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HomeMy WebLinkAbout2782DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -1 -54 BOX 23 I ru ., MIN IN 06 yl kmi T :L 61 �L rL r � W � r AJ61 CsNa:m PUTNAM COUNTY DEPARTMENT OF HEALTH EN. A:T ::I��A��..'� v��'� �. ..{r_...::� CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCT W N PE R # �IGSI�iGC d�a� / Located at Town or Village Owner /Applicant Name IQjQf}'/L M6Cd4MnQt Tax Map 7i Block �_ Lot J Formerly Subdivision Name Subd. Lot # Mailing Address J 7/��i�iy" �,��� Q��Tti,� 6� �;1 Zip Date Construction Permit Issued by PCHD 16 171t) /U Sr- Separate Sewerage System built by A A (04.071ICt Address Consisting of IVOO Gallon Septic Tank and 300 Other Requirements: JPoa t'uelA) �11 fZ Talk ' Water Supply: Public Supply From, Address or i) Private Supply Drilled by A)04&10i0 /fwW/LI-4o' y Address f a A/¢g ',/ Number of Bedrooms 3 een-cornpletvu1' ... . "... /... -.^ ��- � ... ...- ..- ..... -.. .... Has garbage grinder been installed? 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 of the Putnam County Department of Health. - Date: ltholzw6 Certified by Address P.E. /f R.A. O� 7�� License # 47� 2& 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. B Title: %� Date: o Lo 7 File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 TNAM COUNTY DEPARTMENT OF HEALTH SIGN OF ENVIRONMENTAL HEALTH SERVICES r:y-a �•. • ^:.'- ��, a - •:.-g:s4s+.'�: C:Ol`n'� IL Ilotir0 101 Pb:l�i'tign r # Located at �.11iS�/I�G /ZGr.�//� Town or Village Aym-tfy-, Subdivision name Subd. Lot # `— Date Subdivision Approved Tax Map Block 1 Lot Renewal - Revision Owner /Applicant Name 4rIIA24 R6 Date of Previous Approval Mailing Address S;Rt rw D1�. �� j- ��.�.� -A/� /�� Zip Amount of Fee Enclosed 4�o - C* Building Type PrElSLo • Lot Area 9 #5� No. of Bedrooms Design Flow GPD Fill Section Only Depth Volume PCIID NOTIFICATION IS REQUIRED WHEN FILL. IS COMPLETED Separate Sewerage System to consist of gallon septic tank and 7v 7 Other Requirements: To be constructed by TZ -D • Address Water Supply: Public Supply From Address � ,/' - -- r... _•.���-..���.:T,_ _..:"vaty,S y.y:illnd -by ,�r�r���/�.�. �_ .:�' A�,`c,.�:Ads'►ress �' ��� �T.�. �_� I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will 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. R.A. Date S O� Address 123 Wjof ItVq Al' 14,049 44-0 License # 0710 tog- -� 1�?' 06-774 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trea nt system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified en c nsidereA necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t. pprov r discharge of domestic sanitary sews a only. By: Title: Date: loh White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 -1-1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Pv -0 q -0 I'S Well Location S.treEt:_.A -u�- ss:�:�.�, _„ �;,,, ,�........- �Te��rr�:►i,age�� RA-1 --m VA-11eq VA-11e Taxiirid! #-.,� Map & t Block/ Lot(s) S4' Well Owner: Name: / Address: (� i . k f �C.. C Use of Well: 1 * primary 2- secondary _/Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment i /Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened _i,,-Upen end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade J o _ft. Diameter j_in. Weight per foot —lb/ft. Materials: 4--Steel Plastic Other Joints: Welded L-Threaded Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes b-N6 I. ILiner: Yes e_--No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped Compressed Air Hours & Yield 1!.L gpm Depth Data Measure from land surface-static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses �r�:.a�cailible;� .e:.a.__,:. please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ZA ft. ft. Land Surface 10 - v L4, o L �• ,... _. __ ._. _.n.: .._._ -- ....... - .. .�. t::��., ' • o� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type S ��;6,Capacity •5— Depth 38�o Model Voltages 17IP Tank Type 4kL,' - Volume h as Date `W rI Completed Putnam County Certification No. W ' Date of Report Wel D 'Iler (signature) Tj �J r NOTE: 'Exact location of well viA* hd istan at least two permanent landmarks to be provided on a separate sheet/plan./j t 1,�. Well Driller's Name Address:.IS o� d c . •� �t tt Signature: � �p � .41. 4 _ _ A �t Date: `� f r� Wh ite cop rn w copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WG97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT I1✓ -0 q _® ��:c;i•L�eati���n- • •: sir, ���- ���u .:���-: ;::�,- „.::::..�_., -�� �./:_ - . VII(Itj M Map & 1-Block Lot(s) Well Owner: N Name: Address: / 6 �l wV-d tM �`t_ C - b 4�& ��L Use of Well: _ _j/Residential Public Supply Air cond/heat pump Irrigation Drilling Equipment _ _IZRotary Cable percussion Compressed air percussion Other (specify) ell Type S Screened __j,,L6pen end casing Open hole in bedrock Other Casing Details L Total length � E� ft. M Materials: L--Steel Plastic Other Joints: _ Welded &-Threaded _ Other Seal: Cement grout " Bentonite Other Drive shoe: Yes (,No L Liner: Yes L--No Screen Details F Diameter (in) S Slot Size L Length(ft) D Depth to Screen (ft) D Developed? First Y Yes No Second H Well Yield Test B Bailed Pumped 1:_ Compressed Air H Hours & Y Yield JfL gpm Depth Data M Measure from land surface - static (specify ft) D During yield test(ft) D Depth of completed well in feet Well Log D Depth From S Surface W Water W Well F Formation ft. f ft. B Land Surface 1 10. O O U e_-r v 4 400 _.. -.. _ _,.._ -. NOTE: Exact location of well V d /� des at least two permanent landmarks to be provided on a separate sheet/plan.