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HomeMy WebLinkAbout2894DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 62.13 -2 -18 BOX 24 or ILI _ , 4 SHERLITAAMLER, MD, MS, FAAP ; Commissioner of Health Associate Commissioner of Health ROBERT J. BONDI County Executive Director DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ADDITION APPLICATION RESIDENTIAL ONLY "E7. _ _ Health STREET Sty We &J: Shure r. ve TOWN PA ut' TAX MAP # 6 Z , 13-?_-1 NAME :54.0--, Zi . V 6Lao PHONE,'4S -•- 5Z cl 3 ZO PCHD# MAILING U5 ADDRESS S o t�Jes� S k)(-e. uk-. DESCRIPTION O ADDITION r 2) 6ar CA NUMBER OF EXISTING BEDROOMS a-- PROPOSED # OF BEDROOMS_ (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans.(Construction permit): prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 - 6130. 1. Certified check or money order for .$100.00. "2: Sketches of existing floor plan (drawn to scale, all living area including basement, to be shown; and. dimensioned and use of each roo:ri specifie &j. -'See Section3.cofBulletin HA -1) 3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #) 'r Non- professional sketches are acceptable and preferred. (See Section 3:d of Bulletin HA -1) 4. Copy of survey showing all well and. septic locations. on the subject property to the best of your knowledge. Include date of installation known. Contact this office with any questions. 5. .Copy of Certificate of Occupancy from the Town or Certification from the Building Department with legal bedroom count of dwelling: OFFICE USE COMMENTS 5. 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678. Early Intervention / Preschool (845) 228 -2841 Fax (845) 225=1580 J� G� SHERLITA AMLER, MD, MS, FAAP. - ROBERT J. BONDI Commissioner. of Health "< County Executive Associate Commissioner of Health Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 Town Legal Bedroom Count & Proposed Addition Status Re: JULIANO (Owner's Name) Tax Map # 62.13 -2 -18 Address: 50 West Shore Drive Town: Pii to am Valley Year Built:. 2002 According to records maintained by the Town, the above noted dwelling, is . � in compliance with Town Code. Is not in compliance with Town Code. The Legal Bedroom Count is: This information has been obtained from: Certificate of'.Occupancy: CO # 2 0 0 2 -13 3. . Other: The plans for the proposed addition are considered: New Construction xx Addition to existing house only Teardown and /or re -build allowed under Town Regulations 4/30/10 :...:.. -... Buildi.49 Inspe. _tor . _. .Date 6. ' Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing.Services (845)278-655.8 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 PUTNAM COUNTY DEPARTMENT OF HEALTH D �P�0,N C!F-- F- ..NVlRO�N�4�E.NT' AL HEAL-- TI SEP'_VICES - CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # /`'`' ,1� ^'f Located a ' �% :. ' r '' �`, y` Town or Village ,c�, Or C✓�% Owner /Applicant Name «=+ %s d' Tax Map • Block Lot f Formerly Subdivision Name Subd. Lot # Mailing g Address . w Zip A �4_�; Date Construction Permit Issued by PCHD '. Separate Sewerage System built by .s //,r 4�. to e MiWdress : '!w , Consisting of Gallon Septic Tank and. z ., ; ....,,,.Other Requirements:'. Wafer Suooly; Public Supply From Address or 1 Private Supply Drilled by Address jr" `�t•; �` /� ' ulldul� 1'y�l� . :sf % .,c,.0 Has erosion -controi been completed? Number of Bedrooms- :, 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 wi � PCHD Construction Permit and approved plans and the standatds, rules and regulations. of the Put tment of Health. { CO Date: /.� 2 Certified by :.r * a . P.E. . - : R.A. Address V72 �-,�` �'_ =.� -; ,.-- �' � . <. License # An ersorf occupying ser�d� the abo : s em � Any p py g p y y t ptly 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 sod as a public sanitary. sewer becomes available and the approval of the private water supply shall become hull' id void when a public water supply becomes available. Such approvals are subject to m.@'ifi. 6.ni or change when, in the judgment of the Public Health Director, such revocation, modification or change is. necessary. A By: t 4 , Title- , . c °r:� Date: - 70 c White copy - HD File; Y116 copy - Building Inspector; Pink copy - Owner; OraQ copy - Design Professional Form CC -97 v Sherlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE Director of Environmental Health Sam Juliano 50 West Shore Drive Putnam Valley, NY 10579 Dear Mr. Juliano: Robert J. Bondi County Executive Department of Health 1 Geneva Road, Brewster, NY 10509 Office (845) 808 -1390 Fax (845) 808 -1937 October 18, 2010 Re: Addition- A- 084 -10 No Increase in Number of Bedrooms 50 West Shore Drive (T) Putnam Valley, T.M. # 62.13 -1 -18 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated October 18, 2010. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at four without prior approval by this Department. 2. 'The area of the existing sewage disposal system and its expansion area must be rnaintailled. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets etc. 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not obtained proper approvals Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you have any questions, please contact me at (845) 808 -1390, ext. 43261. GDR:kly cc: BI, (T) Putnam Valley Sincerely, Gene D. Reed Senior Engineering Aide Sherlita Amler, MD, MS, FAAP o� Commissioner of Health - -- 'Robert, Morris. PF_. __ .. - ..._..._ Director of Environmental Health , Sam Juliano 50 West Shore Drive Putnam Valley, NY 10579 Dear Mr. Juliano: Robert J. Bondi County Executive Department of Health 1 Geneva Road, Brewster, NY 10509 June 7, 2010 Re: Addition — A- 084 -10 50 West Shore Drive (T) Putnam Valley, TM # 62.13 -1 -18 I have received arid- reviewed- the house plans- for the proposed addition -to- the - above- mentioned - -- residence. Based on the information submitted, the above mentioned addition cannot be approved for the following reasons: 1. The legal bedroom count for the dwelling is four. The potential bedroom count of your Yrp�ncFrS � �jitign -1S lve. _Th?.rt ow...ti led.b� _iis r�?ni11 -7S Ci`,ilSldeTed a p�tetitzal_.... bedroom. 