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Home My WebLink About3175DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72.-l-24.14 BOX 26 03175 prlo a him me r }, , for I�� ; r 16 ,jg SIB. or ,_ , • ■ zLl no ' in i I r 03175 a, g. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -OF ; ENVIRONME.NTAL- HEALTH-. SERVICES _ CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 10 V —/ 3 " 9 X -rm °* %Z — I — Z 4, j ri Located at l0 � �-�-� p �1dW GI , . Town or Village 4iA"f" 0 en V Q. I le f'►�1 i �h�l �+-ey arch Owner /Applicant Name G aG a. e- Tax Map i oc Formerly CGS a Yh, ar t &0 Subdivision Name 146 r-4-d n W, ! I, —& Subd. Lot # Mailing Address Jl H6 (--f'Q n =1 10Hf K Date Construction Permit Issued by PCHD 7 I—A— LS q Separate Sewerage System built by �oti C-X C ., 1.", c-, Address 38 RtJ \Aa wk "Aaw EDP k )kfr) -5ef S s, Y. /L.Sr o Consisting of IR,5'0 Gallon Septic Tank and Y791-6 . 214" w 1 Q,e. T r•ew Gk, % Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by 2rr)4d 0 Anh XSD&, b1CAddress Q✓' `J'A/ as . c.rc . sion_ . _ co_ n_terc._. been n . _ c_o_m..pl. ea ted? Tvn_Buildin e .. Number of Bedroomsr'3 Has garbage grinder been installed? IV n b 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: G /�.,Z Certified by /_ ), -:,T - ��!�,�T�% P.E. -` R.A. (Design Professional) _License # < ; 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 ' modifi ti %or By: Title: Date: 2 3 C>'o White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVIC WELL COMPLETION REPORT Z - Z`r{ W: 3:`Laa - a- °� 1 ` ri` p B c ot( Well Owner: e: Address: � 2 - � X- A Y= 2 A,', Use of Well: 1- primary 2- secondary -2L- Residential lic 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 ><, Open hole in bedrock Other Casing Details Total length ft. Length below grade Diameter in. Weight per foot lb /ft. Materials: Steel - Plastic Other Joints: _ Welded Threaded _ Other Seal:'—/- Cement grout _ Bentonite Other Drive shoe: j-- 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 2• '`Compressed Air Hours -� Yield -,r gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieye- anal.,yrses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface (�' � 1-4-7-41,",411414 - �'� L►.�j If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type L Capacity 45� go Depth '' 11 Model a.... Voltagq,,23Q HP JAP Tank TypegW X 3p�Volume jEjPM EL — � XrkpL Date W Il Completed Putnam County Certification No. Date of Report Well Driller (signature) NO E: Fx ct location of well with distances to at least two permane landmarks to be provided on a separate sheet/plan. // Well Drillees Name lkgl!ep- . ,/1 Address: Signature: t (�/�'�� Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Fonn WC -97 •. i i I i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 7Z ��•'� � `^ �c1 pry C�. � � � �° �� • f , Owner or Purchaser of Building Tax Map Block Lot' I Building Constructed by 14— 0 }i..vn 4-c Cl �L! }'j o a C Location - Street Building Type Tow�nNillage Subdivision Name Subdivision Lot # jq 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 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 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. Month - Day General Contractor Corporation Name (if corporation) Address:28- ��✓ State Llaie_ Zip ,. f , Title: r,I cy n Corporation Na 7 a (if co o tion) 6�T c Address: r fI47A a ja,, r State Form GS -97 ~. ` YML ENVIRONMENTAL SERVICES �� 0 ��q 8 321 Kear Street �y�� U � (�-U,v�� , , � -' - Yorktowg Hei s, N.Y' 10598 (f1'4 >'-MM8{0 * Albert H. Padovani, Director LAB #: 32.907076 CLIENT #: 11392 NON STAT PROC PAGE 1 CACACE, MICHELE DATE/TIME TAKEN: 10/28/99 02:30P 67 HORTON HOLLOW RD DATE/TIME REC'D: 10/28/99 03:00P PUTNAM VALLEY, NY 10579 REPORT DATE: 11/19/99 PHONE: (914)-762-0924 SAMPLING SITE: SAME SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE COL'D BY: SAME TEMPERATURE..: < 4C NOTES...: KIT TAP COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 10/28/99 LEAD (IMS) 10/28/99 NITRATE NITROG 10/28/99 