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Home My WebLink About3146DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72. -1 -1.1 BOX 26 03146 . . - :: I I ` ' L Ir f •f1 I 03146 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - - CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # a >> Located ate; "�r�fc� %r��' � Town or Village Owner /Applicant Nam '1A1 2h j Tax Map �� Block Lot � Formerly Mailing Address Subdivision Name Subd. Lot # Date Construction Permit Issued by PCHD 2- N Zip /el_` -79 Separate Sewerage System built by ,'40 y !- %'� r' �^ ��' Address Vo d Cry rbi� 4)' r Y4( r!.5 e✓ y Consisting of 1 e, * o Gallon Septic Tank and 3 75- Other Requirements: 2 p� Water Sup&: Public Supply From Address or: Private Supply Drilled by /Y'. �c� .�r�c�✓� Address�/ a r✓ / "e-,,4V x Building Type 1 ?v G'� .�1 t° v .. ,,:. -Has- erosion_ c.:ntrol been completed ?. _ - _ Number of Bedrooms Has garbage grinder been installed? Ald I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: 2 e Certified by Address�1'% Any per n occup �prem/lise served to secure the correction of any unsanitary con treatment system shall become null and void as of the private water supply shall become null < P.E. -*' R.A. License # r m promptly take such action as may be necessary such usage. Approval of the separate sewage sanitary sewer becomes available and the approval a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. By Title: j Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY I➢EPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT 114V 1 E: Cxact location or wen wttn atstances to at least two permanent landmarks to be proven a separate sheet/plan. WellDriller'sN~ P9ill Drilling, Inc. Address: 75 Putnam Ave., Brewster, NY Signature: Date: R, -ri1 30r2003 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 uaress:' -"hown/Vili`age: Indian Lake -Club West Sub -Di Putnam Valley Wax grid # j MapgA Block / Lot(s) 2 Well Owner: Name: Address: Brian Behan 14 Ross Drive - Yorktown Heights, NY 10598 Use of Well: 1- primary XXXXX 2- secondary X Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment 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 41 ft. Length below grade 40 ft. Diameter 6 in. Weight per foot 17 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 _ No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours Yield —ar_ gpm Depth Data Measure from land surface- static (specify ft) 110 During yield test(ft) 900 Depth of completed well in feet 965 Well Log If more detailed information descriptions or Sic can lyses..,...._ I, are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 0 8- Fill - ....8. 9nQ _. _Iltaics'_ ' � (;la K .G.r •..� - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 965 5 Pump Type cis h Capacity ter._ Depth 660 Model 5GS15412 Voltage 230 HP '1.5 Tank Type QWhrag)ljolume 120 Date Well Completed 1.0/1.7/02 Putnam County Certification No. 2 Date of Report 1:0/29/02 Well Driller ignature) 114V 1 E: Cxact location or wen wttn atstances to at least two permanent landmarks to be proven a separate sheet/plan. WellDriller'sN~ P9ill Drilling, Inc. Address: 75 Putnam Ave., Brewster, NY Signature: Date: R, -ri1 30r2003 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPAMENT OF HEALTH _ DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ >.='.:.�' , -. . "::ce°.::w .".;,.•�va+i..`�«� -. .-.. ,c...'.iuw'- �:.,:ei'± : w:.m::.•:,: n':,:�w >:r";� ma �._-. ,:- :°.i w.- ...'�'�.y�...:.�... '. '? :.Ne.,?:ti-- .."s:...': i:i':a.�.:•:�. /Je�hpin Owner or Purcliaser of Building /r Building Constructed` by Location - /Street Municipality Building Type 72 /A Section Block Lot Subdivision Name Subdivision Lot # GUARAN'T'EE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, wor)ananship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the _.