2. The addition of potential bedroom requires this Department's approval of a revised septic system plan from a professional engineer. Please revise the proposed floor plan to reflect no more than four potential bedrooms, or have a professional engineer or registered architect design a sub - surface sewage treatment system meeting present code requirements. GDR:kly Sincerely, Gene D. Reed Sr. Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845.).225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing / Home Care Agency (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 MA AL- V. r_ - - - -- - -- I -: } ; now or formerlys of ,� 9w lYo%7i an YQC 1 ,w 520 LOT #6 - FM #1652 - M.ER 13 tt �•� / 8 ,..WSW 0 6Df Lot% a E` 5719$,75 SQ. FT. ' 1 ! 1.31 :�O ACRES 43 45' SE, �� ��',1 ! , j 160.06° `t � X42 l J Albop IQ lip 0 480 40 woodo Y Y 1.7,� .yam J 'm 4 c1 6 \\11 fill 11 j. t � �� X11 ;� ��� � y ► � t • �j1 +4 `j,i1l t I� f i i � i! �! I f + 1 t �►; t t t f���1�'�' ► \ - 480 470 _ o 500 4 sic -vr 2432 2432 0[ El 0 x 2 44*-0• 3446 2432 2-3046 BDRM 4 QDRM 3 1 l'- 6 x 9' 7" 10'-0" x 15'-0 1/2" z Z w oo 3: 0 0 MC14 LD26 PON 026 024 (S SE) x 25 i12 -4 heCOOLAAI ROW A 1/2* MICROLAM ROOF WFeF= D26 N I I I I I I I BP , .01 OPEN W 4 1/2• TO BELOW 3M 10411 r 18-3046-18 V— Y- QDRM 2 14'-2 1/2" x 10'-8" 3046 3046 6'-9" 4'-0" NCO J.� CC LLJ a- I I r - -- I I I I I i M SPAN BETWUH COLUMNS 7. -6' I' -7' t 14' -10 1/4" T— - FOUNDATION WALL-:::;/, , I 1 I I FOOTIN 1 ! I I I I I 1 0+ N I I I I I 1 iLq 14' -$ 3 14'-S" 14' -10 1/4" r F- --I r- --I r- --'I I I I I I 1 0+ N I I I I I 1 ,y� a MRS DESIGNED do C ZbNSTRUCTED BY SP A I I I I I I I EXIST BATNW. I EXISTIWG BEDROOM EXISTNG BEDROOM __ =A&N&T RDM EXISTIWG HALLI - - - - - ON t7F. TO DiELM WftTw$ VIII iv-v rm I n ! 25'-0' .pct k" J U 7s 44'-2° i9 I) i� j S} _ C )�XSTNCI KIT EN LIP NEW HWESTCM PCRTW , I I. �.� ------------------------- I I I I t - - - - -- --- I - - - -- ----- - - - - -- I I I I � I t I I NM SLOP Ow I -------------------- i I' y� m i - ► + NEW WR4GE I A rr I I I I I I I x I I I I I I I I I I I I I I I 1 --- - - - - -- --- - - - - -- ' I I -------------------------- - - - - -- -� .6L; - 4-.01 ------------------:- ------------- r", OA .@is �. ,' ,! '| r------____ � i--- -----------� ' | ` | ' | ' | } | r--�-------------- - . . . _ __________�___-� ' | / | � || �_______________________________�-� | .� ' / � 0� / PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION- OF, ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERNUT # Located at // - /��� Subdivision name AA-r;" Subd. Lot # 7 Date Subdivision Approved If 7B f / Owner /Applicant Name;��,� �✓as �1'r� Town or Village /ZfAWI)�, Tax Map &'2•2-3 Block Lot Renewal Revision Date of Previous Approval / 9 P .3 Mailing Address Amount of Fee Enclosed Building Type � yr -e Lot Area ,-SA4No. of Bedrooms 33 Design Flow GPD &', c' Fill Section Only Depth Volume IF--'PVHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To be constructed by /Pv y , zle- /.,o- P.E. gallon septic tank and 3 -z;, e, Address Water Suooly: „ Public Supply From Address or: Private Supply Drilled by 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 z 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. bF NEW Signed: Address 2� Y/,?— 1151-11 e R.A. Date License # D-1 APPROVED FOR CONSTRUCTI , 1 expires two years from the date issued unless construction of the sewage treatment system has been coin pected 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. Approve discharge of domestic.sanitary sewage only. By:�.. , ----' - Title: :�' �/y� Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr fessional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PLICATION TO CONSTRUCT A WATER^� Pkhit- piintori e . - - - _x ..._:FLIPF�erniic ;,d s•'! . .- Well Location: Street Address: Town/Village Tax Grid # Block Lot(s) l e Well Owner: Name: Address: Use of Well: 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 :3� gpm # People Served -A Est. of Daily Usage day' gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling l"New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision -5�e- G A I'a/% , V e - r Ae- r --f Lot No. Water Well, Contractor: All A,7 a4e7 ,� Address: earl Is Public Water Supply available to site? .................................. ............................... Yes No i-- Name of Public Water Supply: Town/Village -9 Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date:: /! . - .Applicant. Signature:. /_ �'s 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. