The URL can be used to link to this page

Home My WebLink About3416DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.17 -1 -22 BOX 27 ar �� oil ,. 03416 PUTNAM COUNTY DEPARTMENT OF HEALTH DFEN NIaO.NNr[ ALIW J.TH. SERVICE' CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at Lvt --I Town or Village Owner /Applicant Name N12. d d L5 - P "� ak Tax Map i 7 Block 1 Lot 2 Zi Formerly D "Nno Subdivision Name Subd. Lot # Mailing Address I /"r_6 Date Construction Permit Issued by PCHD Zip Za Separate Sewerage System built by 13-DA ( CCA-T � t-/ O 't Address ?-- Consisting of 2-5' Gallon Septic Tank and 000 )aC Other Requirements: , °4A_ Water Supply: Public Supply From. Address W or: Private Supply Drilled by X A4c-x� /we_ Address /S 2 ,440M ... . Has erosion t.ori&,")r�been cbrripleted? � : %� - • _ . Number of Bedrooms fi-- Has garbage grinder been installed? I certify that the system(s), as listed, serving the. above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulatio the Putn County Department of Health. Date: /O I S_ Certified by P.E. X R.A. (Design Professional) q Address /73 WA-S_ W4_-XW is �QSE 4- /vim �1,�G�'e C-7— License # 076 %7.3 a�7Z,L 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 revocatio modification or ch a is necessary. B Title:� Date: copy - HD File; Yellow copy - Buildin spector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �( 3 0 0--. Ili .� #' I `'� Iii ale e i ;��. i L1 I l 1 1la _ �` �/ 1 h, 0011 GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Am-- s Owner or Purchaser of Building J4 6 4 Building Constructed by zr Lv / C I Location - Street. Building Type -/?-(7 / . z. z,., Tax Map Block Lot Town/Village Subdivision Name :Subdivision Lot # 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. Dated: Month . l0 Day S Year Ze General Contractor (Owner) - Signature Corporation Name (if corporation) Signature Title:�ry - Corporation Name (if corporation) . Address: Address:, State Zip State Zip Form GS -97 trI.1".1Z PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Wtll.,-Locati6i� trebt "A &I acj� TO tillage:.`,�, T�Lx-1 Grid 4.1 _-v Map Block Lot(s) Well Owner: Name- Address- Z R�w , Zu Use of Well: 1-primary 2-secondary X Residential P66lic Supply Air cond/heat Kmp _LIrrigation 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 A- Open hole in bedrock Other Casing Details Total length ft. Length below grade aft. Diameter in. Weight per foot lb/ft. Materials: Steel Plastic — Other Joints: Welded Threaded Other Seal: -_>< Cement grout Bentonite Other Drive shoe: -2!fYes No ILiner: 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 -/--Compressed Air Hourp-21 I Yield P 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 sieve,-analyses. are available, please attach.. Depth From Surface 'Water Bearing Well Diameteron) Formation Description ft. ft. Land Surface o2 0 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Typq,,,_ Capacity 5,- SAS' Depth -14W Model o S - I Voltage ;X3 e* HP lffy ./t6P Tank TypeW 2<6 Vol me It,(, Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) NOTLV-. E act location of well with distances to at least two permane t landmarks to be provided on a separate sheet/plan. Well Driller's Name Address: Signature: Date: i4j 1 0 White copy: HE) File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 t,52 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Nealth Director Director of Patient Services Environmental Health- (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM TAX MAP NUMBER: 73, 17 1 — Z Z E911 ADDRESS: S. TOWN: ��✓ ir'O�dt �f.�- AUTHORIZED TOWN OFFICIAL:. 5.-- 47— DATE: /0 // -7 /() 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 Certifcatc of Construction Compliance. (E911 verfrm) AJ_-�,_� � YML,`G��IRON��NTAL SERV[CES Street [� �^ ��t��P��ovan i / Director | - NORMAN ANDERSON INC. DATE /TlME TAKEN: 09120105 152 BARGER ST DATE/TlNE REC'D: 09/20/05 02:50 PUTNAM VALLEY, NY 10579 REPORT DATE: 10/O3/05 PHONE: (9J.4)-528-149l SAMPLING SITE: EDWARDS . : 52 LUIGI ROAD COL'D BY: SARAH ANDERSON NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PUTNAM CNTY 09/2O705 09/27/05 09/22/05 O9/22/05 09/22/05 09/28/O5 09/28/05 09/2l/85 09/26/65 O9/27/O5 09/26/05 ` PROF'I'LE SA ' LE TYPE..: POTABLE P� SERVATIVES: NONE COLlFDRM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MF T. COLIFORM ABSENT /100 ML ABSENT 1008 LEAD ({MG) <L.O p p b 0-15 pp 9003 ' NITRATE NITROG 1.94 MG/L 0 - 10 9052 NITRITE NITROS ` <0.0l MG /L N/A 9!62 lRON (Fe> <O.O6O MG/L 0-0.3 mg /l 9002 . M'NGANESE (Mn) <0.010 MG7L 0-O.3 mg/1 9OO2 SODIUM (Na) 19.7 MG /L. N/A 9002 pH 6.0 UNITS 6.5-8.5 9043 HARDNESS, TOTAL ' 101 IIG/L N/A ALKALINITY (AS 42.0 MG/L N/A 900l ' (TUR ' <1_NTU U 'TURBIDITY ` \ COMMENTS: ` BACT THESE RESULTS INDICATE.