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HomeMy WebLinkAbout3148DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72. -1 -1.3 BOX 26 03148 - NAM COUNTY DEPARTMENT OF HEALT�� LO -H i► °i``'ce � �'t � _� CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # ( t.-,/'G' 3 h 4 Located at �iu.> ,�r �'S € Town or Village Owner /Applicant Name %`�i� /� -..S ✓ c� r�,�Tax Map i7 Block �_ Lot Formerly Subdivision Name,/e, Subd. Lot # Mailing Address 'J�, t� ��7i1 /r�rcv lle a Zip /G- Date Construction Permit Issued by PCHD Separate Sewerage System built by Address Z!`' 15:; a JAU Consisting of /2511 Gallon Septic Tank and ` !'•~ �� Other Requirements: Water Supply: Public Supply From. Address or: Private Supply Drilled by Address��r� liutlding hype` C L -C.� _ alas erosion control been completedi'. 5 -- Number of Bedrooms !� Has garbage grinder been installed? ,file" 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, �tnlent of Health. Date: .S �, -�i' Certified by P.E. t-'" R.A. Address �� (Design Pr A d %gl' /r7c"i�c��r-.'Y_ o cense # i� ?assn Any es person occupying premis erved by t above syste take such action as may be necessary to secure the correction of any unsanitary conditions resulting usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. Title: e copy -I-ID File; Yellow copy - Building Inspector; Pink copy - Owner; Date: f 7 Orange copy - Design Professional Form CC -97 11 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT NOTEYExa6t location of well with distances to at least two perman t larnamarks to be provided on a separate snecupidn. Well Drille Signature: r's Name �/ Address: Date: X 1 16 4,'7 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 ; ;Yet Ci V'­­ Map '7a Block Lot(s)1,3 Well Owner: Na e: Address: AM, y Z9.110— � Use of Well: 1-primary 2-secondary LX_ Residential V Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment __X- Rotary _ Cable. percussion Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length #0 ft. Length below grade 31? 1ft. Diameter —in. Weight per foot /w/ lb/ft. Materials: _X Steel Plastic Other Joints: Welded ->e Threaded Other Seal: -,e, 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 9 Compressed Air Hours:,TtT Yield LL gpm Depth Data Measure from land surface-static (specify 30 1 During yield test(ft) ----------- Depth of completed well in feet .540, Well Log If more detailed information descriptions or aieve analyses.. - are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface -14 77.1 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Typed Capacity Depth SU-6- Mode Voltage 290 HP Tank Type& ),.(b Volu e b45l, Date Well Completed Putnam County Certification no. Date of eport Well Driller (signature) NOTEYExa6t location of well with distances to at least two perman t larnamarks to be provided on a separate snecupidn. Well Drille Signature: r's Name �/ Address: Date: X 1 16 4,'7 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 12:1;19 i_-'R0fI:?UTNHrI C0JATY DEPART 845-278-7921 T0:919145_,:­24= W'11 WIlk Kratrh Dyte. ,.id, D'2PAPTM,.Nr OF FEALTH' P Ocama Road.. Brews*;- New Yoik IQSP-. EnAraptuentsil Heakh (914) Z'S - 6130 Im, (014) 276 .1921. - NurAlng Servlc,!s (914)219 -655; WIC (914)219•! S Fix 0) 14) .t7(• Asirly Intervention {514)278 -6014 fteseboal (914)2i8f12 -6648 7-- LO AS A TOWN: ;X Tile t.-tuhmin County Department of Health'i,01 itot isme a Ceiti I[i; x1l, C orlsihi I C "to mplianii ­ iti­ ihi al) i ' fan" i0l EL Co !e ur ss e ove a is complated., Le., lit ped by ail RUthoriudiawn official. witIl the' 1I,PAkafi0,nf0,.� Ce4fidlte ofCon"Sitfitctiort 0 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 �- Albert H. Padovani, Director LAB - #: 1.603010 CLIENT � #: 59395�����M NMNM�NNMNON�STAT�PROC' PAGE- ��M1--NM SPOONHOUR, GILES R. DATE /TIME TAKEN: 05/22/06 12:15 P.O. BOX 223 DATE /TIME REC'D: 05/22/06 01:45 PUTNAM VALLEY, NY 10579 REPORT DATE: 05/30/06 PHONE: SAMPLING SITE: 57 INDIAN LAKE ROAD SAMPLE TYPE..: POTABLE PUTNAM VALLEY PRESERVATIVES: NONE COL'D BY: TEMPERATURE..: < 4C NOTES...: WATER TANK COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 05/22/06 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 05/24/06 LEAD (IMS) 28.5 ppb 0 -15 ppb 9003 05/25/06 NITRATE NITROG 0.53 MG /L 0 - 10 9052 05/24/06 NITRITE NITROG '<0.01 MG /L N/A 916 -,2 05/26/06 IRON (Fe) <0.060*MG /L 0 -0.3 mg /1' 9002 05/30/06 MANGANESE (Mn) <0.010 MG /L 0 -0.3 mg /l 9002 05/26/06 SODIUM (Na) 3.49 MG /L N/A 9002 05/22/06 pH 7.4 UNITS .6.5 -8.5 9043 05/30/06 HARDNESS,TOTAL 96.0 MG /L N/A 05/30/06 ALKALINITY (AS 76.0 MG /L N/A 9001 05/25/06 TURBIDITY (TUR 2.5 NTU 0 -5 NTLT COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS) (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p, EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. iblic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg /L, else water undertaken to reduce the waters corrosive Fe /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet ;the water should contain no more than 20-mg/L of Sodium. -For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 . � s -.. .. w .re _ z.u: �.a..,s r...c ...... .. m .... a.r. w' _-� E:. ar ,. ��.