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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.17 -1 -37 BOX 27 03426 Ll. Ir 03426 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES v_ .. 3'• +<, :ate ' 4 , . ' a ^' «:.esa'��+.,. "i.C`n'f .'., ..,..: ; i.i:'::.4::..- °` ' ' -.,sa �...- < ... >z,'a,ia':,+... ":,G'r ra+:�.: .....': ✓.i i a :.is CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P V-0/ —/y Located att' /, 14. ° �o A o or Village t, -t-'4c' V �rG G Owner /Applicant Name —Toel ae'1141,y, Tax Map %. 1-) Block Lot —3 1 Formerly e 0 rL,^ J n Subdivision Name Subd. Lot # Mailing Address 2-13 's i Ile, i.J L) -!j Or �c. �b ,�„ N y Zip Date Construction Permit Issued by PCHD 3.t"S" GfapFh �! Ipo�.d Separate Sewerage System built by L u aJ pr + �-c C . Address 1, ,�, lit , IVY Consisting of Gallon Septic Tank and 410S / n -( Z y lJfo% fi�so�y�u� Other Requirements Water Supply: Public Supply From _ Address °t 1� Z QRIE�r /L r ke1' or: X - Private Supply Drilled by lm- Address ali, i ollj4 AlY _ q 's_ _ _. _ . Has erosion control been completed . �� Building-Type. ��,. �_ � �� ._ � � � 1-5 Number of Bedrooms _ Has garbage grinder been installed? /10 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: Z-116,111 Certified by -S -fe-pL ,\ Q v r n S P.E. ,�L R.A. -T Me sign Professional) Address 2 �(d tJr'%J N a I S C. C, l.Jc ,! «s /--.. 115License # a `b `1 Z-3 (� Y ia 440J 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 Director /Commissioner, such revocalion, modification or change is necessary. Title: _ Date: copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 SHERLITA AM LER, MD, YKS, FAAP Commissioner of Health 1bT.A!IORR&4,TE ;r Director of Environmental Health . PAUL ELDRIDGE County Erecudve DEPARTMENT OF HEALTH 1 Geneva Road, .Brewster, New York 10509 Office (845) 808 -1390 Fax (845) 278 -7921 or (845) 808 -1937 April 1, 2011 ` Barger & Miller Steve Burns P.E. 280 New Hackensack Road Wappingers Falls, NY 12590 Re: Construction Compliance — Bellamy 19 Luigi Road (T) Putnam Valley. TM 73.17 -1 -37 Dear Mr. Bums: This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. 1. The E -911 address is to appear on all documents and the as -built plan.. 2. The as -built plans need to be reprinted. The eastern trenches and corresponding labels - for the a -built dimensions are fad' &6hd•hard: This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 43157 if any questions arise. JSP:cw V truly yours, J seph S. Paravati, Jr., P.E. Assistant Public Health Engineer --'�,-YUTNAM-COU, -N� TY-,,-DEP.ARTMXNX-OE�I3EA-L- TR - DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION El JOSEPH KGENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed prior to any Trenches. �0 inspections being made. PCHD Construction Permit 4t ey Located: Z 1 ' -& � 4 "X 0 6(v) Qwner/ApplicadName: 16dw TM 3 /7 Block Lot' 3 Formerly: gubdivision Name: Subdivision Lot 4 Is system fill completed? A/� Date: Is system complete? 95 Date:— /2-./ Z /D Is system constructed as per plans? Is well drilled? ' V e- S Date: EXi3�(Al- Is well located as pef plans? yLs Are erosion control measures in place? 1 certify that the system(s), as listed, at the above preniises has been constructed and I h ' aveinspected 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 Health.. Date: 312-4Z11 Certified by:, ERA DAigin Professional Address: 2- 90/v,� Li 7 20'' Jr c. 4 A 41f I I f k/ty 19- Comments: Form FIR-99 SHERL]TA AMIZR, ND, MS, PAAP Commissioner ofHealth PAUL ELDRIDGE County Executive ROBERT MORRIS, PE 'Zt± ..' �d�iE' Cto%.' �P��.? 13J '02Yt7d�i�2`L"d.�1tT�.C��'... _ ._._.,. .._...> _.-'�" "`�•_...._��: .< .�.<is:`.'i.b�i........ 'a"' "._',..`- "�.._.._..!: - •�— _,....._. -. r _._. DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Office (845) 808 -1390 Fax (845) 278 -7921 or (845) 808 -1937 April 10, 2011 Barger & Miller Stephen K. Bums 280 New Hackensack Road Wappingers Falls. NY 12590 Re: Field Inspection — Bellamy Luigi Road (T) Putnam Valley, TM 73.17 -1 -37 Dear Mr. Burns: A re- inspection at the above referenced lot has been completed. There are no further comments. If you have any further questions, please contact me at (845) 808 -1390, ext. 43163. MDL:cw Sincerely, ww�\ Mitchell D. Lee Public Health Technician Jun.29- 2011 11:19AM Barger and Miller No.8775 P. 2 BRUCE IL FOLEY lWo HaM Dr wfw DEPARTMENT OF HEALTH I Geneva Road, Brewster, lkw York 10509 ik.t. wS.N. Associate Pubbe MaM DMW DOMor of Patied SeMm Environmental Health (845) 278 - 6130 Fox (84$) 773 - 7921 - NwsW3 Savkc(80)Z78-655$ WIC(845)278-6678 F1ix(545)279-6W Early bbrventimuffirembed (145)278-6014 Fa: (945)279-6M KtIl-ADDRE SS VERIFICATION FORM nUrNMR WAMR- 1. `TAX mu -NLTmBFx. Ye- L 73, 4'j - VI( - I - L of 3 7 E011 ADDRESS: 1 q T -iii gi - gna d TOWN: Putnam Valley AUTHORIZED TOWN OFFICIAL;, (Sip) The Putnam County Department ofHeafth wi11 not issue a Certificate of construction CompUance unless the A= form is compld4 i.e., a Ind E911 addrets is assigned by an autho&cd town officiaL This form is to be submitted with the application for a Certificatc of Construction Compliance. Phone 914 273 -3448 45 Maple Avenue Fax 914 273 -2204 P.O. Box 271 �t +'. ii /La�`4 t- �1.