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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -4.2 BOX 24 I FINE .__ .�, C' mr ,1 ti �., j ; .� , ; ,' , IN , r ' .; .., IN 02787 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT GPS : 41' 22' 53.9 N 073049'23.9 W Well Location Street Address: 538 Peekskill Hollow Road Town/Village: Putnam Valley Tax Grid # Map 62. Block -2 Lot(s) -4.2 Well Owner: Name: Address: Ralph Adorno, P. 0. Box 637, Putnam Valley, NY 10579 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type— Screened Open end casing X Open hole in bedrock _ Other Casing Details Total length 31 ft. Length below grade 30 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner _ Yes -I- No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second 'b�.�c,a-s'relu'Tes- - - _ Daiaeu _ Fun pezi' i;:imlciesscii'Hir- �`__ - • : - HdRuPsi wpm - Depth Data Measure from land surface- static (specify ft) overflowing During yield test(ft) 440' Depth of completed well in feet 505' Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 15 Drillinq in over urden. clay. and boulders Hit rock at 15' 15 31 Dr ' 1 ' 31 505 Drilling in rock granite If yield was tested at different depths during drilling, list: Feet j . Gallons Per Minute Pump /Storage Tank Information 'ry Pump Type sub Capacity Depth 460' Model --S S Voltage 230 HP 1 Tank Type WX102 Volume 4.4 gallons ,�j:�; =' Date Well Completed 4/21/10 Putnam County Certification No. NYS #NYRD10105 Driller #019 Pump Ilst. #02 Date of Report 8/23/10 W Iler ature) � � 04111y iatt ew L. Beal n L) i h: txact location or well with aistances to at least two permanent lanamarxs to be proviaea on a separate snovpian. Well Driller's Name e_al &,ion Inc Address: 4 Pi A,TP $r!rstPr ,NY .?(?.... Signature:: /�� %t�fL��� Date: 8/23/j0 _it�am F- . i1atthew L. Beal White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller RECD OCT 21 2010 Form WC -97 DIVISION OF ENVIRONMENTAL HEALTH SEF CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT* PV- 01 -69 Located at 53$ Pff,9510 V- " *(,WW P-oA;D Town or Village WTN" Vf1'i L5V Owner /Applicant Name Rmptl ftow.Aro Tax Map 6 7, Block Lot y, z Formerly N461)00rLD Subdivision Name &r. 7p� Subd. Lot # I Mailing Address,,,. 556 - 559 ?mss K 1i_ Hi1L ,ow go,&] ' v0vAm Zip 1-0549 Date Construction Permit Issued by PCHD V/3 J-/09 1q(o CpRa ILL RvekQ Separate Sewerage System built by RN0 , /NC, Address YOml'euuw efiti Ts Consisting of �b ^_ Gallon Septic Tank and q0 Jf .p ✓C Apr- tN 2 �'' G2 v P,�✓cu Other.Requirements: 41 QEFP Cu R,Tpi N "Do-AIN Water Supply: Public Supply From Address UrA46TOOL or: X Private Supply Drilled by P, F. B fAt- 4 SotJ S Address jay 10 ,509 Building Type S lNhLF fftll,4 R6 Has erosion control been completed? U� Number of Bedrooms q Has garbage grinder I certify that the system(s), as listed, serving the ab built plans (copies of which are attached), in a or plans and the standards, rules and regulat' s o Date: 09L22holo Certified by (Design Address 2 JOKA/ vM4 H W LV p, . p,ucK [U_ /1/0 re con tially as shown on the as- ue� Con tru ion Permit and approved ' r P.E. X R.A. ti . ,.. ,JFE�T;`icense # uozuo 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 r e pwd ah,,m odific n fhange is necessary. �-° y /�'l"��,rt✓- ,� ��',�I itle: o �'��� Date: e� VbVai'e copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 Sherlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE Director of Environmental Health October 20, 2010 Department of Health 1 Geneva Road, Brewster, NY 10509 Office (845) 808 -1390 Fax (845) 808 -1937 Timothy Cronin, PE The Lindy Building, Ste 200 2 John Walsh Blvd. Peekskill, NY 10566 Re: Field Inspection — Adorno 538 Peekskill Hollow Road (T) Putnam Valley, TM # 62. -2 -4.2 Dear Mr. Cronin: Robert J. Bondi County Executive A re- inspection at the above referenced lot has been completed; there are no further comments to be addressed at this time in reference to this Department open work inspection. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, , Q,-,: 9., -b , -� z 4 Gene D. Reed Sr. Environmental Health Engineering Aide GDR:kly RONIN ENGINEERING, PE, PC The Lindy Building, Suite 200, 2 John Walsh Boulevard, Peekskill, New York 10566 Tel.: 914- 736 -3664 9 Fax: 914 - 736 -3693 September 28, 2010 Mr. Joseph Paravati, P.E. Assistant Public Health Engineer Putnam County Health Department 1 Geneva Road Brewster, New York 10509 VIA HAND DELIVERY Re: Ralph Adorno Certificate of Construction Compliance 4 Bedroom Residence 238 Peekskill Hollow Road Town of Putnam Valley, New York 90579 Section: 6200, B lock., 2, Lot: 4.2 aMLI Pam .. — - - -- - . .. - - -- • -- - - - -. e.... r r �. f, i1 i fir. � v- sib -v✓`` - - Dear Mr. Paravati, Enclosed for your review and approval please find the following items regarding the application for a Certificate of Construction Compliance at the above referenced project: 1. One (1) Certified Check in the amount of $300 made payable to the Putnam County Health Department. I 2. Three (3) Copies of a two (2) year guarantee signed by the Owner & the Installer 3. Four (4) Well Completion Reports signed by Matthew Beal (The Well Driller) 4. One (1) Copy of Satisfactory Results of a Water Analysis by a NYSDOH Approved Laboratory. 