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HomeMy WebLinkAbout3169DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72. -1 -23.3 BOX 26 03169 ' 4 ; ■� �r i� `l .� Vr r' L fir' � 1. , k.! f �r 4 �'4� T1� � I r �� or T 03169 PUTNAM COUNTY DEPARTMENT OF HEALTH ,1'_., :5'� ` •.• ter, .. - .. _ � �l� 1 �� 1►31,0 O 1'�T�I li�iy N l E —NT 1'. c —L-HE . CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # PV-4(3-00 Located at 440(ZM'113 40LLOVA `jZO Town or Village Owner /Applicant Name e*cz 13CG 0,5Hf::i6i0 &ax Map 72- Block I — Lot 2 Formerly �,/J Subdivision Name Wes t-ic�Li 040& Subd. Lot # 3 Mailing Address ✓(�('•.IGT Z- Zip cno -3 Date Construction Permit Issued by PCHD. It 2--1 00 Separate Sewerage System built by - CA-&JOPt $ 6 aW,5'T(2> Address PLAT*JAM VMAA Consisting of 1 V50 Gallon Septic Tank and 400 LS-- - 2 �� 141 k QG- AC3SOMP 100 79483-3 C., I ©. -C-, Other Requirements: Water Supply: Public Supply From Address or.----)( Private Supply Drilled by W Qi? IS 0 N Address {'%.k-cQAcX1 J Building Type IZE' (A�l_. Has erosion control been comple -ted? " " °4 iFFS Number of Bedrooms 4 Has garbage grinder been installed? 1� 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: 0 Address P.E. R.A. Xy2C_49 Any person occupying premises served by the above system(s) shall promptly 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 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 revoca on, modification or change is necessary. C � % f r L By: A 4� Title: Date: White copy - HD ile; ell w copy - Building Inspector; Pink copy - wner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -3 FlpnRT Well Location Street Add es T e• Tax Grid # W'74 ' b� � Map�a1 Block i Lot(s)a3 3 Well Owner: N e: I fo-e—o�� . � A ess: (/ I .Q Use of Well: Residential Public Supply Air d/heat pump Irrigation 1- primary Business Farm Test/monitoring Other(specify) 2- secondary Industrial Institutional Standby Drilling Equipment >�, Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened open end casing Open hole in bedrock Other . Total length / ft. Materials: /- Steel _ Plastic Other Casing Details Length below grade / Joints: _ Welded >'Threaded _ Other Diameter in. Seal: 7' Cement grout _ Bentonite Other Weight per foot _G lb /ft._ Drive shoe: -/-, Yes No Liner: Yes >- No Diameter (in) Slot Size Length(ft) Depth to Screen (ft) ` Developed? Screen, Details First Yes—No Second Hours Well _Yield Testµ Bailed_ Pumped X Compressed Air Hours Yield 9 gpm ' Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log' Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface �, " - v - descXiptions or. ` .._ -. e_:• sieve analyses .,. -._ .. .. . � --.. _ -_ - w -- -� - /! ,.: ._T -__ . �._ .� _ •, . -,�. _�:. -.� � _�_ �.. __i -,.�.:...d are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Typ 4,c, Capacity during drilling, Depth aIS2) Model 4� O �,� list: Voltage 213 D HP re� /% Tarlk T e - Y Volu 0 Date Well Comp eted Putnam County Mt1fication No. Date o Report Well Driller Iii nature) Y/" NOT 19: act location of well with distances to at least two perman t lXndmarks to be provided on a separate sheet/plan. Well Driller's Name Address: 4 / Signature: p,2 Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 YML ENVIRONMENTAL SERVICES 321 Vqa r, f tr `��� (914) 245-2800 Albert H. Padovani, Director LAB #: 32.202061 CLIENT #: 55297 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ BOGUSHEFSKY, G. C/O JOE TAVERNESE 80 FOREST AVE GLEN COVE, NY 11542 DATE/TIME TAKEN: 03/21/02 11:15A DATE/TIME REC'D: 03/21/00 Il:50A REPORT DATE: 03/28/()2 PHONE: (516)-671-0797 SAMPLING SITE: LOT # 3, HORTON HOLLOW ROAD SAMPLE TYPE..: POTABLE : KIT TAP PRESERVATIVES: NONE COL'D BY: JOE TAVERNESE TEMPERATURE..: < 4C NOTES"".: _ COLIFORM METH: 101F ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL- RANGE PUTNAM CNTY PROFILE 63/21/02 OF T. COLlFORM ABSENT /100 ML ABSENT 03/21/02 LEAD (IMS) <1 ppb 0-15 ppb 03/21./(52 NITRATE NITROG 0.27 MG/L 0 - 10 03/21/02 NITRITE NITRO8 <0.01 MG/L N/A /21/02 IRON (Fe) 0.389 MG /L 0-0.3 mg/1 03/21/02 MANGANESE (Mn) 0.056 MG/L 0-O.3 mg/l //~' 03/21/02 SODIUM (Na) 7.24 MG/L N/A 03/21/02 pH 6,8 UNITS 6.5-8.5 03/21/02 HARDNESS,TOTAL 150 MG/L N/A _ 03121102 ALKALINITY (AS 76,0 MG/L N/A ---''' "TURBI[)ITY- 00---L A-0,0 U ��'�'Q-`5NTU ` COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI :jtz 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. p a 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 guidelAnes 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 is suggested. METHOD 1O08 9101 9139 9146 2037 2037 9043 YML ENVIRONMENTAL SERVICES ' 3P1]Kear Street (914) 245-2800 ' Albert H. Padovani, Director LAB th 32.202061 CLIENT th 55297 NON STAT PROC PAGE 2 BOGUSHEFSKY. G. DATE/TIME : 03/21/02 11:15A C/O JOE TAVERNESE DATE/TIME REC'D: 03/21/02 11:50A 80 FOREST AVE REPORT DATE: 03/28/02 GLEN COVE, NY 11542 PHONE: (516)-671-0797 SAMPLING SITE: LOT # 3, HORTON HOLLOW ROAD SAMPLE TYPE. .: POTABLE : KIT TAP PRESERVATIVES: NONE COL'D BY: JOE TAVEFrNESE TEMPERATURE..: < 4C DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD !� ' ' SCALE AT PH pH S _ E IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE �[MPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. TE'A' WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.570 8.5. ! ` Hd TOTAL HARDNE SS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM C0NCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN HG/L. THE HARDNESS MAY RANGE FROM O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. S- FT.WATER, 0-70 MG /L VERY HARD WATER: ABOVE 300 MG/L -�'-- - IODE�AlE[ `* ` 4RD''-WATER. 70-140 HG/L � '� �C/L� - �M�[L G����' PER'LlTEk- HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: ` Director' ELAP# 1032,33 YML ENVIRONMENTAL SERVICES 321 Kear Street ' (914) 245-2800 Albert H. Padovarii , Director LAB #: 32.202558 CLIENT #.- 55374 TAVERNESE, JOE %BOGUSHEFSKY' BADEY/WATSON 3063 RT. 9 ' COLD SPRING, NY 10516 SAMPLING SITE: 3 HORTON HOLLOW RD,PUT VA| : KIT TAP COL'D BY: JOE TAVERNESE 'NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG pROCEDURE STAT PRQC PAGE 1 DATE/TIME TAKEN: 04 / 1*0:00A DATE/TIME REC/D: 04/08/02 10:15A REPORT DATE: 04/09/02 PHONE: (516)-671-0797 LLE9,NY SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE � TEMPERATURE... COLIFORM METH. - N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD 04/0�8/02' IRON (Fe) 0.108 MG /L 0-0.3 mg/} 2037 ^ ' ` CunnEm/S:,. . Fe/Mn I th iron and manganese are present, their total value c ned shall not exceed 0.5 mg/L. , / SUBMITTED BY: Albert Padovani, M.T.(ASCP) Director ELAP# 10323 2Pe� c . :.Q_ JJltUI..r, t(. l'UY .t- •„-... :....,....►..:s.. -. ;w - -•>-:; 4 .:,� ..- - _::�..vT cr��`,-;; m^ 5 r;�.�cr r�r�a•n T. 2R_�1�r'�, Public Health Director F� Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 . Enviromnental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: George Bogushevsky TAX MAP NUMBER: 72.4-23.3 E911 ADDRESS: Q r 6) k? 80H00 R01 TOWN: TOWN OF PUTNAM VALLEY ju AUTHORIZED T OWN OFFICIAL ` Iv (Signature) _ o� DATE: oC =T-(� �' G Y oS O 01 The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911VERFRM) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALT H SERVICES _. (�11ARA1VTUE OF SukkAiAu`S�:'►�VAtTJN. George Bogushevsky 72. 