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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.18 -1 -34.2 BOX 28 03465 /I h PUTNAM COUNTY DEPARTMENT OF CERTIFICATE OF CONSTRUCTIO COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # �t �\;,�3' '_�•} Oil" �<<t 0 Located at fv2/LS �lny�7 Ca Town or Village VTrv-? � Owner /Applicant Name _bAW14e RGaysofa Tax Map 3, %9 Block Lot 3Y, 7�l Formerl Subdivision Name(/ryS�i/�L Subd. Lot # oZ Mailing Address l i f A� 4e & r"r7 r ��G�� —zip f oL7.. Date Construction Permit Issued by PCHD Separate Sewerage System built by Z?X 1A0 Address ZZ 4I1-4 -1X4 Consisting of /Z So Gallon Septic Tank and 460 1 /` Zy W�� ,9i 5�rt�,✓ Other Requirements: Water Su /nuly: Public Supply From Address or: ✓ Private Supply Drilled by �. 6lu Address y v //f v Building Type 51-1414 y__ .� _ _ Has erosion control been completed? Number of Bedrooms y Has garbage grinder been installed? WAWA 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 Pvn County Department of Health. Date: LZ-1 Certified by P.E. R.A. Address LOA la-q 7 epr License # 0 %�7f� a 77 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, on.cl apge when, in the judgment of the Director /Commissioner, such revoca 'on, modification or change is necessary., y: Title: _ Date: `7 ! o lg- copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 t. II Location Owner: Use of Well: I - Primary 2- SecondarZ W- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Street Address: Town/Village: Tax Map # 41�1.491N 20 Kramers Pond Road Putnam Valley Map73.18 Block -1 Lot(s)34.2 730 50.980W Name: Address: Dan Munsell, 20 Kramers Pond -Road, Putnam Valley, NY 10579 X Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Drilling Equipment I X Rotary _Cable percussion XCompressed air percussion _Other(specif) Well Type Screened _Open end casing X Open hole in bedrock 'Other Total Length 121 ft. Materials: X Steel Plastic Other Casing Details Length below grade ?CIt. Joints: Welded X Threaded Other Diameter 6 in. Seal: _X _Cement grout _Bentonite Other Weight per foot 19 lb/ft Drive shoe: X Yes _ No Liner: _Yes Diameter (in) Slot Size Length (ft) Dept to Screen Screen Details First Seco Well Yield Test Depth Date Well Log If more detailed ir..fcrme ±inn descriptions or sieve analyses are available, please attach. it yiela was testea at different depths during drilling list: ed X Pumped X Com 30' Depth From Surface ft. ft. Water .S'.rfece _ ._ 61 Dri ili ....»- •..-. ��_� « -..ter .. -� -_ '-^+ .. Hit ro 6' 21' Drilli 21' 225' D eet I Gallons Per Minute Air Hours 6 lYie unng y1eld test n) 160' Well Diameter ring (inl Pump Type sub Depth 180 Voltage 230 Tank Tvpe A30 _NO ft ) Developed _Yes _No Hours 9pm completed well In ft. 225' Formation Description anK information Capacity 7gpm Model 7GS07412 HP 3/4 Volume 86 eal . NOTE: Exact Location of well with distances'to at least two permanent landmarks to be provided 6 a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 _ 4 PUTNAM' COUNTY DEPARTMENT O, FH' HEALTH �� >, v!"' ..s..V'� ,..,iteri''' "iJ � A.7Z V 1 \ � V 1' L �• 1i_� �� Y A •11i1�� i1 ` R • }H ICES tics GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by Location - Street Building Type Tax Map Block Lot PV7-1V,0r6j_ TownNillage P,1." 4-AM Subdivision Name 2 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 4L b K.= . 48 4 i . system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated; Month _ Day 2— Year 7--dI Z- Signat General Contratrtor (Owner) - Signature Corporation Name (if corporation) Address: State Zip Title: Corporation Name (if corporation) Address: Z Z �eorhy --✓v State A Al Zip g a-7 Form OS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Q . We ImseP/� jIt�'#�_ WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Map # _. Map Block Lot(s).`� >' Well Owner: Name: Address: Use of Well: Residential Public Supply Air cond /heat pump ,Irrigation 'I- Primary Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Drilling Equipment Rotary _Gable percussion :- .Compressed air percussion Other(specify) Well Type Screened _Open end casing - Open hole in bedrock Other Total Length ` ; ft. Materials: Steel Plastic Other Casing Details Length below grade,: ft. Joints: Welded Threaded Other Diameter in. Seal: Cement grout Bentonite Other Weight per foot ::_, Ib /ft . Drive shoe: Yes _ No Liner: _Yes No Diameter (in) Slot. Size Length (ft) Dept to Screen ft Developed? Screen Details First _Yes No Second Hours Well Yield Test _Bailed Pumped _Compressed Air Hours Yield ^, gpm Depth Date eaisure Gin land surface- static (specify ft) During yield test (ft) epth o completed well in ft. Well Log Depth From Surface Well Diameter If more detailed ft. ft. Water Bearing in Formation Description' - lLaf'Y._.:.l�l'i`�_ descriptions or sieve analyses are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Type.., :: Capacity during drilling Depth o Model - j.;.