5. One (1) E911 Address Verification Form 6. Four (4) Certificates of Construction Compliance 7. Four (4) Sets of "As- Built" Plans signed and sealed by the Design Professional. 8. One (1) Copy of As -Built Foundation Survey by Baxter Land Surveying. Please review the above items at your earliest convenience and should you have any questions or require additional information, please do not hesitate in contacting me at the number above. Respectfully Submitted, J Teed Project Engineer cc: Ralph Adomo- Owner File- Paravati- Adomo- Peekskill Hollow RoadSSTS- As- Built- Trans- JT- 20100928.doc PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT GPS : 41' 22' 53.9 N 073'49'23.9 W Well Location Street Address: 538 Peekskill Hollow Road Town/Village: Putnam Valley IMap62. Tax Grid # Block -2 Lot(s) -4.2 Well Owner: Name: Address: Ralph Adorno, P. 0. Box 637, Putnam Valley, NY 10579 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type'- Screened Open end casing X Open hole in bedrock Other L" Casing Details Total length 31 ft. Length below grade 30 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes —No I Liner: Yes _X_ No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second V� 7 �1•_t T .. .... -.. r.►�tla.Vl.lrr(1'i+�5$ .•.- ..T....'1... l.. �....[!. -T -.. ... - TT._....!1 .�.,' -'neitr�i . _ nYuiu�Stfi:,` "'a l.VSILFIIGJ�GQ-tl11, - - S:1ll1S -(1 "� '-1 1GSa1 •G�!" �Si.l1i"' -:•'! Depth Data Measure from land surface- static (specify ft) overflowing During yield test(ft) 440' Depth of completed well in feet 505' Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 15 Drilling in over r Hit rock at 15' 15 31 Dril 31. 505 Drilling in rock Rranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 10.q-,m. Depth 460' Model 10GS'> 5 Voltage 230 HP 1 1 Tank Type WX102 Volume 4.4 gallons Date Well Completed 4/21/10 Putnam County Certification No. NYS #NYRD10105 Driller #019 Pump I..st. #02 Date of Report 8/23/10 er stun ) tit. - L. Beal NOTE: Exact location or well with distances to at least two permanent lanamarKs to De proviaea on a separate sricrupian. Well Driller's Name E.-Peal & on In Signature: Matthew L. Beal Address: 4 Putnam Ave Brewster NY 1 Q5()9 Date: 8/23/10 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM R OWNERS NAME: Ralph Adorno Section: 62. 00, Block: Lot: 4.2 E911 ADDRESS: 538 Peekskill Hollow Road TOWN: Putnam Valley_ AUTHORIZED TOWN OFFICIAL: �X / (Signature) DATE: , Lav'l 6 The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificatc of Construction Compliance. ,. (E91 I verfrm) • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Ralph Adorno 62 2 4.2 Owner or Purchaser of Building Ralph Adorno Building Constructed by 538 Peekskill Hollow Road Location - Street Single Family Residence Tax Map Block Lot Putnam Valley TownNillage Ralph Adorno Subdivision Name 1 Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, �n ctjCt;nn,a1A dra.inagP -_Qh sewag }rP.�ti;lf![lf_¢VCtPt1f1, CPI VI lO, t} I_ P.. ay ]�1VP._t�PSr�IhP[�.r1[lpP�[1( ,ATIt� 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 oc system. Dated: Ye a�W Signati (Owner) - Signature Corporation Name (if corporation) Title: Corporation Name (if corporation) Address: f WW#4L Address: Y eR� ` n � State '• Zip � . .. _ ........ State Zip Form GS -97 imsEuvlronrnarrfal Services, Inc. t'iATER. S!.JiL AND AJG iNAI.Y:?J':• A P F Bey Mailing Information: Name: P F Beal and Sons Inc Address: 4 Putnam Avenue City: Brewster State: NY Zip: 10509 Phone: (845) 279 -2460 Fax: (845) 279 Sample's Information: Site: Kitchen Tap Preservative: N/A Temperature: 6.0° C Matrix: Water Page 1 of 2, 41 Kenosia Avenue Danbury. Connecticut 06810 1 Telaphons 203 -798 -2229 it and Sons Inc: Troy Adorno Collector's Information: JMS ID: 096395 Name: Charlie Address of site: 538 Peekskill Hollow Road_ City: Putnam Valley State: NY Zip: 6613 Phone: Sample ID: 1 Date Collected: 9/15/2010 Time Collected: 4:15:00 PM Date Analyzed Test Name 09/21/10 Iron *0.349 mg /L . Viangariese: _.._•_- 09/21/10 Sodium 09/16/10 4:00 PM E. Coli 09/16/10 4:00 PM Total Coliform 09/17/10 Lead 09/16/10 Color 09/16/10 Turbidity 09/16/10 Odor 09/22/10 Alkalinity 09/22/10 Hardness 09/21/10 Chloride 09/17/10 Nitrate 09/17/10 Nitrite 09/17/10 Sulfate 09/16/10 pH Date Received: 9/16/2010 Time Received: 3:30:00 PM Lab No.: J1006904 Result MCL Method *0.349 mg /L . 0.3 mg /L 200.7 Rev. 4.4 - 20i�.-7-Re'v: _...,......�- 36.4 mg /L N/A 200.7 Rev. 4.4 Absent Absent Colitag Absent Absent Colitag 2.08 ppb 15 ppb E 200.7 ND SMWW 2120 B 0.61 NTU 5 NTU SMWW 2130 B ND 3 TON SMWW 2150 B 50 mg /L N/A SMWW 2320 B 90 mg /L N/A SMWW 2340 C 60.4 mg /L 250 mg /L SMWW 4110 B 0.17 mg /L 10 mg /L SMWW 4110 B <0.05 mg /L 1 mg /L SMWW 4110 B 12.6 mg /L 250 mg /L SMWW 4110 B 7.89 S. U. 6.4 -10 S.U. SMWW 4500 H B Comments: *ABOVE MCL At the time of the analysis t rie sample was Acceptable for Total Coliform At the time of the analysis t rie sample was Acceptable for E. Coli pH was received and analyzed after the EPA required 1 hour holding time. CFU = Coliform Forming Units M L = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable N = None Detected . _ NTU = Nephelopmetric Turbidity Unit ppb = parts per billion S. . = Standard Unit TON = Threshold Odor Number Units = Units - Tall Free 666 -:JFaS -5097 I Coil:-:rate F X 2031-79B -2408 I Lab FiX 203 -`798 -2107 1 w,a a.jmsen�irc,nrr�ntal.o��i A .o , Page 2 of 2 favironmenta! Services, Inc. 41 Kenosia Avenu9' e�j tV JFA, ^rJ(L AtJCi ,414 Ah' t Y ;'> Danbury. COnlleCtlCUt 08810 1 Telephone 203 -798 -2229 P F Bea I and Sons Inc: Troy Adorno Mailing Information: Collector's Information: JMS ID: 096395 Name: P F Beal and Sons Inc Name: Charlie Address: 4 Putnam Avenue Address of site: 538 Peekskill Hollow Road City: Brewster City: Putnam Valley State: NY Zip: 10509 State: NY Zip: Phone: (845) 279 -2460 Fax: (845) 279 6613 Phone: Sample's Information: Site: Kitchen Tap Preservative: N/A Temperature: 6.0° C Matrix: Water Michael E prriarr- President . Sample ID: 1 Date C Ilected: 9/15/2010 Time C Ilected: 4:15:00 PM Date Received: 9/16/2010 Time Received: 3:30:00 PM Lab No.: J1006904 Reviewed By: Michael Lapman,:- State #: PH -0218 ELAP #: 11715 T611 Free 866 -JMS -5097 1 Corte -rate x 203 798 2308 1 L.3b Fax 203 798 -2107 1 w•.vv.jmsenuironrr- ntaLccm Sherlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE Director of Environmental Health April 28, 2010 Timothy Cronin, PE The Lindy Building, Ste 200 2 John Walsh Blvd. Peekskill, NY 10566 Department of Health 1 Geneva Road, Brewster, NY 10509 Robert J. Bondi County Executive Re: Field Inspection — Adorno 538 Peekskill Hollow Road (T) Putnam Valley, TM # 62. -2 -4.2 Dear Mr. Cronin: The above referenced separate sewage treatment system can be backfilled. The following comment needs to be addressed. e An extra room was added to the second floor of which is not shown on the approved floor plans. This room is considered a potential bedroom giving the house a bedroom count of five (5). If you have any further questions, please contact me at (845) 278 -6130, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:kly — - avironmenWl"rlealtb Water Supply Section (845) 225 -5186 Fax (845.),225-5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing / Home Care Agency (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 '10 -04 -22 11:57 FROM- T -742 P0001/0001 F -421 FA,x io Oq5) Zq8 —'921 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION J,JOSEPH ENE MUEST F_ OR FINAL INSPECTION For fill _ All :information must be fully completed prior to any Trenches inspections being made. PCHD Construe 'on Permit # 1 U t7J.— 019 Located: �53� t AX ILG KOc�t.M &W -- 0 �� Owner /Applicant Name: M 09&Q TM Z Block 2 of Z Formerly: Rofg Mft!: -MyMn Subdivision Name: h GWv'D Subdivision Lot #, Is system fill completed? Date: A _ Is ssystem com l! � Date: 26 ip I5 5ys'ieta CoIlstrltCted as I3g+rgia�ls'1 •.P/ y.. _.. __..._. __.__. _.... .. -- - __ . Is well drilled? DIES Date: iL Is well located as per pl s? _ ves _ iAut erosion control measures in lace? T certify that the system(s), as listed, at the above premi� ' art' .. and I have inspected and verified their cornpletion in acecyrdance with two ', d <P, I4�� o�� ction Permit and approved plans and the Standards, Mules and Regu�iyo `o##,,ttaa ty Department of Health, Date. 117- ! Certified by: ` "°: o • —81-4 4° +� F'�' l PE RA �1?lG1 es U�� /y 1 Y! ` �f: Address: Comments: CCU, 1 l Q rL - q('04 nvoo . Pittuv' -76 - - - -- Form FIR -99 Atll�C�� P,r S,1 T ti V %'yr. %© X�W'cv rl , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES //iq —0/z FINAL SITE INSPECTION Date- 2 Vro Inspected by: Street Locationir319 Owner AV_0r%"%_4? Town Permit #* PV�1—e q TM Subdivision Lot 1. Sewaze System Area a. STS area located as * er approved plans .......... p ................. h. 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 ................................... .n Sewage Svstem a. Septic tank size.- I,000....,..(__1,,2591 .........other ................. b. S eptic'tank installed level .............................................. c. 10' minimum from foundation ............................. d. Distribution Box 1. All outlets at same elevation-watertested ................ 2. Protected below frost .................................................. 3. -, Nlinimurn 2 ft. Original soil between box & trenches e. Junction Box '- pro.perly set ...................... .................. 6. Trenches 7 7., . 2. Distance to watercourse m'-easured -�- ie P . OFt .......... 3. Installed according to plan ........................................ .4, Slope of trench acceptable 1116 - 1/32"/foot .............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6., Depth of trench <30 inches from surfice ................. 7. "Room allowed for expansion, 100% ........ .......... S.. Size of gravel 3/4 7 VA" diameter clean ........ 9. Depth of gravel in trench 12" minimum ........ 10. Pipe ends capped ........................................................ g. Pump or Dosed Systems 1. Size of pump chamber ................................................. ,2. Overflow tank ......... — ............. : .................................. 3. Alarm, visual/audio ................................................... 4. Pump easily accessible, manhole to grade........ :........ .. 5. Firk box baffled ............................ '�W�c ........... 6. Cycle witnessed by, H.D.estimated DI Elouse/Buildiiia !'a a. House located erapproved plam ..... b. Number of bedrooms.... oomq ...... 