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue Permit Issuing Offici -y - Date of Expiration .Z Title: Permit is Non-Transfeirabre White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT 0 ALL LOCATION Stree . Address 110�7 11 Q`� Town/Village/city Tax Grid Number WELL OWNER Name V ® IF717 Mailing Address � %. rivate 0Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ® BUSINESS ® INDUSTRIAL ®PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP ® ABANDONED ® FARM Q TEST /OBSERVATION 0 OTHER (specify U INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. ® REPLACE EXISTING SUPPLY ® TEST/ OBSERVATION NKNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL OF DAILY USAGE :�P 0 stal D: ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE kQDRILLED DRIVEN ®DUG 0 GRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN 'A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ors Lot No. WATER WELL CONTRACTOR: Name_ Al. Address: dw p IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES m/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY - DISTANCE-TO - PROPER U 'FROM' NE -daES1 'WATER-1 oily LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE , PON SEPARATE SHEET is (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of 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 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 attached to this permit. 3. Submit a Well Completion Report on -a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue 19%-= Date of Expiration 19. Permit Issuing ffficial� Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at 1�7U T/V 107'194Aw yajle- Tax Map # !0&12. Block Lot " Subdivision of Subdivision Lot # Filed Map # % 5 '_2 Date Filed Gentlemen: This. letter is to authorize a u s "—r'f"P /9 / a duly licensed Professional Engineer A,," 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 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 (—'.ounty Sanitary:Cpde..- Very truly yours, o° t Countersigned: ='FNE S igned: oq (o ner of Propeny) Mailing Addr c ) r�C: S �, Mailing Address: State • Zip /e�1 S _F7 State A-' Zip 6� Telephoner Telephone: �� �� �✓ `�' Form LA -97 r P v -(, -- q t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER.SUPPLY & SUBSURFACE SWAGE TREA:T..MENT. SYSTEMS SHEETf�FOR (CONSTRUCTION PERMIT STREET LOCATION / ' �' �"` (/ ° NAME OF OWNER f 1GLQi -'y REVIEWED BY • DATE <) % TAX MAP # i3 - _I- Y DOCUMENTS 6PERMIT APPLICATION PC -I WELL PERMIT PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS - THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST —63-1ji-A-UlA039 2' CONTOURS EXISTING & PROPOSED D AY & FOOTING /GUTTER/CURTAIN DRAINS COMMENTS: EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCA REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE. NO BENDS; MAX.BENDS 45° P-OGRADE OUT FILL SYSTEM CLAY BARRIER 10- FT. HORIZONTAL;SLOPE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GUAGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA ,Q TRENCIJ LF i BENCH PV6ViDEu 13-v 6U-Fl-MAX' _ % C7 100% EXPANSION PROVIDED S i ON PLAN - FROM SSTS: TO P.L.; DRIVEWAY, LARGE TI 20' TO FOUNDATION WALLS TO WELL, 200' IN DLOD, 150'1 UURSE LEGAL SUBDMSION 4/1 SUBDIVISION APPROVAL CHECKED 50' TO CATCH BASIN, 35' STO 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE C( 200'/500' RESERVOIR, ETC. _150' 15'min to CDS= >5 %,10'- 4 %,25' -3 %,31 20'min to CD discharge/ 100'with 182 ' PERC RATE REQUIRED DEPTH f CURTAIN DRAIN REQUIRED STANDPIPES GENERA L PeATED IN NYC WATERSHED 15L S SUBMITTED TO DEP ELEGATED TO PCHD EP APPROVAL, IF REQ'D ...__ _. _ ,.r`f��•Ep TEST•I?O:,ES O}3SEaVED: - -. __.., ;. _. _ _ _... PERCS WITNESSED, IF REQ'D EX- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BUZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMITS) REQUIRED DETAILS ON PLANS MCONSTRUCTION SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW NOTES 2' CONTOURS EXISTING & PROPOSED D AY & FOOTING /GUTTER/CURTAIN DRAINS COMMENTS: EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCA REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE. NO BENDS; MAX.BENDS 45° P-OGRADE OUT FILL SYSTEM CLAY BARRIER 10- FT. HORIZONTAL;SLOPE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GUAGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA ,Q TRENCIJ LF i BENCH PV6ViDEu 13-v 6U-Fl-MAX' _ % C7 100% EXPANSION PROVIDED S i ON PLAN - FROM SSTS: LEES, TOP OF FILL 15'WELL TO PL 'ITS 4 LAKE (inc. expan 1URSE GALLEY SYSTEMS )'- 2 0/.,35' -I %,100' - <1% :ons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL r pz, �y INA, bell "-I I-- I a- FOrT-& TO P.L.; DRIVEWAY, LARGE TI 20' TO FOUNDATION WALLS TO WELL, 200' IN DLOD, 150'1 UURSE 4/1 50' TO CATCH BASIN, 35' STO 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE C( 200'/500' RESERVOIR, ETC. _150' 15'min to CDS= >5 %,10'- 4 %,25' -3 %,31 20'min to CD discharge/ 100'with 182 ' f LEES, TOP OF FILL 15'WELL TO PL 'ITS 4 LAKE (inc. expan 1URSE GALLEY SYSTEMS )'- 2 0/.,35' -I %,100' - <1% :ons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL r pz, �y INA, bell "-I I-- I a- FOrT-& . � I , Dldii atiaebetlraUbl Bs>lOfi taadtu. � II.T. l�Slt � A OF t�wY� Pwi i 1lM SDWAM Burg AL SY"S!!l� Parttt _ 44V A� 61 "UAW" 411 VSiieYwc. �.aAG.; /C++ rLN .0 .uniAmM motx.., Od � e,�� o i+tlrlr� Z �a / ►' i +r.(✓ °' �d PerMAre. � Al p V or�r Date Subdivision //Annroved IVI 'cl Fee Enclosed ❑ Amn„nt- obis TMW lot Atsa --3/ / / PB geeam Dopm vdmw Ntarbr III sedmm& Dodo Flow G PD PCSD NNbeatlM Is logdmd Wheat Pis Y *r/Wad &WWAb sb.esew Sys m. M arttlat of f B D U mess, Sq* Task Ova % /C 2,4r i 1 : G Ti be eoabrelad.aw AddNaa WaMr sl..trs loan. gab, Fter Adler otbe DatrieraNtt 1 repre ent'.thet I am wholly and completely responsible for the design and location of the proposed syttamp) j 11 that the Y eta veer di YI slam above described will be constructed as shown on the approved amendment there to and in accordance ndrds, rules a raga ns COOmty 000e WMK of HMRN MW that On ComplotiOn.th reof a "Certificate of Construction ory, to the Commissioner M HwNhwill be mbMRted to the Deport and a written gursrltee will be furnished the owner, his if >�p, by the builder. that said builder will pinta in Hood .eperatllle COrklNfow.any Wirt of sold sawaM disposal system dwfng the per o ( "'P weir following thedote of the isau- all* of the asorowt of the CortNlnte of Constnsetlen Compliance, of the original sy or r s It { 2 hat the drilled will ' c ON octavo WE be located as shower on the a0proeN plan and that Yid well will be Installed in atooMa w ajpd reeU�a oriT Ii of the Putnam County D4wftm" of ~b, r C, oats Address Z-�%'L n• ^. /i t.k»me. N2=0 APPROVED FOR CONSTRUCT10Nt This approval expint two yaws from the data i n a n�Ql''tl�'i building has been undertaken and It VOMUbla for Cause Or may, be amended or modified when considered naeemary by the Comml fipt�F Ith.