1 23.3 Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Horton Hollow Road Location- Street Residential Building Type Putnam Valley Town/Village Westchester Holding Parcel H Subdivision Name Subdivision Lot # 3 I 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 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 "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate 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 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 �(` Day /L Year — - 1 z4n24 General Cont r (Owner) - Signature Canopus Construction Co. Corporation Name (if corporation) Address: Canopus Hollow, Putnam Valley Signature: Title: �c.�- �--- -- Corporation Name (if corporation) Address: State NY Zip 12579 State Zip Form GS -97 BADEY & WATSON LETTER of TRANSMITTAL 3063 Route 9, Cold Spring, New York 10516 Date: 16 Apr 2002 (845) 265-9217 (914) 628-1800 (914) 739-3577 (845) 225-3312 FAX (845) 265-4428 File No. 98-105 W. 0. # 14858 RE: Certificate of Construction Compliance Bogushevsky TO: 23 Horton Hollow Road Shawn Rogan Putnam County Department of Health I Geneva Road Westchester Holding Co. Inc. Subd. Lot No. 3 Tax Map 72.-1-23.3 Permit # PV-40-00 Brewster, NY 10509 Sent via: US MAIL El UPS-NIGHT W MESSENGER El UPS-2 DAY El PICK-UP 0 UPS-3 DAY El FAX 11 UPS-GROUN El UPS-COD We are sending: copies date description of document F-1] 114-Mar-02 lCertificate of Construction Compliance for Sewer Treatment System [-3] 116-Apr-02 IGuarantee of Subsurface Sewage Treatment System [71 125-Oct-02 JE911 Address Verification Form F-1] 128-Mar-02 lWell Water Test Results F-1] 109-Apr-02 -7 lWell Water Test Results - Re-test for IRON F-1] 105-Apr-02 on Report 4 F 104-Apr-02 jApplication Fee ___1 E_ El I I F-1 1 __711 REMARKS: Signed: John P. Delano, P.E. Copies to: File PUTNAM COUNTY DEPARTMENT OF HEALTH ND rtrt IVISION. OF ENVIRONMENTAL_ HEALTH_ SERVICES, ,w e., 1= �•rsc.? .r4.... r p ':�.: .. ,o.�.x pis -..;- ..,.ems �.r., .:i.... .� =, -..�. ,-.... _ .ti. •i -,<� .-w tea•,,. _...:.+r:. -'rev. .....:�. -i.:T ,r':: v..:.: V CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P V - V0 — C Located at Ro T OIV N OLL OI.�v i� n Woc,TC V1C;STC V__ Subdivision name NOt_bi N & PQ_C Off -Subd. Lot # 2) Date Subdivision Approved ` y%RQ_'0 10, J-000 Owner /Applicant Name C -E CR-C -6 B00 -0,' RU- V_ �,` Town or Village Pu - I N A i'N U A LLE Tax Map _ .2.. Block 1 Lot Renewal Revision Date of Previous Approval Mailing Address .A NUE A l Poi.T 16PLRiA1. b &P I , X1.0`1 WEST NEW*U. NI Zip 070M Amount of Fee Enclosed TD DG, 00 Building Type R I: S)DENTIAL Lot Areas H6 K No. of Bedrooms Design Flow GPDgJ )0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED 't Separate Sewerage System to consist of E5 gallon septic tank and � DU LE W IbE -TK fv1Q4ES SP6CCb 8T (P FT. 0, C. Other Requirements: To be constructed by CAN) QPL' Tl QQ Address PL T N (�A) kl P-L,Lt4 -Water Suualy'_ -- -- - Public- Sup ply.F m -_,. _ Asidmss or: -N ��' Private Supply Drilled by K)OU11 A-N1bG•S©ly Address P0 T1Lt�T iALLC� I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments stem 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 R.A. Date oci I3 UU License # S D S APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and. is revocable for cause or may be amended or modified when consid red necessary y the Public Health Director. Any revision or alteration of the approved plan requires a new vertgN Appro*d &dNchargA of domestic sanitary sewage only. f 0 Title: White copy - HD File; Yellow copy - Building Inspector; Pink Date: IJ I Z - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES please print or type Well Location: Street Address: Town/Village Tax Grid # Hofflcw 14W PUIULM OLLE Map —j Block Lot(s)2 3 Well Owner: Name: C CplG -E- Address: R O& S Mitl 14 RUE. S1 E- W GU ? Q 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 fir- _ gpm #People Served _(0 Est. of Daily Usage OD 0 gal. Reason for Replace Existing Supply Test/Observation . Additional Supply Drilling _ New Supply (new dwelling) Deepen Existing Well Detailed Reason PROV1hG 0 7"AL -E W0,76( C )& W (Z.i✓S LI- PL JI-� for Drilling Well Type_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes k No Name of subdivision iUt= S7c-'4 ✓STe;� -1 pu')) NC7 CG1� 1 NC, . Pp,�G 1— U Lot.No. 3 Water Well Contractor: NO -MAN 4`DC9-SQ N Address: PU TNRY" VALLf—,-� Is Public Water Supply available to site? .................................. ............................... Yes No X_ Name of Public Water Supply: N !