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02857
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PUTNAM COUNTY O DEPARTMENT F HEALTH L% ✓ ��
T
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #
Located at /�/l,J cv3 c,,J V ��,� . �r Y� Town or Village s_ %%T
Subdivision name
Date Subdivision Approved
Subd. Lot # --r Tax Map dP—, % Block I Lot 3
Owner /Applicant Name 141/�
Mailing Address
:�� crr y .rte rr� .✓,�lr��` r�
Renewal '— Revision
Date of Previous Approval
Zip le-5,71
Amount of Fee Enclosed
Building Type157e- j ;e,4- e- e- Lot Area No. of Bedrooms 2- Design Flow GPD *010
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of a !U / 'gallon septic tank and `¢,9 L
Other Requirements:
To be constructed by Address ��4 u .Yip
Water Supply: Public Sunny 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 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: G P.E. Date
0
Address `lT� �r^�'IG ✓�� ��r� r� % /%.,� %5 01ceinis
APPROVED FOR CONSTRUCTION: This approval expires two years ,Ihes I 's nless construction of the
sewage treatment system has been completed and inspected by the PC] an �t� o��able f ;` se or may be amended or
modified when considered necessary by the Public Health Director. Any revisioh'W'a; the approved plan requires
a new permit. Approv c_sanitary sewage only.
B Title: Date:
Y•
White copy - HD File; Yellow copy - Building Inspector; Pink copy - wner; Orange copy - Design P of sional
Form CP -97
FA
D. INSPECTION Date Inspector
0110 evidence of failure ClEvidence of failure ClEvidence of seasonal failure
- ------------------ — -------------- ------------------------------------------------------
(Indicate North)
(1) Indicate location of SSTS.
A. Size and type of septic tank _ gallons
®Metal ❑oncrete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3.. Gallies
(2) indicafe, setbacks, front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTING WATER SUPPLY
®PWS ❑Shared well 91-ndi'vidual well
❑ ODug L.1Casing above ground
7
(7 >
COMNIENTS:
REPAIRS ONLY:
As Built Inspection Required:
As Built Inspection Done:
Status:
As Built Submitted:
Inspector:
C\
HOUSE
------------- ----------------------------------------------------------------------- ----------
(1) Indicate location of SSTS.
A. Size and type of septic tank _ gallons
®Metal ❑oncrete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3.. Gallies
(2) indicafe, setbacks, front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTING WATER SUPPLY
®PWS ❑Shared well 91-ndi'vidual well
❑ ODug L.1Casing above ground
7
(7 >
COMNIENTS:
REPAIRS ONLY:
As Built Inspection Required:
As Built Inspection Done:
Status:
As Built Submitted:
Inspector:
J
R
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPA.IR FORM
SECTION A: GENERAL INFORMATION
Name ofF'roject Z.5 A-A 5oz Vi e. k/ (T)(V) (/ TM#
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. L dilly ®Rolling OSteep Slope ®Gentle Slope ®Flat
2. ®Evidence of wetland Clow area subject to flooding ®Bodies of water
®Drainage ditches Rock outcrop
YES NO
J. Property lines evident? ® _
4. Water courses exist on, or adjacent to parcel:
.5. Existing individual wells within 200ft of the existing SSTS?
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ®Level Mentle, Slope LJSteep slope
B. ®Well drained L= /Moderately well drained
®Somewhat poorly drained ®Poorly drained
C. Area available for SSTS. (Primary & Reserve)
®Extremely limited ®Somewhat limited gAdequate fix ft
14-18.4 (2187) —Text 12
PROJECT I.D. NUMBER 617.21 SEOR
Apndl -C
8tats Environmental Ousllty Review _
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART !—PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1.. APPLICANT /SPONSOR_
2. PROJECT NAME. K
3. PROJECT LOCATION: /_
Aa �C- P,
Municipality /G! �r County
4. PRECISE LOCATION (Street address and road Inter tlons, prominent landmarks, etc., or provide map)
.4411
5. 5. IS PROPOSED ACTION:
ew ❑ Expansion ❑ Modification /alteration
6. DESCRIBE PROJECT BRIE /FLY:
,,t2
7. AMOUNT OF LAND FFECTED:
Initially acres Ultimately acres
8. WIL. PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Yes ❑ No If No, describe briefly
8. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
Residential ❑ Industrial _ . .. ❑ Commercial O Agriculture_ IJ ParklFn!es!(APen -snar. ,:-- ----- :- •Other..
