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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -2 -6.1 BOX 23 I 1 11 1 � r!� _L16' , .� or WL VMNAM COUNTY DEPARTMENT OF HEA N:UF ENVIRQN .l1�[ENTAL_HEQI.,TH SERyI . D CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # V GD Located at C ko Town or W a e Owner /Applicant Name v L Tax Map �� , Block - Lot td Formerly Subdivision Name CC. " ci PUS wc"o �i S Subd. Lot # Mailing Address /Loge! Pu ttia .,, V ,Ileg &J Zip BGS% _ I , Date Construction Permit Issued by PCHD 0 7 Separate Sewerage System built by Dow,"I A kll Address--77 6e,11 ",4j dU R V, J Consisting of 12.S-C) Gallon Septic Tank and 9'86 Other Requirements: )JICu Water Supply: Public. Supply From Address. or: Private Supply Drilled by Address -.I uildingType ° 'Has.-erosio •co :trot - •been - completed ? -.: -- e°5 Number of Bedrooms Has garbage grinder been installed? 1J d 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 regulatigro of the Ppam CountX D partment of Health. Date: 7�,-) , = 0 8 Certified by Address / ' o' , .8,6 k 2�2 4 r � P.E. zZ R.A. License # 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 clAnge is necessary. Y: Gz -t«'Q Title: Date: ash e copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 Jul 16 08 09:53a BUILDING DEPT 9145268806 p.2 JUL -16 -2008 18:11 AM HARRY W NICHOLS 914 279 4867 P.02 BRUCE F:: i0L8Y- 1.AR8t'l°N MOWHANP.H ,; M.6.PI. •' Ptld +e Nral�h AirelM' IkYPOfotb fW16 xle fj ' D4tetar' . •. .' .. �Gotrar of PotteW &wkn':� . DEPARTWNT OF HEALTH I 40BaYe Road l)rowatar, New York 10509 • Y.e.lroueeeld tlee� �91n 711.6110 Fee (yJ /) !1i • ia1 t . Mahe{ tMrHea (914yi/1 •a37t .WIC ( ►tgiit •6H8 Fes pt4) 878 • da8f • 80� '1'li�e�r'teBde'(iiUt'il'•tOta ►nubaal pu)in�o¢n Fa�iayYr�•6baa. . 9Y DRESS S 1L .RRIE .ATi MEM O'WKtR9 NAME. TAX MAP NTJMMEIL E911 ADBRESS: TOWN; AUTBORIxW Town t (Signature) DATE-, The "Putaiam County Department o4 Health will not issue a Ceitttcate.of CoQstruction ComyVance unic3s for abo -ye. for m b_completsd; .I.e.; Regal °) 911 i - _. %e Ith the Applfaotlou for a Certliicate of Construction Compliance.. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES F WELL COMPLETION REPORT Well Location Street Address: / Town/Village: Tax Map # L2 l` 2. Ce,l Map Block Lot(s) ;GP�S, Well Owner: Name: Address: - &1_ _ "_" � � ' r� l Use of Well: >e Residential _Public Supply Air cond /heat pump _I rigation 1- Primary Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion Xcompressed air percussion Other(specify) Well Type _Screened _Open end casing _�L Open hole in bedrock _Other Total Length a_ft. Materials: y Steel Plastic Other Joints: Welded X Threaded Other Casing Details Length below gradeAOft. Seal: Cement grout Bentonite Other Diameter 6 in.. Drive shoe: V es _ No Liner: _Yes No Weight per foot Ib /ft Diameter in Slot Size Length ft Dept to Screen_ ft Develo ped? Screen Details First --dHours _Yes _No Second Well Yield Test _Bailed _Pumped Compressed Air Hours Yield gpm Depth Date Measure from an su ace- static specs ) During yield test h ept o completed we n Well Log Depth From Surface Well Diameter ft. ft. If more detailed Water Bearing in Formation Description information Land Surface G(� descrlptlons,er sieve analyses are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information 1112 Pump Type SL, Capacity 11 Depth_ 06 1- /& P/ Model ' 8QT4,Q1Tl Voltage HP at different depths during drilling list: ' Tank Type Volume Dttate eWellljCom leted Well Qr Ille . f %kpp Installer;PC PC Cerfiflcate # Q�J S J i4 .,, g 'K kl w '4k �M nLJ -: R" rY f} fMN Ya^M. 3yy1 Gertifcate # ➢ rc+`+'�'^i"` :I , IAN/ . {I{F" A�jj: r� 1 h R; i Welf DtllName,$ C k sky s V4 10141.1 gr ur) �, ii:ry f rTM ICY � � 1..'I"k!u!'pjt•.d7'YWiFµ :�' Pum : Insta ler Name �Adtlress x�.J,�( Y .Pk di x a R n :p y °ap, Pustaller st Y ypS °,i °� r Ri r .^nd. ..... I .. d9 %» k* :T,r 'Cf . .rib b..k :1T i l :i!yr 3 '. :,. i' :r; S..liry: %'Re i l k�i')# S:e}'ny y' •Y''d 't J 4rfi 3i, f. ". T'"1�'W4� ui' Mr'rr ;± x a kF'I{pt, ^I. h &A "{ NOTE:/Exact Location of well with "distances to at least two permanent landmarks(to be provided o separate s t/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 -Albert H.- Padov ni, - D-i'�bbctd LAB #: 9.801000 CLIENT #: 60913 STAT PROC PAGE: 1 of 2 DANFORD, CAROLINE DATE /TIME TAKEN: 07/21/08 07:32 DONALD KLYBAS DATE /TIME RECD: 07/21/08 09:20 77 BELL HOLLOW RD REPORT DATE: 07/28/08 PUTNAM VALLEY, NY 10579 PHONE: (845)- 306 -8342 SAMPLING SITE: 24 CANOPUS HILL RD, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE KITCHEN TAP -- COIF- D - --BY: - ^DONALD KLYBAS _ . .. NOTES...: DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 07/21/08 MF T. COLIFORM 07/24/08 LEAD (IMS) 07/24/08 NITRATE NITROG 07/23/08 NITRITE NITROG 07/23/08 IRON (Fe) 07/23/08 MANGANESE (Mn) 07/23/08 SODIUM (Na) 07/21/08 pH 07/23/08 HARDNESS,TOTAL 07/23/08 ALKALINITY (AS 07/23/08 TURBIDITY (TUR COMMENTS: 'PICK UP IN YORKTOWN h.W.. PRESERVATIVES: NONE -- TEMPERA'I'-LTRE "_. < 4C -_ COLIFORM METH: MF RESULT NORMAL - RANGE ABSENT /100 <1 ppb <0:2 MG /L <0.01 MG /L <0.060'MG /L <0.010 MG /L 2.81.MG /L 6.6 UNITS 68.0 MG /L 52.0 MG /L <1 NTU ML ABSENT 0 -15 ppb .0 - 10 1.,0 MG /L 0-0.3 mg /l 0 -0.3 mg /l N/A 6.5 -8.5 N/A N/A 0 -5 NTU METHOD SM 18 -20 9222B SM 18 -19 3113B SM18- 20450ONO3 SM18- 20450ONO2 SM 18 -20 3111B SM 18 -20 3111B SM 18 -20 3111B SM18 -20 4500HB SM 18 -20 2340C SM 18 -20 2320B SM 18 (2130B) ,y` f COMMENTS,: MFTC THESE RESULTS INDICATE. THAT THE WAT &�HE (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCOR NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED,--.,AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 100 of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg /L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe /Mn If'both iron and manganese are.present,.their total value combined shall not exceed 0.5 mg /L. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 i,r Albert- =.IT -!%P adova n-i -�- -D -rector-" LAB #: 9.801000 CLIENT #: 60913 STAT PROC PAGE: 2 of 2 DANFORD, CAROLINE DATE /TIME TAKEN: 07/21/08 07:32 DONALD KLYBAS- DATE /TIME RECD: 07/21/08 09:20 77 BELL HOLLOW RD REPORT DATE: 07/28/08 PUTNAM VALLEY, NY 10579 PHONE: (845)- 306 -8342 SAMPLING SITE: 24 CANOPUS HILL RD, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE KITCHEN TAP PRESERVATIVES: NONE COLD BY: DONALD'KLYBAS. TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium is suggested. PH Hd pH SCALE INWATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A•LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES., THE NORMAL RANGE OF pH IS 6.5 TO 8.5. TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE,.IN.._MG /L. THE HA &DNS;S :MAX -R. GE FROM -O _TO HiII`SDREDS _:pF_- MG %Lr; DEPENI?S._ON -THE __. -.:. _...,..::....._ SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD WATER: 70 -140 MG /L MG /L = MILLIGRAM PER LITER HARD WATER: 14.0 -300 MG /L (1 grain /gallon 17.2 MG /L) SUBMITTED BY: Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISI ®N, OF..ENVIRONMENTAE A_JLTH' SE VICES GUARANTEE OF SV13SURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Building Constructed by = Location - Street J". 't Building Type TownNillage __Cak U V�OUd�, - Subdivisio Name Stibdiv-ision Lot # I represent that I.. am wholly and completely responsible for the location, workmanship, material, constructiorr and-draind'ge of the sewageireatment system set' ing the'above- desci�ibecf 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 parr-of said • -S �stetn constructed by ' me which fails) to operate fora 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 willful failure.to willful :^ t of the occupant of the building utilizing the. ; operate properly is caused by the w or negligent ac system =... The undersigned further agrees to accept as conclusive .the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the"failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing: the system. Dated: Month 67 Days Year 2.o o Signatures_ �-" General Co ractor (0 ) = Signature . y GcJ �• e r - .. Corporation Name (if corporation) Corporation Name (if corporation) Address: 7� �,�� t i tv l�o J l ,, V. Address: � � �J e l � X10 6 4 /C o State Zip 165775 Statet�i,�`K� �wl.t Zi td Form GS -97 To: P — t r I/ I 200-d Attention: Jos-cfl S', — ---v- A Pw4 lic- )4 Gentle en- We enclose (�Icqpies of 615'1W Prints 0 Specifications Description: 0 Reproducibles 0 Memorandum Harry W. Nichols Jr., P.E. P.O. Box 252 Ni` 1-10509 Tel (845) 855-9275 Date: v I' 3 .Q00 Job No.: Project 5515' CajV-)It"tr-:e 2A 'T, 4 • Reports 0 Tracings • Copy of letter 0 Sent Via: 0-<Ur Messenger 0 Blueprinter _ 0 Your Messenger 0 Hand Delivery Copy to 0 First Class Mail Revision/Date No. dcv, 09 - 13 -08 0 Special Delivery Ve,y truly yours, � a h Harry W. * hols Jr., P.E. 11/ SHEIRLIT'A AMLER, MD, MS, FAAP _, . ... _ . Commissioner,.of Health. ,.._ .A..;,�.::� • -., .:,: . , ._:_: . LORET'T'A MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, P.E. P.O. Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI ROBERT MORRIS, PE Director of Environmental Health August 8, 2008 Re: Construction Compliance- Klybas 24 Canopus Hill Rd, (T) Putnam Valley T.M.# 61 -2 -6.1 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. 2. The existing well is not shown and dimensions to the well are to be provided from two fixed points. The pump installer did not sign the well completion report. This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. JSP /ens V truly yours, / Joseph S. Paravati,,Js. Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Harry W. Nichols Jr., P.E. V A V P.O. Box 25 - 2 Tel (845) 855-9275 Date: -. 0 P A —0 To: Job No.: PC I�D oce -O:ZA ''o I P r- L4 �e, eOL RO CL Project -TLLJIj/tJuq) SST5 C0k','JC(I1ee-- kl4no 8 Ir'C'Lo 24 l =aLA04vS 49a Attention: /04 4r, /0 v +-i4 , cc �41 J. Aw � 2- Gentle en: We enclose (;-�copies of ZZr r i n t s 0 Reproducibles 0 Reports 0 Tracings 0 Specifications 0 Memorandum 0 CORY of letter 0 Description: 'a J 'k J, 57— ] C'-r- r e o G 3, Ye,e 3) C-0 IQ I Ic"5 Revision/Date No. A P / Ct 4% O-e a ) 1 e- 0-7 —16 -OS . Sent Via: Our Messenger 0 Blueprinter 0 First Class Mad 0 Special Delivery. 