--A Town/Village N, Distance to property from nearest water main: > 1 M I <✓� Proposed well location & sources of contamination to be provided on separate sheet/plan. bk: A._.. 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 c i ed Putnam County. Date of Issue 2i OQ I Permit Issu' g Official: Date of Expiration! I i O Title: Permit is loon- Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 P.02/02 OCT-29-2001 1 9 BADEY & WATSON, PC PCD 1+ & 1.(pr?Y-0 j 4 % % Z6, +r . I 150 N T= m Of PION T4NeH 6'M I N. (T (Typ A, s a==Z. JLATI S S DISTRIBUTION BOX WITH BAFFLE & FOOTING TO 42" PROVIDE "SPEED LEVELERS". PROVIDE CLEAN0UT---,.,' 1/8 PER FT,• MIW'PITCH ' I .. '. . 1250 GAL. 'PREAST CONC. SEPTIC- TANK 0 tj 4'y S T-0 --TOTAL P.02 OCT -29 -2001 14:19 BADEY & WATSON, PC O O DATE. BADEY $L WQ 'Surveying and En P -01/02 ieering .1? C. Or 3063 Route 9, Cold Spring, New York 10516 (845) 265 -9217 GlennonJ. Watson, LS,- (845) 225 -3312 John P. Delano, PE, FAX: (845) 265 -4428 (9 14) 628 -18W Peter Meisler, L.S. (914) 739 -3577 Stephen R. Miller, L.S. (877) 314 -1593 Jennifer W. Reap, L.S. FA.X TRANSMITTAL Oe°rge A- Sadq, L.S., Senior Consultant James W. Irish, Jr., PE,, I.S., Senior Consultant Mary Rice, R.L.A,, Consultant FAX # A 2 •v N'UMER OF PAGES INCLUDING THIS ONE . MOEY & WATSON FILE # AS- la PLEASE CALL IF ALL PAGES DO NOT GO THROUGD Owners of the records and files of Taconic Surveying & Engineering, P.C,, Burgess & Behr, Roy Burgess, J. Wilbur Irish, joseph S. Agnoli, Vincent Burruano, Hudson 'Valley Engineering Company, Inc., Douglas. A. Merril, -E. B. Moebus and Reynolds & Chase i, 0 SENDING CONFIRMATION DATE : OCT-29 -2001 MON 15:25 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 92654428 PAGES 2/2 START TIME OCT -29 15:24 ELAPSED TIME 01,011, MODE : ECM RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... - .. : �i•: 7 %IIr„Fo;a+n{�;.- y=A�!',"H'euaiuM �e.�aA'a•�y';; mod': ^T:awwt �fosna boy_ ' '+ wawa' oaaaiww +�e�a:�r�- := ��•-��• ».s,�o ". ... ... _ .. , Roam= 00.1019 00 S3'JY4 T" Al TWD x5valm . A MW 190S.LYM V EYdYH . �, Zti0 6�i,,fL�ir`JtdQtl'1�[.�II bifO�'d dO N�1iL1N ' rkk 1' \� . v 9d 'W51kn 7 A3Mbl 6T PVT saw -W -Im a o K 01 acva f. �J�wi�LTii�w� t�oat^so s!�9 `8'L'A�pBY°t°4 -s-2 low it-AB Ltta'9EL(fti) �\ "a1'+�P►1'l+�'6 OEBI.9i9nld 9Ewmota17cra '3'd''?�MQa�Nf EI65`SEi(Si11 '8'I'�M'ip°�ID LIE6rC9i (9191 •• 91101 §"OlT J'd OILil37 :lfOli,�r_"'$lft�7/LpJ�'� ♦�A�N'�d691�b MOSJ. YA 79 A.7,U R. �'• 9d 'W51kn 7 A3Mbl 6T PVT saw -W -Im a PUTNAM COUNTYDEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES � � � "( FINAL SITE INSPECTION _. - Date: (0 3 c7 i Inspecte - C P� r nm �f,p ,w 1r - - -- • TOWn _ �� Permit TM r i- Z 3.3 Subdivision Lot 9 1. SeNvage Svsteih 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 ...... ............................... II. SeaQe System a. epti� cwt n • size -1,000 .......125 .......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.0riginal soil between box & trenches e. Junction Box - properly set ..... ............................... . f, Trenches `� . 1. Length required Length installe 2. Distance to watercourse measur - -- Ft.:::. 3. Installed according to. plan ....... 4. Slope of tre h acceptable 111 1/32 "!foot ..... :. .5. 