`.;.,:< list: Voltage HP Tank Type Volume pate weir completed Well Driller ate o PC Certificate : NY`;State # Report" ! - 4 r ' �. ': :. it .. �I t ,. Purnp;lnstaller PC Certificate #' _ = ' Well Driller Name & Address V!lell Dnylle, slgnattre} f i o f r k4 e t w tci 2 .: i - >l-0 Pump Installer Name Address p u tarll h P mp Ins er`(slgnature) E S k y Z tea_ 4 Y 1' P 7 hi'• AS:..f� r,. x.r.. A.. NOTE: Exact Location of well with distances to-at least two permanent landmarks to be provided on a separate sheet/plan. _ White copy: HD File; eeow copy - Building Inspector, Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 .:,Kyy „�y �'•� ��...�.� '.'l.CPSfx- �a.�i�'va''' t BRUCE K FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fait (845) 278 - 7921 Nursing services (845) 278 - 6558 WIC (843) 278.6678 Fax (845) 278 - 6085 Early intervention/Preschool (845) 278 - 6014 Fax (US) 278.6648 OWNERS NAME: E911 ADDRESS VERIFICATION FORM V TAX MAP NUMBER: -73. /6 — I — 3 X 2-1 E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: DATE: "r ✓i3 /VV The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911verftm) Environmental Laboratories, Inc:... 587 East, Middle Turnpike, P.O.Box 370, Manchester, CT 06045 Tel. (860) 645 -1102 Fax (860) 645 -0823 Analysis Report March 20, 2012 SamDle Information Matrix: DRINKING WATER Location Code: PFBEAL Rush Request: Standard P.O. #: Project ID: BRUCE BERGH JR. Client ID: 20 KRAMERS POND RD. FOR: Attn: Mr Chris Beal P F Beal & Sons #4 Putnam Avenue Brewster NY 10509 Custody Information Collected by: Received by: LB Analyzed by: see "By" below I i ;�) m 1N AG.C� ��0 qOq NY #:1:1301' Date Time 03/15/12 15:00 03/16/12 .16:50 SDG ID: GBB54896 Phoenix ID: BB54896 Parameter Result RL Units Date Time By Reference Calcium . 77.6 0.010 mg /L 03/19/12 EK 6010/200.7 Iron 0.025 0.005 . mg /L 03/19/12 EK' 6010/200.7 Hardness (CaCO3) 211 0.1 mg /L 03/19/12 SW6010/EPA200.7 Magnesium 4.24 0.01 mg /L 03/19/12 EK . 6010/200.7 Manganese < 0.002 ,0.002 mg /L 03/19/12 EK 6010/200.7 �r _ .1 ...._ _ m O t! �f ?L EK .:. _ ....,.� ._ ___. W0.7 5y432 <_ Escherichia Coli Absent 0 /100 MIS 03/16/12 18:00 K/R SM 9223B Total Coliforms Absent 0 /100 MIS 03/16/12 18:00 K/R 9223B Alkalinity -CaCO3 171 20 mg /L 03/17/12 BS /EG SM 2320B Chloride 54.3 3.0 mg /L 03/17/12 BS /EG 300.0 Color <1 1 Color Units 03/16/12 18:13 BS /EG SM 2120B Nitrite as Nitrogen < 0.01 0.01 mg/L 03/17/12 6:38 BS /EG 300.0 Nitrate as Nitrogen 1.79 0.05 mg /L 03/17/12 6:38 BS /EG 300.0 Odor <1 1 T.O.N. 03/16/12 18:13 BS /EG SM 21508 pH 7,89 0,10 pH Units 03/17/12 10:58 BS /EG 4500 -H B Sulfate 17.3 3.0 mg /L 03/17/12 BS /EG 300.0 Turbidity 0.54 0.20 NTU 03/16/12 18:13 BS /EG E180.1 Page 1 of 2 Ver 1 Project ID: BRUCE BERGH JR. Phoenix I.D.: BB54896 Client ID: 20 KRQMERS POND RD. z tiro. .m..n i.s ..7.'a'"Jtr:s �..y . ..i:,d :a 1. � 'T, ••' -:.< .x., "0. - _ , � ��-..eyaGy•'n. � s i ".. a � a• , v.�.; 1 = This parameter is not certified by NY NELAC for this matrix. NY NELAC does not offer certification for all parameters. Comments: The regulatory hold time for pH is immediately. This pH was performed in the laboratory and may be considered outside of hold -time. If there are any questions regarding this data, please call Phoenix Client Services at extension 200. ND =Not detected BDL =Below Detection Level RL= Reporting Level This report must not be reproduced except in full as defined by the attached chain of custody. U� Phyllis hiller, Laboratory Director March 20, 2012 . Page 2 of 2 Ver 1 Q' „ 'a. ,�..�.. -. �y.4...++o ablca -..� •. n .a+, .... - ._are_s.. � :Y..+. \1.���rJ{Y �t.�C�'S' .-. c+ �l/ r �P` �>.. '. �y. Y (n.� .. .r .�., Environmental Laboratories, Inc. " 587 East Middle Turnpike, P.O.Box 370, Manchester, CT 06045 NY #.113.1. Tel. (860) 645 -1102 Fax (860) 645 -0823 QA/QC Report March 20, 2012 QA/QC Data SDG I.D.: GBB54896 Page 1 of 2 o� o� Sample Dup Dup LCS LCSD LCS MS MSD . MS Rec RPD Parameter Blank Result Result RPD % % RPD % % RPD Limits Limits QA/QC Batch 196483, QC Sample No: BB53324 (BB54896) ICP Metals - Aqueous Calcium BDL 13.9 13.7 1.40 102 102 0.0 75-125 20 Iron BDL 0.062 0.061 1.60 101 102 1.0 75 -125 20 Magnesium BDL 3.66 3.63 0.80 99.9 101 1.1 75-125 20 Manganese BDL 0.008 0.008 NC 101 102 1.0 75-125 20 Sodium BDL 14.2 13.7 3.60 91.9 92.4 0.5 75-125 20 Page 1 of 2 ri�K "•y,':l:`^t, �:�iP� +%:io�oi. -s ..r .A.