0 Your Messenger El Hand Delivery 0 Copy to V l truly 1� ,y ru y yours, �CV Harry W. ichols Jr., P.E. PUTNAM COUNT' DEPAR.TM[ENT OF HEALTH t DIVISION OF ENVIRONMENTAL REALTH ,SERVICES G 3 oB�QI�. c FINAL SITE INSPECTION Date: 2 / jog treetl cation 4iji � a -...i� -� �C-' a`D °-Cmer� t.. Town P1JTA4nA xlAi.c_CV Pernut# p d - t o -©6 TM # 6 1, - - . I Subdivision.Lot # 1. -Sewage System Area a ,STS area located as pen4pproved plans ..........:...... V'j- s ionI-date -of placement 3 :1.,barner Lgth. Width Avg.Dpth c. Natural soil not. stripped ........ ............................... A Stone, brush,.etc.,greatertpan 15' from STS area, e. 1.00' -from water course/ wetlands ............................ Z Sewage System a. Septictank size -1,000 ... .1,250 .......other...... b. 'Septic*tank installed level c. 10' minimum from foundation .......................:....... d. -Distribution Box 1..All outlets at same :elevation -water tested..:::.', 2. Protected below frost...... ... .......................... ...... 3. ,.1&nimum.2 ft. Original. soil between box & trej e. Junction Box properly set ............................... 6. Drenches. 1. `:Length.:required _g- -7 / Length installed 2. Distance to watercourse measured oc?Ft...... 3 . `Installed ,accordingto.: plan... ...... ......................... 4. Slope .oftrench acceptable 1116 1/32 "5oot.... 5. 101. ..from property:line - 20 ft., foundations.. 6. Depth of trench <30.inches from surfize.......... 7. `Room allowed for expansion, '100% 0 .........:....... 8. Size of gravel. 3/4 - 11/2" diameter clean........... 9.. Depth of gravel in 12'' minimum.......:... , 10;.oPipe&nds.: can ed� .:.::....:. .......:..:.....:.............. pp g. Pumn:orposei Systems 1. Size of pump chamber ...... ............................... .2. Overflow tank....... _ ......... ............................... . 1 Alarm,:—visual/.audio ::.....::... 4. Pump easily accessible, manhole .to grade........ 5. First `box baffled ........................... . .................... 6 . :Cycle witnessed by H.D.estimated flow /cycle.. D1 House7Building a. :PIouse located per.;approved plans ................ b.:Number.c bedrooms .. ............................... .... W. W611 Well located as per approved plans . ......:........................ b.. Distance from STS area measured + ( cue - ft.. c. Casing 18" above grade ....... ............................... d. Surface drainage around well :acceptable .............. V. Overall Workmanshia . a.. .Boxes properly grouted ........................ b.. Allpipes partially backfilled ... ............................... c. All pipes flush with inside of box .......................... d.. Backf ll material contains stones <4" diameter...... e. .Curtain drain & standpipes installed according to f. Curtain draiii outfall -protected & dir.to exist wate g. Fro frog drains discharge-away frrom-0 S area...... h. ace -water pr otection -,adequate :° ............... i. Erosion control provided ...... ............................... Rev. 12/02 MAY -21 -2008 09_58 AM HARRY W NICHOLS 914 279 4567, P.01 i .._.... rw PU`I'�iT�1;NYUUI�I'i`r1' DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH S) RVICES UQUEST .. P.P-C7fO For: Pill Date:. ca Trenches PCHI? Construction Permit # p V I Q – 0 ge— _ LaGat'ed: C' �� s 1 d �. d _ Mp) ..F 4,1.i kcc v" Owner /Applicant Name: _ TM _ _� 1 Block .,� Lot Formerly: Subdivision Name: , c kU a ilz Subdivision Lot # Is system fill completed? — Date: 1 6 Is system complete? r late: Is system constructed as per plans? - V; _f Is well drilled? _.._...Tr,� Date: 1r ja e Is well located as per plazas? Are erosion control measures in place? yzx _ I cortify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHia Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. . Date: 4 aft Certified by aar� _ Address �. , L3 � � Luc. # Comments: FOR: .Cl ADAM GENE O (NAME) Form FIR -99 s SHERILITA AMLER, MD, MS, I+AAP Commissioner of Health °n.' . . � _ � .;.�.s - -- .--� re -: �✓ . r. a ;- ... >Fara r--. LORETTA MOLINARI, RN, NISN Associate Commissioner of Health Harry Nichols, P.E. P.O. Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva. Road, Brewster, New York 10509 ROBERT .I. B ®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health May 27, 2008 Re: Field Inspection Canopus Hill Road (T) Putnam Valley, TM # 61. -2 -6.1 The above referenced separate sewage treatment system can be backfilled. The following comments:must' &..corrected - -in= the - field: ...,.__..,_. ._ a......_ 1. Silt fence needs to be installed in the ground. 2. The fill pad needs to extend ten feet past the last trench and maintain a three on one slope back to grade. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:kly Very truly yours, Gene D. Reed Sr. Environmental Health 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 I SHERLITA AMLER, MD, MS, FAAP „� ROBERT J. BONDI Commissioner of Health * �t County Executive LORETTA MOLINARI, RN, MSN �4W , ROBERT MORRIS, PE Associate Commissioner of Health Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 June 4, 2008 Harry Nichols, P.E. P.O. Box 252 Brewster, NY 10509 Re: Field Inspection Canopus Hill Road (T) Putnam Valley, TM # 61. -2 -6.1 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled - .There .are.no,further. _ =comments tabe addressed at. this -'time;— If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:kly Very truly yours, Gene D. Reed Sr. Environmental Health 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 InterventioniPreschool(845)278 -6014 Fax(845)278 -6648 p nu ION ngmi f"Ok 9EWAd,E tkkA 'MENT SYSTEM PEI i[I�' # " 10 Located at �� o U!