•.:J'[ lava n.i .r. u...rt. f:.�.. 14.G:rr �. .. - �1� � w .vw %vai Ci ✓r: V4 la.nn .Ca .....e1G.l V:S. {J l..�/.Ia .. _ - .r �80 JAMES TORLISH & SONS . Artesian Fells - Water Pumps Armonk, New York 10504 Mr. Joe Bellamy 2333 Willoway Street Yorktown Heights, N.Y. 10598 Re: 19 Luigi Road Putnam Valley.,.NY Dear Mr- Bellamy: July 7, 2011 Please be informed that on July 7, 2011 the well at the above address had a 6 hour pump test. The well is producing seven (7) gallons per minute. lr If you have any questions, please feel free to call use Sincerely yours, JAMES TORLISH & SONS By ,,. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 _.. _._(914) 245 -2800 - .H /;�w K -. ,h .�..ti i=wvo:.'5..� t' .. w. .+. .. ..-��..... - Albe�t�``H: "P'�a'��ani, 'Director - ** TEST REPORT ** LAB #: 1.102762 CLIENT #: 6.2562 14ON STAT PROC PAGE: 1 of 2 BELLAMY, JODY DATE /TIME TAKEN: 06/29/11 12:00 2333 WILLOWAY STREET DATE /TIME RECD: 06/30/11 01:21 YORKTOWN HGTS, NY 10598 REPORT DATE: 07/07/11 PHONE: (914)- 962 -9868 SAMPLING SITE: 19 LUIGI RD, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE KITCHEN TAP PRESERVATIVES: HNO3 COL'D'BY: JODY BELLAMY TEMPERATURE..: <20>40C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE. PUTNAM CNTY PROFILE 07/01/11 MF T. COLIFORM ABSENT /100 ML ABSENT 07/06/11 LEAD (IMS) 2.6 ppb 0 -15 ppb 07/01/11 NITRATE NITROG 2.95 MG /L 0 - 10 07/01/11 NITRITE NITROG <0.01 MG /L 1.0 MG /L 07%07/11 IRON (Fe) 0.522 MG /L 0 -0.3 mg /l 07/07/11 MANGANESE (Mn) 0.014 MG /L 0 -0.3 mg /1 07/01/11 SODIUM '(Na) ' 42. -6 MG-/L N/A 06/30/11 pH 7.3 UNITS 6.5 -8.5 07/01/11 HARDNESS,TOTAL 68.0 MG /L N/A 07/01/11 ALKALINITY (AS 72.0 MG /L N/A 07/01/11 TURBIDITY (TUR 4.1 NTU 0 -5 NTU METHOD SM 18 -20 9222B SM 18- 19'3113B SM18- 20450ONO3 SM18- 20450ONO2 SM 18 -20 3111B SM 18 -20 3111B SM 18 -20 3111B SM18 -20 4500HB SM 18 -20 2340C SM 18 -20 2320B SM 18 (2130B) COMMENTS: MFTC a Coliform = This result indicates that the water (was), Z(was not) of a satisfactory sanitary quality according to ew York State and EPA federal drinking water standard for ,this parameter. This comment applies to the Total Coliform test only. Pb /Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ublic 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. IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT) NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER RUNNING FOR 10 -15 MINUTES MINIMUM) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 0 , [�, i +ai; :i:.t1. .off �n< i• o�rrr.','.y.. x=:.c• ,�.:- ��y:F. -�:..� .Y :' - : .r., ..�. ... -_� p ,. t . ,,.. - - .aatti;�.: m+s.4rt•. - sw•raoi:>m � ., �..... ..•�:�.:� .. ��i ...... Albert !I . `Paao'v'ni Iii f'eCr' ** TEST REPORT ** LAB #: 1.102762 CLIENT #: 62562 NON STAT PROC PAGE: 2 of 2 BELLAMY, JODY DATE /TIME TAKEN: 06/29/11 12:00 2333 WILLOWAY STREET DATE /TIME REC'D: 06/30/11 01:21 YORKTOWN HGTS, NY 10598 REPORT DATE: 07/07/11 PHONE: '(914)- 962 -9868 SAMPLING SITE: 19 LUIGI RD, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE KITCHEN TAP PRESERVATIVES: HNO3 COLD BY: JODY BELLAMY TEMPERATURE..: <20 >40C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 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. pH IS A FIELD MEASUREMENT AND IS REPORTED FOR REFERENCE ONLY. ALK TOTAL- HARDNSSS"-I-9- DEFINED AS THE SUIT 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) (ALKALINITY REPORTED AT pH 4.5) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE ONLY T T E SAM(PS RECEIVED BY THE LAB SUBMITTED BY: Alber . Pa ovani, M.T.(ASCP) Director ELAP# 10323 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health January 20, 2010 Stephen J. Ferreira,pE P.O. Box 1047 New Milford, CT 06776 Dear Mr. Ferreira: . DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed SSTS - Orlando Luigi Road . (T) Putnam Valley, TM # 73.17 -1 -37 This office has received and reviewed the most recent set of plans for the above - mentioned project. would like to offer the following comments for your review and consideration. 1. Please number the deep and perc holes based on field testing labeling. 2. The deep holes witnessed by this Department had the same description. 3. Required length of fields for a 4 bedroom,. 1-7 perc rate is 400 LF, not 405 LF. 4. Proposed well location is to be removed from the legend. We "Thig'office"will'coritiffd fWreview upon consideration of the above = mentioned 'comments:' °Please.feel free to contact me at ext. 43157 if any questions arise. JSP /kly truly you s, . Joseph S. Paravati, Jr., PE Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 PUT AM COUNTY DEPARTNENT OF BEA]LTH ATTENTION OSEP]a ® GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fatly completed prior to auy Trenches inspections being made. PCHD Construction Permit # PV " ©1 " w Located: A �- m Ovmer /Applican Name: 166 ®� 3, I `1 Biotic F armerly: M Df ubdi-vis' Name: Subdivision Lot # is system fill completed? /V /A Date:. 