•�.:+c.� -. ..�...... . �+�� -,�.:_ i. n. __ :.. .... w...... �- �i. �.r .. :.ti.'e •- .- ..z.: :. =.ws• r .... s» . ' Albert H. Padovani, Director LAB #: 1.603010 CLIENT #: 59395 NON STAT PROC PAGE: 2 SPOONHOUR, GILES R. DATE /TIME TAKEN: 05/22/06 12:15 P.O. BOX 223 DATE /TIME RECD: 05/22/06 01:45 PUTNAM VALLEY, NY 10579 REPORT DATE: 05/30/06 PHONE: SAMPLING SITE: 57 INDIAN LAKE ROAD SAMPLE TYPE..: POTABLE PUTNAM VALLEY PRESERVATIVES: NONE COLD BY:. TEMPERATURE..: < 4C NOTES...: WATER TANK COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L . �. .r , �i�r- RA'1,'� %i.. riAFcL .iti[ TER.:_._ 7.0. -�40 _ M_ G/L , . :�lG: _ - I�ilLi� wG'_?3,t�i _PER LITER _:r HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) SUBMITTED BY: Albert H. dovani., M.T.(ASCP) Director ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear. Street Yorktown Heic ' r Albert H. Padovani, Director , ` LAB #: 1.603209 Q-JEN[ #: '593,7-5 NON STAT PROC FAGE: 1 SPOONFIOUR, GILES R. DATE/TIME TAKEN: 06f01/06 12:15 P.O. BOX 223 DATE/TIME REC'D: 06/01/06 12:45 PUTNAM VALLEY, NY 10579 REPORT DATE: . 06/08/06 PHONE: SAMPLING SITE: 57 INDIAN LAKE ROAD SAMPLE TYPE..: POTABLE : PUTNAM VALLEY PRESERVATI VES: NONE COL^D BY: GlLES TEMPERATURE..: NOTES...: HOLDING TANK CDL]FORM METH: N/A DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 06/05/06 LEAD COMMENTS: Pb /CU LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be t ti l po en a � <1 p p b 0-15opb 9003 mb}ic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have aLEAD value of more COPPER value of 1.3 mg/L, else water- Undertaken to reduce the waters corrosive M.T.(ASCP) �` ELAP# 10323 PUMAM COUNTY MARTM= OF HEALTH � -��- _. �. _ ur. •..._.Y ..� .__ �- 77, r - -• �T ;:7 .-�c� .�^nerro s�nr�ar, Far `� Owner or Purchaser - 4ff Building Building Constructed by Location - Street Munici lity Building Type Section Block Lot /l, y l%1G� Subdivision Name Subdivision Lot # GUARANI'E'E OF SUBSURFACE SSOCE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location., workmanship, 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 f?. 4. period -of _twQ years immediately following the date of approval of the repairs made by me to such system, except where the failure to operate properly is ~' caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the.Division of Environmental 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 buildthq utilizing the system. Dated thi r -'�-�— day of C� eral ntractor (Owner) - Signature rporation Name (if Corp.) Address rev. 9/85 mk Signature Title Corporati8n- Name (if Corp.) • :t - SHERLITA AMLER, MD, MS, FAA_ P .iv :.. -�: ...�..,�:. .- MTV.:' L': i!>: w�+: �::' n; ggfi.j ��� %;�r�•:�.- e�..'�s::.c:.= _� -..c a.. . ..n LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 December 12, 2005 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 1.0598 Re: Dear Mr. Sullivan: ROBERT J. BONDI J Field Inspection — Spoonhour 57 Indian Lake Road, (T) Putnam Valley TM# 72 -1 -1.3 A site inspection was made for the above referenced project on December 8, 2005. The following comments must be corrected in the field. 1` The SDR -35 between the house and the tank needs to be completed. �.k, 2. The 45° bend in the SDR -35 needs a cleanout or be replaced with a series of 22° elbows. 3. The well cup is loose and needs to be tightened. 4. System can be backfilled. Up If you Y , ou have any further questions, + please contact meat (845) Y27.8 -6130 ext. 2157. "im Sincerely, Joseph S. Paravati, Jr. Assistant Public Health Engineer. JSP:cj 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 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 1 J. IT d y Street Location Town P L/ Permit # _3 l,✓-- v 3 TM # �, - / — "3 Subdivision Lot # jo tj 4 !a% LA/es 1. Sewage System Area •a. STS area located as per approved plans .......... :................. b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped .............. ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands .............................. t j. j'.A II. Sewage System a. Septic tank size - 1,000 .........1,250...` other ................ b. 'S eptic' tank installed level ................ ...........:................... c. 10' minimum from foun dation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested.....' 2. Protected below frost .................. ............................... 3... Nfinimum 2 ft. Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. Trenches 1. Length required 'Y 00 Length installed 2. Distance to watercourse measured Ft .... W 3. Installed according to plan ............. 4. Slope of trench acceptable 1/16 - 1/32" /foot........ .I.... 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ........:......... 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: :., .....:._._....,. 9,. Depth of gravel in trench 12 minimum. ... :... .. .....:....................:.... g. Pump or Dosed Svstems 1. Size of pump chamber ................. ............................... 2. Overflow tank ................. ".. . 3. Alarm, visual /audio ........:........: /.V........................: 4. Pump easily accessible, manhole t grade ................. 5. First box baffled .......................... ............................... 6. C�yycle witnessed by H.D.estimated flow /cycle........... III. Houselucilding a. house located per approved plans .... .....................:::....... b Number of bedrooms ......... ............................... . IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measure '00 ft ........... c. Casing. 18" above grade ....................................... I......... d. Surface drainage around well acceptable ....................... V. Overall Worlomanship . 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 pl� f. Curtain drain outfall -protected & dinto exist watercni-rii g. Footing drains discharge away from STS .area ............... h. Surface water protection adequate ........ :.......................... i. Erosion control provided ................. ............................... Rev, 12/02 YE ' NO COALULNTS w =LX ' lute FL =.7 5 -- �Zr• r i ►� I. a iSe.. ° s Q /L 7 5' L/ �r 1. s Form _ Le` 12/04/2005 11:25 9149624248 JOSEPH SULLIVAN PAGE 01 -47 PLTNAMC0UNWDZPARnWT0W=",Tj6j DWSION OF IMMOMENTAL =ALIN S=VKM ATTEUIN'TION 0 GENE All infbivatiou inug ix-, fully completed prior t.6 any impe.,flors being; made. PCID bons "MOtion Permit #--5'b/ d3-e4 OwnWA-) licatt Name: 3 �Aof 14 loo- TW2.2 P Formerly -�Blarck SubdiVidoNow Subdhulmi Lot # 2.11111111t.- Is sydew fill coqiletai? ISSY."teMC04.,ete? Is system Const.-umed n. per plans? Is w.0 chilled? Is wall located .as per: plans? Are traiwa conVol. inplac .41-11 I certify that the syma(l), as listed at the above p, revim ha Imft acaftsakd and I hav L, i.3 Rad verified their wmpletWu is accordance with the h ?do Cioustmedon t; i ;iad o-t,-e-1 p1m:; Dw, Certified by: ;> Address: # -7- V its, y 400 -A 7ep Folin ECK-99 : PUTNAM COUNTY DEPARTMENT OF HEALTH _DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEW ENT SYSTEM PERMIT # If—az sul Located at Zia h L�� y v d Subdivision name 'r.� a Subd. Lot # Date Subdivision Approved _ ?Z/ Owner /Applicant Name dre 3 ��► dd s� /� 8 !' Mailing Address L� fi�i " /��v� ��✓r.� ►'� Amount of Fee Enclosed d Town or Village Gi►ey' Tax Map Block � Lot Renewal Revision Date of Previous Approval Zip Building Type ,,s' 11 ;0-n C C- Lot Area 5 :; 44 No. of Bedrooms 4(- Design Flow GPD _Z a Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of er 27-P" W Other Requirements: lq ll ,5 2J,& To be constructed by gallon septic tank and 4 c e ) - )�' Address _._.W. _ater S11p ply: y_ Public Supply From Address or: Private Supply Drilled by G/' "��✓� Address %°� _ ._. - _ •: C`. 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. P.E. APPROVED/FOR CONSTRUCTION: Tlfis approval Kxpires two years from sewage treatment system has been completed and inspected by the PCHD and is i modifiel when considered necessary by the Public Health DirecWr. Any revision a new p rmit. Approver discharge of domestic sanitary se age only White copy - HD copy - Bolding Inspector; Pink copy - Date !l _3 construction of the ay be amended or oved plan requires - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL .. _. _,... r: .'c pi tr Pi- ' rc ITiIC Well Location: Street Address: Town/Village Tax Grid # >- a 1a�/ye-. �� '//j�� � ap �7� Block / Lot(s) /.. Well Owner: Name: / ee /�r��r'.3�Gdh6�cyf Address: J ` -1:3 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 `s gpm # People Served _ Est. of Daily Usage oe al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ,t✓l" Supply (new dwelling) Deepen Existing Well Detailed Reason�,„`�y for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ..................................... ............................... Yes � No Name of subdivision e �' At4 !e- Lot No. -eq Water Well Contractor: lVt fir, AAddress: / Is Public Water Supply available to site? ........................... Yes No Name of Public Water Supply: -- Town/Village —° Distance to property from nearest water main: /Y%i f Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: f/ � Applicant Signature:...�c�i���? 