� 1 I�1� �L O Ao Subdivision name GAHO N WM0 Subd. Lot # I Date Subdivision Approved (*/0(,10& Owner /Applicant Name yow R i-,o k—L I W Mailing Address Amount of Fee Enclosed i ';- 0 o c" Building Type�'I��t'� Town or Tillage P V i *,t ?` O k"RG Tax Map 61 Block 1, Lot & 0 I Renewal Revision Date of Previous Approval P Okff� \JWLt11, t4l zip) Lot Area %R No. of Bedrooms 4- Design Flow GPD � 00 Fill Section Only Depth Volume PCHID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of i ��O gallon septic tank and � � G L}' 46 Other Requirements: PJ F 4-1- C4-rA 1tl PA W To be constructed by V Address Water SuRoly: Public Supply From Address or:,..... ._;. Private Supply Drilled :.by. ...: .. _. oAddress I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. /I Signed: Address R.A. Date 041 A' O �) License # 15 61 �A- APPROV EID 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 jnewpe it. Approved for discharge of domestic sanitary sewage only. Title: Date: % - HD File; Yellow copy - Bui 'ng Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD. PP,Im1L # , "WelfUc'Won v � Street Address: Town/Village Tax Grid # i C W0M A- W wV , p U1 �K JNUZ� Map 61 Block �- Lot(s) & � 1 Well Owner: Name: Address: J QAw �Ll �J �%� HO ,0W �Pr P6150W, Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought J5t gpm # People Served 4-& Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason 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 C 1J0?U5 VJ DG M Lot No. Water Well Contractor: i F)2 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 be provided on separate eet/ lan. Date: �—�� n� Applicant Signature: PERMIT TO CONSTRUC A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 917 / 06 Permit Issuing Official A l% Date of Expiration Sr[ 7 jr, g Title: k,(✓ahl ic- 4,p"k - F-mci Permit is Non -Trans White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 a August 1, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 . ATT: Joseph Paravati, APHE Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 _ ~ Paxf- (945)`2794567`_._.., - Email: hnengineer @aol.com RE: Proposed SSTS: Klybas Canopus Hill Road (T) Putnam Valley, T.M. # 61 -2 -6 Dear Mr. Paravati In reference to your July 31, 2006 comment letter, we note the following: 1.. ,58.Q.' .of _trench is now provided for the primary.and expansiorrsysterns,; _ �.w = - - --• -.� ...__ -- -R— quested note has`been added to the map. 3. Grading and expansion layout has been revised in this area. 4. Fill is a minimum of 1.5 feet, but some areas are between 1.5 feet and 2 feet due to the irregular slope of the existing grade. 5. Minimum pitches of pipes has been added to the plan. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nichol Jr., P.E. HWN:gav 06- 024.00 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health ORITa4— MOLINAR ➢; °R1kFYtSly;:u: Associate Commissioner of Health July 31, 2006 Harry Nichols, PE Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT I BONDI County Executive Rogmr(VIOk1'S; ire Director of Environmental Health Re: Proposed SSTS- Klybus Canopus Hollow Road (T) Putnam Valley, TM # 62.4-56.1 This office has received and reviewed the most recent set of plans for the above - mentioned project. We would like to offer the following comments for your review and consideration. 1. The design data box on the plan notes 580LF of trenches provided. The plan shows 60OLF of primary trench and 578LF of expansion trench. Primary and ;expansion needs to be the same total length. 2. The proposed contours are still being shown uneven. This is acceptable as long as it is designed exactly as shown. Please provide a note stating that the proposed fill contours are to be designed exactly as shown or permit will be considered null . ..._.._...._.._.,and vcld. -..... _......�__...�_..___�__ .... ,........_.. __..._..__�. _._..__...._.. ..._...._. _ ._.�_...�...___...._.. _. 3. The proposed fill is not 10 feet horizontally past the last expansion trench and the trench end (southeast corner). 4. The expansion area doesn't appear to have a uniform 1.5 feet of fill. 5. Please note minimum pitch for the cast iron pipe and the SDR -35 pipe in the plan view. The office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. JSP:mcb Very truly yours, �. ��G'CZ,e2,c� oseph S. Paravati, Jr. Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Patterson-ParkSuite 106 2050 Route 22 'Brewster, NY 10509 Fax (845) 2794567 July 10, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Joseph Paravati, APHE RE: Proposed SSTS: Klybas Canopus Hill Road (T) Putnam Valley, T.M. # 61-2-6 Dear Mr. Paravati In reference to your July 5, 2006 comment letter, we note the following: 1. Stamp and signature have been provided on the Design Data Sheets. 2. Overall lot layout has been revised for clarity. 3. Driveway regrading has been added to the plan. 4. Silt Fence has been extended below the proposed house. 5. Fill has been revised to-extend_.1Qjeet.pqst trench ends. 6. Fill 7. Contours have been revised. 