[� !-lo t bt � arty, Well Driller's Name h..C& G d S� k Address: IS al 0. r 4 e-✓ It”. Signature: V444444,, 44r3 Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 .. .. BRUCE MR:» FOLEy Public Health Director -�T"'r t. -4•MV '>R➢ >. rn.v .• �9I,Yn .t+ *+. . >.... >.; ..•�lw•, ,, -9Y LORETTA YMOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278.6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: A�C���oC: Ca�.� "�-. TAX MAP NUMBER: 6 Z , . 1 �7" E911 ADDRESS: TOWN: ko0l (�l V Q�I y► � VA AUTHORIZED TOWN OFFICIAL: J _ -� (Signature) DATE: i The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E91.1 address is assigned by an authorized town official. This form is to be submitted with the application for a Certifcatc of Construction Compliance. (E911 verfrm) M DIVISION OF ENVIRONMENTAL HEALTH SER'V'ICES - - - -- - - - -- w, , = •a::.+c+•.:._...�,.1: : ... �..:.,...: �...r- .:..:m+s.+.ev r:,.r.�. a I ..4r. GUARANT.Eu._E .. .,: O .. : F SUBSURFACE SEWAGE TREATMENT SYSTEM ,� /Cwx/l /pie Owner or Purchaser of Building OW W 4 Building Constructed b Location - Street 5'i�� GEC f7►'?"! � v� ��s /p ��� Building Type Z_ S� Tax Map Block Lot 417-AX-11t TownfVillage Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and. hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the oecuRan %,of:the build �g utilizing the system• Dated: Month Day Year Z General Contractor (Owner) - Signature Corporation Name (if corporation) Address:�'N State (�I�GC / Zip cm Signature: Title: gj,1V_fX- Corporation Name (if corporation) Address: State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Keir Street Yorktown Heights, N.Y. 10598 '_- - � - (914> 4 ' ~u� � ' ` 2 � 5-2 , LAB #: 1.605455 CLIENT #: 2173 NON STAT PROC PAGE: 1 NORMAN ANDERSON INC. DATE/TIME TAKEN: 09/06/06 02:15 152 BARGER ST DATE/TIME REC'D: 09/06/06 02:42 PUTNAM VALLEY, NY 10579 REPORT DATE: 01/25/07 PHONE: (914)-528-1491 SAMPLING SITE: 555 PEEKSKILL HOLLOW RD SAMPLE TYPE..: POTABLE : PU|NAM VALLEY, NY ( MCCORMACK ) PRESERVATIVES: NONE COL'D BY: BEN CRONIN TEMPERATURE..: < 4C NOTES...: BASEMENT OUTLET COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 09/06/06 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIK���f�iHE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION" SUBMITTED BY: Director ELAP# 10323 S4706 �006 �006 �006 �9l6 06 S0O6 800� axKso��oz s�a�em eq� eznpa� oq ua�e��apun a.'+ -em insle T 8�66O3 a_1om J.o e exeq s.ju1:od uoIC�nq���s�p e�om ou 4e1.j� se��nbe� sma�s�S z�lqn6 �o� aln8 s[onqzs z-1:1 ql `leT ue�od � pue qdd l ueq4 � eq o %O1: ueq� �ed (If u3 �J� ^N0112n llO3 �D 314ll S8]l]N�8�J �]Hl HO� ^SOH�DN�lS 8]l�M 9Nl�NIHO l�U]��� �J�] ON� �l�lS �UO� Dl SNlO8O33� AlI KJOO A,8t/llN�S �8Dl3��SIl�S (Sk-IM) U'::llA)M lMHl ]l�3lONl SllDS]8 ]S]Hl l3�8 J_ 114`3 S8U, lN JNO2) �O X3I6 :SlNBNWO3 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3� > I.J. "H`3 .:A �3�NUO3JW O8�H2]8 :A8 O,lO3 ]NON :S! A 71 UA j : 90/'fS/80 T AN ]Nl�/�lt0 8O HllWS NVH6�lS S� 00:60 90/��/80 :N���l �Nll/�l�� H3l8 ^)13�W8O33W ~~~~~~~~~~~~~~~~~~~~~~~~~~ ... ... ~~~~~~~~~~~ ~~~~~ell ~~~ lo: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ � :]SV6 3OHc| l�lS NOM /MCCZ�� :# lJ :# 8V-1 a-1 'iuexope6 '86s 0l ^�^N � ��� | S�3lAu�� /��m3 wmuU�om] �W� | A l{OI8HDl 90/8�/80 � SW 90/9 2 /80 V/N l/8W 0^�6 ^ ��101 SS3N�8�H 90/���/80 S 8 9 Sl1 O 6^9 Hd 90/Sa/80 NDIcfOS 90/9E1 80 l/om C^0-O f", 14 0 1 0/62 /8O � l/Om S^0-0 -K8N O90`0> (a�} NO8I 90/63/8O V/N l/9N T0^0> 8OUlI 1. ",J 90/0 C/80 0 7/8W C2 ^0 80 H1IN ]lV HlIN 90/8 80 qdd �l-0 qdd C^Cl (SNl) Cl W�]] 90/62/80 lN]S8� lW 007/ lNS]86 NHO��I�O3 ^l �]W 90/��/80 NINl1)6 llOS�H ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3� > I.J. "H`3 .:A �3�NUO3JW O8�H2]8 :A8 O,lO3 ]NON :S! A 71 UA j : 90/'fS/80 T AN ]Nl�/�lt0 8O HllWS NVH6�lS S� 00:60 90/��/80 :N���l �Nll/�l�� H3l8 ^)13�W8O33W ~~~~~~~~~~~~~~~~~~~~~~~~~~ ... ... ~~~~~~~~~~~ ~~~~~ell ~~~ lo: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ � :]SV6 3OHc| l�lS NOM /MCCZ�� :# lJ :# 8V-1 a-1 'iuexope6 '86s 0l ^�^N � ��� | S�3lAu�� /��m3 wmuU�om] �W� | YML ENVIRDNMENTAL SERVICES 32� Kear Street Yorktown Heights, N.Y. 10598 Albert H. Padovani, Director LAB #: 1.605270 CLIENT #: 55375 NON STAT PROC PAGE: 2 MCCORMACK, RICH DATE/TINE TAKEN: 08/24/06 O9�O0 23 STEPHAN SMlTH DR DATE/TIME REC`D� 08/24/06 01:59 PUTNAM VALLEY, NY �0579 REPORT DAT�: 08/3l/06 PHONE: (845)-528-1491 SAMPLING SITE: 555 PEEKSKlLL HOLLOW ROAD SAMPLE TYPE,,: POTABLE : PUTNAM VALLEY PRESERVATlVES: NONE COL'D BY: RICHARD MCCORMACK TEMPERATURE,.: < 4C NOTES...: WATER TANK VALVE CDLlFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No 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 muderate}y restricted diet, at maximum of 270 my /I of Sodium is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF­-pH }S ONE OF THE lMPORTANT AND FREQUENTLY USED TESTS lN WATER CHEM�STRY. WATER WITH A LOW pH MlGHT BE CO R ETAL PlPES AND - -E]�lTVRE��` THE NORM�L-RANSE O E ��=�Jl] F[��-' ^f�-/��~ �. /� 10� ' . Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CAI l MAGNESlUM CONCENTRATION, BOTH EXpRESSED AS CALC[UM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L. VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 M(3)/L MG/L = MlLLIGRAM PER L{TER HARD WATER: 140-300 MG/L (J grain/gallon SUBMITTED BY: Director ELAP0 l0323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N,Y, �0598 A�bert H. Padovani, Director LAB #: 1.605455 CLIENT #: 2173 NON STAT PROC PAGE: NORMAN (ANDERSON INC. DATE/TIME TAKEN: 09106106 02:15 152 BARGER ST DATE/TlME REC'D: 09/06/06 02-:42 PUTNAM VALLEY, NY 10579 REPORT DATE: 09/0./06 PHONE: (9�4>-528-�49� SAMPLING SITE: MCCORMlCK SAMPLE TYPE..: POTABLE P H R PUTNAM VALLEY PRESERVATlVES: NONE COL'D BY: BEN CROWN TEMPERATURE.,: < 4C NOTER...: BASEMENT O.UTLET COLlFORM METH: MF COMMENTS: BACT THESE'. RESULTS INDICATE THAT THE WATIER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACT, ORDI HE NEW YORK STATE AND EPA FEDERAL DR}NKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. ^ | ' ` +� �UBMlTTED 8Y: 1008 ELAP# 10323 a BY THIS CERTIFICATE OF COMPLIANCE THE NEW. YORK BOARD OF FIRE UNDERWRITERS w w.. . ,.._..Y ...r.._ BUREAU Oi IfEtb k Cf -Y( -"" ...._. "- - _ 40 FULTON STREET — NEW YORK, NY 10035 n v dJpon the application of JB BROWN ELEC. CONTRS. 17 ERNEST ROAD BREWSTER, NY 10509, CERTIFIES THAT upon premises owned by RV&HARD MCCORMICK 555 PEEKSKILL HOLLOW RD. PUTNAM VALLEY, NY 10579 Located at 555 PEEKSKILL HOLLOW RD, PUTNAM VALLEY, NY 10579 0 Application Number- 3004582 Certificate Number: 3004582 Section: Block: Lot: Building Permit: 1102 -06 BDC: W106 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in /on the premises at: Basement, Outside, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and /or standard promulgated by the State of New York, Department of State Code Enforcement and. Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 2nd Day of November, 2006. Na r� -QTY Rate Rating Circuit T Alarm and Emergency Equipment Panel Board 1 0 SEPTIC Alarm Appliances and Accessories"„ Pump Motor 1 0 SE PTIC : F.H.P. Wiring and Devices - Disconnect 1 0 SEPTIC Motor Control 9= u NOV 0 2005 -; _...... u ,.rerrr�� 1 of 1 seal This certificate may not be altered in any way and is validated only by the,presence of a raised seal at the location indicated. SHERLUTA AMLER, MD, IBS, FAAP Commissioner of Health Associate Commissioner of Health Stephen J. Ferreira 123 Washington Ridge Road New Milford, CT 06776 Dear Mr. Ferriera: R®BERT J. B ®N ®I County Executive ROBERT MORRIS, PE _. Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 January 18, 2007 Re: Construction. Compliance — McCormick 555 Peekskill Hollow Road (T) Putnam Valley, TM# 62 -1 -54 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. The well completion report has not been completed (enclosed). All sections need to be filled in. The retest for bacteria provided doesn't appear to be the original copy. The relocation dimensions for the beggnnina of the trenches have, not been provided. The relocatiori dimensions for the weh has not been provided. Surveyed location of house with respect to the property lines has not been provided. This office will continue its review upon consideration of the above- mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. JSP/kly Enc. Very truly yours, oseph S. Paravati, Jr. Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Rjr snulneeftnffi govVI ON January 2, 2007 Stephen J. Ferreira, P.E. New Milford, Connecticut 06776 Joe Paravati Putnam County Health Department Devision of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit /°� - d 9 — ©��M` Lo/LOe, Sect:e Z Blk: I Lot: Dear Mr. Paravati: Please find the attached as -built plan and associated paperwork for the Certificate of Construction Compliance. Please feel free to contact me if there are any further questions or information required. Sine ...'Yours . _ ...._. _...... `.r � � _ . ............ _v .�. ........._..�__. _... ... �.. _ ,.... _ _, ......_ _ _. _ ..sp• Stephen J. Ferreira ' ��s PUTNAM COUNT' DEPARTMENT OF HEALTH �N�s oNL DIVMSION OF ENVIRONMT.NTAI, BEAT TIT SERVICES FINAL SITE INSPECTION 17 Q� Date: Inspected by: Street Location /`"/ids /Cl%f0 /lam / Ow.er- /h�1`�;l. .. '�uwn - . r. T%Y�i/"�::- � L ''... _. :Permit # � �/ O 67S TM 4- 62,- %— vc° 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 ...... ............................... H. Sewaze System V1,250 a. Septic tank size - 1,000 ............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:'.: Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. Trenches ids 1. Length required 300 Length installed 2. Distance to watercourse measured Ft. lop 3. Installed according to plan ............. ....... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2' diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped ................... _ h. sumo or Dosed Sv�uc-mz ._ :_. ... ........................... -- l7CJ� 1. 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........... M. House/Buildirig a. House located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... 1[V. Well Well located as per approved plans ............... .,. ..... ... b. Distance from STS area measured / 4 ft........�' c. Casing. 18" above grade ............... ..............:................ d. Surface drainage around well .acceptable .................. ... V. Overall Workmanship . 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 & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control pprovided ................. ..............................� Rev. f2/02 D NAM mm.. -� WIN N� 1. IVA mm AI M ! '.. o. �l PUTNAM COUNTY DEPARTMENT OF HEALTH a TON OI ENVIRONMENTAL IMATLFI, ERVI.CES- Flt' l ACTIVITY REPORT NAY u. Po Town State V,4 lry ... Gip -a_.- __...::� .... _ - . T......... _._ -AV04 .P TEST DOSE TEST a REQUMED GALLONS Y 2 Lie ZO U1 i . ... �_....... 't:..EL START EL. ST01 __ �.. ,fir,• ,_,.� iffi.'