��rPrt,�f;cate saf Cnnstxu�tion Compliance" for -the. c�a?l::s�rs ar - -an �.. -•..:£ ...- _ "-"`� - "`� °"'repairs "made ey•me`to- siicYi � system; "'except: where t�i�""tailure �.o operate properly�is "` "" "� ' caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinental Health Services 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. 2 ®v¢ Dated this day of -IV- Signature / rJd Jj 'i`fi 3^ l �Ti General Contrac or (Owner) - Signature 5 di hz � Corporation Name (if Corp.) U.. - rev. 9/85 mk Title �- - Corporation Name (if Corp.) Address Z' JMS ENVIRONMENTAL SERVICES, INC. 15oo SUMMER STREET STAMFORD, CONNECTICUT o6905 NELAC, CT and.AYStpte- Certified. Environmento llabara>:ory_____._; , __ Y ;:a. - - ;r•,.:. - - - -- am —Z. � _...� • , ..� Mailing Information: Collector's Information: r Name: Mill Drilling Co. Client: Brian Behan Name: Russ ec �2- /� . ! L1) T I • r Address: 75 Putnam Ave - Address of site: Lot #2 Club West Subdivision City: Brewster City: Putnam Valley State: NY Zip: 10509 State: NY Zip: Telephone: Fax: 845- 279 -5075 Telephone: Sample's Information: _ Site: well head Date Collected: 4/22/03. Date Received: 4/23/03 Preservative: HNO3 Time Collected: 15:00 Time Received: 12:40 Temperature: <4C Lab No.: J032472 Date Analyzed Test Name Result MCL Method 4/23/03 15:00 Total..Coliform Absent Absent SMWW 9222B 4/23/03 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 4/25/03 Color ND 15 Units SMWW 2120 B 4/25/03 Odor ND 3 TONs SMWW 2150 B 4/25/03 Iron <0.03 mg /L 0.3 mg /L SMWW 3111B 4/25/03 Manganese 0.01 mg /L 0.3 mg /L SMWW 3111 B 4/25/03 Sodium 10.7 mg /L N/A SMWW 3111 B 4/25/03 -- / _. _... Chloride .._.:..._.._......_._._.. :: _: 37.0 mg /L 2.50 mg /L .......... ..__..:.Sp��n/`�!�4500-C! 3 "25iv� _ _ __ "Hard b ZU[ mg /L � N/A � _. SMWW 2340 C 4/25/03 Nitrate 2.66 mg /L 10 mg /L SMWW 4500 NO3E 4/25/03 15:00 Nitrite <0.1 mg /L 1.0 mg /L. SMWW 4500 NO3E 4/23/03 pH 7.45 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 4/25/03 Sulfate 28.8 mg /L 250 mg /L SMWW 4500 SO4F 4/25/03 Turbidity 0.13 NTU 5 NTUs SMWW 2130 B 4/25/03 Lead <1.0 ug /L 15 ug /L SM1IbPVIJ 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Signature: State #: PH -0218 Michael Lapman ELAP #: 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com BRUCE' R. FOLEY Public Tleair ()I. I ' LOI�,'ETTA MOLINARI IVAN" J�J"S.N Director q,/' Paa'ent DEPARTMENT OF HEALTH, I Geneva Road Brewster, New York 10509 Loyiruimmital Health (1)[4)279-6130 Fax (914) 278 - 7921 Nursing Services (914)278-6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Rarly Intervention (914) 278 -6014 Preschool (9)4)2')8-6082 Pax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX NIAP N Ll LNIBER: E911 ADDRESS: '1" 0 NV N': AU"I".140PIA"IZEDTOWN 0.VJ (Sigillatill-C) DATT.`-. At 'nic Putnatu ("OUIlty Department of Health. Nvilf ❑.ot issue a Certificate of miless the above foimi I-S c(impletedy, Le., z,,. Ce-goil E-91 'I addi-ess is 1ISSil"lled by MI aUtI101-iZed tOMI OffiCial. JJjiS form is to be submitted t-) Nvilth the application for a Certificate of Construction Compliance. 0191 i V I:M".ktvl). i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .- «- ..- ..:..�- .....- ,...M,. r....-:u.. . ,. v -.ar1 ...7�; . a.".: 1.: � �.r • 'zlg� i `,.� r-... . s. L ','t�'fui'rny �r "!4'_i L a ®"'i.7.. %JJ.T,i>Q '�i ' �.+v-•w a •.ti' —, .-sa C '"'8 � 10• -o V ••m gTi� "nns PERMIT # -. Located at -71? e./-j ar? %lle ¢d Subdivision name /4'Y c %� M67 Subd. Lot # 2, Date Subdivision Approved / v1 .,/ % Q Owner /Applicant Name ge a r, ®' �4 ,0.. S Mailing Address Town or Village 1.4,74 AId.