8. Fill has been revised so as not to go over the property line. 9. Additional detail has been added to the expansion area. 10. Two dimensions from the well have been provided. 11. 5'-6" water level has been added to the test pit description. 12. Curtain drain discharge pipe has been revised to provide a minimum of 10 feet from the trenches. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry Ni ols Jr., P.E. HWN:gav 06-024.00 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health :t�i�;E'i ITT -A��'+�'�IJS�i���1�,^iVl�l`�•� = ::_;,..:: Associate Commissioner of Health Harry Nichols, PE Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 July 5, 2006 ROBERT J. BONDI County Executive Director of Environmental Health Re:. Proposed SSTS =. Klybus Canopus Hill Road (T) Putnam Valley, TM # 61 -2 -6 This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. he engineer is to certify the field testing by affixing stamp and signing the design data heets. Please provide the scale for the overall lot layout and try to enlarge it so it is more readable. •Please show driveway regrading. The. silt fence should be extended to include the house location. 5. 'Fill needs to extend 10 feet horizontally past all trench ends. The fill notes should be numbered (See bulletin ST -19, Appendix C). �,1� 7- The. fill contours should run parallel to the existing contours and proposed trenches, not �t < <0" "bent" as shown on the plan. 8.... Jtapflears:tbe- regradang:of. the: fill. pad': below. the - expansion. ar. �a.will.go_over.Jhe..property_. . _.._. _.,.... line. :•,�,„�,�� e .Please show the expansion area in the same way as the primary is shown. LO. -Two dimensions from the well to the property lines are required. lWA water level of 5.5' needs to be noted for deep test hole number 4. 12. The solid curtain drain discharge pipe needs to be a minimum of 10 feet from the trenches. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. JSP:mcb trul.jVer� s oseph S. Paravati, Jr. , Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5.186 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 .a PUTNAk COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH R INDIVIDUAL WATER SUPPLY & SUBSURFACE SEW_AGE_�- SYST��rft� -CONST ON FU R 1r�JCTI N PERMIT - NAME OF OWNER: STREET LOCATION:iz� REVIEWED.BY: RM, G 7a. , SRDATE: TAX MAP#: (CONFIRMED)' �4_)WELL DOCUMENTS Y N ARE -U—MM DETAILS ON PLANS CONT'Dl PERMIT APPLICATION (� . HOUSE SEWER - Y4" FT. 4 "0'; TYPE PLPE.CAST IRON PERMIT OR PWS LETTER (�NO BENDS; MAX BENDS 45' W /CLEANOUT (f��UPC =97 q L TER_ ON S GN DATA SHEET (DDS) (U CORPORATE RESOLUT L )SHORT EAF U jPLANS -THREE SETS LU�OUSE PLANS - TWO SETS UUvARIANCE REQUEST SUBDIVISION C,ZLJLEGAL SUBDIVISION ' LUUUSUBDIVISION APPROVAL CHECKED PERC RATE R �7FILL REQUIRE_ D � '� DEPTH .. (U /()CURTAIN DRMN REQUIRED /� GENERAL (U(U✓ LOCATED.IN NYC WATERSHED U P SUB1i1=D TO DEP Uj = TED TO PCHD PROVAL, IF REQ'D . �EEP TEST' HOLES OBSERVED UUPERCS TO BE WITNESSED )(U - APPROVAL SSDS ADJ, LOTS U TLANDS (TOWN/DEC PERMIT REQ'D ?) ),)BATA ON DDS- PLANS & PERMIT SAME 1969 NEIGHBOR NOTIFICATION )SOIL TESTING LOTS >10 YEARS OLD 914:OUMED •DETAILS ON PLANS )SEWAGE SYSTEM PLAN - (NORTH ARROW) )SSDS HYDRAULIC PROPELS )GRAVITY FLOW ;UCTION NOTES 1 -15 DATA: PERC & DEEP RESULTS (DRIVEWAY & SLOPES, CUT fS `3; MO,TII+ ar TTERICL7RTF DRAIN IUSiDA SOIL TYPE BOUNDARIES (TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# [DATE OF DRAWING/REVISION DATUM REFERENCE . (LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. iPROPOSED FINISH FLOOR AND BASENVg NT ELEVATIONS iW�EL4 AC SSDS'S-W ZQO'OF SSTS (PROPERTY METES & BOUNDS,y 5;►. `� (EROSION -CON'T'ROL— & -OR-B- •OUSE: WELL & SSTS, EROSION CONTROL NOTE HEET)09 /01/00 RENEWALS UU E O CHANGE) FILL SYSTEMS UU 10' HONTA,, PAS..T TRENCH SLOPES- 3:1 TO GRADE .U� C L NOTES 1 PROFILE & DLMENSI( IN EXPANSION AREA UU CLAY BARRIER (UL_)FiLL'CERTLFZCA UL_)DEPTH GA 1/j, ' LAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS 'ARATION DISTANCE FROM•TOE OF SLOPE TRENCH TRENCH PROVIDED Cc000 60FT MAIL. EXPANSION PROVIDED - �,,,� FU UST FREE CRUSHED'STONE OR WASHED GRAY L .A6 GEOTEXTILF COVER SEPARATION DISTANCES ON PLAN - FROM'SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL. O' TO FOMATION WALLS 100' TO WELL, 200' IN DLOD,150' T0. PITS 100' TO STREAM, WATERCOURSE, LAXX(iaa eapad.). 50' TO CATCSBAS'. N,15`:ST ;`PIPED - `�t0"TCIWr4`'IERLINE(pits 20') (x )50'• INTERMITTENT DRAINAGE COURSE 200'1500' RESERVOIR, ETC. 150' GALLEY SYSTEMS (UUIO' MDd TO KEDGE OUTCROP SEPTIC TANK ZL—)Io, FROM ZQUIoID T� ION - 50' TO WELL ESSIONS TO LINES 4TION OF SERVICE CO.NNECTIO 15' TOPROPERTY LINE 'SLOPE 'E IN SSTS AREA 20 %) RADED T015 %, W REQUIRED DOSE/PUMF UUP.UM[P NOTES LU(UDOS>r 75% OF . OLUME/DOSE VOLUME NOTED LULUDET FORCKkAIN, (PIPE TYPE, ETC -) U D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM // CURTAIN DRAIN (,.J STANDPIPES, 5' BOTH SIDES, DETAIL (;�',] IS' M%PI to CDS�S ° /u, 0' MI..to_CD.DISCH.APGE/100' with 182 cons day discharge 10' to NOM- PERFORA7fm-PIRE....