10 ft: fr o roperty U -20 f found ions........ 6. Depth of inc es 1 surfa .............. . 7. Room all ed for p io 1 0% .................. 8. Size of gr „ el 314- t 2" ete ean ............ 9. Depth of ravel in t rich minimum................... rrr . ...................... g. PumD or Dose S ste s ize of pu , Lchrber . ..... ..............................,. . ............ . . ... ..........2. Overflow ................... ..........� . . 3. Alarm, ' u 4. Pump e box - 6. Cycle.wi M. House/Buildin� a. ouse ocated b. Number of bei IV. Well a: Well located as per approved plans ........................ ... b. Distance from STS area measured ft. c. Casing 18" above grade ...................... . d. Surface drainage around well accepta le.. ..... 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 & dirto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ........................... ..... n­ COINiMENTS G OCT -03 -2001 16:15 BADEY & WATSON, PC P.02i02 PUTNAM COUNTY DEPARTMENT OF HEALTH DMSYON OF ENVIRONMENTAL HEALTH SERVICES REQUF__ST FOR FINAL iNSPECTiON For: FtSI Trenches .., . Owner/Appli=t Name_ o yg -Vsk Y TM 7Z. Block I Lot Z3. Formerly Subdivision Name- •,.A2 i; 3r- Subdivision Lot'# 3 Is system fill completed? IJA -- Date 62 Z.& Is system complete? Q � � $s~UCP Date W Is system consaucted as per plans? �es._Y Is'weU drilled? Nv Date M7 /o3r[d 1 Is well located as per plans? a% Are erosion control measures in place ?� i certify that the systern(s), as listed, at the above premim has been constructed cud l have hapccted and verified their completion in accordance with the issued PCHD Com tction Pcrwt and approved plans and the Standards, Rules r and Regulations of the Pataam County Departrnew Date• iaia-s /o, Certified by. Z' +4' o P,.�AIAD , P _ E. PE e RA Design Professional Address e> .63ge 0'r, L JA Tsc�Jf Vic. # DrozSMS- Cammetitts: L6MR.c_ a WkiQ COk'-4ee-7 —b .A A- RE�MAJ I &)- �- POP,' XADAM Q%-NE Form FIR-49 . T1TAI P - AP Sent by: Glennon J. Watson, L.S. 914 -265 -4428 07- Sep -00 10:12 AM Page 1 of 1 PUTNAM COUNTY DEPARTMENT OF HEALTH _ DIVISI_ON OF ENVIRONM. NTAI;: HFAT,TN fiF� �It"FS� LETTER OF AUTHORIZATION RE: Property of George Bogushevsky Located at Horton Hollow Road T/V Putnam Valley Tax Map # 72• Block 01 Lot 23.3 Subdivision of Westchester Holding Co., Inc. - Parcel II Subdivision Lot # . - _. -.._ 3._- Filed Map # 2824 Date Filed 10 Mar. 2000 Gentlemen: This letter is to authorize John P. Delano a duly licensed Professional F,ngineer X or Registered Architect --- to apply for the required wastewater treatment andlor water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public H ealth Director of the Putnam County H ealth 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 m conformity with the provisions of Article 145 and /or 147 of the Education Law, the Public H ealth Law, and the Putnam County Sanitary Code. Countersigned: �� Signed: P.E. "AW, # PE 62505 ion Property) Mailing Address Badey &Watson Mailing Address: 4 Ave. at Port Imperial, 3063 Route 9, Cold Spring West New York State New York New Jersey -_Zip 07093 -- Z1P .______10516 — -- -- - State - Telephone.: - __..__...._.__ 914.265 -9217 Telephone: Form LA -97 �: 5FJ'-GJ-GbYlb 10; el. BHI&Y. X WH I bUN9 NC: P. 02/04 . FRom : BASWATOV A FAX N0. 7299345341 P. 17 2000 10:30PM P2 i >; �a 0� z o ° H d � ° C O � F cn EZ., dim Post Ir Fax (vote'~ io 'v ITT Gyi.la oa ok4ee =" TO (A0 WA'($2 RO1" rgcp DUa3wY COJO • ca. MAN. Phom#- 91-1.73 '5.3`S' �7 P?