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HomeMy WebLinkAbout2857DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -1 -3 BOX 24 11 ru IT ho �' I • L �I y I6 I ' I L ' ' kP 02857 �- 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