— THAT THE WAT (WAS NOT) OF A SATISFACTORY SANITARY QUALITy ACCORDI�K��I��HE NEW YORK STATE AND EPA FEDERAL DRINKINGWATER STANDARDS- FOR'THE pARAMETERS. TESTED, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p BPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. �bIic 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 shal1 not exceed 0.5 mg/L. Na Nu limits for Sodium are proscribed. Suggested guidelines state th t f l di t i t d di t th t h 1d a nr peop e on a so um res r c e e , e wa er s ou contain no more than 2O mg/L of Sodium. For those on a moderatealy r�stricted diet, a maximum of 270 mg/L. of Sodium YML ENVlRONMENTAL SERVICES 321 Kear Street '.j 4g1 s (914) 245-2800 K ' Albert H. Padovani, Director | NORMAN ANDERSON lNC� DATE/T{ME TAKEN: 09/2O/05 152 8ARGER ST DATE/TIME REC'D: 09/20/05 02:5� PUTNAM VALLEY, NY 10579 REPORT DATE: l0/03/05 PHONE: (914)-528-1491 SAMPLlNG SITE: EDWARDS : 52 LUlGI ROAD COL'D BY: SARAH ANDERSON NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ is suggested. SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLlFOHM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ pH pH SCALE lN WATER RANGES FROM 1-14. IS ONE OF THE [MPORTANT AND FREQUENTLY USED TESTS lN WATER CHEM[STRY. WATER WITH A LOW pH MlGHT BE CORROSlVE TO METAL PlPES 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 CONCENTRATlON, BOTH E%PRESSED AS CALCIUM CARBDNATE, lN MG/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. VERY HARD = MUUL�H/�LY MHMU �H|�M: 7U-i4V M6/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: 04P Alber . Padovani, M.T.(ASCP) Direcb0r ELAP# �0323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONiVIENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Inspected by: _"sp Street Location ��a, ty (%;'i ✓e - - - Qvuner._. r��o. - : -._.= �.� Permit 4 fV - 3 a a a TM 4— - '3: i Subdivision Lot 4 a`! A X. 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 ....... ............................... II, Sewage System -a. Septic tank size - 1,000 ........... 1,250..Ll..other ................. b. 'Septic* tank installed level ..... ................................ :....... c. 10' minimum from foundation .............I ....... ............ ......... d. Distribution Box 1. All outlets at same elev ' n-wa er tet' sted.....::...:: 0 2. Protected b ost .............:::.:......... 3. um 2 ft.Original soil between box & trenches e. jifinction Box -properly set .......... ............................... 6. renc es 1. Length required ' (00 Length installed 3,-V-0 2. Distance tow atercourse measured. Ft... rt v 3. Installed according to plan ..............:: 4. Slope of trench. acceptable 1/16 - 1/32" /foot ............. 5, 10 ft. -from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface...... ............. 7. Room allowed for expansion, 100 % ......................:.. S. Size of gravel 3/4 -1' /z" diameter clean ...................: 9. 'Depth of gravel in trench 12" minimum ................... 10. Pipe ends ca d ...:......... ........ .. ... g�. PuMn- -wD4se 1. Size of pump chamber ................ .. ....... «..... 2. Overflow tank ............... . .......... ..............:................ .3. Alarm, visuay- ........................ .. :......... ...... 4. Rr m,ea ' y. accessible, manhole to grade .......:......... stbox baffied ................ ............................... :.:.... 6. Cycle witnessed by H.D.estimated flow /cycle........... M House/Building a. douse located per approved plans ......:............ - ;....... b. Number of bedrooms ...... ...........................�`td IV:'. Well Well located as per approved plans . ......:............I........... b. Distance from STS area measured .t ft........... c. Casing. 18" above grade ....:........... ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ......................... :..... b. All pipes partially backfilled .......... ...........................:... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to pla j% f. Curtain drain outfall protected & dir.to exist watercdur�e� g.. Footing drains discharge away from STS area.. :............ h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... Rev. ?2102 IRV SEVELOWITZ Code Enforcement Officer JOHN ALLEN TOWN OF PUTNAM VALLEY Deputy Zoning Inspector BUILDING, ZONING, AND SANITARY DEPARTMENT November 16, 2005 Joseph S. Paravati, Jr. Department of Health 1 Geneva Road Brewster, NY 10509 Re: 52 Luigi Road, Putnam Valley T1VI #73.17 -1 -22 — Edwards Dear Mr. Paravati: °IAM 0L1Y,14.