic Tank • b�w,t Iineal� Feet ;X�� r 7 width trench, S^O 1 a Other reguvements Water. . Supply Public 'Supply From Pnvafe Supply Drilled' BY ���' �IZ�S `W EL`. `��1 G:' Coti„P► i i Address A.N av cLv R U G a, C... —7 I `-Building .Type S�.N'GI;E, �' tnn .N No of B'edrooms' X Datey: permit Issued { a Has Erosion Control Been Completedt' I certify, that the system:(s) as Itsted serving the above premises were constructed essentiall° s' s nr m w s. opleted ork (copies of -which are': i attached) and' in accordance with the standards - ,rules and regulations plans filed, and s ti t PU am Co ty Department of Health. 1 k P Date��_ Certified E R '/4. a , r .• .� Address LI se', No. V , r4 7 a t .� An arson .occu .. h act cure the correction of any unsanhary, y p pying'premises; served by the above systems) shall promptly take such ;' "conditions resulting from such usage. Approval of the. separate, =sewerage'system =shall be. oi�a$ ,a',public sanitary sewer - becomes availati'le and -the approval of the private water. supply shall become null Arid void .when °a pu i ,ecomeF;avallable. Such approvals .are f subJat; to modification or change when, in the. judgmerit of the Com i stoner of Hea h su re wn m8�ki goon or chan�is nece ry. t Date Z U �s: BY Title�w. 01 W WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/11 Division at Environmental Haalth 1;drv1CO3 COUNTY OFFICE BUILDING CARMEL. NEW 'YORK Thic mpo,rv.is, to be completed by w0l driller and su'- %-;tted to County Health Department togethdr with laboratory report of - ;analysis �-`�'/ ."@r szrivie- indiciain9,w<}eSX i - v"atirfactcry baCte, al quality- before certif ICcltC of a'Ott;tFUGIiJ7? COiilj ilus7CCa!S- ISiued. REPORT MUST BE SU 'd111 -TED WITHIN 30 DAYS OF VVELL COMPLETION OWNER NAM ADDRESS LOCATION OF WELL (No. 6 St „„root) (Town) (Lo t;er) Ilk h . _... i � 9 �6A PROPOSED USE OF WELL BU51NESS 77. DOMESTIC ESTABLISHMENT ISHMENT FARM II TEST WELL SUPPLY INDUSTRIAL OTHER CONDITIONING (Spe it ) DRILLING EQUIPMENT � COMPRESSED ❑ CABLE OTHER ROTARY AIR PERCUSSION PERCUSSION (Specify) CASING - DETAILS LENGTH (feet) I DIAMETER (inches) -- -� WEIGHT PER FOOT ` L�,J THREADED- ❑ WELDED. DRtVE SHOE I WYES ❑ NO wAS ASING G ;.OIL— TFIDf- OYES ' L _J NO YIELD TEST HOURS G.P.M. El BAILED PUMPED COMPRESSED AIR . Ir YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE— STATIC (Specily feet) DURING YIELD TEST float) / 0 Depth of Completed Well i 6� Tn feet below land surface: i 6� _ -- -- SCREEN DETAILS MAKE MA __• _ ”- __- . -____ _ _. _. ---KE LENGTH OPEN TO AQUIFER (feet) SLOT SIZE �— DIAMETER (inches) IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL SIZE (inches), FROM (toot) TO (toot) DEPTH FROM tAND SURFACEI FORMATION DESCRIPTION Sketch exact location of well with dstances, to at least two permanent landmarks. aA o If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ATE WEII CO t[tE0 7 OAT OF PORT �. WELL I L/E�R� (Signature) /® r . '. Y a 1 .... .u.. ._n _ �•CW .. ..