`_ PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES __-DESf SUBSURFACE SEWAGE TREATMENT SYSTEM Owner DQHNw 1-Ly blk-6 A'ddressli Located' at (Street) KVv TaxMai)G�-, Block I Lot '56-i (indicate nearest cross street) Municipality _FU rl HA4A A, I Watershed ROP600. P4,F- SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test . ......... ....... ... ... ......... . ........ ............ ... . ....... . ... - . . .......... .......... Ta ae ................ EIa T. e in: o' a ro m urEace: befies, erco agoi RA Hole No Run .`� .0..*�'.-�..-'�`.-`.- .......... ........... .. Start Staff .. . ....... art P�: ix 11C h 2 9,S4 Z5 0A � 3 04 '5 1 _-4 4 5 K A4C 3 4 5 2 3 I - .... .. - b repeated at same depth until approximately equal percolation rates are obtained at each TdsM.Wl t re ' pq . 51 p6i6pliti6h test -hole. i.e. -.5 1 min for 1-30 min/inch, -.5 2 min for 31-60 min/inch) All data to be �;,!s',subm . eO for review. Depth measurements to be made from top of hole. Form DD-97 Indicate level at which groundwater is encountered 5�-(p Indicate level at which mottling is observed WA, Indicate level to which water level rises after being encountered Deep hole observations made by: 1jy '�%kgbKhiL / 605 Design Professional Name: HA - V41 HioiAO�h Address: IW 0 Pr Z� bp-e-Y6 - 13<0s Signature: Design Professional's Seal Re Date TEST PIT DATA 0 I 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST DOLES _..- _- - -_ - - - �..�R- ,.�IQ�E..N- (�- �___.�..b- _.MOLET�TO .�.._ �. ,.:�� - G.L. To 1.0' 1.5' LT , 2.0' ���' ►�'� . ail., 2.5' Sly i-QR� 3.0' WAY bw 4.0' 4.5' ��i� �► °i� '�� 5.0' 5.5' W�tC£- C06� 6.5' ' t" 7.0' 7.5' 8.0' 8.51 9.0' 10.0 Indicate level at which groundwater is encountered 5�-(p Indicate level at which mottling is observed WA, Indicate level to which water level rises after being encountered Deep hole observations made by: 1jy '�%kgbKhiL / 605 Design Professional Name: HA - V41 HioiAO�h Address: IW 0 Pr Z� bp-e-Y6 - 13<0s Signature: Design Professional's Seal Re Date 0 I %. k � 1 1 �� 1416.4 (9/95) —Text 12 PROJECT I.D. NUMBER .617.20 SEAR Appendix C State.Envirorimerdal — . = • . ::,:., -.._:. .,..o..��..w�.,... ;.:�.� : -SHORT ENVIRONMENTAL. .... ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR d�L© V_LiP� 2. PROJECT NAME 3. PROJECT LOCATION: P N �ii✓� Municlpallty v + 1 County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS, PROPOSED ACTION: ,RNeW ❑ Expansion ❑ Modiflcation/alteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFF CTED: Initially acres Ultimately y' pl?i acres 8. WILL ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? "PROPOSED myes ❑ No If No, describe briefly 9. WH T IS PRESENT LAND USE IN. VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ ParklForesUOpen space ❑ Other Describe: 10. DOES 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) and permit/approvals hISM Q LPG I .JlVC1r1� Q Tb441 l�l; Q`f t pl' N \l R1^,� -( 1t. . DOES ANY ASPECT OF THE.ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? .. ❑ Yes Wo If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ' ❑ Yes No. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AppllcanUsponsor ame: NA uv' N 14OLf J 1� �� a(A`� Date: &i) Signature: adeid9 i If the action is in the Coastal Area, and you are a. state agency, complete the . Coastal Assessment Form before proceeding with this assessment. OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) -�- �3y --47 A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes ❑ No B,iNIit�A'TtOP;RL E(;fF C�QORWN .TepQ 9EYIEW E1S:FROVI_DEE) FPF- 7UNiISTED AG7R9N61AI;F.NY f f?;:PAI�T 63Z fi° IS P10 ;;negatjvoid cler »Dion,. may be superseded by another Involved agency: ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater . quality or quantity, noise. levels, existing. traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2: Aesthetic, agricultural; archaeological,•historic, or other natural or cultural resources; or community'or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E: IS'-THERE,; OR'IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL. ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No 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 (f) magnitude: If necessary, add attachments or reference supporti rig, maferials. 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 and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation,'that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible'Officer Signature of Responsible Officer. in Lead Agency Signature oT Prepare r (If different from responsible of icer) Date K PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE- SEWAGE.- TREATME,NT SYSTEM Owner N F3A-UM Address ISM ft(,PV -ruvL p u0 Located at (Street) C,4NoPo S' Rp"w. . 1'LOKU : Tax Map &I Blbck ` Z. Lot C� .(indicate nearest cross.street) Municipality (T) ELM AM V�(U'�"y yDrainage Basin HUD.So.JQ : X17- V61L SOIL PERCOLATION TEST DATA D� Date of Pre-soaking OCR - l 3 ,.o L ' Date of Percolation ")vest 66 o Z Hole No. y Run No. Time Start - Stop Elapse Time (1lin.) De th to Water ; `, From Ground ' Surface (Inches) Start Stop •Water Level Dropp In Incties Percolation Rate Min/IliCh 3A 1 4"' 34 2 43q_Sb4 040 2i �Z 3 !O .4 4 -,44f 3 0 15 — 20 v 15 �� .. ..2. 