`Y.4j (845) 526 -2371 Fax (845) 526 -8806 DOPEEN PIACENTE Bldg. Dept. Clerk This letter is being written in response to your letter dated November 8, 2005 and Official Notice-of Violation for the above named property. The plans submitted to your office as well as this office had both the staircase to the unfinished attic and the unfinished space over the garage on it at submission. The space in question is unfinished and therefore would be considered uninhabitable at this time. ff it ythin fug flier is °required -- contact th 5poffice. , Very truly yours, IRV SEVELOWITZ Code Enforcement Officer Ig /dcp - n''1� t�� `�`7 � "''`" `dam Lic•, Ga. � � �� Commissioner of Health LORETTA MOLINARI; RN, MSN Associate Commissioner of Health ;T.'•r: =A TMrn:.�.+ -..: -r rr �e;�l9il@g1')�I�Y.:J,:: �2ri:i'1 �M.'�I•�� ..%s:.rri:. W�i..A.:...:,wb.t:�l County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Iry Sevelowitz, Building Inspector Putnam Valley Town Hall 265 Oscawana Lake Road Putnam Valley,'New York 10579 Dear Mr. Sevelowitz: November 8, 2005 Re: Construction Compliance — Edwards 52 Luigi Road, Town of Putnam Valley TM # 73.17 -1 -22 This Department conducted an inspection at the above referenced parcel on November 3, 2005 and noted the following: Construction of a habitable structure that was not approved for potential bedroom count by this Department. Specifically, there,is a garage with space above and a third floor that was not included for review. In order for this Department to make a determination on the potential bedrooms, a letter needs to be provided stating whether or not the space in the third floor is considered "habitable space." . Please be advised that in the .future, all floor plans approved by the Town Building Department for construction' needs to have the bedroom count stamp of the Putnam County Department of Health affixed and signed by a representative of the Department. Kindly advise us if there are any questions or concerns. Sincerely, oseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj Cc: Stephen Ferreira Mr. & Mrs. Edwards Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 A r" ' iDHFiR'l.;I A;Ali LEFy- LP4D%j Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health W r R DB it d . �ONIDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 CERTIFIED MAIL RETURN RECEIPT REQUESTED Mr. & Mrs. David Edwards 52 Luigi Road Putnam Valley, New York 10579 PLEASE RETURN CORRESPONDENCE TO: Joseph S. Paravati, Jr. Assistant Public Health Engineer 845- 278 -6130, ext. 2157 November 8, 2005 Re: Property of Edwards 52 Luigi Road, (T) Putnam Valley TM# 73.17 -1 -22 OFFICIAL NOTICE OF VIOLATION ._..Dear Mr. & Mrs. Edwards_ 'c ,.a h..r.� 6- +'.`...y.y wCse'v � c.�. . •-e„rt t Based on a field inspection on November 3,• 2005 and subsequent review of documentation on file by this Department, YOU ARE HEREBY NOTIFIED of non - compliance with the following items of the Putnam County Sanitary Code: o Article III, Section 2(e): No new separate sewage treatment system shall be placed in operation nor shall any new building requiring such system be occupied until a Certificate of Construction Compliance shall have been issued indicating that such treatment system has been constructed in compliance with the terms of the approval issued and the requirements of this Code. All of the above items must be corrected and a Construction Compliance issued by November 23, 2005. These violations may lead to an enforcement hearing and subsequent fines. It is sincerely hoped that the above mentioned further action will not be necessary and that you will cooperate by securing the correction of these conditions. If you believe the above notification is incorrect, please notify this office immediately. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 M I .� Kindly notify the inspector indicated above if you have any questions. Sincerely, Sherlita Amler, MD Commissioner of Health y: Joseph Paravati Jr. Assistant Public Health Engineer SA:cj. cc: Building Inspector, (T) Putnam Valley ATTENTION - ��LJILLVAl�B- ��LY�IJl�Y II�E�L�d�ll� .11811a�'n�im't�JU�Il7l '_S.�.c.°:.`'c'.._.�,:t .. ,..; >.:� <:'.,'o-•:::�.'.- r.t'i-� �i +- DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0 JOSEPH El GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit # 8/01-30 —OZ-- n / . Located: L V®0 ® /4 *6 (T) M 0 V .4ZQS Owner /Applicant Name: "L.