�w .s.w.. yy :J• rY•.. y c_, u —(_ _ :....v u.;7..u:.au.... =w �• -•..W.R. _ .r. W ... w►.•......e: i OW -n°Jr Cr i'lJ. ='C P_3Jei' .Ql 17t:11C'_?� 1'TLl'iC,1pC�!-V� Bui ld .n; , Cons t.r uc : -cJd ,by SeC t `ion °. Location.- Street Block Building Ty-pa Lo GU?RniTTY OF. S-70'n -' iF" 'J� S�rJn- = - E! s_ I' re�resart that I a i ',G ^o__-r d co .,_-r l V y location, .,Tor!, 1- ans".__ J atJ ==' =3 7 CO ?St ' �C�Ji'� ?` v�= a= i'_� -� 'JI. SPJ:ia a y, �_ ,' s 3e dls�o3al s s t -_m ser I1nc the ?b0 T e ':: °sc_ _bed4 �_ = '^J.C? ,.�- a,-.��± i rat 4' •'as e -- const_'ucted a sn'o..__ C 1 ^+c�c - -�.d 1a� Cr a•-J_�`'v ed ?""e 1, ^.�r° - - �O, and in accordance tfie sta ris riles an.+ - - - - CC7u'll-, "!`_±_ --_n � , "J- ^"1, ••J+n- �-- - •a•'^.^w_____ J... .e v..._e "r ___J .. .. .. .. - SO r ':e_rJ or aSJ_ =_ �J ) vO a.,v _n o:- V VaG r'- __'l:r .'.7 d_ said' s rJ L:__ Cons Jr`.J_ JeCi =_ _�_ _ -r_o� .•� J J'. n in-ft-1 System, �C'_'' �' -•',;T rep _='S made • ^vii :`i?' �C o:....`? 3__5._....�7 e:_�.eC- :�i'r1�:'--D to opr'Jr04 p r0 -jer ,- Ca' j? �" ��e _��I' „j •�,� r»�1 ^ten= aC' Or - a 5A_ _ _ J 'J. __e J C U — L ` r , _ pan , o. `uhe bulbar_ �at___z_r_3 SV St -3. T u J- - ^_ - ne�� .0 a c eot' .Gy_...COP1oIaJ= e terminal -ion of t h a D e c t 0 r oi. t-1- D_ :'_s o Vices of J'. PKV_'lw.'i Col t-,.- De )a __ert Of JD ,l�i t"_er or no-, th-e failure of the system to operate ;as Cased b -- th—_ :�rlllf'ul or negli _ent act Of he occuoa t of tL?e buildin -g uti? 1Zinvv �re sySt� V Dated thl s day of /-%u�`I -1975 Si = , ure Tit'! e (T' VCrv'�rv_C n� :J ant. LliREE 'C3/ COP �.':S i�� �i:���ll ?� ��. I'1�._ �1 � -._ \�� ,lJ l'l�_ -''J 0 F 1F T' AL L_ ^ 377'0 R CERTIFICATE OF CO1•u LET O i WILL B 1SSUiD; . . GUt_ ?LT'i'Ot� .S ?E�UIRL'D TO ��'��= ,TOE -r_.OF 0 "`r'E OF 7I?37 USE OF JvST= Division of 2-nvironmmenral. He a1t'n Servica�s, P�utnar~a County Depa,,t;r_ent .of Healt: Number -Bedrooms ' - ,S-'eoarate, Sewe ra' 96 ,System to consist of "To _,'-be .constructed 46A Ay 7 JWater :S uppY l -7— Supply ",; : PilvMe `Supply to a drilled Addreis! 2 'Other- 'Retq'ulreM'qptj,:! and s n sl 6je 01 1, represent� that -.!-�_airt!,whqI y, 9!T_ _91 d6s6rIb6&*ill, bb:constructq as s n , own n wn , the . P. County,, nepartment of. lHealth, :and that on completio --I be`submil ted ;to the Department,' and, a -writte r*-,gua p ace in. _jp . ood. operating . coindit1100i_any part of I said` , _jwcd- of of - C st Mull Certificate of ru, ;the 0, County pe�plrtm!mt., 0 ". I . ff I Heall n , Y Address' 1. 7�7 7 "ApponvFn _tThis.a6 nKl�! nrnwa,i)i6i .K m AftTMEI Irser,y.ices T 77-7 dic Tank VWA I A A of" d ,;.'OF .'HEALTH A` .-Y 4051-2 7, V Town or.Villa .99 aI&C; Z!,: Aze 54-1- V. Ral Habitable Space Square Feet _ meal x --width trench A/ m AI 'VI TOp6s . ed . �systems)!; "11.1hat-the'' Oarate sewage disposal'system or can ce and �regu lat ions of7 -the Futna—m ti o.. —on"liame iii§ e'6"ni misslo'nef 6i,-HeaItffwill is Successo;sj._heiri_,or assions.by. fhe�, builder, that sa'id:b, u ilddr will ifjod -- -b . f- tW (2) �s linrnediaiily4ol - lowing t6e'dati'of,the issu- . . 