2-12 Is system complete? 3LC_S — - hate: is system constructed as per,'plans? Vt Is Well drilled? l S eYy3fr,1 a Date: /Z/13 1/U Is well located as per plans? � � Are erosion control measures in place? -vrS - I certify tat the system(s), as listed, at the above premises has been constructed anal I haveinspected and verified.their complefioa in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and RegulMtions of the Putnam'County Department of Health, Aare: Certified by: 4Dignrofessional Address: 2 A—)tv #& 4k 4e,4 Xd. 6dw &Y, A%' Lic. # 69 � 2- 3 C Comments: 9`1 z a-_ Form FIR-99 as [ A Pup 1;21p9 Wd6S:l[ HE 'OZ 'ups PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYS EIV� _ e 4J �� PERMIT # 'l D -- d�jl�- .�N°�✓ u Located atiq Lit R eai Town or Village win �M ,�,'l le- 1.1w name Date Subdivision Approved Subd. Lot # Tax Map 11 Block ( Lot 3 Renewal Revision Owner /Applicant Name Jb) Q e Date of Previous Approval Mailing Address ✓ cy yr Ic - f- ��,�rn /1%% Zip Amount of Fee Enclosed rp Building Type RA s*-d PC—A h Lot Area No. of Bedrooms A— Design Flow GPD ?00 Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12 S—D gallon septic tank and / U S o Other Requirements: To be constructed by t i id Pr. k Zn t Address Water Supply: Public Supply From Address or: Private Su l-yDrilled b e •�..r• —• � PP Y Y �7�.� �� � s�^ Address ,(��. +„�.� ✓d�11��� 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 Director /Commissioner 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. GC,. Signed: O 1 P.E. R.A. Date Z $ Ir Address ZY° c4! �GC�ians4o� l�. w wl,yers- r, #f /�1� License # 0 2. rr �z r5 v 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 considered necessary by the Director /Commissioner. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. J�2�, By 1,4f . Title: Date: ol-d hite opy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 INW.71T.- rk 1111""1 1PA-171 71 ko 47il I'Al IFN v 12 BadlngType� 1 1 the I am wbolbr wd axq*t* reVanulk for ft bcada% son ul� vu wA dobar Oros nwry bubo" sy mvbgdm -- PS- BPIPMPUVMd .dws,'bas bewconsbuctedas dwm antmopptwiedphnerappv4ed=wndmotdopetN Win V�&Ikistudff& . roks MA les"m ofacham Cmdy Dqm.mm dueft and ba*y pnnnftto ft oww, bb momm help or n*k to pbm in good opmft mffift wy pd of: said ' mo od au wbhi& tab to,,M—wft,for a paw'd of tm yam my y reams mode by arc s .. opmft JJNU ' pft axe ap v dw fm m fa Y %w 40 4*bW L COPO"d=NLW Adimm-33 sft LfL,vf�— I . t Stephen K. Bums, P.E.. 280 New Hackensack Road Wappingers Falls, NY 12590 (845) 463-6555 (845) 463-6914 Fxz: (845) 463-6922 Barger & Miller- Engineering and Land Surveying; P.C. Engineer's Report for Jody Bellamy. 2333 Willow Way Yorktown, NY Town of Putnam Valley Putnam County, New York Prepared By: Stephen K. Bums P.O. Box 1781 - . Wappingers Falls, NY 12590 Date: February 10, 2011 The property is a 1 acre parcel located on Luigi Drive in the Town of Putnam Valley, County of Putnam and the State of New York. Its tax map ID # is 73.17 Block 1 Lot 37. The rlot has an approved tiled field and expansion area for a 4 bedroom house. The approved design was prepared by SH Engineering Services, and was approved by the Putnam County department of Health on January 28, 2010. The design currently proposed is the same as the past approved design. A well exists on the site currently and will be used to serve the house. A well report is attached to this report. Deep test pit data and Percolation test results where taken from the SJF Engineering plans. The results of said percolation testing are hereby attached to and part of this report. Based on results of soil testing and site inspection with a boundary and topographical survey, all wells and the fields along with any other environmental concerns in the immediate area have been located on the plan. A 1250 gallon septic tank has been proposed along with 405' of 24" wide absorption trench. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES. NMrA`811EET-- -SUBSURFAE-E-SEWAG TRVAATMENT SlYS`fEM =__:_: Owner .&— &li &A00 Address Located at (Street) Tax Map 72.1-7 Block (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre- soaking Date of Percolation Test �A O. 1 -2y 3 Z y 4 5 1 2 3 4. 5 1 ' 2 3 4 5 Lot NOTES: 1 Tests to be repeated at same depth until approkimately equal percolation rates are obtained at each percolation test hole. (i.e. <_ 1 min for 1 -30 min/inch, <_ 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 Pg. 1 oft -9/2 P TTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - `SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 10l1/l/1 ®, emnvo Address lb� � IAO Located at (Street) /u//x/ 14 Tax Map ;�/7 Block / Lot _ (indicate nearest cross street) Municipality &AZy=&f Watershed A1,0_0111 94K/ SOIL PERCOLATION TEST DATA Date of Pre - soaking ate of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. _< 1 min for 1 =30 minhnch, <_ 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 Pg. 1 of 2 lb Depth to Water Water' Elapse Time Erom Grouncfl Surface (Inches) Le�e1 drop In Percolation hate lHble Run Np Tirane Start Stop (Man) Staa�yt Stop gnc�hes Min nc 110 r . .. . :. _:...v:.. 