=l# 2-11,74aa7(0 F'" 0 .tq; Z`SS 44 28 . Fax" L 11.74 01 f 3 o LL- I. Cy ., C/o � 2 W � � M H I T 3 � x �z s� c +L. zl I. Cy ., C/o � 2 W � � M H I T 3 � x �z s� c PUTNAM COUNTY DEPARTMENT OF MAUR BE PLANS APPROVED FOR. BEDRWM C0tJNT ONLY, BEDROOMS SUBSEQUENT REVISIONJALTERATIONS TO THESE HOUSE qS_MUST PjE, SWAUTTW TO THE PCDOH FOR APPROVAL 'ATURE & TITLE -4 C3 --I ip —u 6:1 c BASEMENT fit4l5K HOOK etWiXTION 230'-6" cs ts rr PC CJ N. J. ti R . PUTNAM COUNTY DEPARTMENT -OF HEALTH ONLY, A [ESE HOUSE APPROVAL } zs i SSE PLANS APPROVED FOR BEDROOM COUNT BEDROOMS SUBSEQUENT REVISION/ALTERATIONS TO T .'4S S MUST BE SUBMITT TO THE . PCDOH FO R N n n IATURE & TITLE ,(-Y Wfc �f Lf I g _ A i,. ti S.. rr sR � Q �? €� 1 •h f air � M ,i i" H .f 1 ;P BADEY & WATSON LETTER of TRANSMITTAL Surveying & Engineering, P.C. ?�63 7?.nytp 9, X1.7 S »ri' & �Tew. 'd ..k 1 QK t:4 "i2;�. 2; r,. 2L� ..,..0 :.. ,,... _ (845) 265 -9217 (845) 628 -1800 (914) 739 -3577 File No. 98-105 FAX (845) 265 -4428 W. 0. # 13578 RE: Proposed SSTS Bogushevsky TO: Horton Hollow Road Adam Stiebeling Westchester Holding Co. Inc. Subd. Lot No. 3 Putnam County Department of Health Tax Map 72.4-23.3 Permit # IMP- 10751 -L 1 Geneva Road Brewster, NY 10509 Sent via: US MAIL ❑ UPS -NIGHT R MESSENGER ❑ UPS -2 DAY ❑ PICK -UP ❑ UPS -3 DAY ❑ FAX ❑ UPS -GROUN ❑ UPS -COD ❑ We are sending copies date description of document 1 13- Sep -00 _7 lConstruction Permit for Sewage Treatment System ❑ F-1] 113-Sep-00 Letter of Authorization r-11 113-Sep-00 FApp lication for Approval of Plans for a Wastewater Treatment System F-1] 113- Sep -00 —1 Short Environmental Assessment Form ❑1 11 0- Jun -99 IDesign Data Sheet ® 25- Oct -00 ISeparate Sewage Treatment System Sheet 1 of 1 F2 125-Sep-00 Floor Plans i�} 3 inn I F� - U '- X1- 'uVp_.i :I. ++..� -� .Ikl}/11v4LaVi1 �V VU.1.)1`i4L.L 4 1�GL1:V3 IiV1Y+•- •. • "'6+ -..._ �.._ v.v -..r - . +_.- .w.p.- .....re._.,o .- ...r...wi..� A on Fee 5300.00 Certified Check 1 08- Sep -00 I licati ❑ ❑ I REMARKS: Signed: John P. Delano, P.E. Copies to: File ZS :6 !fib 9 Z 100 00 Fy ANJ A!I °moo wyriF in4 _ 3 A 13 0 3 N azao %164(1VW - -Ted 12 PROJECT I.D. NUMBER 817.20 SEQR Appendix C State Environmental Quality Review :. AW 'ON ._ .^. ..r•• __; s. �.r ,...a .: .+1i .fir. SH ail - rik VI. .5 Y ^ i i1 Aw. L: �'.1i' 7' � .1 _ . .. , .:� .. -. _... .._'• ^ `: .al. ii "ii � "r� �aaiilfrr "i i�ft�i�'K Vl ii�_i -i �.IViI For .UNUSTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1 . APPLICANT / SPONSOR 2. PROJECT NAME George Bogushevsky Bogushevsky 3. PROJECT LOCATION: Municipality T/o Putnam Valley County Putnam 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) Horton Hollow Road (see map provided) 5. IS PROPOSED ACTION: %New ❑Fx ansion El Modification/ S. DESCRIBE PROJECT BRIEFLY: Single Family Residence, SSTS and Well 7. AMOUNT OF LAND AFFECTED: Initial) <5 acres Ultimately <5 acres 8. WILL PROPOSED ACTION COMPLY WITH DUSTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ®Yes F-1 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential ❑ Industrial ❑ Commercial ❑ Agriculture E Park/ Forest / Open space ❑ Other Describe: Single Family Homes on 2+ acre lots 1,1) . D090S A.C?ION INV7t VE A. .PERMIT. APPROVAL, OP FUNDING, NOW Oft MAT ELY FROM ANY CtTH..7Z C:)VF_RN!'iE.TAL AGENCY (I MMALJ � rN � t vrt Lvii�j i" ®Yes ❑ No If yes, list agency(s) and permit/ approvals Town of Putnam Valley: driveway & building permits 11. DO ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? X No 'if list es yes, agency name and permit/ approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes ® No I •CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/ sponsor name: John P. Delano P.E. Engineer for Applicant Date: 09/13/00 &izzeze, Signature: % If the action is in the Coastal Area, and you are a state agency, complete the . Coastal Assessment Form before proceeding with this assessment IN PART II - EMARONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EKCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR PART 617.4? If yes, coordinate the review process and use the FULL EAR ❑ Yes ❑ No R WILL ACTICfa-RECEVE CCCMINAT» ;W'IENJ AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 6-17.67 If- No a negative declaration may be supersedes by another invoiveo agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WTH THE FOLLOWNG: (Answers may be handwritten, if legible) C1. 