4�..:131 IV. Well i� -4 * ..... ***'- Wei located as per approved P, Distance from STS area measured ft......... c. Casing, IS" above grade ................................................ d. Surface drainage around well acceptable ...... * .................. V. Overall Workmanship a. Boxes properly grouted .................................................. b. All pipes partially backfilled .......................................... c. All pipes flush with inside of box ................................... d. Backfffl material contains stones <4" diameter .............. "1115 f, Curtain drain outfall protected & dir.to exist waterco e g. Footing drains discharge away from STS area ..............• h. Surface water protection adequate ..................................... i. Erosion control Vided ................................................ Rev. E/002 NO' COMMENTS orin a i - e- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Ai)c)(_ Located at S ll.�oi, VJ0 QV POTNOm k)PiLN Tax Map # 62. Block 2- Lot . Z Subdivision of M 197,j)0N!q7 Subdivision Lot # Filed Map # D� Date-Filed. AP911, ZZr 2a7- Gentlemen: I his letier is to aut%ior�ze 1 "� %lit (�, �2-vi l ( Pd - �• � _ -_ a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules 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 Pn rvise the , ction of said wastewater treatment and/or eater supply systems in conformity e obis Ew cle 145 and/or 147 of the Education Law, the Public Health Law, and th ct e . Countersigne "d.�� P.E., R.A., # g80 Mailing Address 2,,,)o/H N U/ft4H 6 State Zip Telephone: o d��310 — y Very.tru Signed: Mailing Address: 5556 —Sr, -B *Pff6CSk tq- k°q.ow R orr0, State. A/1 Zip Sq� Telephone: Form LA -97 l D , COUNTY NAM DEPARTMENT , DIVISION OF ENVIRONMENTAL HEALTH SE -E, CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYST _ ~J PERMIT # rP\� ^ C) 'C)f - Located at I Ef K9 K 0 L4, kf vu," /I` own or V illage ��1� 1. Subdivision name M oPJ Subd. Lot # Tax Map 4 2- Block . Lot y® Date Subdivision Approved AML ,12 �9 Owner /Applicant Name ADd &A Renewal Revision X_ Date of Previous Approval algAx Mailing Address 566 - 55? ?_FSj AQ LA- (?®Kaw P90, X-MOT Y&1Fj41M( Zip Amount of Fee Enclosed Zbo ° 00 Building Type s B t1�i,�� Lot Area a U& 1 No. of Bedrooms Design Flow GPD 200 A i - I- _ Fill Section Only Depth Volume Separate Sewerage System to consist of 12so gallon septic tank and q05 z°1C;. y01= Other Requirements: 7' PP,67 Cott -Tr44 & To be constructed by -rf f r -P_ Address Water Supply: Public Supply From Address or:— Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment 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 ipn tion any part of said sewage treatment system during the period of two (2) years immediately fo w . e ce of the approval of the Certificate of Construction Compliance of the original system or an e it �• o Signed: f P.E. R.A. Date 08/3 1 �_ Address i Z 40krJ License # ®(o 29 62980 k.: 3��D. W160fki1A,N%4 �(,� APPROVED FOR This approval expires two years from the date issued unless construction of the sewage treatment system mpleted 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 _ �; ii it a iiew li. Appro '•d lscharge 61, do es sanitary Sewage drily: i y: rT Title: 4VT Date: APID e copy - HD File; Yellow copy - Budding Inspector; Pink copy - Owner; Or ge copy - Design Pro essional F rm CP -97 311 1. PUTNAM COUNTY DEPARTMENT OF HEALTH OF ENVIRONMENTAL HEALTH SERVK CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # -- Located at PF-F Sii 1LL dquo aJ RoAp Subdivision name MACDeWALD Subd. Lot # Date Subdivision Approved if R jV 121 200r4- Owner/Applicant Name 0115QT PpN4LD To or Village RJTAft VALLF-V Tax Map QZ Block ,Z Lot . Z Renewal Revision Date of Previous Approval Mailing Address 521 ?F_ €KCKia— f1buao ROAD , PO7NAM. VALLr y . IV U Zip O$ Amount of Fee Enclosed ;'S0O • o0 Building Type S'iN fNmtt.v Lot Area3.Zo(,,LNo. of Bedrooms Design Flow GPD $00 Res io om 4c Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: gallon septic tank and To be constructed by T, 8, V, Address Water Supply: Public Supply From Address or: X Private Supply Drilled by 7 ; At Do Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment 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 pliagQe . Ysfactory to the Public Health Director will be submitted to the Department, and a written guarant d} e, rn 'th6'�wner, his successors, heirs or assigns by the builder, that said builder will place in 93 0"0 eratin co 'on any pkt� 044 sa i, sewage treatment system during the period of two (2) years immediately folloy,i g the date of ; e ' skiancFie appro''�al f the Certificate of Construction Compliance of the original system or any r aus ereto. 3 ' Signed: T E. X- R.A. Date Cic? Address CRavN fij"jj 8jj& License # 062.92-0. APPROVED FOR CONSTRUCTION: This approval expires�tvk years trom, the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires .,... %.- a new perinit. Approved for dis-chargc o dorie��i- 3c.►:aa:;% By `'" Title: Date: ite opy - HD File; Yellow copy - Buildi g 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 Well Location Street Address: 112f pillage: Tax Map # It '%D t`// a4j Map Block 2_ Lot(s) Z Well Owner: Name: Address: Phona ®r 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___ JIF_gpm #People Served Est. of Daily usage ®O gal. Replace Existing Supply Test/Observation Additional Supply Reason for DrillingNew 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 Weil locatto m a realty subclsvts: nn^ .....................:..........:......:.., .....:....;: °.:................ _...... Name of subdivision ROSE91 MAOIDN&P Lot No. , Address: Water Well Contractor: 9 . is, V'-' Is Public Water Supply available on site? ....................................... ...................:........... Yes No Name of Public Water Supply: M& Town/Village ---- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: .24,2 Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. 4y�Tl e�welhdnller shall de a.l cond ons oh,e - .l l':e�_.r_. rn it::.. .... lwzdrwcs in�.g` „so .. erations;therwell drillershall take appropriate action to assure that any and all water and waste products from such well udrilling 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 Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue Permit Issuing Offici Date of. Expiration r 1 Title: Permit is Non- Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health May 29, 2009 James W. Teed, Jr. Cronin Engineering, PE 2 John Walsh Blvd. Peekskill, NY 10566 DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health .. •:,. Ke•. 1':oT OSC(! Jil 1 S - 1V18�1JWJdSl �_.•. - . ..._... ... _ .. - -- ..,. _ __..� ,......e -. Peekskill Hollow Rd (T) Putnam Valley, TM # 62 -2 -4,2 Dear Mr. Teed: 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 NYSDEC. Validation Block is to be signed by a representative of the NYSDEC and the surveyor or engineer. 2. The proposed floor plans contain 6 potential bedrooms (walk -in- closet, and two bedrooms for . bedroom # 2). 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. Very truly yours,. (:C%+'�.cu oseph S. Paravati, Jr. Assistant Public Health Engineer JSP/kly _. .... _:. Erivironinentai Healtn:'(845) 27&-6 30:-FaX'(b45 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention /Preschool (845) 228 -2847 Fax (845) 225 -1580 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health March 9, 2009 James W. Teed, Jr. Cronin Engineering, PE 2 John Walsh Blvd. Peekskill, NY 10566 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT.MORRIS, PE Director of Environmental Health Re: Proposed SSTS — MacDonald Peekskill Hollow Rd (T) Putnam Valley, TM # 62 -2 -4.2 _a. Dear Mr. Teed: - 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. House plans submitted show a total of six (6) potential bedrooms. The proposed bonus room . and the walk -in- closet are considered potential bedrooms. 2. In the absorption trench detail, please note the trench gravel as 3 /4" to 11/:2" clean, dust free, crushed stone or washed gravel. 3. The curtain drain is to be extended to ensure complete coverage of the SSTS area. 4. Basement floor plans are to be provided. 5. The NYSDEC validation block is to.be provided on the plan. 6. The NYSDEC permit has expired. A valid, permit is to be provided. 7. Please verify the tax map number, specifically, the lot number of 4.2. 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. v ry truly' yours, oseph S. Paravati, Jr: Assistant. Public Health Engineer . JSP /kly - c ; ^-7e ,r,.. (ode. :ant <irJnmeseial`Nest„ •34.)r., - ;;1?0._ �.. 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 RONIN ENGINEERING, PE, PC The Lindy Building, Suite 200, 2 John Walsh Boulevard, Peekskill, New York 10566 Tel.: 914 - 736 -3664 • Fax: 914 - 736 -3693 April 13, 2009 Mr. Joseph Paravati Assistant Public Health Engineer Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: MacDonald Subdivision SSTS Construction Permit Revision 1 Peekskill Hollow Road Lot 1 Town of Putnam Valley, New York Section: 62.00, Block. 2, Lot: 4.2 .. __r �..._. Dear Mr:=F�arva` . Pursuant of your comment letter dated March 9, 2009, please find enclosed the following regarding an application for a Subsurface Sewage Treatment Construction Permit Renewal at the above referenced lot: 1. Four (4) Subsurface Sewage Treatment System Construction Permit Plan sets for the above referenced lot. 2. Three (3) Sets of proposed House plans for the above referenced lot. 3. One (1) NYSDEC Wetland Permit Extension for the above referenced location. The following comments have been addressed from your.letter: 1. The house plans have been changed for bedroom count compliance perthe PCDH Rules and Regulations. 2. The absorption trench detail has been altered to correctly denote the proper aggregate. 3. The curtain drain has been extended to ensure complete coverage of the SSTS area. 4. Basement floor plans are now provided 5. The NYSDEC Validation Block is now on the plan. 6. The NYSDEC Permit Extension is included with this letter. 7. The tax map number is correct. Should you have any questions or require additional information, please do not hesitate in contacting me at the number above. Respectful) Submitted, C_L Teed, Jr. r c Engineer cc: Owner- Robert MacDonald File- PCHD - MacDonald - Peekskill Hollow Road -Lot 1- Rev- Trans-JT- 20090513.doc /f c RONIN ENGINEERING, PE, PAC L The Lindy Building, Suite 200, 2 John Walsh Boulevard, Peekskill, New York 10566 Tel.: 914- 736 -3664 Fax: 914 - 736 -3693 February 10, 2009 Mr. Joseph Paravati Assistant Public Health Engineer Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: MacDonald Subdivision SSTS Construction Permit Peekskill Hollow Road- Lot 1 " Town of Putnam Valley, New York Section: 62.00, Block. 