- ...�ir .t�,ve 7TS;�;��. �^iMti 'r- �',ti.1+r, :red' -,i �\� ~ �`-' qy, vn•a ^,. r i Environmental Laboratories, Inc. 587 East Middle Turnpike, P.O.Box 370, Manchester, CT 06045 Tel 18601 645 -1102 Fax (860) 645 -0823 QA/QC Report March 20, 2012 QA/QC Data SDG I.D.: GBB54896 If there are any questions regarding this data, please call Phoenix Client Services at extension 200. RPD - Relative Percent Difference LCS - Laboratory Control Sample LCSD - Laboratory Control Sample Duplicate MS - Matrix Spike MS Dup - Matrix Spike Duplicate Phylli hiller, Laboratory Director NC - No Criteria March 20, 2012 Page 2 of 2 Sample Dup Dup LCS LCSD LCS MS MSD MS Rec RPD Parameter Blank Result Result RPD % RPD % % RPD Limits. Limits QA/QC Batch 196513, QC Sample No: BB54896 (BB54896) Chloride BDL 54.3 54.3 0 92.4 97.5 85-115 20 Nitrate as Nitrogen BDL 1.79 1.84 2.80 95.9 105 85-115 20 Nitrite as Nitrogen BDL <0.01 <0.01 NC 107 98.5 85-115 20 Sulfate BDL 17.3 17.3 0 91.5 97.2 85-115 20 QA/QC Batch 196420, QC Sample No: BB54969 (BB54896) Alkalinity -CaCO3 BDL 224 222 0.90 93.8 85-115 20 QA/QC Batch 196415, QC Sample No: BB54969 (BB54896) pH 7.49 7.47 0.30 98.7 85-115 20 If there are any questions regarding this data, please call Phoenix Client Services at extension 200. RPD - Relative Percent Difference LCS - Laboratory Control Sample LCSD - Laboratory Control Sample Duplicate MS - Matrix Spike MS Dup - Matrix Spike Duplicate Phylli hiller, Laboratory Director NC - No Criteria March 20, 2012 Page 2 of 2 SJLP EnUlzLearlmr HavvIces April 3, 2012 Stephen J. Ferreira, P.E. New Milford, Connecticut 06776 Joe Paravati, P.E. Putnam County Health Department Division of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit Sect: 73.18 Blk: I Lot: 34.21 "Daniel and Sharon Munsell" Kramers Pond Road Putnam Valley, NY 10579 - Dear Mr. Paravati: Please find the As-Built plan and required paperwork for the above-mentioned property. Please feel free to contact me if there are any further questions or information required. Atevhery Ferreira I REBECCA WI-1 ZNBERG, RN, BSN Public Health DbWor Director ofEnvftmneydal Health March 20, 2012 DEPARTAIENT. OF HEALTH I Geneva Road., Brewster, New York 10509 Phone. # (845) 808-1390 Fax # (845) 2784921 Steve Ferreira P.E. PO Box 1047 New. Milford; CT 06776 Dear Mr. Ferreira: MARMLEN ODELL Cowdy EwcubW Re: Field Inspection — PV -01 -11 20 Kramers Pond Road (T) Putnam Valley, T.M. 73.18-1-34.2 The above referenced separate sewage treatment system can be backfilled. There- are no comments to be addressed at this time in reference to this Department's open work inspection. If you have any further questions, please contact me at (845) 808-1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw `�Th. iVf, V; - wt� - ' -4�, RD 7..�,- 2 X - d, lel DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION OJOSEPH GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed prior to any Trenches V"' inspections being made. PCHD Construction Permit # 0 ( — ( , . Located: -,0 I 120 (T) V V Tn_0+-- Vk &i Owner/Applicant Name: '-b f-4 tj xjS•�C-(_ TM -74- 143 Block Lot 3q. Formerly: L/5,fiL Subdivision Name: A,V,*/f .1, L L Subdivision Lot # 14 Is system fill completed? 4 Is system complete? Is system constructed as per plans? Lim Is well drilled? V�3 Is well located as per plans? yt� Are erosion control measures in place? Date:. Date: 3,11y 1-zoil- Date: �7_o I L,• 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 Health, Date: Certified by: PE RA Design P esign lofessional e: /° Lic. 4 Address: IJiZ- �'L/ /�f [ _1W c: t"*' Cr -7 Comments: Form FIR-99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH -SERVICES FINAL SITE INSPECTION Date: _-3 Inspected by: Street Location TM*— 3V,4 1. -Sewage Svstem Area a. STS area:located as per er approved plans .................... b.. Fill section --date of placement 3:1 barrier Lgth. Width -Avg.Dptb,_ c. Natural.soil not stripped...... ................................ d. Stone, brush, etc., greater 15' from STS area... e. 100' from water cours'e/wedands..: ....... I ...................... IL Sewage System a' Septic tank sizi(- 1,000 ...... 11250 ......... other ........ b. Septiciank el .......................................... c. 10, minimum from foundation ........................... ...... d. DistribtitionBox 1. All outlets at game elevation-water.tested ........... 2. Protected below frost .......................................... 3. .. Mniraum. 2 ft. Original soil between box & trenc e, Junction Box -properly set .................................. 