-W Tax Map 72- Block Lot Renewal Revision Date of Previous Approval Zip/osjf, Amount of Fee Enclosed ci:) 6149 Building Type G % vOf CCLot Area 11.71 No. of Bedrooms 3 Design Flow GPD 41�o a Fill Section Only Depth Z / Volume PCIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of /ad e Other Requirements: To be constructed by Water Supply gallon septic tank and 3 7s o4 . r Public Supply From Address Address -_..._-,:_:_. _...ax:._...:._- : ✓_....:Pxivate Supvly.Drilled by.. %1!'• .,�� a° 4.c►'rr.. -- Address )50, eT - `e 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 s,, em 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. OF NEPy�' o ' � �, c Signed: O` ��.}.s R.A. Date Address 1` q 7 Z- License # CAV APPROVE OR CONSTRUCTIION: This app fat I& 8 ars from the date issued unless construction of the 14 sewage treatment'system has been completed and. insp`kt� t1T� and is revocable for cause or may be amended or modified when considered necessary by the Public Health `irector. Any revision or alteration of the approved plan requires a new p� it. Approved or discharge of domestic sanitary se age only. By: �/ _ Title: Q Date: 0-2 7 ti Z White copy - HD lif le; Yell w copy - Building Inspector; Pink cop // Owna'j Orange copy - Design Professional f1 Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL CH Well Location: Street Al ddress: Town/Villa a Tax Grid # - �d1Gri4 d /a '.4 am Map %Z Block Lot(s) %.f Well Owner: Name: Address: d L // Use of Well: r14 Residential Public Supply Air /C nd/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 Apo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling 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 r' No Name of subdivision vyG Lot No. 2 Water Well Contractor: o r 4z 17 e n Address: ' r6O!�fdr-P,`,r �•��1�a //� y Is Public Water Supply available to site? ................................... ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: /"7 i /ems Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: / /Z/ a> Z Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. 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 t well driller certified by Putnam County. 7 / 1 Date of Issue -1 —0 -z-- Permit IssuinA Official: Date of Expiratio — —O Title: " _ _ Permit is Non- Transferrable v White copy - HD file; Yellow copy - Building Inspector; Pink copy - O er; Orange copy - Well driller Form WP -97 Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 ''MU NAR1 K.N.; M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 February 20, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Frank Sullivan, PE 2972 Femcrest Drive Yorktown Heights, NY 10598 Re: Dear Mr. Sullivan: Proposed SSTS - Beham- Mobais Indian Lake Road, (T) Putnam Valley TM# 72.4-1.1 Review o ans and other supporting documents submitted at this time relative to the above regard project has been completed. Comments are offered as follows: A minimum of one (1) deep test hole and one (1) percolation test is required to be in each of the primary and reserve systems. - - rJr:: L 1vVVly� vl u sIiii'lC'vi3VU tc, ieilGi the above corfilricrlts, 1C11S appiicatioii °viii be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj 14-164 ry87)—Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C _ tit l' AkT—u tineniat Wality ievlew y SHORT ENVIRONMENTAL ASSESSMENT FORM.. For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (TO be completed by Applicant or Project sponsor) 1. APPLICAq T /SPONSOR 2. PROJECT NAME 3. PROJECT LOCATI - Afunicipatity `e- County 4. PRECISE LOCATION (Street address and road InterseSM'on$, prominent landmarks, etc., or provide map) �o /Vol 5. 