�Any Change or alteration of construction f"Wires a permit.. AgorarOd for disposal of domestic se"ary mwaft a or priv 0 wet oRiilr. Rev.. Title D�BV data � Q �� il✓ `� ��� �-�� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property ofti/!o76r/7 Located at (T) Subdivision of Lot Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineer -- or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity, wi. ..th the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. st Very truly yours, Counter ]a 6Rk �� PN I S S l- P.E. #G` dre tip- Y Telephone Signed Address 7 r" 3 wn ( p Telephone L`FSIGIv MM SOU SUACE_ 6/9v "DISPOSAL - -SYSTrrI Owner -ZL2 ale Address (� 5a ;,o- r; e_r✓ �'/° y-e_ Located at (Street) 1`1 1W D / ?a <i Sec. 4 Block 3 Lot 1-_>w 7 (indicate nearest cross street) - Municipality may!! d Watershed SOIL PERCOLATION TESL `BATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking Date of Percolation Test % HOLE NUMBER CLOCK TIME PERCOLATION,., PERCOLATION Run Elapse -Depth to Water Fraa Water Level No. Time Ground.Surface'' In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 32 3,3-4 4 2j'� 33#3 3 S" a f zz- Zs 3 ,3 oe 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated are obtained at each for review. 2. Depth measurements to rev. 9/85 at same depth until approximately equal soil rates percolation test hole. All data to' be submitted be made fran top of hole. TEST PIT DATA I R EQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. _-,HOLE NO, OL G.L. jd 1. 21 31 4' 51 61 71 81 91 10, 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: ff 77 DESIGN Soil Rate Used Min/1" Drop: S.D. Usable Area Provided A/ No. of Bedroans Septic Tank Capacity 4D gals. Type//6-fvv.-,V' I Absorption Area Provided By 3PO L.F. x 24" width trench' 1111 M- 7­­ .1 .. .. .. .1 ­rW u, - I -r I V PU TNAM Gf`" Soil Rate Approved sq. ft/gal. Checked by DEPT. 0FDj6-aALTF1 A_F==-MCLC B (Z-77• -7 CE?a SE: La _f SUL, ELI --- 11 '� 7-- ZrZT11=�zz L-1 I -.0 -0_ C_ c a-r it _7 rL-z Ar=-,S;-" li (--- pia= - Tr:nree acle r-cg C=515 tan- perz: REC'..' Ecl.Lsa PIE:--S - T.;c C .7­71 C=. C cata ca ocs P D,= =.j syz- P I D c , <2T Ic- C_r NDC te cu-c: C.Z-- 7 C- ze ECUs= - Nrc. cf-, .we-; im 200 ft. cf se- E E- rr S7_ 10' LE-f Cz z 201 to Fc=ld' ;qE*' 200' is D. -C -Dr 100, to Strearn, Wats:=urs-z' 151 to . :a• E'll tc I• •� f 71' • 'Ji 171 • :1 • i •' • � • -•�' 171 Y• :1 is r7` 414 AR - - - - - - 00:0:0:•- ,> «.:: -a � .,,._.. .. '.�..r.b t�...n...��ra. r ,•:.. � _ a_ - /y' - . r / INSP. _ BY: (Name of Owner) /(Street Location) INITIAL SITE INSPECTION YES NO COMMER S Wetlands on/or proximate to property .............. Property lines or corners .found .................... Can estimate house location ........ 0............... Will- driveway need cut .......... ................... Must trees be removed - note these......... ...... - Deep holes representative of entire SDS area...... Additional deep holes needed... ................... Sufficient SDS area available considering driveway cut, house location, separation. distances, etc... Adjacent .wells /septics............. • ........ .. .. AccAss to nronose well location for drilling..... D.H. 1 Lot Depth to G. W. .--- -- Depth to rock D.E..2 Lot Depth to G.W. Depth to. rock Soil 'Descripticn 0 ft. 0 ft. 3 ft. / /� — �� 3 ft. s y 6 ft. ����� 6 ft. 9 ft - .LL " 16e ..• �. .r • 1L� "f 1..... Descri D.H. - Deep Hol G.W.- Groundwate D.H. 3 Lot Depth to G. W. Depth to rock Soil Desc i 0 ft. 3 ft. 6 ft. 9 ft. �..:: -•_- -_ - 1�•�f�: =�:- ._.�- 0000_ .__,_ -:.:. DATE: FINAL SITE INSP=ION INSP.BY: YES NO CCMMENIS House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line.and.trench acceptable......... Rear allowed for.expansion trenches .............. Over 100 ft. fran w etercourse .................... Natural soil not stripped or SDS area unnecessarly graded............................. 10 ft. maintained from property line and 20 ft. fran house.... o ......................... Distance well to SSDS (ft.)........ ............... Nmmber of bedroacns checks ............... . Stones, brush, stumps,,rubble, etc., greater than 15 ft. from nearest trench ................ 15 fto of. peripheral soil horizontally fran trench .............................. :0000. Boxes properly set ........ 0 ................00..0. Could surface runoff fran driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS......0 FINAL GRADNG OF SITE ACCEPTABLE PUTNAM COUNTY DEPARTMENT OF HEALTH CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHI) CONSTRUCTION PERMIT # Located Town or Vi age Owner /Applicant Name Tax Map Block :Z Lot % Formerly -- Subdivision Name Subd. Lot # Mailing Address J7 -,rti�2/, 00✓z Zip Date Construction Permit Issued by PCHD Separate Sewerage System built by V- ,;� A /C r-' / /,r7,ddress Consisting of ls' Gallon Septic Tank and - f0(&e,, 1,,o4-- �?i� lam"" l�/'���L`" TJ"�'°�'✓C"�� Other Requirements: Water Supply Public Supply From. Address or: Private Supply Drilled by /w .5 Addressr--��' - uiiding type' i�r >> i -Has- erosion °c�riirni- aeen'campieteu? N unber of Bedrooms ., Has garbage grinder been installed? A10 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 Counq Department of Health. Date: �/� Certified by Address ;2— M A-Acense# --'>- - aig�:rt& �y F , Any pets 0 ccupying premises served'by the abov yste ;/D,. -lake such action as may be necessary to secure the correction of any unsanitary conditions res in %singe. Approval of the separate sewage treatment system shall become null and void as soon as a public saiitary 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 revoc tion, modific 'on or change is necessary. o ,g By: 1— Title: !'