•.:. ' ".'�K'iA :." .,r:�t7a'lSi1`.6?.•:!!D.+b� - .. , -e:c•' .. .;nxS:::,�iA _ s��.i:'3:a�r11'F?IC"S'�'.:`.' ^. ..8':. ":l'i St •5'i..: +:.Z!,i "•r,t�i TRT NAMJ--COU.NTY DEP-ART OF EMAL-.TH. DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION COSEPH . ❑ GENE. REQUEST FOR FINAL INSPECTION All information must be fully completed prior to. any inspections being made. For: Fill Trenches PCHD Construction Permit # V — o T — CD � Located: —A,0nffiM&&- Ai skla (V) Owner/Applicant Name: 9.• . AAe- Cr4-&tj c& TM 2— Block Lot Formerly: Subdivision Name: Subdivision Lot # Is system fill completed? Is system complete? S Is system constructed as per plans? Is well drilled? yts- Is well located as per plans? V4S Are .erosion control measures in place? of Date:, Date: . . Date: I certify that the system(s), as listed, at the above premises has been constructed and I have ' inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam Coun(q /Yj Department of �1-- Health. 4%q-41-oy .. . ... .... Date: Certified by: ��pE * RA Design Professional Address: 6, 13 a [Q 7 Lic. # 0 7 Of'7 7.6 Comments: Form FIR-99 &' ER?x,iTA A i1L- P,4 VKDi -NIS "FIAAI ,...., _.... . Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Stephen J' Ferreira 103 Perry Drive New Milford, CT 06776 Dear Mr. Ferreira: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 September 7, 2005 Re: Proposed SSTS: McCormack Peekskill Hollow Road (T) Putnam Valley, TM # 62 -1 -54 County Executive Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. All retaining walls proposed below the SSTS must be shown in the'SSTS profile. 2. Retaining wall detail must be shown on plan and the maximum height. specified. 3___, Neighbor notifGati.on.is to; be_comnleted.. . The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will'be considered further. RM:kly Ve7tvy yours, t Robert Morris, P.E. Senior Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 eh y " 45 Y 34.03 AC. 18741 AC. 1.68 A .� 455.00.00 .. / 09 59 9 I � y3s SKY �,�����► �I 10 '��► 64 AC. CAL. •tea � � rn \ c1� \ k\ 17 5.95 AC. CAL. / 9,99 AC. CA ro R,"y� 50 1% 16 �� ° �� 52 7.06 AC.. ;�..........� _.. _ 7.11 AC. 12.54 AC. g 21 1 a�P Polov s �� ��4�'�61 c', hp6 ti6��51 5 $ ��a 51 5.46 AC. �\ - "0 ,' 6 x'2.53 AC "/ 0o�le CAL. `o 94d 4 .:�4 12 a 41 �� 2.67 AC.:._. Po`� � Vic\! �` %i, 13.g' �0�1�¢��`°,�h0 AC:• ; o� 28.86 AC. e' `G� �� 1.09 ti �o" 0�.� `�� CAL....:.. �p AC�9���Q9��`A ��'� 5 ®1.48 Q C. ,� ti °z A ' 1.13' A �h° a� 36 . � - -� 1�' .ro3� C. o 7 � t. rl o hQ' 1. d8 ACS � o .,� �� 1 5 fa �, AC. 1 09 h ou J, o 2 � i . PEEL M I NAR Y MAP SCALE f 1 51 AC. J 62 = - 400' �o/ 2 20-03, O O� �op ,. uIr 04 5.10 AC 6 .58 AC �mca M U.S. Postal ServiceT,., ;�' � r-i CERTIFIED MAtLTr., RECEIPT: (Domestic Mai/ Only; No Insurance Coverage Provid�d) Ln tQ[�t S For delivery information " tl! U Q�n 3 visit our t v+ebsite at www.usps.co P _ $ 0.37 WIT r Postage $ 0.37 e O _ C3 _ Return Receipt Z-i L9, O (Endorsement Required) 1.75 = . IL O Restricted Delivery Fee ,.D (Endorsement Required) C12� ra Total Postage-& Fees 4.42 08/2-4/05 Ln C3 C Sent To C3 ° 1 O PS Form 3800; June 2002 See Reverse for Iris ructions f� Street, Apt No.; - - - •- - or PO Box No. - 5 1 -„j k-j u- 1 - - S- e-Z°P - -- - /--- n- y ° °------- + 4 . -qT /er� P -- --------------------- (B�? U.S. POStat SerVICeTm •( nj h 2 CERTIFIED MAILTr, RECEIPT ^:4 (Domestic Mai/ On /y; No /assurance Coverage rovided) For delivery information visit our website at www.us scom� Ln Ir Postage 1 � - ►tar. 3 Certified Fee IL Return Receipt Fee Pcf,!;n M (Endorsement Required) C3 Restricted Delivery Fee ' Total Postage & Fees 08/24/05- r Pt O�Po // _ / PS Form 3800, June 2002 See Eleversexgr Instructions M r-i Ln tQ[�t S tl! U Q�n ypgj `P�/ ....n Ir r-q Postage $ 0.37 WIT M Certified Fee O Retum Receipt Fee ? Z-i O (Endorsement Required) 1.75 O Restricted Delivery Fee ,.D (Endorsement Required) C12� ra Total Postage & Fees $ 4.42 08/24/05 y' C3 ° Sent To �!(Z,(�pt�1C O f� Street, Apt No.; - - - •- - or PO Box No. - 5 1 -„j k-j u- 1 - - S- e-Z°P - -- - /--- n- y ° °------- + 4 . -qT /er� P -- --------------------- (B�? s • Er E. Ln ra e • �r •. •r .r Postage $ 0.37 e' rrt certified Fee 2 30 P shnark r re C3 Return Receipt Fee 1.75 I= (Endorsement Required) O Restricted DeGvery Fee _° iCQ `4 l _a (Endorsement Required) r=l 4.42 08/2470a''_" r-I Total Postage & Fees $ Ln Sent To p� I` O t o�I�-` f CL -------------------------- sreei, ani Nv.; y., . • m Complete Items 1, 2, and 3. Also complete A. Sig ure Item 4 if Restricted Delivery is desired. ❑ Agent Print your name and address.on the reverse ❑ Addressee so'ti iat `vN6`cail ci(iirri it ie card to yuu. - B. H rfnred Name) ' C. Gate of Ueiivel y - 12 Attach this card to the back of the mall piece, or on the front If space permits.; 1. Article Addressed to: delivery a - erent from item 1? ❑ Yes �. f YES,, t Ii ddress below: ❑ No ,�/ 3. Service Type ❑ Certified Mail ❑ Express Mail { ❑. Registered ❑ Return Receipt for Merchandise 2. Article Number 70 0 '(Transfer from service label) PS Form 3811, February 2004 7% ❑ Insured Mali ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 1160 0003 190.5. 1733 Domestic Return Receipt 102595-02 -M -1540 ' o Complete items 1, 2, and 3. Also complete . A. S item 4 if Restricted Delivery is desired. t M Print your name and address on the reverse ddressee so that we can return the card to you. �,.