2, Lot. 4.2 Dear Mr. Paravati; Please find enclosed the following regarding an application for a Subsurface Sewage Treatment Construction Permit Renewal at the above referenced lot: - -� 1. One (1) Letter of Authorization authorizing Cronin Engineering P.E., P:C. to apply for a construction permit at the above referenced lot. 'at 2. One (1) Certified check for $500 made payable to the Putnam County Health Department on behalf of the above referenced application 3. One (1) Subsurface Sewage Treatment System Construction Permit Plan set for the above referenced lot. 4. Four (4) Subsurface Sewage Treatment System Construction Permit Applications for the above referenced lot. 5. Four (4) Applications to Construct a Water Well for the above referenced lot. 6. One (1) Application for Approval of Plans for a Wastewater Treatment System 7. One (1) NYSDEC SEQR Short Environmental Assessment Form. 8. One (1) Design Data Sheet r- 9. Three (3) Sets of proposed House plans for the above referenced lot. 10. One (1) PCDH Certificate of Approval of Realty Subdivision Plans Signed by Robert Morris, PE. 11. One (1) NYSDEC Wetland Permit Approval for the above referenced location. 12. One (1) Wetland Permit Modification Letter Should you have any questions or require additional information, please do not hesitate in contacting me at the number above. F Respectfully Submitted, = Teed, Jr. roject Engineer cc: "Owner- Robert MacDonald _ - - r- 1 File- PCHD - MacDonald - Peekskill Hollow Road -Lot 1- Trans- JT- 200900210.doc PUTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: , A L A J�:(� STREET LOCATION: REVIEWED.BY: RK )JSr', SRDATE: �Tn'±��07 TAX MAPS: (CONrIRIv1ED) Z Y N DOCUMENTS Y ,' N (REQUIRED DETAILS ON PLANS CONT'Dl L)PERMIT APPLICATION ( UHOUSE SEWER. V7 FT. 4 "0'; TYPE PIPE. CAST IRON (_WELL PERMIT OR PR'S LETTER UUNO BENDS; MAX BENDS 4T W /CLEANOUT RENEWALS 9(_rLETTER OF AUTHORIZATION SITE NOTE (NO CHANGE) �(_DE5IGN DATA SHEET (DDS) FILL SYSTEMS �(_CORPORATE RESOLUTION t 10' HORIZONTAL; PAST TRENCH SLOPES' 3:1 TO GRADE L_)SHORT FAF : (s FILL SPECS/ FILL NOTES 1 -5 PLANS -THREE SETS FILL PROFILE & DIMENSIONS . HOUSE PL�,NS - TWO SETS /Z ✓nL y'' ( U, ILL IN EXPANSION AREA VARIANCE REQUEST �wP-f fG xc� �<' "�7rtC1C'� FILL GREATER TSANlrEET SUBDIVISION ( CLAY BARRIER _: _LEGAL SUBDIVISION � FILL'CERTIFICATION NOTE __)_SUBD'IVZSIONi APPROVAL CHECKED DEPTH GAUGES __)(_PERC RATE � /V ' VOL. ON PLAN FOR R.O.B., tJNCLASSIFIED & IMPERVIOUS _1(_)FTI,I, REntJIIi•ED__ - -_. _. DEPTH ,/f ' _ .crP.�T�AT_Inwr �,TC �A�T .gn CY ^� -'1= - ^_-F .SLOPE.. _ .. _}(_CUR- fA.R`iD7I-U INRLQU!i D "" TRE1VCg...' .. " GENERAL LF TRENCHPROVIDED 60FT MAX. )L ..CATED .IN NYC WATERSHED (PARALLEL . TO CONTOURS 2 LANS SUBMITTED TO DEP r / 100% EXPANSION PROVIDED DELEGATED TO PCHD ' �' ETAdiJDUST FREE CRUSHED'STONE OR WASHED GRAVEL EP APPROVAL; IF RE 'D i�✓4__ �D Q )GEOTEXTILE COVER (_}DEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN : FROM'SSTS / J PERCS TO BE WITNESSED 1 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL U �( JLX- 4PPROVAL SSDS ADJ, LOTS ; il.�. ( � J20' TO FOUNDATION WALLS WETLANDS {TOWN/DEC PERMIT REQ'D ? }�s��` 0100' TO WELL, 200' IN'DLOD,150' TQ MS �.�'� ATA ONDDS-PLANS & PERMIT SAME �L�100' TO STREAM, WATERCOURSE, LAI:M•(inc. ezpati). �6( ✓PRE 1969 NEIGHBOR NOTIFICATION ° 5c'' �j50' TO CATCH BASIN, 35'.STC+RMDRAIN, PIPED WAXER Z LETTER. BMAL C k )10' TO WATERLINE (pits .201) ��' A,00 YR FLOOD ELEVATION W1I 200'' (�f,)50�, DRAINAGE COU1tSE, jsOm:MSTING LOTS>10 YEARS OLD ✓ �` "— X200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS '! RE4UIRED .DETAILS ON PLANS : C- 11_J10' MIN TO LEDGE OUTCROP r( )SEWAGE SYSTEM PLAX� (NORTH ARROW) SEPTIC TANK !�HGRAVITYFLO*r SSDS HYDRAULIC PROFILE _�( 10' FROM FOUNDA -TION; 50' TO WELL WELL ILCONSTRUCTIONNOTES1 -15 (_ /�• ,IDIMENSIONSTO PROPERTY LINES ;DESIGN DATA: PERC &DEEP RESULTS LOCATION OF SERVICE CONNECTION �Z' CONTOURS EXISTING &PROPOSED Lt 15! TO'PROPERTY LINE DRIVEWAY & SLOPES, CUT ,SLOPE // FOOTING /GUTTERICURTA NDRA YS U� OPT; IN SSTS AREA USDA SOIL TYPE BOUNDARIES t /)REGRADED TO 15 %, tv REQUIRED (-)TITLE BLOCK; OWNERS NAME ADDRESS DOSE/PUMP SYSTEMS TM#, PE/RA; NAME, ADDRESS, PHONE# i PUMP NOTES . DATE OF DRAWING/REVISION DOSE 75% OF PIPE VOLUMFJD.OSE VOLUME NOTED lY - )DATUM REFERENCE , DETA L FOR FORCE:MA N, (PIPE TYPE, ETC -) �/L__.)LOCATION OF WALTERCOURSES, PONDS U LAKES,WETLAI`IDS WITHIN Z00' OF P.L. (,PIT AND D -BOX SHOWN & DETA,II.ED �UPROPOSED FINISH FLOOR AND t ` ► ; 1 DAY STORAGE ABOVE ALARM BASEMENT ELEVATIONS 7n nCURTAIlr DRAIN �it� iz1 C7� rr�J�T sbsiS WIN i @0' OF SS S M]N to CDS —>5 %, i0' -4 %, 25' -3 %, 35' -1 %,100 % -<1 %• � PROPERTY METES & BOUNDS — � kc-w �0' MIN to CD DISCHARGE/100' with 182 cons day discharge EROSION CONTROL FOTt:HOUSE, WELL & )10' MIN to NON - PERFORATED PIPE SSTS, EROSION CONTROL NOTE NZIENTS: -- -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Robert MacDonald Located at Peekskill Hollow Road m v Putnam Valley Tax Map # 62 Block 2 Lot 4.2 Subdivision of Robert MacDonald Subdivision Lot # 1 Filed Map # 3046 Date Filed April 12, 2007 Gentlemen: This letter is to authorize Timothy L. Cronin III, P.E. a duly licensed Professional Engineer I ✓ I 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 . gohiF4 ,of said wastewater tretment and /or water supply systems in conformity with the�p�avtsfns o icy 145 and/or 147 of the Education Law, the Public Health Law, and the Putna�r�'ililty Start' ddb. Countersign P.E., R.A., h Mailing Address Cronin Engineering P.E., P.C. 2 John Walsh Boulevard, Peekskill State New York Zip 10566 Telephone: (914) 736 -3664 Very truly yours, Signed: r (Owner of Property) Mailing Address: 527 Peekskill Hollow Road Putnam Valley State New York Zip 10579 Telephone: F V'57- '5 �2 CT - go 7 Ce-il : q l V- q6 -0- 07 K 2 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Robert MacDonald 2. 