�'- ►-'�1� Date: "' G— White copy - HD File; Yelldw copy - Building Inspector; Pink copy - 0*ner; OraiW copy - Design Professional Form CC -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT -.. - _ �. - ..� - Well Location - w..ie�- w•w�'!•r.. . -. .- _ .. - _ _ - Street Address: oWest Shore Drive .. _- _ ...��. _ .. Town/Village: Putnam Valley -.. _ _gym _ .... z.-¢:aF. i.Yr. - :vr Tax Grid # Map 42,13Block ? Lot(s)i Well Owner: Name: Address: Westchester Modular Homes, 1995 Route 22, Brewster, INY 10509 Use of Well: I- 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 72 ft. Length below grade 71 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 X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 10 gpm Depth Data Measure from land surface - static (specify ft) 40' During yield test(ft) 100' Depth of completed well in feet 165' Well Log If more detailed information descriptions or sle- ..- a::.l,s_s._ . - are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 55 Drilling in over urden clay and boulders 55 Hit roc at 55' - -.. 55 12. . - Drillin -in rock sci;. Cd�1rr route 72 165 Drilling in rock cfranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 7 qm Depth 120' Model 7GS05412 Voltage 230 HP Tank Type WX302 8 al. Date Well Completed 4/8/02 Putnam County Certification No. 002 Date of Report 4/30/02 e,;74 ll r ) L. Bea NOTE: Exact location of well wtttt atstances tq,at te�yt two permanent tanamarxs to m7taea on a separate sneeuptan. Well Driller's Name P. B / o . Inc. Address: 4 Patna¢n Avenue, Brewster, NY Im Signature: ® Date: 4/30/02 White copy: HD File; Xllow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET m STAMFORD, CONNECTICUT o6905 NELAC, CT and NV State Certified Environmental Laboratory Mailing Information: Name: PF Beal & Sons Address: 4 Putnam Ave City: Brewster State: NY Telephone: Sample's Information: Client: Westchester-'Modular Zip: 10509 Fax: Collector's Information: Name: Chris Beal Address of site: West Shore Dr City: Putnam Valley State: NY Zip: Telephone: Site: tank hose bib Date Collected: 4/25/02 Date Received: 4/26/02 Preservative: N/A Time Collected: 15:10 Time Received: 10:15 Temperature: <4C Lab No.: J021578 Date Analyzed Test Name Result MCL Method 4/26/02 15:00 Total Coliform Absent Absent SMWW 9222B 4/26/02 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 4/26/02 Color ND 15 Units SMWW 2120 B 4/26/02 Odor. _ ND 3 TONs SMWW 2150 B 4/27/02 "Iron <0.03 mg /L 0.3 mg /L SMWW 3111 B 4/27/02 Manganese 0.014 mg /L 0.3 mg /L SMWW 3111 B 4 /2T /02 Sodium= = 4ZZmg /L -_ __�, ... .N %Pr= r ° = - SMV1/_W_31_1 -1:63 4/26/02 Chloride 63 mg /L 250 mg /L SMWW 4500 CI C 4%26/02 Hardness 180 mg /L N/A SMWW 2340 C — 4/26/02 _ Nitrate - 0.286 Mg /L - 1'U Moil _ .SMV W 4500 NO3E 4/26/02 11:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E. 4/26/02 pH 7.04 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 4/26/02 Sulfate 13.1 mg /L 250 mg /L SMWW 4500 SO4F 4/26/02 Turbidity 0.69 NTU 5 NTUs SMWW 2130 B 4/27/02 Lead 3.98 ug /L 15 ug /L SMWW 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable S.U.= Standard Unit MCL- Max. Contaminant Level ug /L- micrograms per Liter . .. � . . Signature: Michael Lapman President mg /L- milligrams per Liter ND- None Detected NTU- Nephelometric Turbidity Unit TON- Threshold Odor Number State #: PH -0218. - ELAP M 11715 Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com .I a. I cmv-i-rA. ILI I." Nr Public Health Director Associate Public Health Director Director of Patient Scivices DEPARTMENT OF HEALTH I Geneva Road Brewster, Nev York Environmental Health (914) 279-6130 Fax (914) 278 - 7921 Nursing Services. (914) 278 - 6558 WIC (91 4) 278 - 6678 . Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278-6082 Fax (914) 278 - 6648 -. --OWNERS NAME: TAX MAP.NVMBER: E911 ADDRESS: TOWN: . ............... .... . AUTHORIZED TOWN OFFICIAL: (Siguature) DATE,: .2 U .1-1 A �, kle The Putnam County Department of Health will not issue a Cerfi&aiite of Construction Compliance unless the above form is completed i. a legal E911 adUTess is assigned by an authorized town official. This form is to be submitted Vith the a pplkation, for a Certificate of Construction Co m' pli n (�-:,q 1 IvERFM MAY -OZ -2002 09:36 AM HARRY W NICHOLS 914 279 4567 P.02 PUTNAM COUNTY DEPARTMENT OF HEALTH Envtit�l`vN-' AE HAI'X`i StVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by w 6© Location - Street Building Type 6;, • 13 ` 2- --lei Tax Map Block Lot TownNillage Subdivision Name . Subdivision Lot # 1 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 pan 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 eai;sed by the wilift l or negligei; act of the_oc:cunam ofsbe bu ldi:tn ulili_ing system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the' failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month l Day 3 d Year 0'Z— ,I P..tt�,4, ! j d- � cz General Contractor (Owner) - Signature /A �A/l A"U'lAvviLls� L, orporation Name (if corporation) Address; State Zip Title: -� ta Corporation Name (if corporation) Address: GZ Wo Z7' Z Z_ State X_ Zip Form GS -97 04/05/2002 13:54 9149624248 JOSEPH SULLIVAN PAGE 01 r.s.... .. . .