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. . I Date of Issue 7,-2, --o 4, Permit Date of Expiration 2 -o 1�7 Title: _ Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector;. Pink copy - OwneF,, Orange copy - Well driller 6-� Form WP -97 qEW YORK STATE DEPARTMENT OF HEALTH Specific .Waiver 3ureau of Community Sanitation and Food Protection from Requirements of Part 75 a,,,,d Ap p.endl x,73-4. 1014YORR sewage - Treatment "Syste'rns, Last Name First M.L i i Name of Applicant _ �00 No. Street Cityrrown State zip "V Address ZA7 21/6? a Ile, /%e It 1J X11.77.7"*9 V a No. Street city(TWW" stale zip -Locatio Site n 72 1. Reason why site does. not meet I ONYORR. Appendix 75-A (check appropriate box(es)): Separation distance cannot be achieved. 72EXcessive.slop6. High groundwater: ,17 Inadequate depth to bedrock or Impermeable layer. Soil unsuitable. []other (explain) ............................................................................................................................................................................ 2. Proposed design or conditions of waiver ................. ..................................- .... . ...... t .. .......... ......... . . ............ .}'%.. . ................. 0 40 0 .......... # .... 7 .. ...... ..................................................... .. g ..................................................... ............................................... .................. ...... w_ ...... ........... ........................ ............... ......... I ........................ 3. The proposed design may have the following limitations (check appropriate box(es)): Increased risk' of well ' or spring contamination. increased risk of surface water contamination, Expected design life of the system will be diminished. Operation of sewage system is subject to mechanical problems. Other(explain) ..................................................................................................................... .............................. .................. . .............................. :. . . . . . . . . . . . . . . .. . . . . . . . . . .... . . . . . . . . . .. . . . . .. ............................................................................................... ; ........... . .......................................... .]Additional information attached Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. In accordance with Now York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver may be revoked by Jhe issuing official for.a change in conditions for which this waiver was granted. . ....... I ................................ It- T . .. ........­.. 7 ORIGINAL - Local Health Agency 6013Y.Applicant/Design Professional ..... ... . .... BRUCE, R. FOLEY Z I'C'RE17th MG-L•mAiil R.N., M.S.N. Associate Public. Health Director Director of Patient Services DEPARTMENT OF HEALTH I - Geneva Road Brewster', New - York. 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 218 - 6558 WIC (845) 278 - 6678 Fax (845) 278 -6085 Early Intervention (845) 278 - 6014 Preschool (845)228-6108 Fax (945) 278 - 6648 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER NAME: ADDRESS:* SITE LOCATION: 7L;J�m-,, L,,kz DATE: . / /13 (PLI STAFF PRESENT: SPECIFIC WAVIER REQUEST: IT Sf ANOW., Rob M., Mike B-AdMAZ7, Gene R., Shawn R- Bill H. S�- !� 'nEVQ -21-1,2 'FIROPOSED VAiCIANCE. REQUEST POSE A HEALTH HAZARD OR ENVIRONMENTAL CONTAMINATION PROBLEM? YES NO WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP? YES NO DISCUSSION. REQUEST APPROVAL OR DENIED //0 DENIED REASON FOR DENAL DATE. DIRECTOR vut HEALTH* (SPECWAIVER) -St-)-03--rjf PART II - .IMPACT. ASSESSMENT To be completed.by Lead : "L�U� HL1 iCSTS'ER�EU`A`NY TYPE 1`THkESHOLD IN 6 NYCRR, PART 617..4? If yes, coordinate the review process and use the FULL EAF. ,Yes �No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN•6 NYCRR, PART 617.6 ?.• If No, a negative declaration may superseded by another involved agency. El Yes `C_.J- C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing'traffic pattern, solid waste: production or disposal,* potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or comrnu[nity or neighborhood character? Explain briefly: AAA C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endarigered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of.use of land or other natural resources? Explain briefly: C5. Growths, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: fv �� C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: •.i 1 `ice - , .T: C7. Other impacts (including changes in use of either quantity or type of energy? .Explain briar- i D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA (If des, explain briefly: .. n77 . ....., a .- r. .... ..ti_.- .... -v _. ... a+•.�a.