6. 'jurenches T L required �106� Length installed �le 2. Distance to watercourse measured -/- le e7t ......... 3. Installed according. to plan ................................... 4. Slope of trench acceptable' 1116 - 1/32" /foot....... � I00 e0 vel.. 5. 101 from pri ert .property y he - 20 ft, foundations..... 6. Depth of trench <30 inches from surface ............. 7_1Room allowed for expansion, 10.0% ......... Z .......... S.. Size of gravel 3/4 -I Ik" diameter clean .............. 9. Depth of gravel intrench 121l minirnurn_' 10. Pipe ends!, .ca ppe .... .............................. 1. Size of pump chamber ............................................ 2. Overflow tahk- ......... ......................... 3. Alarm, -, s. .0 ............................................... 4. Pump easily accessible, manhole to grade ............ 5. Firkbo;XbaZed..* ............................ ...................... 6. Cy ewitness'edbyHD.estirnate.d'flow/cycle ..... EGL House/Bufldixie a. House located per approved plans.,,** b. Number of bedroords .................... .. IV. Well. Well located as per approved plans ................................. b, Distance from STS area measured c. Casing. 18" above grade .......... ............................... d. Surface drainage around well acceptable .................. Y.'Over-all Workmanshi a, Boxes properly grouted ........................................... b. All pipes partially backfilled ..................................... c, All pipes.' flush with inside of box .............................. d. Backfill material contains stone's <4" diameter........., e Curtain drain & standpipes installed according to pl. f Curtain draki outfall protected & dinto exist waters g. Footing drains discharge away from STS area.......... h. Surface water protection adequate....,.. * - "**** .... * i. Erosion control provided .......................... I ............. Rev. 12/02 Permit # — V/ — /,/ . Subdivision Lot 4 V_ PUTNAM COUNTY DEPARTMENT OF HEALTH nivi-4zinm OF rmvInnmMr:mT,&! HEALTH SFRVlr WELL COMPLETION REPORT Well Location Street Address: 20 Kramers Pond Road Town/Village: Putnam Valley ITax Map # MaP73.18 Block -1 Lot(s)34.273' 50.980 W Well Owner: Name: Address: Dan Mansell, 20 E-"zs Pond Road, Puffin Valley, NY 10579 Use of Well: 1- Primary 2-Secondary X Residential Public Supply Air cond/heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary _Cable percussion X Compressed air percussion _Other(specify) Well Type Screened _Open end casing X Open hole in bedrock -Other Casing Details Total Length 21 ft. Length below grade20 ft. Diameter 6 in. Weight per foot 19 lb/ft Materials: X Steel Plastic Other Joints: Welded X Threaded Other Seal: X Cement grout _Bentonite Other Drive shoe: X Yes No 1Liner: Yes X No- I grouted I Diameter (in) ISlot Size I Length (ft) I Dept to Screen TO IDeveloped? 11Screen Details I First Well Yield Test IlDepth Date - Well Log If more detailed ;nfori-naflon- descriptions or sieve analyses are available, please attach. If yield was tested at different depths during drilling list: —Yes —No Hours 11 Bailed X Pumped X Compressed Air Hours __.2 ( _ lYield— 20 gpm Measure from and surface-static (specify 30' During yield test (ft) 160' Depth of completed well in ft. 225' Depth From Surface Water Bearing Well Diameter (in) Formation Description ft. I ft. Led''Sui face Drillkn ov Hit rock at 6' e, id-:,, (),Uri - H2': 21' lDrillinjq in rock, set casijg. grouted 225' 1 Drilline!-in rock eranite Feet Gallons Per Minute vumplb� Pump Type suh_ Depth 1801 Voltage 230 Tank Tvoe WX30 Tank Information Capacity_jgpm- Model 7GS07412 HP 3/4 Volume 86 eal. 7. 1.4 '711 IWA NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided on a separate (W::hite copy- HD File Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH lr DIVISION OF ENVIRONMENTAL HEALTH SERVICES is . - _ - ^':ate' � ' �'.f,Y'4!' ��- :t ^;?�.E -«= -� i�r -i• +a ��c•'i�.v1'�dti .si.-irrr :': - ". __::tiwri5..' y'P -7:' � i -: ,=o=j r_9� �" _ °'./"�'."G;� °�t�,y � w .. z �:. ..`•. - ii y ..'�y.. CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYS'It { i PERMIT # 01 490 Located at Ay,1tL -y Alvo Dom- Town or Village kza Subdivision name PAl7NSCU,- Subd. • Lot # Tax Map -73.18 Block [_ Lot 3 Q. b Date Subdivision Approved Az vST 261 z) Renewal Revision Owner /Applicant Name ` wf-j t CL. 4 S iPA& uNSCU— Date of Previous Approval Mailing Address Zee K (2 -S ecri -O PV ru✓+&t !�U � Ny Zip -/.a39,P Amount of Fee Enclosed e,5�0 - 00 Building Type 15,f Lot Area •1/ZA No. of Bedrooms 4- Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of i7 SD gallon septic tank and 4ob P NC14-9- ��c- o sL Zy Y w t !