9, ­ 4yea! m 'or -any -repairs th et6 - 2):t that I he�'d r ii led wei i describ6d'akicive 'e e Stan s, rules an._­(,e'j qia�tlqjnt f�_,� the,. Putnam P.E. ,-' - - _, R.A. �YiniP license No- unless con I st ryct - ion . the-, building'- has ,been- unde and is 'alteration-ol-C6 ns tr, ction.- • -.0 A 7 7 PUTNAM COUNTS Division k,; p prita ,,.,, CONSTRUCTION :"-PERMIT "Subdivision Number -Bedrooms ' - ,S-'eoarate, Sewe ra' 96 ,System to consist of "To _,'-be .constructed 46A Ay 7 JWater :S uppY l -7— Supply ",; : PilvMe `Supply to a drilled Addreis! 2 'Other- 'Retq'ulreM'qptj,:! and s n sl 6je 01 1, represent� that -.!-�_airt!,whqI y, 9!T_ _91 d6s6rIb6&*ill, bb:constructq as s n , own n wn , the . P. County,, nepartment of. lHealth, :and that on completio --I be`submil ted ;to the Department,' and, a -writte r*-,gua p ace in. _jp . ood. operating . coindit1100i_any part of I said` , _jwcd- of of - C st Mull Certificate of ru, ;the 0, County pe�plrtm!mt., 0 ". I . ff I Heall n , Y Address' 1. 7�7 7 "ApponvFn _tThis.a6 nKl�! nrnwa,i)i6i .K m AftTMEI Irser,y.ices T 77-7 dic Tank VWA I A A of" d ,;.'OF .'HEALTH A` .-Y 4051-2 7, V Town or.Villa .99 aI&C; Z!,: Aze 54-1- V. Ral Habitable Space Square Feet _ meal x --width trench A/ m AI 'VI TOp6s . ed . �systems)!; "11.1hat-the'' Oarate sewage disposal'system or can ce and �regu lat ions of7 -the Futna—m ti o.. —on"liame iii§ e'6"ni misslo'nef 6i,-HeaItffwill is Successo;sj._heiri_,or assions.by. fhe�, builder, that sa'id:b, u ilddr will ifjod -- -b . f- tW (2) �s linrnediaiily4ol - lowing t6e'dati'of,the issu- . . 9, ­ 4yea! m 'or -any -repairs th et6 - 2):t that I he�'d r ii led wei i describ6d'akicive 'e e Stan s, rules an._­(,e'j qia�tlqjnt f�_,� the,. Putnam P.E. ,-' - - _, R.A. �YiniP license No- unless con I st ryct - ion . the-, building'- has ,been- unde and is 'alteration-ol-C6 ns tr, ction.- • -.0 A 7 7 H�_- tLT PUTNAM COUNTY D.E?`LRT'•rNT.OF H DIVISI0N OF ENVIRO`�CNTAL.HEALTH SERVICES DESIGN DATA SHEET'- SEPARATE SEA. AGE DISPOSAL. SYSTE�1 ' . FhLE NO . Ocaner �o z: :. 5; V/,- Address %� ✓e614i4 az✓ �21�f��� y Gs4lctf ff,, Located at (S Lreet).�'il eT J� /cc ;e', xy fte. Block... -3 . .. Lot . ;. (Indicate nearest cross street)r C. Municipality . fouw o.� A'i, . U,4146 il.atershed Nvp�l' / �t.ai,✓, ,f��Lwt SOIL PERCOLATION TEST DATA REQUIRED 'TO BE SUE'iiTTED PITH APPLICATION Hole Number CLOCK TIME PE RC0TATI0N PEP.COLATIO` .. , 'Run- Elabse Dept- to fates fluter L _bve1 No. Time` From Ground Sur =ace in. Inches Soil Rate Start ' Stop Min. Start Stop Drop in. Inches Incises Inches 9; 3 3 `0.'�3 �3c, f� . 173/4 /�/4 % ?. c� 3 A. ?, - 2 f � 1 ,. =- ' - S � 4 5 Notes: 1) Tests to be repeated at same depth until approxi a'-e1% ecaual. soil rates are,:'.'