1S PROPOSED ACTION: e'+v D Ex ;aasion D Medificationlalteration 6. DESCR!3E PROJECT BRIEFLY: ' C ?. AMOUNT OF LAND AFFECTED: Initially _ acres Ultimately Ati—e- acres 8. WILL PROPOS:,rYtACTION COMPLY WITH EXISTING ZONIN49 OR OTHER EXISTING LAND USE RESTRICTIONS? Zes t ± No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? r� I R sidentia! _ Gindustrial 11pamnerciai L..3A ;r,,v%ura_ 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCALr? /mil Res ❑ No It yes, list agency(s) and permitlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? Yes D No It yes, list agency name and permit/approval 12. AS A P.ESULTtOOFPROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? y ❑ Yes bo I CERTIFY THAT THE INFORMATION PROVIDED ABBOOOV�E, IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponsor name: / ��"� -Z y� Date: Z Signature: FW.0511VA �*, V =e/ rr. If the action is in the Coastal Area, and you are a state agency, complete'the Coastal Assessment Form before proceeding with this assessment nvt:ct PART II- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION QXCEED ANY TYPE I THRESHOLD iN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. Dyes o B. WILL ACTION RECEIVE COORDItlATF.c Fw:,EN, r�P't,;r_., �' `- `'rr ' ° s_ � ....1..; �., v,'IVna sN b N"Y�'R; PA�7 617.62 {! No, a negative detlaralion� - -- �?.= �y`tr: =sy�yeueu`by en_oltie'r' In`voived agency... . C1 Yes b C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) Ct. 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: f). iS T il; ❑ Yes OR IS 'THERE LiKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? o It Yes, explain briefly PART 111 — 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 lts.(a) setting (i.e. urban or.rural);_(b) probability.of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (I) 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•slgnificant 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: A's k.1 Print or T e frame of Resp*Aible Officer in Lead Agency A ncy ' • T' e o Respansib a er Signature o Prepares It different from responsible o titer) 2 - . e t C3. Vegetation or fauna, fish, shellfish wildlife species, significant habitats, or threatened or endangered species? Explain briefly: a C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or othet natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be lnduced'by the proposed action? Explain briefly. C.n C8. Long term, short tern, cumulative, or other effects not identified in CI-05? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. f). iS T il; ❑ Yes OR IS 'THERE LiKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? o It Yes, explain briefly PART 111 — 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 lts.(a) setting (i.e. urban or.rural);_(b) probability.of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (I) 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•slgnificant 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: A's k.1 Print or T e frame of Resp*Aible Officer in Lead Agency A ncy ' • T' e o Respansib a er Signature o Prepares It different from responsible o titer) 2 - . e t BRUCE R FOLEY Public Health Director DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health. Direci ogr c?irLrror'"'Sj'�r'a> ent S'e`rvi`c'es - Environmental Health (914)278-6130 Fax (914) 278-7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 COVER SHEET PROJECT (O',Amers Name): /J IJIl_e,7,4 r� STREET: �,` �� G `��i' /��r NIUNICEPALITY:� �✓ 1� 1 TAX MAP NUMBER: DESIGN PROFESSIONAL: -- t —( lit l / i �� DATE: s dZ REVISION El REQUESTED ADDITIONAL INFORMATION OTHER I,ITERE� PUTNAM COUNTY DEPARTtNIEN? OF HEALTH DWISION OF ENVIRO\liE\ ?AL HEALTH L- DWIDUALWATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS - - - VIEW - - .