� � �- 6:56�•rta�v '>�- �+�1'l Other Requirements: To be constructed by T,'8.D • Address Water Supply: Public Supply From Address °"� .�iri':"_ Y'i3:aw ai; ►�tj�' if fl �iy "" ?isi�iCJa1'v �%►+�iy.%i�% f+1f� ","iCSoAi 1 M 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. Signed: Address R.A. Date 7-a 1 License # D'7 b 7 93 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. By�j=d`/.L.," � � A Title: _A014je Date: , �pfcopy - HD File; Yellow copy `Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type $NCH ®yPe�f�ITllt " Well Location Street Address: Town/Village: Tax Map # xlt4m °'� �- D�� 4WMap%3 %S ( ® Block Lot(s) 3 - 2r Well Owner: Name: Address: Phone #y tw JC44W � Use of Well: Residential `Public Supply Air /cond /heat pump _Irrigation I - Primary Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 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 T e Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ Nok_ Is well located in a realty subdivision? ........................................... ............................... Yes .�C No Name of subdivision DA+ut tUJ 5/44 UAi AllMAKE-I , Lot No.�2_ Water Well Contractor: NQ to a4tsO,'J Address: Is Public Water Supply available on site? ....................................... ............................... Y s _ No Name of Public Water Supply: '- Town/Village Distance to property from nearest water main: Ss�tGGS Proposed well location & sources of contamination to be provided on separate sheet/plan. l Arjai,-c3ii3;;SiC(iiaturEE_..� 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 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 Putna unty. Date of Issue � 1 6� Permit Is uin Offi ial: Permit is Non - Transfera White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 NVIF Rasineerinv services F ... � �1. •_�.�. t'�r r..t .... ��,r «. � , -� -• •_ .. ..�PJ^^ :.c- ,n P.O. Box 1047 New Milford, Connecticut 06776 MIM(;u02;rfvaMI , f -C- Joe Paravati, P.E. Putnam County Health Department Division of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit Sect: 73.18 Blk: 1 Lot: 34.2 "Daniel and Sharon Munsell" Kramers Pond Road Putnam Valley, NY 10579 r 23o0--I-y/NSki;t Dear Mr. M%pati: Please find enclosed: March 15, 2011 1. (3) copies of the proposed septic system trench plan. 2. (3) Three sets of house plans. 3. Constructions permit application. 4. Letter of Authorization. _..�_..— 5.. ?ication -for approval of mans.. approval .._ _._.e.._.,......'_.... ..,....._.. 6. .. ._o.._,.,.a.._ ....:..�....,�•...�....,..._.. _. ,..........._.- Application to construct water well. -' 7. Soil Data Sheet. 8. Short environmental assessment form. 9. Property Survey, filed subdivision map. 10. $500.00 Certified Check. 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. Sinc �el IFeira Stephen J. 14-16.4 (2187) =Text 12 PROJECT I.D. NUMBER SIT*M SEOR +) Appendix C . SHORT. ENVIRONMENTAL ASSESSMENT FORM. For UNLISTED ACTIONS Only PART I— pROJFCT INFORMATION rro be comDleted by ADDIiCant•or Project sponS0o 1. APPLICANT /SPONSOR 2. PROJECT NAME. v�S�� Sr ��/ 1f�t 3. PROJECT LOCATION.,. Mynicipallty County >� 4. PRECISE LOCATION (Street address and road ntersections, prominent landmarks, etc., or provide map) 5. IS PRO ACTION: ,PdED New D Expansion D Modlficatlon /altaratlon 6. DESCRIBE PROJECT BRIEFLY: NE+ti S tL� �.�cKr�j /-�o � �ctiO�rl/i Ar✓/Pt- w�s�` .- 9177G- 7. AMOUNT OF LAND AFFECTED: , d 0 Initially acres Uftimstaly acres 8. WILL 96OPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? es [I No If No, describe briefly 0. VVHAJ48 PRESENT LAND USE IN VICINITY OF PROJECT? D Resldenlial D Industrial D Commercial D Agricultur© LJ Park/ForoetlOpen space other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL., STATE LOCAL)? Yes ❑ No It yes, list agency(e) and permlVapprovals v�r� it. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? &Yes D No If yes, list agency name and permlUapproval <6,O!(/l�t .4+t✓0 S1T� ®c�sv ��/'GllrJt<dva p��%v;�/f�`t 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? I ❑ Yos M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponsor name: Date. Signature: if the action is in the Coaltstai Arei, and you are a state agency, compiet® the C®astai Assessment (Form before proceeding With this assessment 9 PART II-- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) ,A, DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 817.12? If yes, coordinate the review process and use the FULL BAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED-, ACTIONS IN 8 NYCRR, PART 617.8? It No, a negative declaration may be superseded by another Involved agency. o'. •`••«�+T�"r:;?