2 3 _ 37 q`` -7z 4 - 5 3 17 - ZX ID Z Z- �� 7 4 5 cl 1 P Q1-- 9= 7 V N 2 �s_�.�o Ds 19`'— z� . of Jr 4 0� ' —l�'7 2 rd �� 7 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. _< 1 min for 1 =30 minhnch, <_ 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 Pg. 1 of 2 lb TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES -HOLE.N, N G.L. 0.51 1.01 A ki 1.5' 2.0' 2.5' 5,4tA 3.01 3.5' 4.0' 4.51 5.0' 5.5' 6.01 6.5' 7.0' 8.01 8.51 9.01 9.51 Indicate level at which groundwater is encountered j/,# Indicate level at which mottling is observed Indicate level to which water level rises after encountered being unt red A414- ., Deep hole observations made by: Awg- Date Professional Name: Address: Signature: I 71.3 Design Professional=s Seal f NEF O H CO 070 3 ................................................................................ anssi jo alep wojj jeaA euo sajidxa 1!wjad si Ole' a 'A .41 :RON a 'A�,V�Mffd -N ZO .................. l� ...................................................................................................................................................................................................... .. . ........ ... - . ... ... ....... ..................................................... p.I.C.)qq.o.j ...... 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OaNvqao mHor ...................................... ................................. . .............. .......................... SGS'wGJd JO U011"01 N1 GH izilfiq 'AWNU DNWIMG ------------------------------------------------------------------------------------------------------- 'WtLL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTF 3171 Division of -Environmental Hoalth Services COUNTY OFFICE •ITUILDING • CArtMEL. NCW YORK ;ttLd- 's;g:QSint.t, :l calt�h:d'�f,?t ;ment tGgc fter yvjfkT lab0 rat0ry ►,eRgJU ^of.., analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SU13TAITTED V11THIN 30 DAYS OF %YELL COMPLETION NNAAEE %� ADDRESS OWNER V L/ �Gf /7 J Ct n asr. LOCATION (No. 6 Strectt) U (Town) (Lot Number) OF YlELL p T n e> „N (/I 'L. ® BUSINESS .0 � ►ROPOSED DOMESTIC ESTAMISHMENT FARM TEST WELL USE OF WELL OTHER SUPPLY INDUSTRIAL CONDITIONING pecif ) DRILLING © COMPRESSED ❑ CABLE OTHER EQUIPMENT ROTARY AIR PERCUSSION PERCUSSION (Specify) CASING LENGTH (feet) I DIAMETER (inches) WEIGHT PER FOOT —61FIVE SHO 10YES IPA CA NO UTED? DETAILS 1 � � THREADED WELDED NO YES NO YIELD a ® HOURS( GJ YIELD (G.P.M.) TEST CAVED PUMPED COMPRESSED AIR S WATER MEASURE FROM LAND SURFACE— STATIC(Specllyfec►J DURING YIELD TEST fleet) Depot of Completed Well LEVEL 0 In ket below Land surface: MAKE LENGTH OPEN TO AQUIFER ( leer) SCREEN DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: OEPIN rtOyt tAND SUt:FACE �--j FORMATION DESCRIPTION _j -h- 0 4;d ' mod" o D_ C)- aY, IZd kid -7- L car.T / If yield was tested of different depths during drilling, list below FEET GALLONS PER MINUTE r?S Glznn .41 r 11% n n rlo Diameter of well including I gravel pack (inches): 3kotcA erael location of well with dlsrsnces, to at /east two permanent landmarks. DA)Xy 9FNPfOQT I WELL DAyI.•LEn (S!gnslure)/3 L —DIVISION ISIO OF ENVIRONMENTAL HEALTH SERVICES ., __ 1. u:. PJll� .ttu- A.a•rN.vJ:�.��..= .r.�'. •..�.:}.,. ,�," ,h'.q- ��..,•:a� ✓a'M1r"°�i:Varn t" �1a,:. 3: it: u.:. r=•>....+_. �._. Q- ra,.. y.- wa... r_ u: ..,::�r.•�+.+- V•.•- .�„r,«p:.... s�i.0 �-- .,,.Nsa ws^y.•x�..a..o LETTER OF AUTHORIZATION RE: Property of 1- (111 A Located at 6N jLt(lt"T V-fleid Tax Map # -3 , 7 Block Subdivision of Subdivision Lot # Gentlemen: Filed Map # Date Filed Lot 3 7 This letter is to authorize S4e, pAe-,% & r,, s a duly. licensed Professional Engineer _ X or Registered Architect to apply for the required wastewater - treatment and/or water supply permits) 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 fotmn -y -rprc %is o �:,� ii l�.�4 nd�oYr d7 _of the Edueat on_L w;• }he;�Public Dealt - : :� Law, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # D Z Z Mailing Address Z !r�b 4n d State /v'e�� i0�- Ic Zip /)- r b Telephone: ($.�S-) 416 3 — SS Very truly yours, Signed: wner of Property) Mailing Address: 2,2 3 3 LJ .1( r") W4 'r'r /G 7'6l..l /7 State 4tj Y"/- Zip /USi'j Telephone: 6 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVE( IT`F `SE- WX61f`TREAT1i kft'SW PERMIT # —` Located at ,�l/ /G� /�ar� Town or Village A KP- -4 Subdivision name - Subd. Lot # Tax Map / 7 Block _�_ Lot Date Subdivision Approved Renewal V Revision — Owner /Applicant Name Mzm e-A(14 oo Date of Previous - Approval jVIVezE • )U97,7 Mailing Address Amount of Fee EnclosedG� °'�' �.• / 71,E 7 Building Type Lot Area �o. of Bedrooms Design Flow GPD Zip Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of %Z-1G gallon septic tank and �/670 L al— Other Requirements: To be constructed by 7 • �- Address Water Sunnly: Public Supply From Address - Private Supply Drilled :ty_- 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 motor /Commissioner 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 P.E. R.A. Date // Zi /elf 10 V7 /I&iJAi /,f.