3 Sit , tJ' dK 30 4 5 .1 2 3 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 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 DEPTH G.L: 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 2 TEST PIT DATA LS- --T S� i . O _ HOLE NO. � ee l�l� tee 91 elAAvel, HOLE NO._ _ 7bP �lL " r� 100r, (3U 5WN (^r&44 1 rWAPP 6&AASg 44Aab'k 4nArv9. �--1 HOLE N0. e� $6 rr Gtt�q �� cr�n�G 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' r' 7.0' 7.5' 8.0' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered 6-S, f Indicate level at which mottling is observed {�J� Indicate level to which water level rises after being encountered 5 -S r Deep hole observations made by: GRo&tij exAjoaM0 f4DH Date p5-3o• oZ �,— -, --r -- - Design Professional Name: ::Dt,vTjy 1,0 Address: Z .Jo4o wALt6l+ SLgb. Signature: Design Professional's Seal •t• w�vv y •�'' \try l.. iU, � �� h G v a`�so ��� NHUFESS10NP\' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES APPLICATION FOR APPROVAL OF PLANS FOR . A WASTEW ,'T]ER.TREA'T11V4EN7['-SS7CEIVI y1.y Name 2and Yaddress of applicant: 00�JN1.10 F� t� 2. Name of project: L I 3. Location T/V: F \ l N RAY\ 4. Design Professional: WW �O ti 0lU �5. Address:. �Ko K 6. Drainage Basin: iL_0 OL W; 7. Tyne of Project: X 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. TYPe,II Unlisted X 9. Is a Draft Environmental impact Statement (DEIS) required? �( .10. Has'DEIS been completed and found . acceptable byLeadAgency? ..... ........... 11. Name of Lead Agency (� . 12. Is this project in. an area under the control of local planning, zoning; or other. officials, ordinances ?. .. ' ....................... y 13. If so, have plans been submitted-to such authorities? ...:......... :...... :..................... �0 14. Has preliminary approval been granted by such authorities? �JO 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) ,... ............. ................................................... �J 18'. Is project located near .a public water supply system? ....... ...................:..,........ . . (�(� 19. If yes, name .of water. supply �J,( Distance to water supply. 20. -Is project-site-near a public sewage collection or treatment system? ...... .::::..:.:... NO 21. Name of sewage-system tJA Distance to sewage system 22. Date test holes observed 0 1 m° / b 23. Name of Health Inspector 66-H 6 24. Project design flow (gallons per 'day) ........:........................ .........I.....................: Boo. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?:.. 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?. 10 28. Wetlands ID Number....... ............................................................. .. 2q: Ime— tlands Ferinit required'? .......................... .................... ............................... �0 . Has application been made to Town or Local DEC office? .:............ t�A 30. Does project require a DEC Stream Disturbance Permit? ..................................... 31. Is or-was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling; sludge application or industrial activity? .... Yes/No 32. Is project located within 1,000 feet .of existing or abandoned landfill, . . hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ........... Yes/No DESCRIBE:. • . 33. Is.there a local master plan.on file with the Town or Village? .::...................... 34. Are community water and/or sewer facilities planned to be developed within 15 years -in or adjacent to project site?..,, ..................................................... A 35. Are any sewage treatment areas in.excess.of 15% slope? . .. .........................::::.4 36. Tax Map ID Number ......................... :....................... ............ Mal) Q Block. I Lot �o► 37. Approved plans are to be. returned to ..... Applicant X Design*Professional NOTE:.AII_applications.£or review.and approval,of a new SSTS.to be located within the'l,YYC.Watershed shall ° - be sent to the7SepkEe'nt, 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 1.,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, Lander penalty of perjury, that information provided on thisforMis true to the best of racy knowledge and belief. False statements made herein are punishable as a ClassA misdemeanor pursuant to Section'210:45 of the Penq aw. SIGNATURES & OFFICIAL TIT'.LES. Mailing Address :.... ............................... PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES TLETTER OF AUTHORIZATION RE: Property of P9N KID -lit ? A,5 Located at Gk 0 0 ?J 45 �k 1 Vt PO P�G T/V QUI P1+ ��`i Tax Map # al..% .. Block 2 Lot 611 Subdivision of Subdivision Lot # Filed Map #y'� Date Filed �� OS OCo Gentlemen: This letter is to authorize a duly licensed Professional Engineer k or Registered Architect to apply for the required wastewater treatment and/or water supply permits) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in . conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health .a�,.-and - the:Putnar County:Sanitary_.Code..�. 4• y• . 09 Very truly yours, Countersigned: P.E., R.A., # Mailing Address State ip. 0 Telephone:( %44 2, 1 J 40ot Signed: (Owner of Property) Mailing Address: �oDL, pvj State Zip �I Telephone: Form LA -97 May 11, 2006 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Michael J. Budzinski, P.E. Director of Engineering Harry W. Nichols Jr., P.E. Patterson Park - Suite 106' 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Email: hnengineer@aol.com RE: Individual SSTS - Canopus Woods -Lot #1 Town of Putnam Valley T.M. # 61. -2 -6.1 Dear Mr. Budzinski: Enclosed are the following: - J-� -�� Five-.