- :,;�:'4�,r,v -�-: .. �- air.w�s�.. —. ::.`o'e:- r.:..,7�,i, �-w:ai,��= woe ..�s..v�'w.i�K.- .`..--- e,�t:., .. .. .. .. ,�..... C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (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 briefly: 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, eignificent. habitats, or threatened or endangered species? Explain briefly: 04. A community's existing plans or goals as Officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth; subsequent development, orrelated activities likely to be lnduced.by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? _ „ "ate% -2s _... _ � No.. _ .tt iea:•.:YBtric�,hrlrtiv:.R . ._�...._. .. ,. ...... .. a ._ .... - . .. ..- �... _ --, -. ...� - � • _.- .....,.�......... PART III -- DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It is substantial, large, Important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility,. (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a'posittve 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: Name of ea Agency Print or ype Name of esponsi a Officer in ead Agency Tit[* -al Responsible Off icer ignature o Responsible 5ff icer in Lead Agency Signature of reparer I different from responsible otticerl Date EAS Form 14 -16-4 (Page 2 of 2) Neighbor Notifications: 1 Kroboth 15 Briar Ridge Lane Putnam Valley, NY 10579 2 Rush P.O. Box 4 Putnam Valley, NY 10579 8 Kramers Pond Road 10 Kramers Pond Road Putnam Valley, NY 10579 Putnam Valley, NY 10579 5 J. Vaughan Kramers Pond Road Putnam Valley, NY 10579 7 Cohen 1 Briar Ridge Lane Putnam Valley, NY 10579 9 Deruggero 9 Briar Ridge Lane Putnam Valley, NY 10579 6 Munson/Schilling 24 Kramers. Pond Road Putnam Valley, NY 10579 8 I. Bomba 3 Briar Ridge Lane Putnam Valley, NY 10579 L a r a r P. u Ln ❑ a r 0 0 Sent To . 6 61: or PO Box N& crry, were, zrPta I :aE A69usk 2000 PUTNAM COUNTY DEPARTMENT OF HEALTH �DIVISION.OF ENVIRONMENTAL HEALTH SERVICES �.'� ;,�'::s'+.�s�:c{a+. <Ft .•;7�we o' iii- �Z'ft."•�ip':�'a`ir`�+.�nF!i 7 f WELL COMPLETION REPORT Well Location Street Address: 20 Kramers Pond Road Town/Village: Putnam Valley Tax Map # Map73.18 Ble Well Owner: Name: Address: Dan Munsell, 20 Kramers Pond Road, Putnam Valley, N! Use of Well:. 1- Primary 2- Secondary X Residential _Public Supply Air cond /heat Business Farm Test/monitorh Industrial Institutional Standby. Drilling Equipment %Rotary _Cable percussion %Compressed air percussion _0 Well Type Screened _Open end casing % Open hole in bedrock _Otl Casing Details Total Length 21 ft. Length below grade 2 %. Diameter Erin. Weight per foot 19 lb/ft Materials: X Steel Plastic Joints: Welded X Threaded Seal: Cement grout Bentonite Drive shoe: X_ Yes i No Lin Screen Details Diameter in Slot Size Length ft De First Second Well Yield Test _Bailed X Pumped __I Compressed Air Hours 6— Yie Depth Date measure from land su ace -stet c (specify 30' During yield est 160' - Well Log If more detailed descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter ft. ft. iia`3tfe• °ti �1,. ....J 5 "— -1 ,.; nn.. �.r.._ -7•: Hit rock k at ' 6' (iin '_'bL *r}cy .Cl _.. t _ - 6' 21' Drill_ 21' 225' Drilling If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Sto Pump Type su Depth 180' Voltage 230 Tank Type WX302 40 j �W r x I 3I - 1 vI q 'E.. '� jylir : �`Yk.."T t.: a� W 1 1- ell'�11' Ii �gR tig I Pamsia(tfa&Adtll� i1 1 1 , lwE�i �x�a Ali rcT�il : ha i r 1 ln 't4�` YY� : .1 .. °Yy � distances twat least two permanent I ill!'s t i i��k nf ' .. ndmarks to be d NOTE: Exact Location of well with provided White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange Er Ir C3 r-1 Ln C3 ru C3 0 C3 0 r-1 X r-1 Er O O ru 0 Er ru C3 Rf C3 (Endon r3 Restfi, 0 (Endon Total • en Er 0 't 0 or P01 S. Pi5stafservibeTP.1 CERTIFIED MAIL,,., RECEIPT 1 (Domestic Mail Only; No Insurance Coverage Provided) 4g—fbr,.061** r'y* !%�6 f information our,we site at www , IC I 'A L U S E -OFF ....... ........... or PO Box N.. ............ --- ---------------- - ------ --- - --------- ----------- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -'r E.A s Nr,& W— ur" ; Owner �✓NS,ELL Address QO,�,l�ht �,va f���• Located at (Street) lowb f2o.4�,P Tax Map 73•/8 Block l Lot 3� Z (indicate nearest cross street) Municipality p�,rf/," tL4ft Watershed }�vpsrn/ 4z V/ SOIL PERCOLATION TEST DATA Date of Pre - soaking 5Zb lo9 Date of Percolation Test Y/91 1(2 NOTES: 1. Tests to be repeated at same depth until approximately 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 ISeptb to "Water{ V(?ater� i {{ �Iid Iti il, {�Q� 1i rT I.i Iii : t �,I i ..r1 t ] I i � ElApse I'im 'y Y{rom.