NITRITE NITROG 10/28/99 IRON (Fe) 10/28/99 MANGANESE (Mn) 10/28/99 SODIUM (Na) 10/28/99 pH 10/28/99 HARDNESS,TOTAL 10/28/99 ALKALINITY (AS 10/28/99 TURBIDITY (TUR ' COhMENT6:7 ' ' Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. RESULT <1 ppb 0.21 MG/L <0.01 MG/L <0.060.MG/L 0.013 MG/L 1.49 MG/L 7.7 UNITS 124 MG/L 108 MG/L <1 NTU NORMAL - RANGE 0-15 ppb 0 - 10 N/A 0-0.3 mg/1 0-0.3 mg/1 N/A 6.5-8.5 N/A N/A 0-5 NTU ublic schools are set at 15 ppb. Rule for Public Systems requires that no distribution points have a LEAD value of 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. more more 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 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. METHOD 9101 9139 9146 2037 2037 9043 A, . YML ENVIRONMENTAL SERVICES 321 Kear Street Yr�k� t ~~mH - _ Albert H. Padovani, Director LAB #: 32.907294 CLIENT #: 11392 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CACACE, MICHELE 67 HORTON HOLLOW RD PUTNAM VALLEY, NY 10579 SAMPLING SITE: SAME : COL'D BY: SAME NOTES...: KIT TAP ' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE/TIME TAKEN: 11/08/99 10:30A DATE/TIME RECW: 11/08/99 10:45A REPORT DATE: 11/19/99 PHONE: (914)-762-0924 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD 11/08/99 MF T. COLIFORM ABSENT /100 ML ABSENT COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (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. SUBMITTED BY: D i r e c Fol�r 10O8 ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street - - Yocktown Heig -- - -~ 2�5�28h0~' Albert H. Padovani, Director LAB #: 32.907076 CLIENT #: 11392 NON STAT PROC PAGE 2 CACACE, MICHELE DATE/TIME TAKEN: 10/28/99 02:30P 67 HORTON HOLLOW RD DATE/TIME REC'D: 10/28/99 03:00P PUTNAM VALLEY, NY 10579 REPORT DATE: 11/19/99 PHONE: (914)-762-0924 SAMPLING SITE: SAME : COL'D BY: SAME NOTES...: KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD HO 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 MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date i Re: Property of Located at (P (T) VALLO-C Section _,Block, Lot i Subdivision of N-or-4-an 14.6) )bw ec-54 +eS Subdv. Lot # 4 Filed Map # Date Gentlemen: This letter is to authorize Donald R. Knapp a duly licensed professional engineer (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said - <....Y.:.,w ►stE:c.. or -sys -terns in conformity o.r..._ - 147, Education Law,..tdi -�blic Health Law, and the Putnam County Sani- tary Code. � r �y sF o�2no . op'�OfESS10Np�' Countersigned: P.E. , R.A. , # 072770 2 Dale Avenue, Somers, New York 10589 Address (914) 248 -7726 FAX (914) 248 -7557 Telephone Very truly yours, Signed O +er of Prbjpc'rty /og 1 1-40Y-jy:4 1- 01 �� w R_ Address ?u4no-mVoJkQ Town I/q- 5 - ('�� Telephone TINT r PUTNAM COUNTY DEPARTMENT OF HEALTH o 1.� I SION OF ENVIRONMENTAL HEALTH SERVI( FINAL SITE INSPECTION ler Permit Subdivision Lot r ' 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 ...... ............................... I enaa e System a. Septic tank si ze - 1,000 20....... other ................ b. Septic tank installed level .............................................. c. 10' minimum from foundation .......... ............................... d. Distribtuion Box outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. ivlinimum 2 ft.Original soil between box & trenches Junction Box - properly set .............. ............................... .. ength required 4— Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according plan ......... ..........:..:................. 4. Sl o rich ac table 16 - 1/3 Koot ... .......... 5� ftfro p p line - 0 fo a ns.......... 6. pt of en ches e .................. 7. Rom a we or oxpans' n, o. 8. Si gravel 3/4 e er le .................. 9. Depth of gravel in tre ch 2" `c 10. Pipz -ends capped. 1. Size ot pump c am er ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ............ ............................... .... 6. Cycle witnessed by H.D.estimate o ycl HouseBBuillddin� arouse located per approved plan ............. 