• tained at each percolation test hole all data to be submitted for reviecu. ;J 301:. 36?1. 42:, 48!r 54t1 6 0" 2:. a N ii ri i8t1 84 .. a l TEST PIT DATA REQUIRED TO PE S BIMITTED ::ITH. APPLICATIO\ ;r DESCRIPTION OF SOILS. E`: __t;`TERED L`: 'VEST HOLES TESTS ,itaDE BY . - sTA/lfG4 =L/ _/. G//.cf✓���c. Date 7 -2z- 71 �L C� • DEPTH HOLE N0 HOL n NT0 . HOLE N0 G . L : �( / Dro? - 61T °' ro-. i Qd ,DO No. of Eedroo-.s 4 Septic. Tank Cap.c =tS' 121: s�ti� c�:yr�x <s�.� ��r�k.�d - �c,•gy <�r�k . —'. are le; T Provided By L.F.Y2':`` b. 2 4t1 301:. 36?1. 42:, 48!r 54t1 6 0" 2:. a N ii ri i8t1 84 INDICATE•"LEVEL AT I C H GROUND MATER IS ENCOUNTERED INDICATE LEVEL TO WHICH tvATER . LE`iEL; R IS =S AFTER B E i ENCOUNTERED TESTS ,itaDE BY . - sTA/lfG4 =L/ _/. G//.cf✓���c. Date 7 -2z- 71 Soil Rai-e Used ?0 Mir; /1" Dro? - S.D. U ale Area °' ro-. i Qd ,DO No. of Eedroo-.s 4 Septic. Tank Cap.c =tS' /Zc�a Gals. Type /�1 c,, ,41eig. are Absorption. area Provided By L.F.Y2':`` width trench. Other Nam Le S-: AN Fy UNDER SiC .Address S X 26.1 j /ln n, n, GfAA,7d 11 f +�.G�(?nlil.. 245-2 45 PUTNA M COUNTY DEPARTLT,NT. OF HEALTH Soil Pate Approved^ Sq. Ft. /Gal Checked b %, e Date PtPMAM 'COUNTY D�AAT. LO uc* . v r . . . U ... =. %• 777- t • H ER T ZO S { S AY DIVMION 'OP L I'iRO Prape°t.y ..Q • t, Yi0t38st8d c'irt ✓� `.5 i ` GG p •: :2r \j!p'mtlem�3PA This l®tt®tr ie b a�a��iari�� a `ia1y `.ls ®sec: ptoeeeanal, engin ®r X . or regiote°d �h {� �. :t'® epply for m Const�euetion. Permit`ar a; eepat' se�rg� stG A ,e .. -.. Y'"P0•• YIl� .' ed '• ?raperty ..�8'3 Bt�+$1C�$SC6 ter'e�tlataxis' ayev�s,4d by. the Ceiaeo�ex: o''t�® nL z nw �8 a °tffieB' 'Qg rHe�t h - tiftd td ign t l b@ Q.OYlBIO(�' F>it.` W71tl1 this t8t and t'Q Sti �3ervisv the Q.©het tuck � 04Z K, gst; a .a�ret s aemfa mitt ;with. th ®.. � r1wS ;F:a 147 Edueatiari '.Y;�w;�, the. Pub]:ia Health Lawn d _ 1 � very trU�.y' �'® ?i�Sfgned ..� ' (hBY°`.' b r0� �s•°�` Po. P,o o. "eP, tsi�e 1r" tie Q�p4E$SIO�i! .0 4 y� n l Y No, 827 HIY iPl P�.Irm .�!e� ®��e�a� � - .Of NEB y • . , PEEKSKILL MEDICAL. LABORATORY 1579 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1 ,York 10566_....._._..__ - , .. Peekskill, New - _..Kw..•,.y.....,... ,..- :..n -c .., ..r -_••a. ., :.u..r_.- .cam:.: ,: ,.r u:.a, ._,...r.aa. <., . •. .w.. ^-: .....o:....:�..o:_. .•s......x: y.ns.•, .�. _ .-n -�r7J ._..�'J�7r7_ _ DATE COLLECTED RESULTS OF EXAMINATION OF WATER OWNER DATE RECEIVED A Il tin' �1- -r,75 CITY, VILLAGE, TOWN 6 /OR NAME OF SUPPLY DATE REPORTED. fl-, )) SPA 1111 , 1/n llu.) 3 75 A'AWYI 1LV 15 YVLN 1 f �IP11 BACTERIA PER ML. (Agar plate count at 35 C). COLIFORM GROUP (Most "probable N6, /100m1.) HARDNESS-TOTAL -ppm DETERGENTS - ppm NITRATES (as N) - ppm IRON, TOTAL - ppm. FLOURIDE (F) - mg. /1. These results indicate that the water was �1C.3 of a satisfactory sanitary quality when the sample was collected. 