4. 6. 7. 9. 10. 11. 527 Peekskill Hollow Road Putnam Valley, New York 10579 Name of Project: MacDonald- Lot 1 Design Professional: Timothy L. Cronin III Drainage Basin: Peekskill Hollow Brook Type of Project: 3. Location: T/V: Putnam Valley 5. Address: 2 John Walsh Boulevard Peekskill, New York 10566 ✓ Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial Mobile Home Park Other (specify) Isjhis project subiect_to State. Environmental. nuality Review (SEQ.R)2.............. Yes/.No . No YP ( one)..'.'.*..* ...... ............. .... ....... Type I Kxempt Type Status check one ....�. ...... ...... Type e II Unlisted Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/No No Has DEIS been completed and found acceptable by Lead Agency? Name of Lead Agency Not Applicable Yes/No N/A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............................................................. ............................... Yes/No Yes 13. If so, have plans been submitted to such authorities? .. ............................... Yes/No Yes 14. Has preliminary approval been granted by such authorities? Yes Date granted: August 2006 15. Type of sewage treatment system discharge ........................ surface water ✓ groundwater 16. If surface water discharge, what is the stream class designation? .......................... N/A 17. Waters index number (surface) ............................................. ............................... N/A 18. 19. 20. 21. 22. Is project located near a public water supply system? Yes/No None If yes, name of water supply Not Applicable Distance to water supply N/A Is project site near a public sewage collection or treatment system? .......... Yes/No None Name of sewage system Not Applicable Distance to sewage system N/A Date test holes observed 07 -07 -2005 23. Name of Health Inspector Joe Paravati 24. Project design flow (gallons per day) ............................. ............................... 25. Is State Pollutant Discharge Elimination system (SPDES) Permit required? 2.5 Ar�F Av ! r t;� .h��.;.�4>, rya �1 77'��rn offfi . :,a:J' '[. � t J.�?a... w7r5.1!. 1 .... •.1 7!4. ....J IY�. - :li'lJ�.: :..l i( e: ... e ...... ... ........ Rev. 11/02 uuu t.ru Yes/No No Form PC -97 Pg. 1 of 2 V M1 27. Is any portion of this project located within a designated Town or State wetland ?... Yes/No Yes State 28. Wetlands ID number ............ OL -72 ...................................................... ............................... 29. Is Wetlands Permit required? ...................................... ............................... Yes/No Yes Has application been made to Town or Local DEC ........................... Yes/No Yes 30. Does project require a DEC Stream Disturbance Permit? .... .........................Yes/No No 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 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 No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .........................Yes/No Yes 34. Are community water and /or sewer facilities planned to be developed within 15 years in or adjacent to project site? .................................. .........................Yes/No No 35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No No 36. Tax Map ID Number p 62.00 2 L 4.2 .............. ............................... Ma Block Lot 37. Approved plans are to be returned to ................ Applicant * 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 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 bow i_rl�Item 1, the application must be .- F.� , accompanied by a Letter of Authorization (Form LA -97). j�ai i► b i��-dbrt w. ith this provision may be grounds for the rejection of any submission.`i' I hereby affirm, under penalty of perjury, t my knowledge and belief. False statements pursuant to Section 210.45 of the Penal La SIGNATURES & OFFICIAL TITLES: Mailing Address:..... Timothy L. Q ...... Cronin Engine 2 John Walsh s form is true to the best of a Class A misdemeanor /' !` Cj Peekskill, NY Form PC -97 L, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner I' A&4.GDAjAt_jS Address svi nm-y�61�iLt_ tbLLow c"b vTt4AM y Located at (Street) p�eY-5y.La- Ebu.,gw TLo M) Tax Map (,,Z- Block Z Lot , 2 wt�GG�, ' (indicate nearest cross street) /2bate' ' ality QtrC�vArn ykw,6t Drainage Basin _>'�5kLL UtUoW SOIL PERCOLAT ION TEST DATA Pre-soaking 05 -$1.0 57 Date of Percolation .Test 0(o - v 0 5 Hole No. Run No. r to 1 2 3 4 Percolation Rate itilin/Inch 3 Z+ 5 Zg" 2 lbw' I I C", 3 1101- 1 116 l� ,�� 7,0 4 5 1 2 3 - 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each :.. , ,.:.. .......:.._.... „,��.