1.K �° b. Number of bedrooms ........ e ......................... + V. Well a.�dell Iocated as per approved plan ............ .................. b. Distance from STS area measured ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall `Vorkmanshin a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... : d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... Erosion control provided. Rev. 1/97 ................ ............................... Date: 7 Psi: by= uc >< r ri iris _ MOM I�� 1 ISAM M ■ (. 1- - ri ter -�ti� M Vym Z NAM COUNTY DEPARTMENT OF HEALTH ON OF ENVIRONMENTAL HEALTH SERVICES ONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM i PERMIT # -/3-99 Located at 21441K Ad, %a zS/. lFo wa-/ Town or Village��Aa(m 4l/!:• Subdivision name ubd. Lot # _� Tax Map 7,;-1. 1 Block AW Lot /4- Date Subdivision Approved Renewal Revision i Owner /Applicant Name r •^ -i d-a e—e Date of Previous Approval Mailing Address ;2-3 a / 4/ by 005j-,o 'j? A11. 1 Amount of Fee Enclosed �3 O d Building Type AG4 '- 11z:rWcC Lot Area 3 No. of Bedrooms 4 Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED to Sewerage -System to consist 07 Other Requirements: To be constructed by ) 2 -Ira gallon septic tank and Address Water Supply: Public Supply From Address ui • v -Private Suppiy Drilled by �R _ .. __ . - Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the seAaratg sewage treatment �. sY tem 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. ✓� r OF �,V Signed: Ar� R.A. Date Address �-/'/t ri * License # y0s APPROVED FO CONSTRUCTION: This approval }r in the date issued unless construction of the sewage treatment system has been completed and inspected ,, d is revocable for cause or may be amended or modified.when considered necessary by the Public Health Direc ora- revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. By: --f� Title: ;f.3 Date: - White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Desi rofes ' nal Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL (pJ P- ,._. _ _..s. ,- ��12A'Y�_ih .kY? �,�:•°{- -. .,. .. .. .. -_� -, ..5 ..M _l•'�5... _�•tiZ::4ir.'. �,', Well Location: Street Address: Town/Vjillage Tax Grid # ! / n �I // lD/JGi l 1j� %1vLh7A I'al// MaP ,t.f Block 2 Lot(s)/,4 Well Owner: Name: Address: Use of Well: X '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 , gpm # People Served .4 Est. of Daily Usage g ®e" gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling k," New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling - Well Type ,r Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No o-, Is well located in a realty subdivision? ............................................... .................... Yes v' No �� 1 Name of subdivision /r�' %��% /o �✓ Lot No. Water Well Contractor: Al Address: J Ra-9(-971J!y Is Public Water Supply available to site? .................................. ............................... Yes No y Name of Public Water Supply: --* Town/Village —• Distance to property from nearest water main:, `r�l Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: ZZ12 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 by Putnam County. Date of Issue r 9" Permit Issuing Offi Date of Expiration 9- Title: Permit is Non- Transfe abl White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WP -97 FU i NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT�.SYSTEI!!I;_., 1. Name and address of applicant: 2. Name of project: 4!!57- 3. Location TN: Pulo�7 m 6-14 ' 4. Design Professional: �� %' ✓� 5. Address: If 7 ��rr��r•� -�� %�'� 6. Drainage Basin: /V o �� d✓�? /5`"�j �% 7. Type of Project: - /'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 1 Exempt t/ Type II _ Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Alo 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities ?,y Date granted: 19 9 !$A 15. Type of Sewage Treatment System Discharge ................. surface water 1' groundwater 16. If surface water discharge, what is the stream class designation? .......,............ 