�-.. ware- t. J.a. +e. ... .r. • .......- - � ..�+•r r.. ��� � ...Y '... .. ... h.-. a .: �,. +. . � •... 4 -.. v.. ,.a. ..� - -... .u_. . -. .... � r •�.F � ... PUTNAM COUNTY DEPARTMENT OF $EALT%I DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ❑ ADAM e4 All information must be fully completed prior to any inspections being made. GENE For: Fill Trenches G' PCHD Construction Perini # Located: (T) M ,oe Owmer /Applicant Name: 060-12,W-6 TM __..__� Block Lot. Formerly: division Name: Subdivision Lot # ? Is system 5ll completed? Date: Is system complete? , y'� Date: a'.a Is system constructed as per plans? Ir Is well drilled? Date: Is well located as per plans? Are erosion control measures in place? 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 _County Department of _ Date: ��– _— Certified by: j�ZZ�Y.w� Design Professional Address: �r� �"�r Lie. # Comments: iWD Form FTR 99 �k d" APR -5 -2002 FRI 02:14 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL, HEALTH SERVICES 3�Y ')C '1`1 GiN rERI IT"°� ct tS VVAl 1+:'1'KjE�: iVY :I�')<` 1VY PERMIT # 0 Located at l w on or Village��`��'� Subdivision name j2G— '40A e Subd. Lot # __;P_1 Tax Map 4ZU_3 Block Z Lot /9 Date Subdivision Approved / % Renewal Revision Owner /Applicant Name A�,aif �� j� /V Date of Previous Approval Mailing Address X'-AG (Vx IC r'a z9i/ // _12 IV 1( Zip !o ; Amount of Fee Enclosed Building Type /le�'i cec Lot Area I & No. of Bedrooms A/° Design Flow GPD Y49 � Fill Section Only Separate Sewerage System to consist of Depth Volume ��� gallon septic tank and Other Requirements: To be constructed by Z!--/' Address Water Supply: Public Supply From Address or: Pr-' ate.:Supply B =ii �d by - �'� r• i�.�'1�rsc� - 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: R.A. Date / ✓s cr y License # � Address Y ZP, 4"° APPROVED FO CON RUCTION: This 8' ears from the date issued unless construction of the sewage treatment system has been completed an tg and is revocable for cause or may be amended or modified when consP ecessary y ublic y revision or alteration of the approved plan requires 'anew pe Appr di o d estic s g only. Y: Title: Date: Z p kite copy- HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Design P fe sional Form CP -97 l 1� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _._. 77� please print or type Well Location: Street Address: TowniVillage a Tax Grid # - 4 0, Map,4 Block Lot(s) jam' Well Owner: Name: Address: f J7i7 i S �e- %o /Gtd ��6 ®X�vo �i-� i r.✓�arl� iV' YAO yd3 Use of Well: esidential 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 gpm # People Served ¢ Est. of Daily Usage 'o o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ........................... ........... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes r' No Name of subdivision �.-C �, A 4 ah'r J�4e Lot No. Water Well Contractor: Address: , 4�r4��J`�,/..r?J -f AV'1 Is Public Water Supply available to site? .................................. ............................... Yes No ✓' Name of Public Water Supply: -- Town/Village -- Distance to property from nearest water main: `e----�r Proposed well location & sources of contamination to be provided on separate sheet/plan. �� � %Date: / 'rS3 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. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well dri ler ce ' y tram County. Date of Issue t D f . Permit Issum* fficial: Date of Expiration 0 o Title: ~ Permit is Non- Transferra e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF I-T_TE+'ALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Y �/ Date: S~Luc° ticiri" 'hkr 6/14ft wner Town qr�. i% Permit # TM # — Subdivision Lot #. 1 Sewage System Area ? j � � �. . a STS area�locatedas per approved .plans ............:........ b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth e. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank size - 1,000 ...... COD .......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 .............. cam. .......:......:.......... .. f.. Trenches T. Length required rOZ1 Length installed L10d 2. Distance to watercourse measured t7Ft.. /P.6. 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6 Depth of trench <30 inches from surface ................. �'1�7 — Roomallowedifoiex cans on, —1:00 0:... X81. Size of gravel 3/4 - 1' /z" diameter clean .................... .9. Depth. of gravel •i n trench i "' .miminium: ' °10: -ripe erids capped...........:... ......... ............................... g. Pump or Dosed Systems 1. Size ot pump chamber ................ ............................... 2. Overflow tank ..............:.............. ......:....: :.................. 3. Alarm, visual / audio...... ............ ...............:.:............. 4. Pump easily accessible, manhole to grade ................. 5., First box baffled ..............:........... ............................... 6. Cycle witnessed by kEestimated flow /cycle........... III. ouse/Buildin m ? b. Number of bedrooms ................... .....(.(..KJ................... IV. Well v a. Well located as per approved plans . ............................... b. Distance from STS area measured ' dot., 9(&e in X138" ab ve grade. ............ ............................... g - a ,. ce drainage ar iu well acceptable ....................... V. Overal Workmanship a. Boxes properly grouted ..................... ............................... b. All pipes partially backfilled ..:........ ............................... 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 provided ................. ............................... n___ a In-7 r, Aj �� �.�_ - -_- 1. -9 • ,`.