� E. IS THERE, Oal.S THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: Yes No PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important orotherNise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impactof the proposed action on the environmental characteristics of theCEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the F 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 ai WILL NOT result in any significant adverse environmental impacts AND provide, on attachments a necessary, the reasons supporting deter mi tion, �C� 0 / Name of Lead Agency Date c, �rJCA e Z Print r Type a Responsible Officer in Lead Agency Title of Responsible t fficer PROJECT ID NUMBER 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS. Qnly �. .. io`oe "completednby "Applicant o�Proiect Sponsor) PART 'i = rrCCi ii=(1 IivrURIviA'I ION .SEAR 1. APPLICANT/ SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: Municipality 1;P7057"- �Q p / y 1! County 4.-PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc - or providde� map .',;. .-troo 5. IS PROPOSED ACTION: Fx7 New Expansion El Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: d1'; /� �/ % -�%"�/ -�' Jam`! 1 �l!� s' �G'�- .5��-.s :: • 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately % acres '• ``' )' ° ' ' 8. WILL ROPOSED ACTr6N COMPLY WITH EXISTING ZONING OR OTHER RESTRICZIOIVS ?.. `- Yes E No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? •(Choose as many. as.apply.) J5 Residential Industrial Commercial Agriculture Park /Forest /Open Space a Other (describe) . 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY.OTHER'. GOVERNMENTAL AGENCY, (Federal, State or Local) / Yes a No If yes, list agency name and permit / approval: 11. DOS ANY,ASPECT OF THE ACTION HAVE A CURRENTLY VALID :PEfiMIT OR APPROVAL ?....,. es No -If yes, list agency name and permit / approvak [ �7� o/� �1!✓� ice' �/- 3:., 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? QYes ❑ No I CERTIFY THAT THE; INFORMATION PROVIDED ABOVE IS TRUE TO THE BE~S:T OF MY KNOWLEDGE Applicant / Sponsor Name ; i Date: Signature_______ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before'proceeding with this assessment LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 January 13, 2004 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Dear Mr. Sullivan: ROBERT J. BONDI County Executive Re: Waiver Determination — Spoonhour Indian Lake Road, (T) Putnam Valley TM# 72 -1 -1.3 The Putnam County Health Department reviewed the waiver request for the above regarded project on January 13, 2004. The following determination has been made: ❑ The Waiver request was approved. ?'� The Vdal`vCr rCGr+fS "vvzS Cpliditi,on lly approved. However Ile revis10n�S/ 11Jlnu b ?�0 must be completed prior to the issuance of a permit. ❑ The Waiver request was denied..An explanation has been noted below. ❑ The Waiver request was not voted on. Explanation noted below. 1. It appears that the latest floor plans on record are for five (5) bedrooms. Current SSTS design is for four (4) bedrooms. Revised floor plans for four bedrooms must be submitted before permit is issued. If there are any questions regarding this matter, please contact me at (845) 278 -6130, ext. 2157. V yours, V'/' I . Paravati, Jr. Assistant Public Health Engineer JSP:cj LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845)278-6130 Fax(845)278-7921 Nursing Services (845)278-6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 December 1, 2003 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Re Dear Mr. Sullivan: Proposed SSTS Renewal — Spoonhour Indian Lake Road, (T) Putnam Valley TM# 72 -1 -1.3 ROBERT J. BONDI County Executive This office has received and reviewed the most recent set of plans for the Above mentioned project. We would like to offer the following comments for your review and consideration. The following item does not meet current code: _ ._._. .. _. a.._. Proposed SSTS,at 179oslope. Due to the above, the current application is denied. However, you can request a waiver. �i Please provide short EAF form (both sides). Perc rate on the design data sheet is 5 min/inch and on the plans it is 6 min/inch. Please clarify. 4 Please show any driveway regarding. The proposed seepage /leaching pit for roof and footing drains needs to be a minimum of 50 feet from the proposed SSTS. ,-6'*" (1) foot of ROB fill is not shown on the 20 -scale plan. ..7' Although trenches are labeled at 50 feet, they are not 50 feet by scale. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj Public Health Director .d�L:+.i�«n.s: -a -..o.. .. �c'i__.a- '..a".n._. ?. Ji.:i�:wi +w. a:'►'.::w'= . ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845)278-6130 Fax(845)278-7921. Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085 Early Intervention/Preschool (845)278-6014 Fax (845) 278 - 6648 December 1, 2003 Frank Sullivan, PE 2972 Femcrest Drive Yorktown Heights, New York 10598 Re: Proposed SSTS Renewal — Spoonhour Indian Lake Road, (T) Putnam Valley TM## 72 -1=1.3 Dear Mr. Sullivan: This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. i I. The following item does not meet current code: i a. Proposed SSTS at.17 %slope. Due to the above, the current application is denied. However, you can request a waiver. V 2. Please provide short EAF form (both sides). 3. Perc rate on the design data sheet is 5 min/inch and on the plans it is 6 min/inch. Please clarilf . v 4. Please show any driveway regarding. 5. The proposed seepage /leaching pit for roof and footing drains needs to be a minimum of 50 feet from the proposed SSTS. 6. One (1) foot of ROB fill is not shown on the 20 -scale plan. k/ 7. Although trenches are labeled at 50 feet, they are not 50 feet by scale. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours., . Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & NAME OF OWNER: 11hoLlP` REVIEWED.BY: RM, GR, SRDATE: DOCUMENTS Y E PERMIT APPLICATION WELL PERMIT OR PWS LETTER PC=97 LETTER OF AUTHORIZATION D SIGN DATA SHEET (DDS) ORATE RESOLUTION ) SHORT EAF 1) PLANS -THREE SETS (� OUSE PLANS - TWO SETS (!)(VARIANCE REQUEST SUBDIVISION ( L(: )LEGAL SUBDIVISION ' (�(�SUBDIVISION PROV L CHECKED STREET LOCATION: _ ctrl t�'cw (Lcy.G>l % °3 Tt1X MAP#: (COI IRIviED) 79 -1 r' Y /K (REQUIRED DETAILS ON PLANS CONT'Dti (�C�OUSE SEWER - %" FT. 4 "0'; TYPE PIPE. CAST IRON (_}(! jNO BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS SITE NOTE (NO CHANGE) FILL SYSTEMS U(.j10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (—J(_: jFILL SPECS/ FILL. NOTES 1 -5 rk�(,' on Jv S�• -�'� (J(JFI LL PROFILE & DIMENSIONS .p(-A a- i--S 0' C-0 L-)L--)FILL IN =MANSION AREA •C-jLJ CLAY BARRIER UU.UFILL'CERTIFICkT1011J NOTE UUDEPTH GAUGICS PERC RATE �EQ (_}�II.REQ UIREDEPTH (-- )(- �- �- .)�VOL -: ON PLAN FOR R.O.B., 'UNCLASSIFFIED &IMPERVIOUS (( CURTED U•EPARATION DISTANCE FROM'TOE OF SLOPE GENERAL TRENCH LFTRENCHPROVIDED-� 60FTMAX. {poi.F (Jvwt (__)( r/� OCATED.IN NYC WATERSHED PARALLEL TO CONTOURS f L,�LANS SUBMITTED TO DEP (� 100% EXPANSION PROVIDED • % - r --il'S (DELEGATED TO PCHD �DETAGJDUST FREE CRUSHED'STONE OR WASHED GRAVEL C�_J� DEP APPROVAL, IF REQ'D (�(„_)GEOTEXTILE COVER, l �LJ EEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM'SSTS (��ERCS TO BE WITNESSED ( 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (JC.,::JtX- APPROVAL SSDS ADJ, LOTS TO FOUNDATION WALLS (_J . LANDS - OWNIDEC k.. U1Q0' TO WELL, 200' IN DLOD,150' T0, PITS DATA ON DDS PLANS & PERMIT S c�^ (_) 100' TO STREAM, WATERCOURSE, LAKE iac, ez an), (� 1969 NEIGHBOR ATION D S C .AO' T.O CATCHRAS- BAS- 35! *ZT0Rly Dl2rilNf.P ?Ft�%w TIER BUZBA °; ,,,rd� -•,s ::.` J.< i0' t,TN iv A�CF�it E (pits - 20') U Vi U50 INTERMITTENT DRAINAGE COURSE (� SOIL TESTING LOTS >10 YEARS OLD &CL-)10'MIN 1200'/500' RESERVOIk ETC. 150' GALLEY SYSTEMS REQUIRED DETAILS ON PLANS TO LEDGE OUTCROP (�USEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK E�SSDS HYDRAULIC PROFILE 10' FROM FOUNDATION; 50' TO WELL (GRAVITY FLOW (CONSTRUCTION NOTES 1 -15 (✓jLJDIMEI�ISIONS TO PROPERTY LINES DESIGN DATA: PERC & DEEP RESULTS L�.�� LOCATION OF SERVICE CONNECTION ' C �SLO �=G &PROPOSED UUMIN IS' TO PROPERTY LINE �� %� SLOPE FOO G G AIN D --ia'50 USDA SOIL TYPE BOUND` 2��(�—JR"E�GtDED X1 TO 15 %, IV REQUIRED(TITLE BLACK; OWNERS NAME ADDRESS D TM #, PE/RA; NAME, ADDRESS, PHONE# JLJDATE OF DRAWING/REVISION UUPUMP NOTES . ((=) : L` DATUM REFERENCE . U.) )DOSE 75% OF PIPE VOL SE VOLUME NOTED LOCATION OF WATERCOURSES, PONDS UUDETAII. FORFORCE�MAIN, (PIPE TYPE, ETC.) ^ f� LAIaS,WETLANDS WITHIN 200' OF P.L. C —)UPIT AND D -SOX SHOWN & DETAILED (PROPOSED FINISH FLOOR AND JC -=� ;" TO�'GE ABOVE ALARM BASEMENT ELEVATIONS �' CURTAIN DRAIN / �� UUSTANDPIPFS T BOTH SIDES DET I ( lk' )WELLS & SSDS'S WM( 200' OF SSTS �J(-)15' MIN to CDS =>S %, 20'-4° -%, 35' -1 %,100 °! °/ / (,--)PROPERTY METES & BOUNDS • ( EROSION CONTROL FOR-HOUSE, WELL & (-, J - _-)20 IS ' MIN to CD D GE/100' with 182 cons day discharge • SSTS, EROSION CONTROL NOTE UUIO' MIN to PERFORATED PIPE DMMENTS: EVSHEET109 /01/00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of _ Located at LETTER OF AUTHORIZATION ely T W X ax Map # Block / Lot /. 3 Subdivision of �� ~��� 14le- Subdivision Lot # Filed Map # �'/ Date Filed _ rrI.P p c,;1 Gentlemen: This letter is to authorize 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 Health _ - - Law ; -ai ii-iiiC`PUinaln-Couii [ y jani-i- code. Countersigned: Telephone: �%z a y Very truly (Owner of Mailing Address: �rlL %�✓��I �/�lGV / State �%� Zip 1 Telephone: Form LA -97 PUT'NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES `COI�T'I'Id�(,1'I��I �'l.I�1V1iT I+Olt� �i+ 1�AtBEREl�i��t+:f� PERMIT # PV-)9-01 Located at lz� d-'a .7 4 * 11le- 1�?U el-7el Town or Village Subdivision name 7- y eZIJ WSubd. Lot # _, Tax Map Block f Lot %• �✓ Date Subdivision Approved J Owner /Applicant Name zjjz� ;/�&&s Renewal Revision Date of Previous Approval Mailing Address �y Zip,) 7 v Amount of Fee Enclosed 3®e' Building Type 4F if Lot Area S l S No. of Bedrooms -?�- Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To be constructed by Water Supply: -;-2 U gallon septic tank and�U e�� 10 Address Public Supply From Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address ;2 cy //;7 %` sewage treatment system has been P.E. R.A. Date 1,12-111&1 4f License # 2, y .piWs two years from the date issued unless construction of the by the PCHD and is revocable for cause or may be amended or modified when considered necessary' ' lie' .W lWlth Director. Any revision or alteration of the approved plan requires �,.:,,: anew pe Appr ve fo dis ar f domestic sanitary se age only. - -_ By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pro essional Form CP -97 a W PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL p PCHD Perm ?t #.. r U -_�C} Well Location: Street Address: TownNillage Tax Grid # Map 72 Block l Lot(s) J Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrig ion 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought -5' gpm # People Served Est. of Daily Usage v , gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ilNew 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 er No Name of subdivision % ® "'y C4r Z Lot No. -- Water Well Contractor: i' .:91,,`4 -� r2 Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: `" Town/Village °- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: ?,12Ai o/ 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 water well driller certified b Putnam County. CL Date of Issue Permit Issuing O icial: Date of Expiration I Title: Ano t Permit is Non-TransferralAe White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant 2. Name of project: _ �� ��_ 3. Location TN- 4. Desigrn Professional: ,;r � �� !�'`�✓,►� 6. ly e ofProlect: i Prlvate/Resldentlal Apartments Office Building Food Service Institutional Realty Subidvision Connerclal Mobile Home Park Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Ala Type Status (check one) ................... Type I Exempt Type II — Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 10. Name of Lead Agency i Tr This roject i i Gill area under ine'contfol 'ot local planning, zoning, or other officials, ordinances? ............................ ............................... ............... ....... 12. If so, have plans been submitted to such authorities .............� 13. Has preliminary approval been granted by such authorities ? jDate granted:�� l 14. Type of Sewage Treatment System-Discharge ................. surface water _L% 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? ....... ............................... A10 Y. 18. If yes, name of water supply Distance to water supply L11. - 19. Is project site near a public sewage collection or treatment system? ................ 20. Name of sewage system. Distance to sewage system '.1. Date test holes observed _ i'q 22. Name of Health Inspector 19 aim' Form PC -97 2 3. Project design flow (gallons per day) ................. .Q . .....,. ...`.^ •: _ —... .__ __� rs�li�li'ge i -Eitnimatioii ;system (SPDES) 1'ernlit required ?... A/ V Has Sl'D.1 S .A.pplication been submitted to local DEC office? ......................... is any portion Uthis project located within a designated Town or State wetland? J Wetlands 11) Numberr .............. Is Wetlands Permit required? .............................. ..., ........ ............... ........... ......... Aly Has application been made to Town of Local DEC office? ............................... �-- Does project require a DEC Stream Disturbance Permit'? ... ..............................© Is or was project site used for agricultural activity involving applicUion,of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No ,A%v 1. is project loccfted. 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.contarnination? ... ............................... Yes/No A/�� DESCR_IB ",: 1s these a local master plan on. file with the Town or Village`? ......................... /✓d Are community water and /or sewer facilities pla>uied to be developed within 15 years in or adjaceilt to project site' ?........... 