&W O TM 7 f! Block _/ Lot 2� Formerly: Subdivision Name: Subdivision Lot # Is system fill completed? �V Is system complete? Is system constructed as per plans? Is well drilled? S(C$ Is well located as per plans? Of Are erosion control measures in place? Date: Date: Date: I certify that the system(s), as listed, at the above premises has been constructed and I have.inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of *Desig=n Date: E� z9 Certified by: PE RA rofessional Address: l®;? Ag MI14r C�f 0&776 Lic. # Q %4 % 29 Comments: Form FIR -99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT-SYSTEM PERMIT # Located at .v% r Y 4"; e Town or Village '` ''rs ► �,r�� Subdivision name Subd. Lot # Tax Map! Block � Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name &-7 �� yn %��r'l%' Date of Previous Approval Mailing Address Amount of Fee Enclosed v Building TypeAlr e Lot Area T i �. of Bedrooms _:t—_ Design Flow GPD zip %'`�✓ Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED ate Sewerage System to consist of // / 2..' gallon septic tank and Other Requirements: To be constructed by z AVI' Address Water Sunoly: Public Supply From Address � C� �L�,,s-�c� ✓.� Address Ems' 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: , P.E. Cass Address M 0 eatment system has been completed and inspected by the 1 Date #r issued unless construction of the 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 rmi Appro d for discharge of domestic sanitary sew ge only. / By: u� �"v Title: Date: / J 2�'� z-- White copy - HD jii Yel w copy - Building Inspector; Pink copy - er; copy - Design Professional Form CP -97 PUT NAM COUNTY DEPARTMENT OIF HEALTH IIDI[ IKON OTF ENVIRONMENTAL HEALTH SERW CES Al1nIP]l.,)CC TJ J ��C I C81C�A N.-A1 .nN .....� < -. •nom,. ".r�:+e -t :�• '•� - a:wri. ...-- ..,es =re: please print or type PCHD Permit #'� Well Location: Street Address: TownNillage Tax Grid # Map 7.3. Block / Lot(s) 2:%_ Well Owner: Name: Address: Use of Well: ___I_ esidential Public Supply Air /Cond/Heat Pump Irriga ion I- primmary Business Farm - Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought ��i ' gpm # People Served __ 17 Est. of Daily Usage ''A�� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _ZNew Supply (new dwelling) Deepen Existing Well Detailled Reason for Drilling Well Type _�/'brilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No d— Is well located in a realty subdivision? ...................................... ............................... Yes No 1/ Name of subdivision Lot No. �— Water Well Contractor: A4 ddress: �`' Is Public Water Supply available to site? ................................. ............................... Yes No to° Name of Public Water Supply: —° TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Late: Applicant: Sighat&6 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. Al?]?ROV EflD.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 Ovate well driller certified by Putnam County. Date of Issue `—Z -0 Permit Is g Offici Date of Expiration — 2 f %)47 Title: Permit is Non- Tranafferrablle 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 LETTER OF AUTHORIZATION RE: Property of Located at T/V.i Tax Map # Subdivision of Subdivision Lot # 7--,7-17 Block. / Lot Filed Map # - Date Filed Gentlemen: This letter is to authorize' /' J .1,1-4 t a duly licensed Professional Engineer 17 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, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # of NEW Mailing Address 'E I State Telephone:TT�� .5. Very truly yours, Signed- _ l (Owner roperty) /—Mailing Address: ,;� �%C % �C State ,L/i 4;*I l Zip Telephoner ��5 S"A 5'91 V/F5 % Form LA -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: ' /,��,j 2. Name of project:_ 3. Location T/V: 4. Design Professional: 5. Address: 6. Drainage Basin: ,U 5 t,•7 � / Cr�li� /� 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)? /1'1 Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 4 11. Name of Lead Agency/' :.;::12; ::Is this praject'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? Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water ;-"*' groundwater 16. If surface water discharge, what is the stream class designation? .................... d 17. Waters index number (surface) ........................................... ............................... �. 18. Is project located near a public water supply system? ....... ............................... 19. If yes, name of water supply AV'101 Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ 41el 21. Name of sewage system Distance to sewage system 22. Date test holes observed .23. Name of Health Inspector 24. Project design flow (gallons per day) ................. ................ ............. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.:. Alll�lj 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 2 27. Is any portion of this project located.within a designated Town or State wetland? 4a 28. Wetlands ID Number ............................ ............................... _ ..... 9r Is VECTa ds Periiiil required? y ........................................... ............................... Has application been made to Town or Local DEC office? ............................... 111, - 30. Does project require a DEC Stream Disturbance Permit? .. ............................... ll� 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 Al>i 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous' waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No%'� DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... Alel' 1 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... _ .046, 35. Are an se y wage treatment areas in excess- of 1'5% slope? . ............................... 36. Tax Map ID Number .......................... ............................... Map % /% Block_ Lot 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All applications for review and approval of a new SSTS to berlocated within the`NYC. Watershed shall . be sent�ta the I partmeA aril ne&riot be sent in duplicate to the DEP, although the project may requireREP; ; , approval of the SSTS prior to final approval by the Department. Projects within the watershed maga-ls0 "1 require DEP review and approval of other aspects of a project, such as stormwater plans or the creattuh orl , impervious surfaces, and the project applicant should obtain the appropriate forms for such activitierorrr-- DEP and submit those forms to DEP for review and approval.'*, If the application is signed by a person other than the applicant shown in Item l.,the applicatio?mq be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this prwisia- may be grounds for the rejection of any submission. I hereby affirm, ender 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 misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: J �� '�� % Ld'J Mailing Address: 2- TEST PIT DATA 2 DE,43CMPTIONOF SOILS ENCOUNTEw.D IN TEST HOLES DLPTI- . HOLE NO, Gl. e 0.51 1.01 15 /V� ',f 3.0' 33 4.01 45 5.0' 5.51 6.o' 6. 7.01 7.5 r 8.0 8.5, 9.01 10.91 HOLE HOLE NO. at which groundwater is encountered Indiu,i.c:c lcvul at -which mottling is observed Indlu,ac lev('.1 'to which walcr level rises after being cn=lritcrecl Deop lJole. observations made by,: Date C01I.C,I)SIollEll Name: Addro,s-.;: ....... ... Design Professional's Seal j' i . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH - )rT►JIV[Di1L CATER. STL+IVIS�� REVIEW SHEET FOR CONSTRUCTION PERMTT NAME OF OWNER: STREET LOCATION: L ut- Tsr REVIEWED BY: RM, GR, 00, SRDATE: ' �3 �� TAX MAP#: (CONFIRMED) • . l �- -v� v�- Y/ N DOCUMENTS L�)PERMIT APPLICATION -/ /WELL PERMIT OR PWS LETTER �(�PC -97 7(�j(�i.ETTER OF AUTHORIZATION fU/ UDESIGN DATA SHEET (DDS) / SHORT EAF j `PLANS -THREE SETTS UCJHOUSE PLANS - TWO.SETS . SUBDIVISION /� UULE L SUBDIVISION / J J a ( )( )SUBDtMO OVAL CHECKED LJ REQUIRED. DEPTH IN CURTA DRAIN REQ GENERAL C-JC-JLOCATED IN NY W: • RSHED C-J(,JPLANS D TO DEP (� GATED TO PCHD ! EP APPROVALIREQ (:(�DETAHJDUST FREE CRUSHED STONE OR WA- SHED`GAAVEL ; F 'D - (� GEOTEXTII.E COVER (�(_} EP TEST HOLES OBSERVED 1�,° C- PERCS TO BE WITNESSED ,,i� �—)L_J APPROVAL SSDS ADJ,DOTS T -A." (TOWN P mow. T 3 S ECPERMIT D 'ATA ON DDS PLANSUPERMLT_SAME : S C ��) CONSTRUCTION NOTES 1 -15 DOSE/PUMP S MS UUP NoTEs UC L�C�STANDP , o L ON -PE !OM1I�NTS: PP ty � R v i�S � S N y v wt CL 6 6cGGlil l7v Y /N ( REOUIRED DETAIIS ON PLANS CONT'D) CN HOUSE SEWER -'/1' FT. 4 "0'; TYPE PIPE CAST IRON ✓JUNO BENDS; MAX BENDS 45' W /CLEANOUT t PE- 0T -(N ES4NGE)'V / Ai- FILL SYSTE S (�U10' HORIZONTAL; PAST CH SLOPES 3:1 TO RADE UC FILL CSI FIL TES 1 -5 /�- ()UFILL PRO IONS (UU �ANSION AREA FILL GREATER THAN2 FEET CUU CLAY ARRIER / C-- �CJFit,L TIFICATION TE �%/ 4- UUDEPTH GA ( ,(�VOL. ON PL 0 B., UNCLASSIFIED & E�IPERVIOUS (-JUSEPARA N DISTANCE FROM TOE OF SLOPE `// TRENCH TRENCH PROVIDED 60FT MAX. SEPARATION DISTANCES ON PLAN - FItOM'SSTS 10' TO P.L. DRIVEVYAY, LARGE TREES, TOP OF FILL (g�20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TQ PITS ' -" 100' TO STREAM, WATERCOURSE, LAKE. (iuc,, espaca C.r. ., � 0'_�CO:- C,,'A''~CS ]&ASIl`i; 35'•3'TOYiIi+iIDRAIN; P1P1ED W�i1'EEt�"_."...."