&ie/l C'T 007ZC License # Q %10 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 considered necessary by the Director /Commissioner. Any revision or alteration of the approved plan requires a new peltnit. Appro71a', discharge of domestic sanitary sewage only. GC�vl$ !�� Title:�PJ Date: �It copy - HD File; Yellow copy - B 'lding Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -APPL:ICATiON"TO` CONSTRUCT A WATERIffEELL';' please print or type�eU[Ai&r Well Location Street Address: Town/Village: Tax Map � A PllYA9W V)" Map 131ocIW Lots, Well Owner: Ida e: MAP/ Oaf Address ek hone W7 ® — % 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 gpm -# People Served A Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type_ Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ No Is well located in a realty subdivision? ........................................... ............................... Yes —No x Blame of subdivision -- Lot No. Water Well Contractor: /Vol Address: Is Public Water Supply available on site? ....................................... ............................... Yes No Name of Public Water Supply: Town/Nillage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: l/ Q Applicant Signature: Date: r. 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 Deoartment. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmei 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 Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by PMa �� $ ° Permit Issu Date of Issue jng Offi Date -of Expiration 6 I /fir 14i0' . Title:--j7, SAS Ce � /,,a�,L• Permit is Non - Transfer /able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -g7 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,o.V:�i- '•YC�" <-�.cJ. +ate.:- '..- .._:' +: ��.=.. �.. •moo . •.-o � �,-.. ..�,�: .. � .. ._.�� .......- .- .__v.�..r• r. Y.- .L�:::a :'.aim:: -e �-- :.A. -�.d : ...e � �: r'. ;.:+.+i.•'`�.iw..�i �.�[I LETTER OF AU'FIfORIZAT101 RE: Property of Located at Aa& 44" TN Tax Map # 73.17 Block Lot -?7 Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize s�7-ni Aru t a duly licensed Professional Engineer X. 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., # Z77 (v %� � Mailing Address P-0- 6 O X %d !�Z n &nl—I l%LIry 14,10 State Zip 06 7C Telephone: j? ro -- Very•traly y firs; - { Signed: (owner of petty) Mailing Address: iT Z T %% silo K l�'t sc, m. State iV Zip Telephone: ( CO Form LA -97 •a PI. TNAM COUNTY DEPARTMENT DE HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES :�ir�� r.:.Y,�`,'i•�nr.t ".wee+.wr.�:. �Jl'�.UlV,1lY�YL-➢ IJJlYJU1GT — y�J�dD�IU�[ ��1 ,.1P�r���a'i"�'�.YJCJ`Jl''JIt LPL" �ll1VIl�1L�1VT '���Y'lY "d�1�i17H " "��, -� `.,-�- ._ �'-���',':'•k•••:.. y.c..x Owner Address Located at (Street) Tax Map 71.17 Block /' Lot y 7 (indicate nearest cross street) Municipality ehig 0 Watershed 11(/,0,f &y SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test DOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. _< 1 min for 1 =30 mmhnch, _< 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 Pg. 1 of 2 16 Depth,to Water ; Water: ' r From Ground Level: Percolation 'rime Elapse Time Surface (Inches) Drop gn Rate hole l+to Run 1�10 x Start Sto P (Min) Start Stop, Inches Mm /Inch x .. 1 1 •a3r9f8 ��� 3 377 Z, -711 4 5 1 10,,ax -xin a - Z Z 4 5 1 PIT— ? ,?Y_ N �r�-- 3 2 s � 9, z z �� S 4 5 DOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. _< 1 min for 1 =30 mmhnch, _< 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 Pg. 1 of 2 16 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �sl6E += IDATAwSHf,ET� --S TBSURFACE- SEWAGLT -: It9AT- Mt9g&V8T -E Owner ®� (1, O x,,400 Address Located at (Street), Tax Map -2? Block Lot T-7_ (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approkimately equal percolation rates are obtained at each percolation test hole. (i.e. 5 1 min for 1 -30 min/inch, <_ 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 Pg. 1 of 2 1 /' /-rvo 2 3 4 5 1 2 _ 3. 4 5 1 2. 3 4 5 NOTES: 1. Tests to be repeated at same depth until approkimately equal percolation rates are obtained at each percolation test hole. (i.e. 5 1 min for 1 -30 min/inch, <_ 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 Pg. 1 of 2 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered P %4- Deep hole observations. made by: 4 Date Design Professional Name: -C-%F Address: - .L",Lj a-,ft6 Ad CIE 6 77 G Signature: Design Professional =s Seal %3 F NE Y H CO O 0767 A9�FESS10���` TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES r,..: <ti(�I N _ ::� - OL- E,�N,: .v. ., a r:1'7 .. G.L. . _;HQa• . 0.5' All 1.5' �i wl v�- r�risW 2.0' 2.5' _ -5,& �l 3.0' %?-,�9 � ,�>gt S' G u S- d l 604fi-'-7 3.5' GrtC.- 4.0' 4.5' 5.0' 5.5' .6.0' 6.5' 7.0' 7.5' Ao, W4.7-P-4--le w M/ 8.0' 8.5' 9.0' 9.5' 10.0'_. +..- ..w G.r_�yrr �.- se+— � .. ..f..� _ _ .- w � -r.� «+-na- .-� a..+ -..s.. v _..........n "- --' s .. .., z , a s-.. .... ..-� .....r. - >'•.- +.- ..r...��.•+... +.C. +o t._.i.