11G "c;;11' ;N.;:() fC (_e<�"xtCl'l ti'ieilS "lrl CXCeSS of 1570 slope? .. _�� •E ... Tax Map 1D Nurnber ......................................................... Map i2- Blocky Lot /--S Approved plans are to be returned to ..... ^ Applicant Design Professional le application is signed by a person other than the applicant shown in Item l.,the application must iccor ipanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision be grounds f*>r the rejection of any submission. I hereby rc,1irm, under penalty of'perjuty, that ittfortnation provided on this form is true to the best of lny knowledge and belief. False statements trade herein are punishable as a Class A misdetneanor pursuant to Section 210.45 of the Penal Law. V11 T U1 ?.1;'S' & OFFI C'I11L TITLES: ng Address: ................................... / �> PUTNAMCOUNTY DEPARTMENT OF HEALTH 'I)I*V'S .ION O.'F'ENVI'.RON*ME,N'l-A.L.H,'EALT[t,5ER Tr Y-1 R" .E. Property of Lc)c,au�d at LE 0F.A.UT11 ORIZATI ON 6,i lei -17 1/1; vAr e--,v /?w r„/' U T'-ix Mup -8 1:2, Blo& Lot 3 ouy l.,Vsiori C).f Subdivision Lot #­ J."Iled Map # Date Filed . 2z >Ye�z Genticnien: Tl-uS ICRef' IS W ftifl-lorize ,t duLY licensed oy to apply for the required wa"."tewlatc.1, 12'eati.rICIA andlor water supglypenmt(s) to sei-ve the above-noted property in accordance Wiffi 4 Q- '-A-,Nndayds, Y\Ats or rcguilauons as promulgaled by the Public Health Director of the PLAIMM Cou(1011-1,clalth Department, and cc) sign at( necessary papers on my be-11'eff i1l Inoj 1:0 SLIPCI.11isc the consil-I.IC1101.2 of S81d �112(1101-. water SLLPJ)(Y SYSCeMs in. wll.Vorn-l' 1), M1161 the provisions ol'Artic)c 145 and /or 147 oj' the Education Lavv, the, PuMc. Ffca)tk--! Ulw, ,md the Plitilarl! VCI-)' 11111Y YOUI-S., courael'sIgned: signuc( (owner of Vropefly) M�tdillg Addre, /,t/1 iling Addr(�ssi at 1 -3 !411 ttl S t I. tc _,P ; s t , —tc 4 4 Z'P J-7 T(de y/ >–, �/ �- 2— 2 Fonn LA-97 tP)'.JTN'A.M COUNTY DEP A.R THE T OF HEALTH DT.V"SI.ON OF ENVIRONMENTAL E.ALTH SERVICES :i x_113' S ifik ACE SEWAGE TRIPATMENT SYSTEM Owner � -�,�r� � ��� /��✓�__ Address �i� .X�''� �' Located,.) ;;t,:t:�.t`, ��i��i�rr� ��� _��p� Tax Map Block Lot J 3 (indicate nearest c:russ street) Muzlicil.�.a'.iiy Watershed SOIL PE.RCOL /UJON TEST DATA Date o1_ i', ,: , c> 1,,_:`rl _ _1 %s�._ _.__.. Dare of Percolation Test ��_ -- Depth to Water..... Water, Frolzl GroUud 'Level erco�A cil� r C a��4: X 1a use Time Sul -face (inches): D.rop In Raft:.':'. . h <)QXe 1��,. }.t.ui.s �io.:_latt.�,SloZ�..: (i(YJ<irl.) Scarf Stop )one es Ax?�,C.;> :. ro 4 f � OT , S: Tests to be repeated at same depth until approximately equal percolation rates are obtained at each per: oli?tioll test 1101e. (i.e. S 1 111111 for 1 -3 0 min /111011, s 2 min for 31 -60 minlinch) All data to be s�,l rillcted for review. rtiUsurements to be made from too of hole, Form DD-97 Indict ,!I.t., at which �-Mlnd,,,-vater is encountered . 1410�le Ind 1 ci.ae c, v !at �hlch niot[l ir, h t s 0 lndic:;.ioLe. 4,v:l-l! to W--hicli WLt'L-er level rises aflcu being encountered Dec, p hole obsemation's made by: Date .7342// t'e s lonal Name: Design professional's SL','tl cjF NEW I U'STPIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES -fj 1. - 1, 0 LT NO. MOLE NO. HOLE NO. 0. 5' 1.01 2,0' 2.5' 3.0' 33 4,0' 43 5.0' 5.51 6. 5' 7.5' UY 8.5, 9.0` Indict ,!I.t., at which �-Mlnd,,,-vater is encountered . 1410�le Ind 1 ci.ae c, v !at �hlch niot[l ir, h t s 0 lndic:;.ioLe. 4,v:l-l! to W--hicli WLt'L-er level rises aflcu being encountered Dec, p hole obsemation's made by: Date .7342// t'e s lonal Name: Design professional's SL','tl cjF NEW PUTNAM COUNTY DEPARTMENT OF HEALTH DIVIS1ONlOF'EN"RONMENTAL HEALTH SERVICES WF'I.T -� ')( 1_VTPT FTTON- RU�ORT �., r •• Well Location Street Address: T n/Village: Tax Grid # Map `i�. Block B Lots) �, Well Owner: I Na e: Address: I A�9� y A Use of Well: 1- primary 2- secondary L_X- Residential V Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length O ft. Length below grade 1ft. Diameter G" in. Weight per foot !( lb /ft. Materials: -;< Steel _ Plastic _ Other Joints: _ Welded x' Threaded _ Other Seal: ,G 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 Yep No Hours Second Well Yield Test Bailed _ Pumped _2�_ Compressed Air Hours Yield ZL gpm Depth Data Measure from land surface - static (specify ft) 36 ��a� During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses' are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Types Capacity Depth ,3 o Mode S � 0 S� Voltage 2-.To HP � y Tank Type /t//_ Zsd Volu e �. ;,'�� ` ` Date Well Completed d Putnam County Certification No. 70/ l ate of Report / O lG Well Driller (signature) GAL NOTE�Exact location of well with distances to at least two permane,tit Idndmarks to be provided on a separate sheet/plan. Well Driller's Name;- // Signature: f2 ez4z4:2= n� G Address: Date: 1 6 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 LAS RAp _Y oe . 4 = s ant q ��„ �r► , . `� '' � fps �• � `' �. � � u� � r� �, t p7 Mr+ - y .:, � �� ,� .v ' !r t� � Q• :.ice T �r 1 _ jti � �R T.. P �� 00a of L' Ono 4 0 w