�.. -. �' 10' TO WATER LINE, (pits - 20') 0' INTERNIITTENT DRAINAGE COURSE (��i' 200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS C__)C�10' MIN TO LEDGE QUTCROP . SEPTIC TANK C!�U10' FROM FOUNDATION; 50' TO WELL � WELL UC_?DIIVIENSIONS TO PROPERTY LINES (LOCATION OF SERVICE CONNECTION UUMIN 15' TO PROPERTY LINE (� PE IN SSTS AREA � S 20 %) U�GRADED TO 15 %, IF REQUIRED , �(„�PRE 1969 NEIGHBOR N TIFiC_ATION, _•�_ 36 (,� 0 YR. FLOOD ELEVATION W/I 200' 6ts ��' (�(�OII, TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS /.SEWAGE SYSTEM PLAN (NORTH ARROW) � SDS HYDRAULIC PROFILE GRAVITY FLOW DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING &PROPOSED J�DRIVEWAY &SLOPES, CUT " FOOTING /GUTTER/CURTAIN DRAINS SL R )USRA SOIL TYPE BOi1NDARIES (�(___) —TITLE BLOCK; OWNERS NAME ADDRESS TM#, PElRA; NAME, ADDRESS, PHONE# (� DATE OF DRAWING/REVISION C✓DATUM REFERENCE C,�(__)LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS W1THII�T 200' OF P.L. �(-PROPOSED FINISH FLOOR AND /" BASEMENT ELEVATIONS (" WELLS & SSDS'S W/II�1200' OF SSTS . ��PROPERTY METES &BOUNDS . .C__)(,,,JERQSION CONTROL FOR HOUSE, WELL & . SSTS, EROSION CONTROL NOTE U(�DOSE 7 + P � OLUMEJDOSE VOLUME NOTED U(�DETAIL F - (PIPE TYPE, ETC.) d.• �G„ UUPTT -BOX SHOWN@ 6 AY STORAGE ABOVE ALARM UU1s' Nmv to UU2o' MIN to UU1o' x Gts3� • o�.. �." r �s � CURTAIN DRAIN TH S TAIL /o, 15'-3%35'-l%, 100 % - <1% E 'with 18 cons day discharge RFO PIP Uv o� wc�i i3 (as JOSEPH F. SULLIVAN, P.E. 2972 FERNCREST DRIVE YORKTOWN HEIGHTS, N.Y. 10598 �` -� /��„ D (91 4) 962.4248 v� F/L�i / ��✓�tV�+ AL 3 °ublic Health Director r x,-41 -& k aUT- T&LMOI Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 REQUEST FOR FIELD TESTING ATTENTION: ❑ ADAM STIEBELING ❑ GENE REED All information below must be fully completes; prior to any scheduling. DATE: ENGINEER OR FIRM: ,� ; ,Jc,t ✓') 1 �= PHONE #: - •' cr >—V, REASON:, DEEPS: PERCS: ❑ PUINIP TEST: ❑ ROAD /STREET: TOWN• t Nv' h �• �.. � -TAX MAN: Z � • I ? -- 1 -- � •Z -�- SUBDIVISION: �— LOT #: pi -j ate. /- YES NO . .:. Proposed SSTS:.within the drainage basin of West Bra�neh o Bolds Corner Reservoirs; o Proposed'ST within 500 feet of a reservoir, reservoir stem or:control lake. ❑ Sg� Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ ,>�{ Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department ;will determine .the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. DATE: �O �, FOR COU:i T USE ONLY Io` ' 3O P/"' , CONSMENTS: (FMLDTEST) .0- EN V1-1C1J1:'ll^. EN AL 11 r AL :.: :.1':;r.�• :.: • .T.: _.._. —. e —.- . 1 GENEVA ROAD BREWSTER, NEW YORK 10509 Phone: 1 - 845 -278 -6130 Fax: 1- 845 -278 -7921 FAX NUMBER TRANSMITTED TO: i- l 12'—W -7 - gRg' 1�f- S l To: ��~r� Sul(; ✓wN �� Of From: Date: Number of Pages: • t MIUI M )'Pit �S�rieh HS IF YOU DO NOT RECEIVE ALL PAGES, PLEASE TELEPHONE US IMMEDIATELY AT 845- 278 -6130 Eu ` oZl S 7 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION 17 REPORT Well Lo ca 'io Street JTA�Tillage: Tax Grid# Map,711 Block Lot(s)Zj., Well Owner: Name Address: Use of Well: 1-primary 2-secondary X Residential P661ic Supply Air cond/heat pdinp 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 ".I—ft. Diameter gol in. Weight per foot lb/ft. Materials: Steel Plastic = Other Joints: Welded � Threaded Other Seal: -,-x Cement grout Bentonite Other Drive shoe: Yes No ILiner: 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 -7"Compressed Air Hour? Yield ja 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 are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface P,16 ol If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Typg3j4a&z Capacity 5� Depth Model -S'T 0 Voltage :,2_30 HP j Tank Typc(2/X ;Z !;e5 Vol6me L qty y Date Well Completed 1111e, A Putnam County Certification No. .9 Date of Report Well Driller (signature) NOTE, hPct location of well With distances to at least two permanefit landmarks to be provided on a separate sheet/plan. Well Driller's Name Address: 1L;1__2 'L11'q-' :26_�2� aii&19 6L Signature: '2 -. � ' Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 ' •PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES' '!i "l`JYCMiL.Jii.L\M1 --SITE SM- . N V�l11 ~_-• SECTION A. GENERAI INFORMATION Name of Project �` �-'�� _ (T) (V)' County Site Location - Vic Building construction begun Extent . r.. Is property within NYC. Watershed ? ................. a Yes No SECTION.B. TOPOGRAPHY (Please check all appropriate boxes) 1. F-1 My-, .0 Rolling a Steep slope �-Gentle slope Flat 2. O. Evidence -of wetlands a Low-area subject to flooding F7 Bodies of water Drainage ditches 'Rock outcrops 3.. Property lines or: corners. evident ..:.......................,............................ . Yes :: o 4. Do water courses exist on or adjoin the property? ................................. Ye s o . 5. Will these affect the design f the sews a ss stem facilities ?............ � g Y Yes No 6. Do watershed regulations apply in this development ? ....................... Y o 7 Will extensive grading be necessary? ................. ........ : ............. ......... Yes_ No 8. Will extensive fill be necessary . for SSTS? ......:.. .........:..................:.. Yes - yNo........ . 9'._ Do filled`are'as exist withmthe SSTS area ?....... Yes No .............................. �. �• If yes, what is' the condition of the fill? SECTION.C.- SOIL OBSERVATIONS 10. Appearance of soil: 0 Sand Gravel Q Loam a Clay a Hardpan Mixture 11. Observed from: F7 B'o:rings F_� Bank cut F,7Backhoe excavations . 12. Soil borings /excavations observed by '5 P d frog NIf' J1 t ✓fitti on 13. Depth to groundwater 1� on 14. Depth to mottling 15. Are test holes representative of primary & reserve areas ..:... ....... .....................:,.. on Yes F-1 No lb. Soil percolation. tests made by on 17. Soil percolation tests witnessed by on SECTION D (on, back) Form ST -1 .24. Site observer /inspector and title A eH. � 25. Dates) of observation(s)inspection(s) 10 : v d? TEST PIT PROFILES Hole # Lot # Hole # 'Lot # ..Hole # Lot # Depth to water Depth to water AJ f! Depth to water Depth to mottling 'yj /M.I]/ D epth to- mottling, Deh .'..• . ...n. ..q�- .1.•:L: .�"v'� ..A°J"'°� K • - _� ss ... ....... +.5 •Y t��i Depth to rock/imp. Depth to rock/imp. �� Depth to rock/imp.' G.L. fi 5 . ,� f S G.L. ' i GJ� o ' G.L. 'j ' ` 10 1.0 ��`IlGe��'^ 1.0 3.0' L��:'''"`: 3.0 f'yj �'w"^ 3.0 4.0 4.0 4.0 5.0 5.0 5.0 . 6.0 6.0 6.0 7.0 8.0 7.0 7.0 8.0 8.0 9.0 9.0 9.0. 10.0 10.0 10.0 2 MUM 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Q Yes �No 19. Will groundwater or surface drainage require special consideration? ..........:...... :..:. F-J'Yes [�J'No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ?... ...................... a Yes F:�'No SECTION E. RI EMARKS 21. If a common water supply is proposed; has an inspection been made of the existing or proposed source and facilities? ......................................... ......... . ...... ......... 0 Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist ?......... 0 Yes. No' 23. Additional comments .24. Site observer /inspector and title A eH. � 25. Dates) of observation(s)inspection(s) 10 : v d? TEST PIT PROFILES Hole # Lot # Hole # 'Lot # ..Hole # Lot # Depth to water Depth to water AJ f! Depth to water Depth to mottling 'yj /M.I]/ D epth to- mottling, Deh .'..• . ...n. ..q�- .1.•:L: .�"v'� ..A°J"'°� K • - _� ss ... ....... +.5 •Y t��i Depth to rock/imp. Depth to rock/imp. �� Depth to rock/imp.' G.L. fi 5 . ,� f S G.L. ' i GJ� o ' G.L. 'j ' ` 10 1.0 ��`IlGe��'^ 1.0 3.0' L��:'''"`: 3.0 f'yj �'w"^ 3.0 4.0 4.0 4.0 5.0 5.0 5.0 . 6.0 6.0 6.0 7.0 8.0 7.0 7.0 8.0 8.0 9.0 9.0 9.0. 10.0 10.0 10.0 13.16 -4 (2,67) -Text 12 PROJECT I.D. NUMBER 617 .21 SE peodix -V:.- "ai2'wi:�. - a :_:r' .;o'rFa . �� : vc:..3'v -:•.�i i•�z •.:,is�- ^•ri...• < °,w..,.eii• State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM.. For UNL)STED ACTIONS only..'_ PART I— PROJECT INFORMATION (To be completed by ApQlicant or Project sponsor) -- - -. 1. APPLICANT ISFONSOR 2. PROJECT NAME. . 3. PROJECT LO TIO�,N�:! � �>�t'i %�! ^i ✓c' Municipality J (.�'� /�!i _ �' �� County 3. PRECISE LOCATION (Street address and road intense ions, pro inent landmarks, etc., or provide map) v zy 5. IS PROPOSED AIZT10N: ex . ❑Expansion ..... ..... . Mcditicationlalterattan -- — - - 6. DESCRl3E PROJECT 8RIEFLY: 7. AMOU.ri OF LAND AFFECT - /gip Q indkaiIy UUic aiety " `' _ _ acres acres a.-YIiLL PROPOSE• ACTION COMPLY WITH EXISTING ZONiNG OR OTHER EXISTING LAND USE RESTRICTIONS? F34e3 [ No it No, descrl.e bdeiry _.. . S. V T IS PRESENT LAND USE IN VICINITY OF PROJECT? _. Rasidentia': °..:�! ic�'ustiiai- Commercial Ayticultuie ❑ ParklForesUOpen space ❑Other Describe: 1C. DOES ACT104 INVOLVE A PERMIT APPROVAL, OR FUNDING, NOVI OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAIW }Flyes ❑ No 11 yes, Ikst agency(s) and permittapprovals 11.. DOES ANY AS?-CT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes 'igtio It yes, list agency name and permiUapprovaf - 7 12. AS A RESULT OF PROPOSED ACTION WALL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? 