- - _'- Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered P %4- Deep hole observations. made by: 4 Date Design Professional Name: -C-%F Address: - .L",Lj a-,ft6 Ad CIE 6 77 G Signature: Design Professional =s Seal %3 F NE Y H CO O 0767 A9�FESS10���` �. n'�+.F �t.'s.J'�4'... 4 M•t!.M .4 \'.R �W'l�l.•.�IVJ� . \r.. �..a a \N �. -_.T. • . .,.ei�l if .... �<±v ..moo. a, - .. ..'irt� .. `... ... .«. v..� . .;�r.�.`.�oi -.:i. cs i.ta +a. 6' /.. r ^J' ^c i Pi' \l w n, ..:y . � �. ..ti:•n u i+� a vNU�. ffi 1.19 AC. CAL. 26 1.03'AC. CAL. N� S� 'AL. 1oap J jS5.22 7 s �1g kA 0 1 1.2 29 1.41 AC. CAL. 1.32 AC. 1.09 AC. CAL. . to 3� 0 t 8 3.00 AN 148.64 1.23 AC. CAL. 160 ti ® 37 'a ep I s 1.00 AC. CAL. 9 1.00 AC. 1.11 AC.'CAL. 255.79 -- 153.00 150 S 2.05 AC. CAL. • 17. b) a 36 � s 3 1 nn ar% r%e1 14 -164 ( Fj --YeX 12 �� PROJECT I.C. NUMBER ��A.� Appendix C rr:_ ....� �4` ":'.:6iY` ..��;- _ .r ..,,::'•t_'� ` `<c . --,= :•' -.. .. �,, ! �Qate :�rtvlatai�nlLtat14131.Cee$18y� Rsvte��: ;= •�c;;. �� <:�a�• ; .. _ •�x: , _. i, � SHORT. ENVIRONMENTAL ASSESSMENT FORM kir 6 NUSTED ACTIONS Only PART I— PROJECT INFORMATION (ro be Completed by Appkant•or Project sponsor) 1. APPLICANT !SPONSOR 2. PROJECT-NAME, 3. FfFIOJECT LOCATION: M4nicipallty County 0 4. PRECISE LOCATION (Sttgreet ddress and road IInnt�afteecctl prominent landmarks, ootc., or provide map) ®ones^, 6.-►1 �iPi % ice/ y OAC AW 5. 18 P OPOSED ACTION: XNew ❑ Expansion 0 Modtf [cat ionlalteration S. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: (2457 Initially acres Ultimately acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING) OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 0. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Resldential ❑ Industrial ❑ Commercial ❑ Agrlcuituro ❑ Park/Foroet/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Yes ❑ No it yes, list agency(g) and permiUrspprovals -ro,vw �� ����.� �1�� _ �'�T�P���j�r� °•CPL'` ti, DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes Zo If yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yos No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantisponsor name: ° Date. _ J�• /�!% lUti Signature- 2 It the action Is In the Coastal Area, and you are is state agency, complete' the Coastal Assessment Fort before proceeding with thls assessmeng PART If— EPI,VIRONMENTAL ASSESSMENT (To be completed by Agency) 0 0 A: S ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? It yes, coordinate the review process and use the FULL FAF. Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑Ye3� No� ..v - .ti.._. .. '�,... .. .e. "'• .w...l «,:. -�nrzi ...:w*.•.. - •.o-`s - -.. ,i._..:i�!. z.' .. ,r :: ;.:�5.. -_,x �'t':.'..a,,,•.:.:•w.•::• , . C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE t OLLOWING: (Answers may be handwritten, It 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 brief ly: 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 C5. Growth; subsequent development, or related activities likely to be Induced.Qy the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In CI-CS? Explain briefly. C7. Other Imparts (Including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR I$ THE(3E LIKE V TO BE, CONTROVERSY BELATED TO POTENTIAL. ADVERSE ENVIRONMENTAL IMPACTS? .•• r -- • : -� ... ❑Yes ° ° ❑No 7f Yea. ezpialri 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) netting (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 esponsi e Officer in Lead Agency Signature ol Responsible Officer in Lead Agency Name of ea Agency Date Title —of Responsible Off icer Signature of reparer different from responsisle o icer EAS Form 14 -16-4 (Page 2 of 2) !rT:.4eo,`2 P.O. Box 1047 New Milford, Connecticut 06776 Joe Paravati Putnam County Health Department Division of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit Sect: 73.17 Blk: 1 Lot: 37 Philip Orlando Luigi Road Putnam Valley, NY 10579', Dear Mr. Paravati: Please find enclosed: 1. (3) copies of septic trench plan. 2. Two sets of 4 bedroom home plans. 3. Construction permit application. 4. Letter of Authorization. :5. Application: for approval of plans. 4 6. Application to construct a water well. 7. Soil Data Sheet. 8.. Short environmental assessment form. 9. Property Survey. 10. $500.00 Money Order. 11. List of property owners notified in accordance with the required neighbor notification. The information enclosed is provided based on our recent conversations and our field inspections. Please feel free to contact me if there are any further questions or information required. 