1 H. PA VANI, M. T. (ASCP) . � r PUTNAM COUNTY DEPARTMENT OF xHF4 H x w Division` of Environmental Healih Ser`v'ices bGa�mel N Y 0512 CONSTRUCTION PERMIT.,OQ SEWAGE_Y DISPOSAL SYSTEM 4 0,6 T'.ny ,; VY� 1-LC. y Town or Ilage ^� At _ u `f �: -Z- t _ SecL1onl BiocK - 1 Job SubdWision e u k v owner R Nom' L1� - S • �) I�j .�'-- k5 I' Address `SU N C /./ r L Bulld�hg TYpe: sl iVC� -I f •►RYA m���9 LOt Area.C21� Pli r� %A l Number'oi Bedrooms• " tTOtel Habitable Space Square Feet - separate Sewerage System to cohsist oi, / SD Gal Septic Tank �S- �� lineal feet X .., s width trench a r- !� 1 To b'e constructed by °�V /I`�' .n1� rV f Water Supply Public'Sup ly From _' Private:,SUopIy,' -to be drilled by F�L%G�C.C�1 th.� t.tr ,. sK a ,' Address Il IL SL,m 1 k ,,rrte� n�y�: Other Requirements A> al CV2 l n'. u✓, +�,1� jj�' l Ne�'u /t LZG r1 represent that J am wholly and ;completely responsible for =the design anq location ,'of the' propos'` I '_that .the separate 'sewage disposal system .above described will-be constructed:as, shown on the approved amendment there to and in acco_r v Nt ids, rules an regu a ons o , e:, u nom "County, Department, of''Health,'and fhat.ontcompletion ` tfiereof a:Certificate of Constru �ti oryao the Commi ;sloner of'Healthwill be submitted to' the'De'partm p ; and "'a written`;guararitee wiles be furnished the owners rs;T s by, the builder, that said builder will `place, In good o eratin condition any. ' rt of. :said sewage disposal ,system Burin tli tatel follows the date of the issu- 9 P g ,Pa ,r g. Y: n9 ante of. the approval ' of the Certificate of Construction ,Compliance of ,the or�ginai s e Qt r, a �f hat the drilled well described above wiiF'be located' shown on the approved plan and -that said well will 6e installed in actor i Ivi s; ule and. regu a -Tons of the Putnam County 'Departrhent.;of •.Health: Date_ Signed ' P E x R.A. gildre55 ". License No.� 1 APPROVED FOR CONSTRUCTION This �apprdvpl'i e xpires one year from'the date ued, I rii` e e building has .been undertaken and. is revocable for cause o► may be amended or modifi ed when c d eG necessary by the Com th ny ch ngeL or alteration, of construction requiY new permit A proved for disposal of�dome sa ary d /or priva Date `T.+ BY Title ,r � 1 P - - - - -- = - -- N Cr - - - i i �- - J �_ i t,(,d I to Vv PUTNAM COUNTY. DEPARTMENT OF.. HEALTH I?T�T 4I�Jt1 _.OF- :EN3�?RONMENT�;L....t :�1�.�}I. SrRVTi' 5 Date Re . Property o n Located at "', V�3(" ' 1� I Li, Rte Section _ Block �j Lot. 9 Gentlemen: This letter`` is to authorize a:'•duly licensed professional engineer or registered architect ,. (Indicate) to apply for a Construction Permit for a separate sewage system; to serve the. above noted property in`�yaccordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to -sign all necessary papers on my behalf in connection, with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly vours , Signed�_ err N Owner of Property Counter''s`i Address GYP r Telephone