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
)Yes ❑ No If yes, list agenay(s) +and permit /approvals
11. ,�D{OES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
L^J Yes ❑ No If yes, list agency name and permit/approval / =X
12. AS RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
-A
,1�lYes ❑ No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
"'
Applicantlsponsor ,name: f 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 4GEED TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
❑ Yes No
B: WILL ^- ECG LLI-cL � , Oa e!(5 F�iPR, P ;R? : ° E_, ' 'c et E, ^^0 N r Ya .�c 13T3 1 i�
may be superseded by another Involved agency.
❑ Yes
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIAT� H THE FOLLOWING: (Answers may be handwritten, If legible)
Cf. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly.
C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly.
C7. Other Impacts (Including changes In use of either quantity or type of energy)? Explain briefly.
D: IS THERE, OR IS THERE LIKELY TO BE; CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes El 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.
❑ Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY
occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration.
❑ Check this box if you have determined, based on the Information and analysis above and any supporting
documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Print or Type Name of Responsible Officer in Lead Agency
Signature of Responsible Officer in Lead Agency
Name o Lead Agency
Date
2
Title of Responsible Officer
Signature of Preparer (if different from responsible officer)
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: /mil i
2. Name of project:
4. Design Professional:
6. Type of Pro'ect:
e
3. Location /V:
5. Address:
TT
18. If yes, name of water supply
Distance to water supply
19. Is project site near a public sewage collection or treatment system? ................ Al—c-
20. Name of sewage system
21. Date test holes observed
Distance to sewage system
22. Name of Health Inspector
Form PC -97
Private/Residential Food Service Commercial
Apartments Institutional Mobile Home
Park
Office Building Realty Subidvision Other (specify)
7.
Is this project subject to State Environmental Quality Review (SEQR)? �U
Type Status (check one) ....................... ............................... Type I
Exempt
Type II
Unlisted
8.
Is a Draft Environmental Impact Statement (DEIS) required? .........................�
9.
Has DEIS been completed and found acceptable by Lead Agency? ...............
`-
.. _ 4 0.
Name of Lead Agency
-
11.
If this project is an area under the control of local planning, zoning, or other.
officials, ordinances? .......................................................................................
y S
12.
If so, have plans been submitted to such authorities? ........ ...............................
e
13.
Has preliminary approval been granted by such authorities? Date granted:
r.
14.
Type of Sewage Treatment System Discharge ................. surface water
groundwater
15.
If surface water discharge, what is the stream class designation? ....................
s -
.16.
Waters index number (surface) ........................................... ...............................
–
17.
Is project located near a public water supply system? .......................................
Al a
18. If yes, name of water supply
Distance to water supply
19. Is project site near a public sewage collection or treatment system? ................ Al—c-
20. Name of sewage system
21. Date test holes observed
Distance to sewage system
22. Name of Health Inspector
Form PC -97
2
n-
flow_Cgallons ner._da l ;
..
,. ....,.._ ._ -, ..� .-.. .��- - �....._..^ r-,. ._�.,... >�.•.�._,- .- ,.._.,.�.e« ,.. ,c;..:.,,..... - .....�.�:.'..� .. fir+ �-.., - ..�.....,::�'�.:,.�.a,..�.a... ..- '_.... ..._,
24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?...