�Ground { Surface(Ynt6es)1 4 ,,'1 �y� r { jDrupIr► I.��rcblattOn 14 L ��d•FL III ' {I{ Rate��r5`.I { �i i I Hote F ❑s i Rgtt No T��ne +C i 1j 1VIlnyI i Star# Sto { TnChes 1 IVII�t /Inch JI �!, ,.. LY L i 4 I ND ,' 2 ,Ail' � A{. ♦ k1�I��1* � P.'.. ,'' LI I I 5 .. F+ 5 , i 4h�1 1146 i'' 15 C i {�„ i ,4y. 1 lii� I 1 114,11 {r bl� r i r......_i.�F- ....:..... ... ..'r �..::. I I I ] i r.:� �{ .._4r:: ri ,.. ..:r.,I lil, i C ri il'"5 r.: �.. :.I:ii; is ...I.I r ,1� SI 1� {C� ill any- ?o" 2 9; a3 - 93s f u 2y't- 3*� 3 S 3 : f/o '�rSS �S Z7 - S 4 5 4� 4 5 .3 1 /O:.3S7-10-,50, 15- 27 3# 2 0.• _ ��• �o $ 27 "� 30 3 G 3 /••ii - //•'3 21 2 ��� �o 3 5 NOTES: 1. Tests to be repeated at same depth until approximately 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 PUTNAM COUNTY DEPARTMENT OF HEALTH R1E: Property of LETTER ER ®F AUTHORIZATION 11A1 Located at 4a tid AQ- TN L/ 'Tax Map # Block Lot Subdivision of Subdivision Lot # Filed Map # 12 3 Date Piled AZ 20 vi Gentlemen: This letter is to authorize a duly licensed Professional Engineer ;K- 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 .0 P vj .¢ �C , (,l� ej/ I4"' of tho Eduq,, ¢ion:_La :.P.� tb.° Publ�c .__.. � � �. «f�rifgr.�i�"('v -r :�1Q.,_�13E ,;vro3 ls�tlo s V�'l1a'�Lj 7f_1�..:i"9J a's'.1W �3. _ .� 1 L f:i �^C.ta .. � y'� l,.A`< � . -.. . t+Z.... . ti .. •ate ve. .Y. �.. Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: J Signed: — P.E., R.A., # 076 7V (Owner of Property) Mailing Address 69 - 66 K /D /7 Mailing Address: 02a Ag 114,% 49 State 4AIlf �l Telephone: State i�j Zip 105 'i9 Telephone: Form LA -97 • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner A*V,41, /fvvx-,C -G Address Located at (Street) Tax Map Block Lot (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test S_AA /0 2 It - 4 h r� No Uii!: dhi W. Run No . . . .. . .... .. . .......... .......... . . . . . . . . . . . . . ... .... . .. . ... ET K. T F-19 9 S ... ... . (M rd) . ....... !aq! 1,11 1& dT": I W 01 a m N/1 6 2 3 V 4 5 3 4. 5 2 3 4 5 NOTES:. 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. < I min for 1-30 minJinch,:5 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 G.L. 0.51 1.01 1.5' 2.0' 2.51 3.0' 3.5' 4.0' 4.51 5.01 5.5' 6.0' 6.5' 7.0' 7.51 8.0' 8.5' 9.01 9.51 L TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES add ec� 5;qmv 6,z4VfL- ooze LA 5fte Al-S +1 op A111 —AA, W-+'rJ56 d, w 1,V I/ t7 Indicate level at which groundwater is encountered -7 Indicate level at which mottling is observed IV6AI-C Indicate level to which water level rises after being encountered Deep hole observations made by: 6,ewc 45" 'Date Y/27/0f. Design Professional Name: Address: 06k 10et17 -4,11 /Z jM4..", I q., 1 77,E Signature: Design Professional=s Seal PUTNAM COUNTY DEPARTMENT OF HEALTH 'VTSIO. Q F ENV. RQI . HEALTH SE VICES. ri y.. '- a,'..'• w'�..ei..w::���'v.•w.�'- :�"'iw: :.r,:.�:•�.siR.jF,aw:a.< . o�L.. T.% 7.`.:;. 1: ,•Sa/N•r.::.i.�Fira.L"+�'►..er Owner or.Purchaser of Building Building Constructed by f Location - Street /,I, "p, X Municipality 'Building -Type Section Block Lot Subdivision Name Subdivision Lot # GUARAMM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that Iam wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and' hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period, of two years immediately following the date of approval of the -•• . _ .. "���;" _ +:f?Cr- C f t'nncTrtl C Compliance" '2�Cr' �hL ;S� fct.`�cTd�'�'��'w1 -S�7St �y �.:,.r, o y- repairs made by me to such system, except where the failure to operate properly i.s caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinental Health Services of the Putnam County Department, of Health as to whether or not the failure of the system to operate was caused. by the willful or negligent act of the occupant of the building utilizing the system. Dated this, day of 19 Signature Title General act ( er) - Signature Corporation Name (if Corp.) Co tion Xi . a /44w Address rev. 9/85 mk kll� e PUTNAM COUNTY DEPARTMENT OF HEALTH Owner or Purchasers of Building Building Constructed by . Location - Street Municipality building Type Section Block Lot Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the ,.. _ _... ur'�;rt.i.''? +'%3:F :c?.l: Co. �i_-!iction�_- Qq i9j , an � _fur the ewatyry "? SF^oc^:Z ►y . ^} —�' , .