4 -Si erely Y Stephen J. erreira BRUCE R. "FOLEY Public Health Director LORETTA MOLINARI RN., M.S.N. Associate Public Health Director -"Ituru -03 Director 01 1 oarvir, DEPARTMENT~ -OF HEALTH Geneva; :;. "Road -Brewster, New York .10509. REQUESI.FOR IULD TESTING. ATTENTION: ❑ JOSEPH PARAVATI C3 GENE REED All information below must be completed p rior to any scheduling. DATE: ENGINEERORFIRM: PHONE #: xO REASON: DEEPS: PERCS:, ❑ PUMP TEST: ❑ ROAbISTRiET: ZV16 TOWN: TAX MAP#: -71-17 1, SUBDIVISION: LOTN: OWNER; NYCDEP CRITERIA FOR 1QU%B931E�y. AND WITNESSING OF SOIL TESTING 7 0 S ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ Proposed SSTS design flow greaterthan 1000 gallons/day or SPDES Permit required. ❑ Proposed SSTS for a Commercial 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 tests. This Department will coordinate a mutually, suitable time for field testing with the Design Professional and NYCDEP.' If a project has been determined to vi`&li .. gated 6 e'd on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re= wit.nessing 6.17the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: COMMENTS: (FIBLI)TEST) Mar 31 09 O2:45p. BUILDIMG DEPT 8455268806 p.3 I 7 c 1 , rr• Fn[ s�� }, a:�ecf 2009 -03- 3103:50 iAh s y f r�+� �t 't r r� � r7 • A b.c.lw'y&�S.,tan,, .I do "Jt� �.� 5 5�(4♦ ti t y :.; �J .y Yt'tih$,F, Y tS. t.F :`t11 �hY!'1" ?.'�ti: r tit 1 t , Jy `i ; 117. " "•. r f ,q _ >, r51 arr • - 7 .ti p T .t 5 u .t bfM1v u, i.. i J "5` I�.hwtn.6biR4 a: -J,. �. •:.: Ap(yg�- �,��[•JM1�. L� S.. � c "MO, « a {„riti`gFj•,aW+: v:+r -.ti., _ ' a . :2`.t aufvl• „t, r� -I .1. 1'� N • . .. 4. - '` zco�:�iic: Ow xt 30 W)` }� a- � r .,��t',j�¢, 3{pp'��t/'�`( try . t �•� % �• e- r}ua,"r' 2�•�3 et�7 'c�� +cd St' 3n.F � 2 � _ � -z.. rw.` ,,;, .,� , ; '` y ���,4r.�k \.,�-,4.���r7y.• v�u F r r TiL k t L : � y � +.5- r.�351. e; � -+ `* •l h Q6EQ- Z9E -fylG XU-A. 13C63SUI dH WdTG;2 6002 TO -JeW PUTMAM,VALLEY T 8455268806 Page 3 4} t . -t F • iiv 7 c 1 , rr• Fn[ s�� }, a:�ecf 2009 -03- 3103:50 iAh s y f r�+� �t 't r r� � r7 • A b.c.lw'y&�S.,tan,, .I do "Jt� �.� 5 5�(4♦ ti t y :.; �J .y Yt'tih$,F, Y tS. t.F :`t11 �hY!'1" ?.'�ti: r tit 1 t , Jy `i ; 117. " "•. r f ,q _ >, r51 arr • - 7 .ti p T .t 5 u .t bfM1v u, i.. i J "5` I�.hwtn.6biR4 a: -J,. �. •:.: Ap(yg�- �,��[•JM1�. L� S.. � c "MO, « a {„riti`gFj•,aW+: v:+r -.ti., _ ' a . :2`.t aufvl• „t, r� -I .1. 1'� N • . .. 4. - '` zco�:�iic: Ow xt 30 W)` }� a- � r .,��t',j�¢, 3{pp'��t/'�`( try . t �•� % �• e- r}ua,"r' 2�•�3 et�7 'c�� +cd St' 3n.F � 2 � _ � -z.. rw.` ,,;, .,� , ; '` y ���,4r.�k \.,�-,4.���r7y.• v�u F r r TiL k t L : � y � +.5- r.�351. e; � -+ `* •l h Q6EQ- Z9E -fylG XU-A. 13C63SUI dH WdTG;2 6002 TO -JeW PUTMAM,VALLEY T 8455268806 Page 3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION 6 ENVIRONMENTAL HEALTH SERVICES ,.APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant:G 16-7 7A)UL PeD AD AJX/ 2. Name of Project: _ � ' 4-0J00 3. Location: T/V: "tw, v 4. Design Professional: 5. Address: P0� &66 61d /7 P� v,�csror e7" `� 7 7L 6. Drainage Basin: bl �otC-" 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) ? .............. Yes/No /w Type Status (check one) ...................................... ............................... Type I Exempt Type 11 Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/a 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes[&o 11. Name of Lead Agency PC A J� 12. Is this project in an area under the control of local planning, zoning', or other officials, _. ordinances? ....................:::....... ................ ..........................VlN07 _ 13. If so, have plans been submitted to such authorities? .. ...................:........... Yes 6? f 14. Has preliminary approval.been granted by such authorities? W Date granted: 15. Type of sewage treatment system discharge ........................ ' surface water _j,, groundwater 16. If surface water discharge, what is the stream class designation? :......................... 17. Waters index number (surface) .................................................. I......................... 18. Is project located near a public water supply system? . ............................... Yes 19. If yes, name of water supply -- Distance to water supply 20. Is project site near a public sewage collection or treatment system? .......... Yes, 21. Name of sewage system Distance to sewage system 22. Date test holes observed - 23. Name of Health Inspector G-g, E eZE-D 24. Project design flow (gallons per day) .................. O 25. Is State Pollutant Discharge Elimination system ( SPDES) Permit required? ... Yes/10- 26. Has SPDES Application been submitted to local DEC office? ......................... Yes/0 Rev. 11/02 Form PC -97 Pg. I of 2 i 27. Is any portion of this project located within a designated Town or State wetland ?... Yes,- 28. J Wetlands ID number .. ....................................... ................................. p:.....: 29. Is Wetlands Permit required? ...................................... ............................... Yes/f o Has application been made to Town or Local DEC ........................... e 30. Does project require a DEC Stream Disturbance Permit? .............. ................ Yes �c 31 WJ 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? ......:................................ ............................Ye, 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/0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ........................ 