17. Waters index number (surface) ........................................... ............................... -Ir 18. Is project located near a public water supply system? ....... ............................... Al-0 19. If yes, name *.bf water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A/o Distance to sewage system Ail-:V 21. Name of sewage system 22. Date test holes observed 23. Name of Health Inspector _ 24. Project design flow (gallons per day} .........:.......... gd`J ............. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... Ala Form PC -97 d 2 23. Project design flow (gallons per day) " � . /.>1-- a.�,�' ev � � -..•. ? 'ac .c"ti� r.• .r HYY.�•+n•1� 'n o�•••• i tah• _.. _ ... or.:.7• . ..r .�. ..tls. ..� .. . o.... -, .. .. i'J'a.iw�.i v•i.+G..1�1L •a�' J'� SL':k�Ci Laaaa�Ja�i�l'a °.i ►i��'v:l: ��:..5:�►�'�� iilYa. T'�✓:i ��'�'.�':• 25. Has SPDES Application been submitted to local DEC office? ......................... 26. Is any portion of this project located within a designated Town or State wetland? O1fo 27. Wetlands ID Number ........................................................... ............................... 28. Is Wetlands Permit required? .............................................. .... ............................ a✓v Has application been made to Town of Local DEC office? ............................... 29. Does project require a DEC Stream Disturbance Permit? .. ............................... a/el 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No Ales 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? O DESCRIBE: 32. Is there a local master plan on file with the Town or Village ? .......................... A44 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................. ............................... AIV -1+: ruC cu y �c1Jd c iicduilZii ai2a� I�3'� CesS'u r% s1G .. ..............................' 35. Tax Map ID Number .......................... .................... ............ Map7P-,/ Block 2f1 Lot 36. Approved plans are to be returned to ..... Applicant ✓ Design Professional If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES. Mailing Address: ................................... yli� /� f �1� PUTNAM COUNTY DEPARTMENT OF HEALTH p. DIVISION OF ENVIRONMENTAL HEALTH SERVICES 117 A _ DESIGN d A1 i �ET' SUBSURFACE ��TI�V t_ri aria► 1 Hit NT SI►y1L�lvl Owner a L c Addresses 7� Located at (Street) /9.44 �� ®rte � Tax Map ;�,/ Block a V Lot (indicate nearest cross street) Municipality 142,v4dAPI /'y le Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre - soaking &�JE5 Date of Percolation Test & Hole No. Run No. Time Start - Stop Ela se Mi Time n.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 � '% 2 Joy/ �/ �� _ 7 3 / j.& /l 4 5 1 f joy �� Z� >Jr � 4 5 1 2 3;'p 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 2 ' r oil TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES M, - 4 -�P�� I- Tvm` 0 % HOLE NO. Z HOLE NO. G.L. f1f s: 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' . 6.5' , 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered P/,, tpe Indicate level at which mottling is observed W"4 _ Indicate level to which water level rises after being encountered -- Deep hole observations made by: Date4_(/wf Design Professional Name: -9° 51- ,e,6f Address: _:7- 9 7 2- � -n 14— Ja IS V I A r Design Professional's Seal 14.164 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C a State Environmental Quality Review t11}- s,ra –; Pii i &i`r d AL SsC III hltll I .. For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME, 3. PROJECT L TIX1114�ar&;J 1707 Municipality Cou nty '!;Pr;1F 4. PRECISE LOCATION (Street address and road Intersectidns, prominent landmarks, etc., or provide map) 499�_c��d^�/d 5. IS PRO OSED ACTION: ow ❑ Expansion ❑ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: f 7. AMOUNT OF LAND FFECTED: Initially acres Ultimately gig! acres 8. WILL ROPOSE ACTION COMPLY WITH EXISTING ZON1144h OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? esidential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ ParklForesUOpen space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? El ��1��i Yes No If yes, list agency(s) and permlU / approvals mar d/ y� 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Ado Yes If yes, list agency name and permlVapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes A9yo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: C; re- q &4 GA C�v de Date: � Signature: If the action is in the Coastal Area, and you are a state agency, complete the I Coastal Assessment Form before proceeding with this assessment OVER 1 PART 11= ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 8 NYCRR, PART 817.12? It yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL A VON RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration Aay be superseded by another Involved agency. 0 Yes El No "I-AWY A-6VEHSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible)4� Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain brlefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. 1 C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box-if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency Date E Title of Responsible officer Signature of reparer (if different from responsible officer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of ff �� v Located at / yAv o Al T/V 161 W a ! Tax Map # Block 2 Lot / 4— Subdivision of leli /�� % %�/ A�s /`X � Subdivision Lot # * Filed Map # Date Filed )3P 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 Plllnatll County Health Department, and to sign all necessary papers on.my behalf in connection with this matter and to supervise the construction of said wastewater treatment and /or water supply systems �- in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: J P.E., R.A., # (Owner Pr eny) Telephone: �'6L ,—>- Y Mailing Address: �y �, State ��'�, Zip—LC) Telephone: D G I -- 0` Q 4 Form LA -97 PUTNAM 'COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT _ i ,4 i. Ti�i�i" • - '�eri2 `: {jOl,Lct�1� NA'NIE OF OWNER' �`�-A coC ro REVIEWED BY / `44M DATE 7/Z1119 TAX NI AP # %Z. DROCUNIENTS APPLICATION ?RMIT _/ PWS LETTER OF AUTHORIZATION DATA SHEET (DDS) ATE RESOLUTION i`1�j� 1AF THREE SETS 'LANS - TWO SETS CE REQUEST SUBDIVISION A.L SUBDIVISION. DIVISION APPROVAL CHECKED RATE REQUIRED DEPTH TAIN DRAIN REQUIRED STANDPIPES GENERAL ATED IN NYC WATERSHED NS SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED s� ZS WITNESSED, IF RFO',D.., - -LANDS (TOWN/DEC PERMIT REQ'D ?) 'A ON DDS PLANS & PERMIT SAME 1969 NEIGHBOR NOTIFICATION TER BUZBA YR. FLOOD ELEVATION ER REQ'D PERMIT(S) . REQUIRED DETAILS ON PLANS 'AGE SYSTEM PLAN - (NORTH ARROW) S HYDRAULIC PROFILE GRAVITY FLOW ISTRUCTION NOTES r IGN DATA: PERC & DEEP RESULTS )NTOURS EXISTING & PROPOSED VEWAY & SLOPES, CUT ,TING /GUTTER/CURTAIN DRAINS COMMENTS: Y EROSION CONTROL:HOUSE,WELL, SSDS . OERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP fir"• AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN ETAILED MOUSE - NO.OF BEDROOMS := I WELLS & SSDS'S W/IN 200' OF Pkdf OSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) 'HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOU,y-'' FILL SYSTEMS CLAY BARRIER FT. HORIZONT • OPE 3:1 TO GRADE FILL CS FILL NOTES FILL CERlff rCA-ZION NOTE ;rGUAGES PROFILE & DIMENSIONS FILL IN EXPANSION AREA TRENCH NCH PROVIDED & 60 FT MAX. PAP -AL EL_ Q CQ NDD—Ir" 100% EXPANSION PROVIDED QN PLAN - FROM SST& 10. P.L., DRIVEWAY, LARGE TREES, TOP OF FILL f0' TO FOUNDATION WALLS _15'WELL TO PL f00' TO WELL, 200' IN DLOD, 150' PITS K' TO STREAM WATERCOURSE LAKE (inc. expan) j,8' -TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER I V TO WATER LINE (pits -20') 60 WTER�IMITTENT DRAINAGE COURSE NO' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS IS min to CDS= >5 %,10'- 4%,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <1% Wmin to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL FORM ST -2