�eive by rl e) C. Date of Delivery El Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery add erent 1? ❑ Yes 1. Articlw Addressed to: If YES, enter d ve ❑ No lr*oL 14w- / 4p ti d 9b." � P4'd"- V 3. Service Type 7VA WO ❑ Certified Mail s Mail - i ❑ Registered ❑ Retum R *;pi for M=— hand!3e ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number 7 0 0,5 116 0 0003 19 0 5 1719 (transfer from service /aben PS Form 3811, February. 2004 Domestic Retum Receipt 102595- 02- M-1540 :SENIDER COMPLETE THIS . . :%COMPLETE THIS SECTION o Complete items 1, 2, and 3. Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent El Print your name and address on the reverse Addressee so that we can return the card to you. B. Reed b d ) C. Date of Delivery o Attach this card to the back of the mailpiece, or on the front if space permits. D. I deli ery ad diffe nt m item 1? 11 Yes 1. Article Addressed to: I enterery a re below: ❑ No all 3. Service Type IV-rA-7A0%'1- ❑ Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number (transfer from service label) 7005 116 0 0003 19 0 5 1726 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1 r P 2. Article Number 70 0 '(Transfer from service label) PS Form 3811, February 2004 7% ❑ Insured Mali ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 1160 0003 190.5. 1733 Domestic Return Receipt 102595-02 -M -1540 ' o Complete items 1, 2, and 3. Also complete . A. S item 4 if Restricted Delivery is desired. t M Print your name and address on the reverse ddressee so that we can return the card to you. �,.�eive by rl e) C. Date of Delivery El Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery add erent 1? ❑ Yes 1. Articlw Addressed to: If YES, enter d ve ❑ No lr*oL 14w- / 4p ti d 9b." � P4'd"- V 3. Service Type 7VA WO ❑ Certified Mail s Mail - i ❑ Registered ❑ Retum R *;pi for M=— hand!3e ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number 7 0 0,5 116 0 0003 19 0 5 1719 (transfer from service /aben PS Form 3811, February. 2004 Domestic Retum Receipt 102595- 02- M-1540 :SENIDER COMPLETE THIS . . :%COMPLETE THIS SECTION o Complete items 1, 2, and 3. Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent El Print your name and address on the reverse Addressee so that we can return the card to you. B. Reed b d ) C. Date of Delivery o Attach this card to the back of the mailpiece, or on the front if space permits. D. I deli ery ad diffe nt m item 1? 11 Yes 1. Article Addressed to: I enterery a re below: ❑ No all 3. Service Type IV-rA-7A0%'1- ❑ Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number (transfer from service label) 7005 116 0 0003 19 0 5 1726 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1 r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION O INDIVIDUAL WATER SUPPLY & SUBSURFACCE SEWAGE TREATMENT SYSTEMS NAME OF OWNER: REVIEWED BY: RM, OR, AS, SRDATE: Y /'TT DOCUMENTS PERMIT APPLICATION WELL PERMIT OR PWS LETTER )(, )PC -97 ETTER OF AUTHORIZATION ESIGN DATA SHEET (DDS) ORPORATE RESOLUTION HORT RAF LANS -THREE SETS 'OUSE PLANS - TWO SETS ARIANCE REQUEST SUBDIVISION F,GAL SUBDIVISION UBDIVISION APPROVAL CHECKED ERC RATE ILL REQUIRED DEPTH jIRTAIN DRAIN REQUIRED GENERAL OCATED IN NYC WATERSHED LANS SUBMITTED TO DEP ELEGATED TO PCHD EP APPROVAL, IF REQ'D REP TEST HOLES OBSERVED FRCS TO BE WITNESSED X- APPROVAL SSDS ADJ, LOTS /E��OWN/DEC PERMIT REQ'D ?) A ON D S PLANS & PERMIT SAME RE 19 IGHBORNOTIFICATION YR: FL(XUI) LLffVA1lON Wif20W - ��( )SOIL TESTING LOTS >10 YEARS OLD REOUMED DETAILS ON PLANS C�� SEWAGE SYSTEM PLAN - (NORTH ARROW) HYDRAULIC PROFILE C )GRAVITY FLOW 3NSTRUCTION NOTES 1 -15 SIGN DATA: PERC & DEEP RESULTS CONTOURS EXISTING & PROPOSED .UVEWAY & SLOPES, CUT )OTING /GUTTER/CURTAIN DRAINS CY)(-_)USDA SOIL TYPE BOUNDARIES (__) TITLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA.; NAME, ADDRESS, PHONE# )DATE OF DRAWING/REVISION . a — DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS �LAKES,WETLANDS WITHIN 200' OF P.L. (— PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS WELLS & SSDS'S WAIN 200' OF SSTS (PROPERTY METES & BOUNDS U(�EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE ' . COMMENTS: (REVSIMT)09 /01 /00 TREET LOCATION: MAP #: (CONFIRMED) . Y ( REOUIRED DETAILS ON PLANS CONT'D) �$OUSE SEWER -'/4" FT. 4 "0'; TYPE PIPE CAST IRON NO BENDS; MAX BENDS 45° W /CLEANOUT RENEWALS C-`- ( )SITE NOTE (NO CHANGE) FILL SYSTEMS - 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS/ FILL NOTES 1 -5 �EFILL FILL PROFILE & DIMENSIONS IN EXPANSION AREA FILL GREATER THAN FEET CLAY BARRIER FILL CERTIFICATION NOTE d� (3 i DEPTH GAUGES (_) VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS SEPARATION DISTANCE FROM TOE OF SLOPE 4�PARALLEL TRENLF TRENCH PROVIDED 60FT MAX. TO CONTOURS 100% EXPANSION PROVIDED DETAIUDUST FREE CRUSHED STONE OR WASHED GRAVEL UGEOTEXTILE COVER / SEPARATION DISTANCES ON PLAN - FROM SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL C &_!�3)20' TO FOUNDATION WALLS )100' TO WELL, 200' IN DLOD,150' TO PITS Ll')L_)100' TO STREAM, WATERCOURSE, LAKE (inc. expan) ( ,,JC )50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER _:..rill _)10' TOr�1 %i'i�F�i�iI(_Ntts 50' INTERMITTENT DRAINAGE COURSE L —)200'/500' RESERVOI , ETC. _ 150' GALLEY SYSTEMS L�(�10' MIN TO LEDGE OUTCROP SEPTIC TANK L�� (_)10' FROM FOUNDATION; 50' TO WELL ' ,� WELL (U DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION MIN 15' TO PROPERTY LINE SLOPE E SLOPE IN SSTS AREA (S20 %) REG ADED TO 15 %, IF REQUIRED - DOSE/PUMP SYSTEMS PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED t(__)DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) l PIT AND D -BOX SHOWN & DETAILED DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL 15' MIN to CDS =>5 %, 20'-4 %, 25' -3 %, 35' -1 %� 100 % - <l% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge 10' MIN to NON - PERFORATED PIPE TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. 