(5) prints .of_SS- 1:,- "Proposed.S.STS "-�. dated - O511:_1/06-:�_ ;.. . 2. "Short EAF ", dated 04/28/06. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 04/28/06. 5. "Application to Construct a Water Well ", dated 04/28/06 6. "Design Data Sheet ". 7. "Letter of Authorization ". 8. Two (2) copies of Residence Floor Plan(s) for "Bedroom Count Only'. 9. , Review Fee in the amount of $500.00. Very truly yours, Harry W. Ni ols Jr., P.E. HWN:gav 06- 024.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Welpp- WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Map # p % /v0 DI AIW,�4,a i� Map Block Lot(s) during drilling Depths' *- /(� p/ Model list: P ' ,r J Voltage HP Tank Type j u1f4 2. Volume AN,21 Wte,Well Completetl Well Duller PC;Certificate'# ;NY State # Date;of Rep rt P,ump.Iristaller PC Certificate'# 4 i NY State # Well:` Dnller Name 8r'Atltlressc�' Well Pump Installer Name & Address x Pumt nstaller;;fs' atuikl ; NOTE:/ Exact Location of well with'distancis to at least two permanent landmark to be provided o separate 777 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 Well Owner: Name: Address: Hours 10 Use of Well: 1- Primary 2- Secondary Residential _Public Supply Air cond /heat pump _I rigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _Rotary _Cable percussion ZCompressed air percussion Other(specify) During yield test ft Well Type _Screened _Open end casing X Open hole in bedrock _Other Casing Details Total Length ft. Length below graderRdit. Diameter to in. Weight per foot Zj lb /ft Materials: Steel Plastic Other Joints: Welded X Threaded Other Seal: Cement grout Bentonite Other Drive shoe: _y Yes _ No Liner: _Yes No ft. Screen Details Diameter in Slot Size Length ft Dept to Screen ft Develo ped? First _ ..._ . _._... _ I _Yes No Hours Second o during drilling Depths' *- /(� p/ Model list: P ' ,r J Voltage HP Tank Type j u1f4 2. Volume AN,21 Wte,Well Completetl Well Duller PC;Certificate'# ;NY State # Date;of Rep rt P,ump.Iristaller PC Certificate'# 4 i NY State # Well:` Dnller Name 8r'Atltlressc�' Well Pump Installer Name & Address x Pumt nstaller;;fs' atuikl ; NOTE:/ Exact Location of well with'distancis to at least two permanent landmark to be provided o separate 777 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 Well Yield Test _Bailed _Pumped Y Compressed Air Hours 10 lYield- gpm Depth Date Measure from and surface-static (specify ft) During yield test ft Dept o compete we n Well Log M If more#Miled "" ' deseriptrtjns or —.4% sieve-ahbIvses are available, �� r.•y, please attach. Depth From Surface Water Bearing Well Diameter (in) Formation Description ft. ft. Land Surface - _ ..._ . _._... _ o If yield was tested at different depths Feet Gallons Per Minute Pump /Storage Tank Information Pump Type S Capacity during drilling Depths' *- /(� p/ Model list: P ' ,r J Voltage HP Tank Type j u1f4 2. Volume AN,21 Wte,Well Completetl Well Duller PC;Certificate'# ;NY State # Date;of Rep rt P,ump.Iristaller PC Certificate'# 4 i NY State # Well:` Dnller Name 8r'Atltlressc�' Well Pump Installer Name & Address x Pumt nstaller;;fs' atuikl ; NOTE:/ Exact Location of well with'distancis to at least two permanent landmark to be provided o separate 777 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 tea} 9 a S r' r. Dl�°1VNSE�R.'(n yet) M3.0 315.; 2. .. ..1 . 95.0 ' � z3.o• . 191.5 128. D. © (4110 • 53.25 1 7 :: 4 82.0 (6:0 • 5 �� 81,_p r�7 � 1.11.5 131.5 20 7.. 73,0 8:0 8 79. 5- 7.0.0 9 80.0. 7 3.o 1 0 80 5' 75.5 . t t .82.0. 78.5 I2 9,.f 0 14. 13 M3.0 315.; 2. N 210 57'50" E 87 '. 52 } 5 191.5 128. D. 16 (4110 • 53.25 1 7 141.0 12-9.0 1 8 1,11.0 13,0.0 9 1.11.5 131.5 20 )421 0 133.0 2 l 192.5 135,0 BOUNDS 1. N 190 23'55" E 315.; 2. N 210 57'50" E 87 '. 52 3. N 17° 36' 40" E 67.16 4. N 14° 27' 48" E • 53.25 5, N 280 23' 40" E 47.42' 6. N 36° 42' 30" E 15.77' 7. N 210 40' 00" E 27.22' S. Ni 280 23' 30'' E 16.07' 9. N 170 43' 34" E 71.9 1 ' 10. N 250 13' 33" E 40.45' 11. N 22° 46' 53" E 34.39' 12. N 270 09' 57" E 208.9,1 13. N 39° 39' 29" E 161:74 14. N 510 29' 3$" E 580.0( 15. N 510 IT 12" E 659.8 16. N 450 02' 04 ", E 403.6,1 17, N 450 02' 04" E 42.36' 18. N 390 21 ' 06" E 53.56' l NO _ �QOP: QES�UENCE EYIST, EL WL ��. N Z. O/. 33s ` 3g F NG� 9 BED R1 Sj ENc 00m .A q 14 CIANOPU5 f4l LL ROAD fi � E ATION PL SIT LOC PROPOSED SSTS CANOPUS WOODS LDT-�t I ��. CIANOPU5 f4l LL ROAD fi E ATION PL SIT LOC i CLIENT: DONALD KLYBAS SCALE: I "f, 7.7 BE HOLLOW ROAD PARCEL -PL-A!4 PROPERTY SHOWN ON TOWN OF PVTNAM = SCALE : I " 200' TAX-MAP: i' ik''50 GAL. sE,PnC TANK "¢ u soLlD PVC/ s ~'--C y' Pvc 1$ 4 A/ � D R A I N 0 SD R-35' B SDR35 ?;f. 4 $8L'� Ate• CTvP :..� J 5 13 I 6OI 6 60' , o" 15 I. 00% EXPANSION AREA�O 35 0 1i s8 4� n 85 20_ q0 i s ; z1 go X13 35 ' E 5'4.06__ N. 47° 99 4 7E N �I7° '49 97E ip EV.,_08-13-08' i. - i PROJECT: PROPOSED SSTS CANOPUS WOODS LDT-�t I ��. CIANOPU5 f4l LL ROAD fi PU -NAM VALLEY' NEW i CLIENT: DONALD KLYBAS 7.7 BE HOLLOW ROAD ��. fi