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 brief) C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species ?Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Bxplain brief C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. 06. Long term, short term, cumulative, or other effects not Identified in Cl- C57 Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy) ? Explain briefly. D. WILL THE PRO.ECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E IS THERE, OR iS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [--]Yes ❑ No If Yes, explain briefly PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSfRETIONS For each adverse effect identified above, determine whether it is substantiad, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (.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. Ensurethat explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part 11 was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which NAY occur. Then proceed directly to the RJL.L EAFand /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 ANJprovide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Frill or Type Name of Responsible Officer In Lead Agency Title of Responsible Officer Signature of Responsible Officer In Lead Agency Signature of Reparer of different from responsible officer) 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM ,. w= : w.: _a►. :: ; : ..:�:.`., : .:. `,�, >{ :4e , ,ter_ if4"'f�YL': A� 3 fii L ilSEiiiilj �r�e[yUZF ' uv�• : s R:..A.. +Owner George Bogushevsky r Address - West New York, NJ 07093 Located at (Street) Horton Hollow Road Tax Map 72 Block 1 Lot 23.3 (indicate nearest cross street) Subdivision Lot #3 Municipality Putnam Valley Drainage Basin Hudson River SOIL PERCOLATION TEST DATA r Date of Pre - soaking 01/07/99 Date of Percolation Test 01/08/99 Hole No. Run No. Time Start - Stop Elapse Time (Min.) Depth to Water From Ground Surface (Inches) Start - Stop Water Level Drop In Inches Percolation Rate Min/Inch A 1 12:28 - 12:46 18 19 - 22 3 6 A 2 12:47 - .1:05 18 19 - 2.2 3 6 A 3 1:06 - 1:27 21 19 - 22 3 7 4 - - 5 B 1 1:06 - 1:12 .6 19 - 22 3 2 B 2 1:12 - 1:17 5 19 - 22 3 2 .....3_- 1:2- Y6+. 4 5 - - 1 - - - 2 - - 3 - - 4 5 - - NOTES: 1. 'Tests' to be' percolation sub n ittle 2.. Devth-meas at same depth until approximately equal percolation rates are obtained at each . (i.e. < 1 min for 1 -30 min/inch, < 2 min for 31 -60 min/inch) All data to be to be made from top of hole. Form DD -97 TEST PIT DATA if 2 DESCRIPTION. OF SOILS ENCOUNTERED IN TEST-.HOLES DEPTH HOLE N0. 1 HOLE N0. 2 HOLE NO. C7.j..._. lopsoll'')' - 0.5' Sand & Silt Sand & Silt 1.5' 2.0' 2.5' Sand & Gravel Sand & Gravel 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' 9.5' Water Indicate level at which groundwater is encountered T -o" Indicate level at which mottling is observed not observed Indicate level to which water level rises after being encountered 6' -0" Deep hole observations made by:. John P. Delano, P.E., Badey & Watson, P.C. Date 06/10/99 witnessed by Adam Stiebling, PCDH Design Professional Name: John P. Delano. P.E. Address: Badey & Watson, P.C. 3063 Route 9, Cold Spring, NY 10516 Signature: Design Professional's Seal Vol o PUTNAM .COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR .. __. n:U� ..,e r.w .. -. . v � «1111 R ..�ti :-.. -� '�:r�rZi I`•'�'>-V'[T �'R "f'1 • n 1`W M`.� r1r.. n A Ti ": a u..r.- ..u- .W.:�. w. .. RF. �.. -0.. y- ....y'. ^.:.�►a .r sa..