2– HOLE N0. G.L.r���o: .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' 9.5' 9, &vj,✓ S✓ &VIV T'�gol1� !� ke jy Sway 'I.A'l "Y v*--194— iVv �� Indicate level at which groundwater is encountered ,%, Y- Indicate level at which mottling is observed --"—" Indicate level to which water level rises after being encountered Deep hole observations made by: Date J o� Design Professional Name: , 06774 Signature: Address: Design Professional =s Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVT ON OF :FNVTLR.ON_M ENT AT IW A;LTIJ _SERV>�CE . -1. .w .f - -•- v- -.ti - ..r. 5- r. .. .. .n .. r APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: l�/�%�i�/LD /�c qg'14a S76Ph ZAI SM17W 04 I/Au.,00 N y /0 -7? 2. Name of Project: ^ 6P_0tR-ck 3. Location: TN: 4. Design Professional: 5. Address: 113 G,/I 11i*f7 .) .44W 44 6. Drainage Basin: AMP, 11vA -dw /90414A- 7. Type of Project: c Private /Residential Food Service Cominercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEAR) ? .............. Y Type Status check one ................ ............................... Type I xem t Type II Unlisted ::�- 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/ A✓ 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes & 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinancesZ .......... _....:.:" ......... ._ ' :..._:_'. ......:.... '/N° 13. If so, have plans been submitted to such authorities? . ............................... <2e) No 14. Has preliminary approval been granted by such authorities? N Date granted: 15. Type of sewage treatment system discharge ........................ surface water V 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? . ............................... Yes / io 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? .......... Yes 21. Name of sewage system Distance to sewage system 22. Date test holes observed ��f 23. Name of Health Inspector go-g 14hy4ew'"T 24. Project design flow (gallons per day) .............................. ............................... &60 25. Is State Pollutant Discharge Elimination system ( SPDES) Pen-nit required? ... Yes(S N° 26. Has SPDES Application been submitted to local DEC office? ......................... Yess /`LO Rev. 11/02 Fonn PC -97 Pg. 1 of 2 27. Is any portion of this project located within a designated Town or State wetland ?... Yes/0 28, 29. 30. 31. 32. 33 34. WetlandsID number ................................................................... .........................�........ _ Is Wetlands Permit required? ...................................... ............................... &�,sl ;o Has application been made to Town or Local DEC ........................... (9/No Does project require a DEC Stream Disturbance Permit? . ............................Yego 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 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? ................................... ............................... YeK9 DESCRIBE: Is there a local master plan on file with the Town or Village? ....................../49/NO Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ...........................Yeso 35. Are any sewage treatment areas in excess of 15% slope? .............................. Yego 36. Tax Map ID Number .............. ............................... Map 62- Block Lot 37. Approved plans are to be returned to ................ Applicants Design Professional - - - - - - NOTE: All applications for review and approval of a new SSTS to be located within the NYC 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 fonns 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 inust be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the PenaWaw. SIGNATURES & OFFICIAL TITLES. Mailing Address: ............ ivy Cr e677, Aevlo hvf'exJ Form PC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH ...n Y:._..:....�...F OAT OF- EN-IRONMF,'�?' ' .: � E.f l' 'l�� : ;? TC' ', .:.� LETTER OF AUTHORIZATION RE: Property of 1141 120 AG 6,Gjam-4116 Located at & 4'M TN Tax Map # �2 o Block l Lot SY Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorizeiEp/',E ^/� a duly licensed Professional Engineer --k_ 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 ' a'Jr�`aiiu u °v•Ptftn air, CC-, PAY •S�::aa:Z� �_` -^ Q »�..__. __.:.:. ..... �.�,_._ a -. _. .. Mailing State C Zip a0 77,6 Telephone: 0%0 --75_e —Z41q Very truly yb s, Signed: v-•.. (owner of Property Mailing Address:�%/E�/Si,., /�/ State Zip 1K77 Telephone: (l /A) 5z16 —I Form LA -97 PUTNA.M COUNTY DEPARTMENT OF HEALTH _ DIVISION OAF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SKEET - SUBSURFACE SEWAGE TREATMENT SYSTEM P�s_&41Owner kc/i 6 Address leo_ Located at (Street) 7%4" Tax Map 61-- Block Lot � � indicate nearest oss street) MunicipaHty llhawr_ Watershed //ca w/ /Zda/X.,-1 SOIL. PERCOLATION TEST DATA Date of Pre - soaking A Les- Date of Percolation Test 4z z�r NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. i . for 1 -30 minhnch, <_ 2 min for 31 -60 min/inch). All _ _( for review. 