-- �,. i J t �- �g�= . ., e 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: 2. Name of project: '>_ �= 4. Design Professional: 9:�g , 4 6. JXpe gi Protect: Private/Residential Apartments Office Building a 3. Location TN: 5. Address: g9�z Food Service Commercial Institutional Mobile Home Park Realty Subidvision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... .............:................. Type I Exempt Type II — Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ......................... A16? 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 10. Name of Lead Agency . ?- t_�:;5 =1" ''j ct is �: urea ale- control of local plar1 ing,. zoning, for other officials, ordinances? ............................ ............................... 12. If so, have plans been submitted to such authorities? .......... .............................�� 13. Has preliminary approval been granted by such authorities ?Y "Igate granted: ZAEZ 14. Type of Sewage Treatment Systerrr Discharge ................. surface water _/groundwater 15. If surface water discharge, what is the stream class designation? .................... 16. Waters index number (surface) .......................................... ............................... 17. Is project located near a public water supply system? ............... I ........ I............. w 18. If yes, name of water supply --- Distance to water supply 19. Is project site near a public sewage collection or treatment, system? ................ 20. Name of sewage system Distance to sewage system 21. Date test holes observed /11z ,Ze�Z 22. Name of Health InspectorAJopn � Form PC -97 r t µb 2 23. Project design flow (gallons per day) .... ............... ............... : ........,...................... 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... Gt% 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? Ve 27. Wetlands I.D Number ................................. ............................... �-- 28. Is Wetlands Permit required? ......................... Ale Has application been made to Town of Local DEC office? ............................... ra. 29. Does project require a DEC Stream Disturbance Permit? .................... I............ //d 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 ,w 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? ... I .............................. 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 15 years in or adjacent to project site?.. .................... ........ U 34. Are any sewage treatment areas in excess of 15% slope? . ............................... 6 Z. /.3 35. Tax Map ID Number .......................... ............................... Map Block Lot / 36. Approved plans are to be returned to ..... Applicant e_ 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 ro 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. JGNATUKES & OFFICIAL TITLES: Mailing Address: ................................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address�W,0 15k � awe Located at (Street) Tax Map Block Lot inM di to nearest cross street) Municipality Z��z Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test 11 NOTES: .1. Tests to be reneated at same denth until annroximately equal percolation rates are o at percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 Depth to From Ground "Level ::i.. ercl DJJ 41., . ... .... ... .... me fl4pse Tj.. Surface (Inchi�) 'Start In. R­ Ni -t' t t stop'.7' ne 017, 31 2 3 4 S 3 iyy 4 5 2 3 11 NOTES: .1. Tests to be reneated at same denth until annroximately equal percolation rates are o at percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. r/ HOLE NO. G.L. 2 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' HOLE NO. Indicate level at which groundwater is encountered o' /,-7e, Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: ,j�f �!j Date Design Professional Name: Address: Signature Design Professional's Seal I Ma M! � - W�, /-A 2 P U A NAM COUNTY DEPARTMENT OF HEALTH ` DIVISION OF ENVIRONMENTAL ,HEALTH SERVICES _ _ _.. v LETTER OF AUT1101UZATION RE: Property of Located at Tax Map l —Block Lot % Subdivision of >lc�� %�C�o�-�c =�'� Subdivision Lot 4 Gentlemen: N Filed Map f ^ Date Filed i This letter is to authorize �� _ - 1 ; ;7 a duly licensed Prolessionat Engineer x Registered to apply for the iequired wastewater treatment and/or water supply perinit(s) to serve the above - notes( property in accordance with the standards, rules or regulations as promulgated by the Public. health Director of the Putnam County Health 1)epartinent, and to sign all necessary papers on my behalf in connection with this matter and to supervise the C011St111C11011 Of Said wasteryclter tretment tlllii %or Water supply systems in conformity with the provisions old Article 145 andlur 141 of the Education Law, the Public'Realth �ht .l ?ut!m'1n Coiunl, 1_t<t('6'. �'rl� r� _ V.. _ ....:.. _ : .... _ .:.. - ._ :.�....... _._.......... _ . -. 2f. Ver}, truly yours, Countersigned: signed: Mailing Address X2Wr m.ailing Address: C, A �PNNC /S. 09 _ [�JiY State 14.1" rM7f- -T#xt II PROJECT LD. NUMBER ....y : ApptiQarr<IIY Watt Environmental OYallty Aaview SHORT ENVIRONMENTAL ASSESSMENT (FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT PG SOR a + 2. PROJECT R s 3. PROJECT LOCATION: Mumicipallly `/"n //G County d PRECISE LOCATION (Stroel address and road ImtersectioiW prominent landmarks. eta., or provide map, r 6. IS PROPOSED ACTION' eW O Expensic 6. DESCRIBE PROJECT BRIEFLY• ❑ ModlflcatlOMaltoretlon I. .AMOUNT OF LAND AFFECTED: initially — Items Ultimately . 8. WILL PROPOSED'ACTION COMPLY WITH EXISTING IONI a 1e� Yes t_.1 No If No, describe briefly .4e— sc,o — OTHER EXISTING LAND USE RESTR)CTIONS? 