>: •• iA�:� Y i�: V�''t� Y LI'�'1-lt:'L�`� 1�`�l�l Y .��' � I�L� lull 1. Name and address of applicant: George Bogushevsky 4 Ave. at Port Imperial, Dept. 404 West New York, NJ 07093 2. Name of project: Bogushevsky 3. LocationT /V:. Putnam Valley 4. Design Professional: John P. Delano, P.E. 5. Address: Badey & Watson, P.C. 6. Drainage Basin: Hudson River Rt.9 Cold .Spring, NY 10516 7. Type of Proiect: X 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)? Type Status (check one) ------------------------------------------------------ - - - - -- Type I Exempt Type II Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ______________________________ No 10. Has DEIS been completed and found acceptable by Lead Agency? ______________ ______ N/A 11. Name of Lead Agency P.C.D.H. 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? _____________ _._ 1111. - -- - : -- -- -- - - - - -- .. Yes 1111 - _. _: 1111 1111.. -- - • - -_.a- . .. ... _ .. -. 1111 1111 13. If so, have plans been submitted to such authorities? ________________ _______________________________ No 14. Has preliminary approval been granted by such authorities? N/A Date granted: N/A 15. Type of Sewage Treatment System Discharge___________________ surface water groundwater 16. If surface water discharge, what is the stream class designation? _________________________ N/A 17. Waters index number (surface) --------------- ___ _ ------ _1111 1111.. -- 111- 1.- ........ N/A 18. Is project located near a public water supply system? ______________ _______________________________ No 19. If yes, name of water supply N/A Distance to water supply N/A 20. Is project site near a public sewage collection or treatment system? _____ ______________ No 21. Name of sewage system N/A Distance to sewage system N/A 22. Date test holes observed 06/10/99 23. Name of Health Inspector ebefi p,C A. Stiebeling 24. Project design flow (gallons per day ________________ ______ --------------------------------------- - - - - -- 1111.. 800 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required?... No 26. Has SPDES Application been submitted to local DEC office? _____________________________ N/A Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number 2 Yes /` l�i"`Y.'C�l"c�.2:,T.:l..'i.- b ., •:TZ?':v= ..i:1,,�,:'� ";a- Z. .. �. rp' �. r_ - .c -r._ . . - _ . - _ - al7i` liCtei\ , '{ , .. ..- - -----------••-•--------_ --------- ------- ---------- -- .._---- - --- -- Has application been made to Town or Local DEC office? ______________ N/A 30: Does project require a DEC Stream Disturbance. Permit? ______ __ _____________________ ___ ___ __ No 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 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 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? ------------------------- ----------------------- - - - - -- -------- - ----- 35. Are any sewage treatment areas in excess of 15% slope? ___ __ ___________ ___ 36. Tax Map ID Number ___ ____ ___ _____ __________•____ 37. Approved plans are to be returned to ..... Yes No No .......... Map 72 Block 1 Lot 23.3 Applicant X. Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall _- •- -• _,beseat to the Department.. and-need not be sent in- dUpli -,-*e toA .DEP,,A]Aough-tll_:prQiept may. requir? DFp_:.; _....- •�.._..z.•s`•• approval otfthe 5STS -prior to tmal approval by the I7epartmenf: projects within tYie wafers ie may also require DEP review and approval of other aspects of a project, such as stormwater 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 1 .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. . I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: T" P4 Fw, r Z-"- CA Badey & Watson, P.C. Mailing Address: ------------------------------------- 3063 Route 9 Cold Spring, NY 10516