�.... RE �� SHEET FOR CO \STR[Jf�LON P_FR�In' NAME OF OWNER: %�(D S �ET LOCATION: a REVEIED BY: R` OR, AS, T ATE: AX biAP ": (CONFIRNIED) 1' \ DOCTRNMN -IS _Y A" (REQUIRED DETAILS ON PLANS COYT'D) 4(JPERINUT APPLICATION (J(_)HOUSE SEWER -'/1' FT. 4 "0'; TYPE PIPE CAST IRON j/JUtiti•ELL PERMIT OR PWS LETTER L ,N 0 BENDS; NLAX BENDS 45° W /CLE.ANOUT (SUP C -97 RENEWALS LQ(JLETTER OF AUTHORIZATION SITE NOTE (NO CH_4NGE) (�LJDESIGN DATA SHEET (DDS) /� FILL SYSTEMS (J(�CORPOR..TE RESOLUTION L/J(J10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (IJUSHORT EAF Jf�FILL SPECS/ FILL NOTES �T A —Y (f UPLANS -THREE SETS UUHOUSE PLANS - TWO SETS NS L Di EXPANSION AREA UUVARLA,NCE REQUEST �UBDiVISI ON FILL GREATER TFId N FEET 2 F,� LEG.A.L SUBDIVISION UU CLAY R j.j p.0._r.S7 _ �—) FILL CERT T NOTE Sry �UU_ APPR CHECKED- -.-- - - UUPERCRATE UUDEPTH GAU t U(JVOL. ON FOR O.B., UNCLASSIFIED & IMPERVIOUS (�(JFILL REQUIRED DEPTH , UUSEP TIO, DISTAN OM TOE OF SLOPE LJ(_CURTAI:\ DRAI`i REQUIRED NC GENERAL L�JLF TRENCH PROVIDED -33 60FT MAX. (J( LOCATED L\ NYC WATERSHED (J(JPAR4LLEL TO CONTOURS UU SUB`IITIED 100% EXPANSION PROVIDED: t,JLJDELEG CHD -- C��DETAiL/DUST FREE CRUSHED STONE OR WASHED, GRAVEL APPROVAL, 'D ( ��jj ' ��GEOTEXTILE COVER DEEP TEST HOLES OBSERVED U SEPARKTION DISTANCES ON PLAN - FROM SSTS (JPERCS TO BE WITNESSED 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (J/'(JEX- APPROVaI. SSDS ADJ, LOTS C 2DX TO FOUNDATION WALLS - U(�vETLAIvDS (LOWN/DEC PERMIT REQ'D ?) - ' U/ 0100' TO WELL, 200' Tl`I DLOD,150' TO PITS (.eJ-(JDATA ON DDS PLANS & PERMIT SA14IE 00' TO STREAM, WATERCOURSE, LAKE (inc. eipan) UL::�JlkE 1969 NEIGHBORNOTIFICATION (x,50' TO CATCH BASIN, 35' STORMDRA3N,PIPED WATER ULl$TTER BUZBA �l� _10' T_O W ATER I.M- ;Tats X20'-1 _:` FLOOn_E.1; VA.fl .t�� vY!?nnc :.- .� : v 1� " j50' I`IRL`ERYII7TENT DRAh`iAGE COURSE L„j(_J�OIL TESTENG LOTS >10 YEARS OLD HB0'LNffiX 00' /500' RESERVOIR, ETC. 150' GALLEY SYSTEMS t�REOUMED DETAILS ON PLANS TO LEDGE OUTCROP SEWAGE SYSTEM PLAN- (NORTH ARROW) (� )SSDS HYDRAULIC PROFILE SEPTIC TANK . �J10' FROM FOUNDATION; 50' TO WELL GRAVITY FLOW /� WELL CONSTRUCTION NOTES 1 -15 (J` DIMENSIONS TO PROPERTY LINES -- -- -" - -- "' (effC DESIGN DATA: PERC &DEEP RESULTS ( }LOCATION OF SERVICE CONNECTION 2' CONTOURS EXM`IING & PROPOSED _ _._— -_ (� JNW 15' TO PROPERTY LINE ( DRIVEWAY & SLOPES, CUT S LOPE DRAINS Lis SLOPE IN SSTSAREA �4= (520 %) (USDA SOIL TYPE BOUNDARIES' REGRADED TO 15 %, IF REQUIRED � BLOCK; OWNERS NAME ADDRESS DOSE/PUMP SYSTEMS TbLT, PE/RA; NAME, ADDRESS, PHONE I U PUbIP NOT (J DATE OF DRAVMG/REVISION ` J (�i'JDATUII REFERENCE SE 7" ° OF P E VOLUME/DOSE VOLUME NOTED U d(�JLOCATION OF WATERCOURSES, PONDS UDE FOR F RCE MAIN, (PIPE TYPE, ETC.) ' /LAKES,WETLANDS WITHIN 200' OF Y.L. UU AND SHOWN & DETAILED �J(PROPOSED FINISH FLOOR AND U DAY STORA E ABOVE ALARM BASENIENT ELEVATIONS CURTAIN D-EM ( W ELLS & SSDSS WIIN 200' OF SSTS C_ –)ST P S S' BOTH SIDES, DETAIL PROPERTY METES & BOUNDS UU15' h to C SAS %, 20' -4 %, 25 =3%, 35' -1 %,100 % -Q% j (__)L j20' o D DISCHARGE/100' with 182 cons day discharge ML`( to NON - PERFORATED PIPE COMMENTS: r (REVSKEET) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of /Mle/4-5 Located at h �a�f� �a a G T/V P" 410 6�e ax Map # _ Subdivision of Subdivision Lot # Gentlemen: 2 -7 Z Block / - Lot 1.1 Filed Map # This letter is to authorize 7 o -.5 1 q-, P)/ '41A Date Filed S�zi%oJ a duly licensed Professional Engineer or Registered Architect to apply for. the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public ligalth a« - _ _tom - _ . GI "\ �i tll� l�^J UlI1lQ0.Y Countersigned: .