2. Depth measurements to be made from DD -97 of 2 Depth to Watier Water; From Ground Level P:.ercolation ,. Elapse Time Surface (inches) Drop In Rate Hole Run No Time Start =Stop :. (Mm) Start is Stop' Inches' 1VLn/Inch No 2 tout .10:11 lS 2 - V L� � 3 10:5-7_ Zt:le Zi or 70// `7 4 It:1? -- (1:q0 5 1 ol,#y- z"' .._._._ _.......,. __ . . _r.!._. ,..:..... .... _ .__. .._.._....._.�. _... _....,........ ....__.._- .r.,.:_. ��� a �� �' , 3 70 4 5 1 1= 2 d. �.. ,: `zr �'� z� 3 ? 3 2 q r ZP 2 !� 2- 7 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. i . for 1 -30 minhnch, <_ 2 min for 31 -60 min/inch). All _ _( for review. 2. Depth measurements to be made from DD -97 of 2 14.16.4 (11/95) —Text 12 PROJECT I.D. NUMBER 81 %20 SEOR Appendix .0 State Environmental Duality Review SHORT. ENVIRONMENTAL A41SELUMEN:T- fC,PRP.- .._. _ UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME 3. PROJECT LOCATION: ~« PVT/v Municipality bT /o County t 4. PRECISE LOCATION (Street address and ro!0 Int rsections, prominent Is dmarks, tc., or provide map) 5. IS PR POSED ACTION: ew ❑ Expansion ❑ Modification /afteration 6. DESCRIB`E PROJECT BRIEFLY: �� lN��r�i��ic G, ,�j7 �G X/tw Js�4 IQ+ ,(7 � "i /� "' 4 y 7. AMOUNT OF L N FFECTED: Initially acres Ultimately « acres 8. WlkL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 9yes ❑ No If No, describe briefly 9. W&AT IS PRESENT LAND USE IN VICINITY OF PROJECT? gtesidentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest /Open space ❑ Other bbesaibe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL. AGENCY (FFDFRAL, . STAT OR LOCAL)? _ 4i6Yes . . ...._ ... _,.. ._. ...F..., • / � ❑ No . � KPa, la[ �c� ^�i(�� � „�',aeilli /app ?ov3is 11. DOES ANY AqgECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? D'Yes No If yes, list agency name and'permitiapproval 12. AS A RESULT O 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 Applicant/sponsor name: Date: ®� 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 1 PART II:— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) 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: WILL AC1`ION R1= CEIZ;i5C5f;D1�111t`ED FiE171ETN ASc P�tOVif)ED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) 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 Cl -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 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 yesr.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] m pacts 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 esponsi a Officer in Lead Agency Title of esponsi e Officer Signature of Responsible nfficer in I ead Agency. Signature ot Preparer different from responsible officer) Date 45 /I�T�FrIi/T�ux�j,e ry I �� 34.03 AC. � 1841 AC. �0. <b48 . �ry� ? / 8 A 8 455.00 SKY 49 /tip R 64 AC. CAL. 51 AC. a ` F oa 2 20.03 , 5,95 AC, CAL. 9,99 AC. CAL. /// , 53 50 ssnf 51 16 52 7.06 AC.. 7.35 AC. y F '��� 12.54.AC.._._ _ M1�a �``. 7.11 AC. �Nm { z�olsl \ .� � 4.2 _ orjv' �• ,.._- ' Pol o v 6�1 cr ab �S� 5.10 AC 4 92 �t h 16o a 5 �1 $ P��a �r '� O�5\ 5 �t�� / 98i 48 5.46 AC. `\ 51 ��e �, ,'► 6 �e Aso o wm� � 2.53 AC ,' 2 �� Macoond6ld / 00 4 12 a � 2.67AC1 4.1 , ` 13'4 'x, 03 ho 11.2 AC." ; �N: \ 6b. 28. �� co 58 AC 86 AC. ` 1.09 h 2 pP /g 5 CAL,...• - :.:1O AC 48 it a y a1'2 AC.,P�' AC, h0' 1`'�` ,r, °AC. � .z�a ^ 4�6>AC. ' '\ 0 T/ IcI JED � MAP 6 2 . - _ ....,......., R . E �I N _. ARY SCALE 400 1 I� I (1f I-11 ITS I A �.1 i n i i r—\/ 05/09/2005 .13:56 1026 Public 1kalth Lvredar r PAGE 01/03 LORETTA MOLINAW R.N., M.S.X. .imodate .Pablk Health Director AlrecW of Patient Savicea DEPARTMENT OF BEALT14 1 Geneva Road Hrew t, New York 10509 RE UEff FOR Eff" UST-MG MENTION: �JOSEPEK PAItAVALT1. ❑ GENE REED Aliiafvrnnatlon below must be ift eomplet ed. prior 4o Ruy schedtillae. DALTE: L °� F,NG.IlVEER OR F : 5rxY F / r PII�i � 4w REASON: DEEPS-. PERCS; a ' PUW; '4 T-. ROAD /STR'EET: TOWN: TAXMAIF*.- SUBDW SION: LOW: e NYCDEP 01n FOR JQ V XVLAND VY OF SOTESnEG YES O ❑ Proposed SSTS witbin the tied brain of.West 8mch or Boyds Cerner rriepvstd SST's within "3bU feet og'a:resemir, resexvoli° stem or controp9 lalae. ❑ Proposed SSTS within 200 Feet of a watercoasrse or a DEC wetland. ❑ Proposed SETS design flow greater than 1000 galions/day or $FIDES Permit required. ❑ Proposed SETS for it Commercial Project. It b the rraponsibfllty of the design professional to provide tip above eu ontatlon prior to soil testing. This jn,,pertment will determine the NYCDEP project status (Joint or Delegated) based on the response, U you answered yu to any of the gnestionih NTC.DEP most. witness the soil tests. This 1Departinent wd) 60ardi' ate a Trautm* suitable time for IieW fisting vwith the Design Professional and NYCDEP. If A project has been determined to be.Delepted boned on Obe above . response and then subsequent informadion indicates NYCDEP is required to wiUm the soil tests, it will be the sole responsibi8ity of the 4"" n prtofesiopal to schedule re-witnessiag of the soil testis with NYCDEP. FOR COY1M USE ONLY' DATE: MWTEST) MAY -9- 2005 . —MON 14:00 TEL:845- 278 -7921 NAME: PUTNAM COUNTY DEPARTMENT OF P. 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ; T u� ,rN I'V ' ; =� j RCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project 610�f,�-It7Z t' M01) Flfh�``�` �j�ti'� County Site Location Building construction begun Extent Is property within NYC Watershed?.. : .............. Q Yes No SECTIONS. TOPOGRAPHY (Please check all appropriate boxes) 1. -'Hilly, Rollin' olling Steep slope Gentle slope Flat ' 2. Q Evidence of wetlands Q Low area subject to flooding 0 Bodies of water. Drainage ditches Eg Rock qutcrops 3. Property lines or corners evident ....................... ............................... 