25. Has SPDES Application been submitted to local DEC office? .........................
26. Is any portion of this project located within a designated Town or State wetland?
27. Wetlands ID Number ........................................................... ...............................
28. Is Wetlands Permit required? .............................................. ...............................
Has application been made to Town of Local DEC office? ......................... :.....
29. Does project require a DEC Stream Disturbance Permit? �a
30. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ........ Yes/No.
31. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potential known source of contamination? ... ............................... Yes/No
DESCRIBE:
32. Is there a local master plan on file with the Town or Village?
33. Are community water and/or sewer facilities planned to be developed within
_ t5. years. in-or adJJ acPnt to.:project site?.............. . ................:..:.::.:::::.
34. Are.any sewage treatment areas in excess of 15% slope? . ...............................
4/1�'
/ilCl"
35. Tax Map ID Number ............... ...O.7......................... Map Block_ Lot
36. Approved plans are to be returned to ..... Applicant Design Professional
If the application is signed by a person other than the applicant shown in Item l .,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
SICNATURI'S & OFFICIAL TITLES. ;T �
Mailing Address: ...................................
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner Address—.,
01
Located at (Street) Tax Map Ig, Block Lot _:_z3 .
(indicate nearest cross street)
Municipality i t �! //� Watershed I .
SOIL PERCOLATION TEST DATA
Date of Pre-soaking
Date of Percolation Test
... ........... 7
.. . ..........
.... ....... ..........
......
... .......
.... ......... .... .
D. ep h to: Water
Wafer . :.
. ........ ......... . ...... . ...X .. .
.. ...
......
.......... ..... .............. ............... ._. _. _ .............. . ...
....... ........
.....
... .......... .... ..
.. ...........
...............
"
Ground
'
-evel'
Perca a qn.:.
............ .. . .........
)EIoIe Nu
........ . .. .....
R�tn No
g. ur >h es)
w ie
... ....... ......... ... ........
......... . . ..............
. .. ...S ...Stop . S .............. ..............................
.....
4
........ ...........
. .
2
3
4
5
2
2
z7
3
4
5
2
3
4
5
L
NOTES: 1.
Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. :5 1
min for 1-30 min/inch, s 2 min for 3 Y-60 min/inch)
All data to be
submitted
for review.
2.
Depth measurements
to be made from top of hole.
Form DD-97
(1
TEST PIT DATA 2
DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES
DEPTH HOLE NO. 1 HOLE NO. ~ �- HOLE NO. _
G.L.
0.5' _
1.0' _
1.5'
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
10.0'
Indicate level at which groundwater is encountered A4'A e-'
Indicate level at which mottling is observed �--
Indicate level to which water level rises after being encountered --
Deep hole observations made by: Date %r 2-,/,
Design Professional IN 1 J ; rcr
Address: -,�, q v
Signature:
Design Professional's Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of _ (►(L, GEkR-T S - aCk- �F,(2,1N-_-
Located at 2,,5 k_ 'QD So N N tLA V kUj, &jT� (o6-7q
T/V W_�W ,, q. Tax Map # 62.13 Block Lot 3
Subdivision of
Subdivision Lot #
Gentlemen:
Filed Map # Date Filed
This letter is to authori7.e C,S � 1 i,t, i f " vcgw
a duly licensed Professional Engineer 'I r.-or Registered Architect to apply for the regwred
wastewater treatment and/or water supply permits) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on ,my behalf in connection with this
matter and to supervise the construction of said wastewater treatment and/or water supply systems
in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
- --
Law, and the. Putnam. County Sanitary Cad?.
Countersigned:
P.E.,1.,
OT NEiY�
Mailing Address
&//4
State
Telephone:
2*
Very truly yours,
Signed: y <�
(Owner of Property)
Mailing Address: ?, _t_hQSot✓Y Vila& J
1?vTN k%A V+ OA'
State tv _"Lip lo5 ?q
Telephone: �q�� S2,G —11 G
Form LA -97