� _ .. -t i .e- t hQi a . I rill_i =o�.._ : ✓:✓ r ilii _�'. -� L'l.11 .�1. Uc - 51 submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Dei1th to Water Water From Ground Level Time Start Stop Ela se Time Surface (Inches) Start Stop Drop.In Inches - (p1lin.) .c 56_ 1 oS woo 11 1-7 l- 7 7-0 Percolation Rate itilin/Inch 3 Z+ 5 Zg" 2 lbw' I I C", 3 1101- 1 116 l� ,�� 7,0 4 5 1 2 3 - 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each :.. , ,.:.. .......:.._.... „,��.� _ .. -t i .e- t hQi a . I rill_i =o�.._ : ✓:✓ r ilii _�'. -� L'l.11 .�1. Uc - 51 submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 i 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES VQ DEPTH HOLE NO. p G.L.. _MP 5mi 0.5' 1.0' 1.5' s 2.0' 2.5' 1,0 Ae+ 3.0' 3.5' 4.0' It . 4.5' WOW)) e5ou wl 5.0' of 4W 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE N0. 5(�' POLi O SPOT M HOLE NO. 0 b PouGc —"13 o f S Io r MOLRCNG o-a 3'�"r' Indicate level at which groundwater is encountered j.16 K tZ eNUuPIL- e-i� Indicate level at which mottling is observed . :Syz -d Indicate level to which water level rises after being encountered Deep hole observations made by: G tzo►AW i kxj G PLD N Date 6'7-d>-7-6':5r Design Professional Name: r-lm � i L% '1 Address: . 3 LUD 17 JA Signature: Design Professional's Seal "�' f- 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I _ PRn -IF(2T INFf)RMOT1f)N ITn hP cmmnleted by Applicant or Prolect Sponsor) ,1. APPLICANT /SPONSOR 2. PROJECT NAME Robert MacDonald Construction of Single Family Residence 3. PROJECT LOCATION: Municipality Town of Putnam Valley County Putnam County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) East Side of Peekskill Hollow Road approximately 200' north of intersection of Peekskill Hollow Road & Tinker Hill Road. Also known as Lot 1 of MacDonald Subdivision 5. PROPOSED ACTION IS: ❑ New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of a new single family residence, SSTS and Private Well Supply. F . AMOUNT OF LAND AFFECTED:... Initially 3.2061 acres Ultimately 3.2061 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? R] Yes F No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? O Residential ❑ Industrial Commercial Agriculture ❑ Park/Forest/Open Space E] Other Describe: Surrounding lands are zoned R -3 (Single Family Residential) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? 0 ✓ Yes No If Yes, list agency(s) name and permittapprovals: Town of Putnam Valley- Building Permit 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ZYes ❑ No If Yes, list agency(s) name and permit/approvals: Town of Putnam Valley & Putnam County Health Department- Subdivision Approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Yes ✓❑ No I CERTIFY THAT THE INFQEhdLTION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Croni sneering, It., P.C./ James W. Teed, Jr. Date: Z Zo Signature: If the action is in the Coastal Area, and you are a state agency, complete the C_oasta! A se _",_m ent. Form.hefore,procee.ding.with.t is,assess.Enent:.,y. OVER 1 t. g "b PART II - IMPACT ASSFSSMFNT 1Tn he rmmnlPtPd by Lead AnPnr_vl A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes [:] No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED 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 pattern, 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 CRITICAL ENVIRONMENTAL AREA (CEA)? ❑ Yes E] No If Yes, explain briefly: ' E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? E] Yes F� 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 yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ElCheck this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the 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 NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this determir Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) New York State Department of Environmental Conservation Division of Environmental Permits, Region 3 21 South Putt Corners Road, New Paltz, New York 12561 -1620 Phone: (845) 256 -3054 - FAX: (845) 255 -4659 Website: www.dec.nv.gov Alexander B. Grannis Commissioner March 12, 2009 Mr. Robert MacDonald 527 Peekskill Hollow Rd. Putnam Valley, NY 10579 RE: DEC Permit No. 3- 3728 - 00179/00001 MacDonald Property - 527 Peekskill Hollow Rd_.,_ T /Putnam Valley, Putnam_ C_ ounty Freshwater Wetland OL -72 - Adjacent Area MODIFICATION TO EXTEND PERMIT Dear lvlr; MacDonald: The NYS Department of Environmental Conservation (DEC) received your letter on February 20, 2009, requesting an additional extension of the expiration date on the above permit for Lot #1. You indicated that no work has begun on Lot #1, and the plans have not changed. You also state that the remaining two parcels have been sold. In accordance with your request, the expiration date of the above -noted permit is hereby extended to December 31, 2010. All other terms and conditions remain as written in the original permit issued May 11, 2006, and modified on May 6, 2008, September 12, 2008, and January 5, 2009. Please attach this modification to the front of the permit. If you should have any questions, please contact Judith Blauvelt of my staff at (845) 256 -2250. ecc: B. D rumm, Bureau of Habitat / lFr►C. l Sinn) Sincerely, C �j .7/�o- Michael D. Merriman Deputy Regional Permit Administrator