'des No 4. 'Do water courses exist on or adjoin the.property? ............................ Yes a No 5: Will these affect the design of the sewage system facilities ?....... ...... Yes M.Nb 6. Do watershed regulations apply in this development ? ....................... Yes • ' No 7 Will extensive grading be necessary? ....... ......................... .,............:.. Yes No � 8. Will extensive fill be necessary for SSTS? ......... .................. <...........: - : -Do filled areas exist within the SSTS area? ........ ..........................:.... Yes . 1 No If yes, what is the condition of the fill? . SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: SandyG ravel l�1 Loam 0 Clay � Hardpan Q Mixture 11. Observed, from: a Borings a Bank cut. F' Backhoe excavations 12. Soil borings /excavations observed by _ 1510 an s�� `dam 13. Depth*to groundwater _ ,S on* 14. Depth'to mottling /WP- on 15. Are test holes representative of primary & reserve areas ...... ............ .................... Yes 0 No 16.. Soil percolation tests made by1r� °'''�` on 17. Soil percolation tests witnessed by ` G�' on . SECTION D (on back) Form ST -1 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter. the natural drainage in this or adjacent areas? Yes M140 19. Will groundwater or surface drainage require special consideration? ...1.'1005e, ::. E'Yes a No 20. Will gullies, ditches, etc:, be filled and watercourses be relocated ? .............. a Yes No SECTION E. REMARKS 21. If .a common water supply is proposed; has an inspection been made of the existing or proposed source and facilities ? .............. ..........:......... Yes No ..........., . .,,1 ' = Inspection data' 22. Do adjacent wells and/or sewage systems exist? . E;Z'Yes =.-No 23. Additional comments PC' �Aikn�1 c.� 5. o vt t� v✓f s .4vlt� a G�l.Cy1/��u�, 24. Site observer /inspector and title .A % 25. Date(s)-of observation(s)inspection(s) (i 4 'PEST PIT PROFILES Hole # i Lot # Hole # Q ' Lot # Hole # Lot # Depth to water p Depth to water � i�-� Depth tQ �statez. ;� -• .._�.- �� - -- - - -• : -:. •; . - � _ -: - =- mottling Depth to mottling Depth to rock/imp. �`f Depth to rock/imp. �� Depth to rock/imp... G.L. G.L. - V G.L. ._ I 0.5 .0.5 0.5 1.0 1.0. 1.0 - Z.o a.o l a53. ���� 2.0 3.0r 3.0 3.0 4.0 4.0 4.0 (V ..6.0 6.0 6.0 7.0 D79 .0 8.0 8.0 8.0 9.0 9.0 9.0 10.0. 10.0 10.0 �wWw ' 05/09/2005 13:56 '1026 PAGE 02/03 46 34.03 AC 4 18741 AC. 465,00 909,39 a&4 0. )1-39 SKY -40 64:AQ CAL.. 51 AC. dl 2 20.03 17 5,95 AC. CAL, 9.99 AC. CAL. 63 50 1p kcr-- .1 .8 52 1.06 A 7.35 AC. AC 54 -AQ 51 AC 2.63 AC CAL 14 4 12 2.67 A C. 11.2 AQ-' 10 CC) 28.86 AC. .1.0 1 - 0. A 11 5 48 1.13.. pb 7 t.36, .. Crb A, IN / 9 �' ,��.�'AC. 4 SAC. P R E N. ARY . . MAP, 62 SC A L E 400' r-NI MAY-9-2005 17--K I A A MON 14:01 \ I' A I I - r-A I TEL:845-278-7921 NAME:PUTNAM COUNTY DEPARTMENT f 10 Ah --6-10AC 4.1 6b.58 AC 05/09/2005 13:56 1026 T PAGE 03/03 licillill r• v O � Q ►v o , Y h Cep ' �`S ' _ •� �._ __ MAY -9 -2005 MON 14:01 TEL:845 -278 -7 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A#-WATER.WF�. - , ' �.AV.��. •'c'J1i'. YtYV � •.'�.'i<:I.••i:R•A.�'.t•.••.xY y,.. z...�._�: . print or type PCHD Permit # Well Location: S Street Address: T wn/Village Tax Grid # �EE �/CG urio✓ TAM/ (AZmUL Map 67, Block Lot(s) Well Owner: N Name: A Addresss -- G ' e Use of Well: R Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary B Business Farm Test/Monitoring Other (specify) 2- secondary I Industrial Institutional Standby Amount of Use Y Yield Sought S gpm # People Served .3 Est. of Daily Usage Z41510 gal. Reason for R Replace Existing Supply Test/observation Additional Supply Drilling N New Supply (new dwelling) Deepen Existing Well Detailed Reason A A/ &. ov 1*10•u,g' for Drilling Well Type D Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: OA094 -W AA4044 -f" Address: 6,fge -off r--. &at-A — LO�' Is Public Water Supply available to site? ................. Yes No Name of Public Water Supply: Town/Village -&-�,q lu Distance to property from nearest water main: Proposed well location & sources of contamination to a provided on separate sheet/plan. - Date:... _ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2. of Part 5 of the New York State Sanitary 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 ell ller c ified by Putnam County. Date of Issue Permit Iss ' 0 ial: Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 SHERLITA AIMILER, MD, MS, I'AAP . ► :.,..t> ..w (,'.' �'�iI!nlSS�np7cr.n�f'%�.�fllth� ., ... �. , . -'r= . <..�_,... LORETTA IMOLINARI, RN, IMSN Associate Commissioner of Health Stephen J. Ferreira 123 Washington Ridge Road New Milford, CT 06776 . Dear Mr. Greenberg: ROBERT J. BONDI - - x �. - • °County - recutive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 September 21, 2005 Re: Proposed SSTS: McCormack 551 Peekskill Hollow Road (T) Putnam Valley, TM # 62 -1 -54 Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. No cuts are allowed within 10 feet of the proposed SSTS. 2. Any cut that starts 10 feet from the SSTS must be at a slope of 3:1. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands effcials- in- this•reb -i.rd _ : � :._.� -... -- ----- Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:kly Ve ly yours, r' Robert Morris, P.E. Senior Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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