13Yes No 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE iS TRUE 70 THE BEST OF MY KNOWLEDGE Appticactlsponscr namz: lloo'_Olei. Date: Signature: c'�`' l ✓L�L If the action is in the Coastal Area, and you are a state agency, complete the ! Coastal Assessment Form before proceeding with this assessment PART Il' - tNVIRONMENTAL ASSESSMENT (O be completed by kgency) A DOES ACTION EXCEED ANY TYPE 17HRESNOLD IN 6 NYCRR, PART 617.122 it yes, coordinate the review process and use the FULL EAF.�� Yes KO _ ;.�.,.• _ =r.. � . - B.,)r((IIA�GTtON E t t1fE;CaORflINASE� RE�/iE1V A5'P�OVtDEO FOR UNLISTED ACnONS iN 6 NYCRR, PART 617.6? it No, a negative deciaration rAay�ie superseded by another Involved agency.. []Yes C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, 'If legible) C1. Existing air quality, surface of *groundwater quality or quantity, noise 1e_4eis; existing Irafiie patterns, solid_ waste production or disposal,. potential for erosion, drainage or flooding problems? Explain brlslty: 1, , JV C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources. or community or neighborhood eharacteR Explain briefly. AJ,-> o C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly /Vo Zte CG. A community's existing plans or goals as officially adapted, or -a change in use or Intensity of us 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. C:7 rr � ® /% �V - C (7 CG__Long term,- short -term; cumulative; o� oothe eeffects not identified in C1457 Explain briefly. Cam C7. Other impacts [nciuding changes in use of either quantity or type of energy)? Explain briefly. ..e - - -. D. IS THERE, OR iS THERE LIKELY TO 9E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes Zff.Uo It Yes, explain briefly ART III — DETERMINATION -OF: SIGNIFICANCE (robe completed by Agency),_-___ - _ INSTRUCTIONS:.- -For each adverse effect identified above, determine_ whether it is substantial, large, important or otherwise significant. Each effect should be. assessed. In connection with lts :(a).setting (i.e. urban or:rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments oe reference supporting materials. Ensure that - explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or'slgnificant adverse impacts which MAY ccur. Then proceed directly to the FULL E4F andlor prepare a positive declaration. KI Check this box if you have determined, based on, the iriformation 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: or f namr vs craw narncy Signature of Preparer it different from responsible officer) c2�-�2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Tax 'Map: Bo Lot Located at (Street) 1 ck (indicate' ea rest cross street) Municipality �t/ Watershed X,7 SOIL PERCOLATION TEST DATA Date of Pre-goaking Date of Percolation Test ... . . . ....... . Dep li�. 6:� .. .. ...... ... .... "Wishes ....... .......... .. ....... ... ..... . Run No Time Start Ap u. ace...j. Slap.:.. Jtr .... ...... ............... . ...... .. .. ...... .... ... .... . .. .... 4j. 713 2 1_7 — ----- 4 5 2 3 ;Y 4 7 3 4 NOTES: L Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. •Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA 2 DESCRIPTION OFSOILS ENCOUNTERED IN TEST HOLES DEPTH,— `��HOLE NO. H NO.. HOLE NO. G.L. _.-.-.'/ 0.5' 1.0 1.51 \ 7-5a". Z4- C? P24Z 2.0 2.5' 3.0' 3.51 Y : 4.01 4.5' .5 5.01 53 6.01 6.51 7.50 77- C 3 Cn ed C-3 C77 V 4L Indicate level at which gr ndwater is encountered which - -- Indicate at ---- which. fi:* ottling is observed 42 Indicate level to whi water level rises after eing encountered 0 W/ Date Deep hole observa ons made by: 'Ll Design Profess' nal Name: 4', Address: 17�1- Signs Design Professional's Seal M I V AND THE NEW YORK STATE DEPARTMENT OF m7rir. IUILT SURVEY BY.' "NO GARBAGE GRINDER WAS INSTALLED" C. MERRITTS LAND SURVEYING, P.C. sic. No. 49510 DFORD ROAD NTVILLE, NY 10570 LOCATIONS A B 1 45.5' 31' 2 74' 34'-4" 3 74'-9" 40' 4 77' -9" 47.5' 5 80'-4„ 54 -8" 83.5' 60Y- 7 116' -3" 60' -8" 8 117" 64' -6" g.. ... � .. 1.1.9',_ . :. .69' -3" 10 12U' 6" ... 74, 11 12_2' -8" 79' 12 —.. 32' 49'-- . :.. 13 35' 52' -10". 14 39' 57' -3" 15 44.5' 64' I COUNTY DEPARTMEfdOF HEALTH I O��NOTED NVIRONME TAIL HEALTH SERVICES FOR CO. FORMANCE WITH . BLE RULES AND REGULATIONS OF THE ICOUNTY HEALTH DEPARTMENT. SSDS LAYOUT "AS- BUILT" PREPARED FOR, MR. AND MRS. ED WARDS SITUATE IN THE TOWN OF P UTNAM VALLEY P UTNAM COUNTY NEW YORK PERMIT: PV-30-03. SECT. • 73.17 BLK. 1 LOT: 22 PREPARED BY. • STEPHEN J. FERREIRA, P. E. N/F Folchetti & J. cobs 3 � o N N M O Z N86 49 D eter Ad- e 31 L.F. OF G 14, AS' -BUILT P- 4" SDR -35 PIPE � GRAPHIC SCA 60 0 15 ( IN FEET ) 1 inr 30 ft