4L9NO 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? . ............................... ...........................Yes 35. Are any sewage treatment areas in excess of 15% slope? .............................. Ye$uw 36. Tax Map ID Number .............. ............................... Map7Jq 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 be located within the NYC Watershed siialr`" be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as 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 kaw. SIGNATURES & OFFICIAL Mailing Address ::::........... 0 r1! " , j,-, Form PC -97 u 98 PUTNAM COUNTY DEPARTMENT OF ETALT'H DIVISION OF ENVIRONMENTAL EMA LTH -SERVICES FINAL SITE INSPECTION Date: Street Locate N Ram Inspected by p z qu - - _ - ,.,�. , -owner °`"� Town" R` +L n nn` _ r .. - 'p -10' a_ . . Y - ..Permit n PV Subdivision Lot # 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section date of placement 3: 1 barrier ' Lgth. w"idih . Avg. Dpth c. Natural soil not stripped....... ............ :.............................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... IL Sewage Svstem a.. Septic-tank size.- 1,000 .......... 1,250 ......... other ................ b. -Septic'tank installed level ..'.......... .. ...........::..:............... c. 10' minimum from foundation ......... ............................... d. Distribution Box 1.' All outlets at same elevation- water.tested ................. 2-. Protected below frost ............................. :.......... ......... 3 Minimum 2 ft. Original soil between box & trenches e. Junction Box properly set .......... ............................... 6, renc es 1. Length required Length installed 4-07., 2. Distance to watercourse measured • Ft.......... 3. Installed according to plan ... ............................... 4. Slope of trench acceptable 1116 - 1/32 " /foot ............. 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 %.1 ....................... 8. 'Size of gravel 3/4 - 1' /2-n diameter clean ...................: 9. Depth of gravel in trench 12" tn;n; „m ................... MPipe ends capped......,.: ............. ....................:.::...::.r .: g � - PUMwor D-osed Svstems -- _ -__ . �_ _ 1. Size of pump chamber ....................................... '......... 2. Overflow tai ............................ ............................... 3. Alarm, visual/ audio ........:............ ............................... 4. Pump easily accessible, manhole to grade ................. 5. -First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... EE House/Buildima a. House located er approved plans ... ............................... b. Number of bedPooms ....................................................... IV. well Well located as per approved plans . ......:........................ b. Distance from STS area measured Wit' ' • ft ........... c. Casing 18" above grade ................ ............................... d. Suiface drainage around well acceptable .....:.................. V. Overall worlomanshii) . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled .......................................... c. All pipes flush with inside of box ... .........................:..... d. Backfll 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....._-..., ....................... 0 i. Erosion control provided ................. ............................... Rev. 12/02 Fill pad located per the approved plan Fill Pad Length Fill Pad Width . Required Length Required Width Fill Pad Depth Required Depth Run -of -Bank Fill Quality v Slope from Top to Toe Impervious Layer Installed trosion Control Installed Sieve Test Results (if applicable) Additional Comments: Reserved for Field Sketch if Applicable . i PUTNAM, COUNTY DEPARTMENT .OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA,SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: /az -73,17 [ g-7 Located at (street): TM # Section: Block _ Lot Municipality: V, Watershed:/ SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: Date of Percolation Test: Notes: 1. Tests to be repeated at same depth until, approximately equal percolation rates are obtained at each percolation test hole. (i.e.; < 1 min for 1-30 min /inch, < 2 min for 31 -60 miniinch). . All data to be submitted.for review. 2. Depth measurements to be made from top of hole. Form DD -97, pg I of'_ Depth to Time Elapse Water from ; Water Percolation Hole No. Run No. - `Start — Time ground level drop. Rate . Stop (min.) surface in inches min /inch (inches) Start - Stop Notes: 1. Tests to be repeated at same depth until, approximately equal percolation rates are obtained at each percolation test hole. (i.e.; < 1 min for 1-30 min /inch, < 2 min for 31 -60 miniinch). . All data to be submitted.for review. 2. Depth measurements to be made from top of hole. Form DD -97, pg I of'_ TEST PIT DATA Design Professional Name., Address: Siaiiature: Design Professional = Seal DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # / HOLE # oZ ',HOLE # 7 HOLE # HOLE # G.L. - 2.0' lu 2.5' , 3.0' 4.0'z°ih, 4.5`� 5a,, G �j Sq�d1 6.0' 6..5' .7.0' ' 75 -7,0� 7,d' 8.0' 8.5'. 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: 6, `IZa f G, F% Date Design Professional Name., Address: Siaiiature: Design Professional = Seal