►'°'°"n"�• P.E., R U # co * a �r Mailing Addr ias rj rG State Zip Telephone: Very truly y urs, Signed: (Owner of Property) Mailing Address: lo ,e e *i,)N Ito / 1 A t 5 A3 Y State A) Z Zip Telephone: '--7 7 0 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES >>�vU'�ti[.� . N ,•v{'s.-1zf.�Sa�mf�i:i&..n.':ii .:.�*.`` \.TI�T•3,�T -�. Air �T � ..-.. ...fw v�.•.1..... ...tm r. a.. w�... .d.... ei.K T:'r•C G. A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 4 C4 2. Name of project:. ,!��3 7-,5 3. Location TN:4C �� 4. Design Professional• �' [ / /.'Np�� 5. Address: 9`7Z �wr��i' f r. 6. Drainage Basin: ;7s2c&Z2 ozg;-e/ee / /-h,l Al y 7. Type of Project: /03 9 y _yam Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? eo Type Status check one yP ( ) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... lVe 10. Has DEIS been completed and found acceptable by Lead Agency? ............... -- 11. Name of Lead Agency _ 12...I<S his pr .an. area under the control of local.plAping,.zon or o ?per °oft vials, oidina CCj? .......:............................................... ............................... _ 13. If so, have plans been submitted to such authorities. 3 - ....... 14. Has preliminary approval been granted by such authorities? Date granted: / o //-f 94,51-2 z. fo/ 15. Type of Sewage Treatment System Discharge ................. surface water v^ groundwater 16. If surface water discharge, what is the stream class designation? .......... ........... /✓ /9. 17. Waters index number (surface) ................................ : ......... - e ......... . ........ r........... A&A 18. Is project located near a public water supply system? ....... ..........................r...0 a 19. If yes, name of water supply -- Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ ed 21. Name of sewage.system Distance to sewage system elho 22. Date test holes observed Cl 23. Name of Health Inspector P G ��•A ,f�r�� 24. Project design flow (gallons per day) .............9. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... Ala 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 M 27. Is any portion of this project located within a designated Town or State wetland? 1416, 28. Wetlands ID Number .................... /✓� - 29.. Is .::........................... ............................... :. y %✓y Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? .......... Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any :. other potentially known source of contamination. Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... /lo 35. Are any sewage treatment areas in excess of 13% slope? ...:................ 36. Tax Map ID Number Map _L2 .......................... ........:...................... Ma 2 Block l Lot J• / 37. Approved plans are to be returned to ..... Applicant P"Design Professional NOTE:.All applications for review and approval of a new SSTS to be located withiln._thP I 'CFate hed,s _. be.sent tot c Depa ,mx er4r attd.n& i e 3uylice to,'ine I5EP, although the project may require DEP M approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as storrnwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application nust be accompanied by .a Letter of Authorization (Form LA -97). Failure to comply with this pr otsion may be grounds for the rejection of any submission. Ihereby a ff irm , ) under penalty o erJ u ry, that in f ormation provided on this f orm is tru �. to the best of my knowledge and belief. False statements made herein are punishable as t 5 a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Lai e-01-1 SIGNATURES & OFFICIAL TITLES:� 7 2- )01ril'drGs Mailing Address: ................................... " 4 y% O � PUTNAM, COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES A V -� i1Niv`'`1' SY� STEM / Owner Address ¢ Ro33 ?r; kle �•► ��h, ••� •� �� Located at (Street) A J2 464 i'! L oyle, � Tax Map 7 Z Block Lot (indic e nearest crass street Municipality _ __� �� Watershed rJ�`� L� SOIL PERCOLATION TEST DATA Date of Pre- soaking 3 -2—d' Date of Percolation Test 3' Zd' — y'7 S f I I I 1 -1 1. Tests to be reueated at same depth until annroximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 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 Water".' �� . :�?4�ater ,. From Ground . . Zevel FercolAtta k;la se Time Surface (Inches) :. ; .11iro In. pp ;...: Pita: ..:<.....:..;}Zuu.;I?(o:;;: `:�5. - a;rt:;:::"�t9g.: ' i.n.) r Sta ... Stu •t p_; nches 11.:... „tuflC::` z 3 5 3 IAI 4 5 � F w� 1 ' a � z 3 4 S f I I I 1 -1 1. Tests to be reueated at same depth until annroximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 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 4 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTHF ' HOLE NOS aHOLE 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 Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: T-1�5 w`Ii`VC., Date % Design Professional Name: -j N) i ✓cud Address: 2- 7 Z_ ,?- w 61- ,,-P w Signature: Design Professional's Seal gyp NEW \\ cis o z i� i f PUTNAM COUNTY DEPARTMENT OF HEALTH rr DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location TM# El Q SewaLye Svstem Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of pl ce nt 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................................................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course /vaetlan s ...... ............................... Sewage System / a. Septic tank size - 1,000 ......... 1, 250 ......... other ................ b.. Septic tank installed level ................ ............................... c. 10' minimum from foundation ................ :... d. Distribution Box 1. All outlets at s vation -water tested ................. 2. Protec ow frost .................. ............................... =um 2 ft.Original soil between box &trenches e. Junction Box - properl ...... 6. renc es �� 1. Length requir d ' ` L Length installed 3� 2. ow e . ..... ..... accordin to ............................. AS 4. ope of trench acceptable 1/16 - 1 /32 " /foot............1�� AAA ft. from property line - 20 ft.- foundations.. C. , .n_ 6. Depth of trench <30 inches from surface................. �`� 7. Room allowed for expansion, 100 %....... WJ' 8. Size of gravel 3/4 - 1112" diameter clean. . 9. Depth of gravel in trench 12" minimum.... ... 10. Pipe ends capped ,. _.......... r. .9i5 w or . /.. ... ,1 1. Size of pump chambe .................... . 2. Overflow, tank.. ...... ....................... ........... 3. Alarm, vi audio ........:........:.. ............................... 4. P asily accessible, manhole to grade ................. 5 first box baffled .........................................................--- wi nesse estimated flow/cycle ....... : °:M —Ouse uilding - - -- a. douse located per approved plans .............. ... ..... ........� /`� b. Number of bedrooms ............................ .................... Well located as per approved plans . ......:........................ b. Distance from STS area measured 14, /PV * - ft........... c. Casing 18" above grade ................ .............1................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ............................... i. Erosion control provided ................. ............................... 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