9. WHAT IS PPESENT LAND use IN VICimiry OF Po4ojeCT? AResidential ❑ Industrial LED COmnlerClal [ Agriaulfure _� Park/Forest/Open space 0 other 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROil ANY OTHER GOVERkMENTAL AGENCY IFEDERAL.: STATE OR LOCAL)? xyllis ❑ No it yea, list spency(s) end poOrmlUapprovala /7 /—/, 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERfrIT OR APPROVA' ? Ayes ❑ No It yoS, 1101 agenoy name and permlVapproval 12 AS A RESULT OF PROPOSED 0 Yes No EXISTING PERMIT /APPROVAL REQUIRIE MODIFICATION? �w r CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS `9UE.TO THE BEST OF MY KNOWLEDGE AppllCant / sponsor name: ���=! / �( .... — — Data: Signature: -- — -- — -- It the motion is in the Coastal Area, and you are s state agency, complete the Coastal Assessment Fofnt galore pmesedinp with this assessment 11VEA 1 01/10/2001 08:12 9149624248 JOSEPH SULLIVAN PAGE 01 OF ''° )'! SAT :I.) AM P!iWAM CTt E14V EALTH FAX !>!.0. 191J27398111 ?. ! BRUCE ti. POLLY LORETTA NOL1NMU ILN., M.S.S. Public ilraltk Drrrrtor Asre ak Public HoalA D wtw Doscror 01 pearm Srntus DEPARTMENT OF HEALTH 1 Geneva Road Brewster, Now York 10509 REQUEST EQFJ FIELI TES' NG A17IENTION: AADAAM STIEBEU G n GENE REED AN lnfortnadon below must be ImUY completed prior to any scheduling. DATE: �B d ENGINEER OR FIRM: t ��/j! r. I/P17 PHON LX: Rf MON: DEEPS: 0< PERCS: U PUMP TEST. o ROAWSTREET: .Jd re Ye Ot /5tsr B /a' TOWN! _ TAX MAI#: �• _� l SUBDIVISION: � � ?'� ��- LOT#:..�,_.., OWNER: � niS a_�► %;ry,�y�'L���J�� N:JCDU CRIUMA F1211313INT RE3r1EAr AND WITUSS G OF S9JiL =11DW YES NO Proposed SSTS within, the drainage basin of West Broch or Boyds Corner Reservoirs, d proposed SSTS within 500 feet of a reservoir, reservoir stem or control Jrke. o Proposed SSTS within 2W feet of a watercourse or a DEC wetland. Proposed SSTS design flow greater than 100 gallonsiday or SPD£S permit required. Q Proposed SSTS for a Commerical Project. 11 is the responsibility of the design professional to provide lot' ®tiovaiafiirittrihon prior to'siiiilesuiig:' -'" ____._:.�_ _ ___ This Department will determine the N'YCDEP project status (Joint or Delegated) based on the response. If you answered XU to any of the questions, N!'CDEP must'witntss the sot testing. This Department wiU coordinate a mutually suitable time for Reid testing with tha FCDOH, the Design Professional and N1i CDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDAP is required to witness.the aoll testing, It will be the sole responsibility of the dtaign professionAl to schedule re- witnessing of the soil testing with NYCDEP. FOR COCNTY USE ONLY /2 dJ} C. I represent that 1 am wholly. and completely responsible for the design and location of the above described will be constructed. as shown *is the approved'arnendment there to and in a County pepartment of .Naj.tn, and, that on•eomplation thereof ,a "Certificate of Constri M. subnnitted to the Oepartnsant . a "i wr od lttM'guarantea wilowner be furnished the owner Place Iii go o�atkq condition any part of said sewage disposal system during anee o1 the approval of ton Cartitieets:o/,COnstruetion Compliance of the ,oris wall be wed " d as shatwn olt. the a_ pprovee Pleii and that sa W wall will be Installed in County Department of. M" h.. Date 5-1 g1 % signed r$ Address APPROVED FOR CONSTRUCTION. Th appiovaI ex; pires two yYt., the `dat revocab* for cause or may be amendisl orniodifkid wheneonsldery by reoui►es a M W mwitt2 Approved for. disposal of domestic tenand /or Rev. Oete S - U _CJ ey 1ut88 _I . Fit system(s); 1) that the separate sewage disposal system with the standards, ►Mesas rpu 0nToi� IVIUitTnam npliance" satisfactory to the Commissioner of Mealthwill s, iiiWor assigns by theDuiklei.`thet,seld builder will 2j years immediately following tlwdate of the Neu- thereto; .2) that the drilled wall despibed -bow rds. rules and reou a�Tiions -of the Putnam P,$1000 R.A. — License NO– in of. the building .has bean undertaken and is It h: Any change or alteration of construction only. Title JOSEPH F. SULLIVAN, P.E. eonsteCtut y �n9in r 2972 FERNCREST DRIVE YORKTOWN HEIGHTS, N. Y. 10598 (914) 962 -4248 May 19,, 1993 Department of Health Division of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 Gentlemen, Enclosed please find a construction permit for the property of Jonno Hanofin on Hilltop Road in the'Town o -f Putnam Valley (TM 62.13-2-18). This design was approved by your department in 1991 (your file No PV 6 -91') From a field inspection of this lot, there have -been no changes in this lot or surrounding lots to adversely affect this design, Very truly yours 4 _m ;� t „�•� � .., _..- ... . - - - , - �.os�gph F_6 -- Sul_h�Tazi P-. �, - � -_- • _ . . - - -. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date L Re: Property of 17n /n v Located at (T) Ili Section Jj� 'V3 ock �' Lot Subdivision of C/a'CE'� A T Subdv. Lot # Filed Map # ��0� Z Date Gentlemen: This letter is to authorize a duly licenged professional-engineer J/ or regist6red architect (Indicate) to apply for %a Construction.Permit for a separate sewage system, to serve the above noted property in accordance 'with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with thia matter and to supervise the construction of said system or systems in. conformity wiich the gkuvisicr.s of ;rtic.10. 145 or 147, Education Law, the Public Health Law, and %the Putnam County Sani- tary Code. Very truly yours, Signed Counter P. E. ti Y; r % /e— er or Fpbperty • -- Adar e s s W3 wn _ 0r- e76 -5'32Y Telephone r F � e/ ' 70 e3 76' Af 4"; t z z � / 74 r F � e/ ' 70 e3 76' Af 4"; t 14 /3 ,- e z 14 /3 ,- e