(?C aY1'; repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinental Health Services of the Putnam County Department-of. Health as to whether -or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this day of 19 Signature 6� Title •(er) - Signature 3 k�' 4tIj rev. 9/85 mk Corporation Name (if Corp.) .F. We* Addriisd lamtod at (SUMPt ) /ire rv-" -":OP,7 Undusto nowt CXQ" street) SW- 72- block lot Watershed Mr Depth to Water Fxcm Water level Time Growd SurfaC8 In Inches SOU Rate Start-Sup Kin• start stop Indwai Inches Drop In Indies Nion MW Q l� 9� Z 24-- 7- 7- 3jVv 'le ?w 4 19 Z 4'— 2,2- 2, iC- 2K 4 2 3 A 4 1. Tests to be repeated at,same depth until approdmately equal soil rates are obtained .at eacb peroolatien test jM1j. All data to• be m9mitted for - awiew. Z. Depth ONAMMOU to bG SIM fm UP 49 hdo.. 9/85 ^ A r ] lV 111V AM COUNTY 1V TY DEPART1V1 E ll OF HEALTH Ji H `�:: '•- po.�.e• �'�y�p���y- mti �.7�..'"a�'-��' ^TS�%T- �L-'•�T F •4�T4 U T�� -{Z!. ���' ._ .. ..i�...� ti::;yr„ F -- ✓i �' 1^c n2 �i .n.. r��ve f g s.S: �. -�'''� - � "-- �.,�..:s ,o ri•i J1JJ11 CJ�l.�IP�1� -�`� tl. elv'° �Y1LL'' o`` �tb�tl�riet��i��'' �7i` ri. e` 1"' �` ii. ezl• nl�' r°.i'i�ii6°�o�elSa.ei:✓•.°"�' °- w••"Q_; i CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR kTMENT SYSTEM PCHI) CONSTRUCTION PERMIT # ?V -( (0-99 Located at Y_' P_JZS POP31> TD&2 Town or Tillage PO i i� � VANS wne Applicant Name'DAr J � :L - Tax Map -73 ? 16 Block I Lot - Formerly Subdivision Name FO//v D c )C TE-A. Subd. Lot # RA Mailing Address 2-,o K(LNme( •S ` yri+7 , VUTrJAM VAi-L201 Zip LO5-79 Date Construction Permit Issued by PCHD AUCa , 14P 1 1 999 000 ©F-0itepi aR-D Selpairate Sewerage System built by 'DAM - i Irl0 (1gjST C - Address 'Pr-kLA- r 0 1 147�Cy�v Q Consisting of /500 Gallon Septic Tank and W(�, ) Pc 1 nti 2,q It ('aAVOL- T'C4 Other Requirements: Water SUDDIa: Public Supply From Address 01r:—)(, Private Supply Drilled by &2p W_ SD6 , 70(, -Address ST 05 ()9' i, p: t .. ^. y9 `. r� "_ �. '.^. ^'-. cc�. ........ .. -. ._.. �.�... Building Type irJi.�'A►Ni I i-�%/ Has erosion control been compieted': y' Number of Bedrooms t V1 Has garbage grinderjx I certify that the system(s), as listed, serving the above built plans (copies of which are attache2tionws ' acc rdanc plans and the standards, rules and reg f tho Date: Z - Z- `t- ° 0 Certified by Lr 0-- Address ?.: 7 _�v PmA W'.,kL as shown on the as- Permit and approved 1 of th. z �` P.E. )4 R.A. 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 revocation, mo 'fica . n or ge is necessary . Title: ® o By: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT ill 110 n1 Street Address: Kramers Pond Road ( #20) Town/Village: Putnam Valley Tax Cirtd Map )$Block Lot(s) Well Owner: Name: Dan Mansell Address: 20 Kramers Pond Road Putnam Valley, NY 10579 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32' ft. Length below grade 31' ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic _ Other Joints: Welded X Threaded Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 20' During yield test(ft) 540' Depth of completed well in feet 605' Well Log If more detailed information descriptions or Clriti� V �•. �1.it'�.._. � � .. are available, please attach. Depth From Surface Water Bearing Well Diameteron) Formation Description ft. ft. Land Surface 10 Drilling in over urden clay and boulders 10 Hit rock at 101 _i f'r .. .,,,.,..,� -' _ .. r _1 1 _ �� ..Y.. -- .i.r,n.., .5ra.. Z� ••r: ^^ < caE' c n - •• i-..n rY .•4::.- •-- •Ga..•_'i: f - �Ll�.. r_. -. �..-. ._ .... ._ 32 605 Drilling in rock ciranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Typamb Capacity 5gpm Depth 560' Model 5GS10412 Voltage 230 HP 1 Tank Type W (iOl Vol Date Well Completed 12/7/99 Ntnam County Certification No. 002 Date of Report 1 /11 /00 Well ri r .Bea NOTE: Exact location of well with distances to at 1 two permanent landmarks to be. prayvlded on a separate sheet/plan. 4 Putnam Avenue Well Driller's Name P. So Inc. Address: Brewster, NY 10509 Signature: Date: 1 /11 /00 Pe L. Beal White copy: HD , Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown ' Albert H. Padovani, Director LAB #t: 32.000896 CLIENT #: 11852 NON STAT PROC PAGE 1 MUNSE:K-L, DAVID. DATE/TIME TAKEN: 03/07/80 03:O0P 20 KRAMERS POND RD. , DATE/TIME REC'D: 03/07/00 03:50P PUTNAM VALLEY, NY 10579 REPORT DATE: 03/10/0(} PHONE: (914)-526-2335 SAMPLING SITE: 20 KRAMERS POND RD. SAMPLE TYPE.": POTABLE _ ^�F- - : PUTNAM VALLEY PRESERVATIVES: NONE COL'D BY: DANIEL MUNSELL TEMPERATURE..: NOTES ... X KIT TAP COLIFORM METH: N/A ----------------- ~ ---------- ~ ----- ---------------- — --------������������� DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD � 03/07/00 IRON (Fe) - <0.060 MG/L 0-0.3 mg/l 2037 COMMENTS: �e/w" rf k"+k ~�.. _-_-__� ' ^^.". ^. ^. ".. =..� mq/�g�//es� c,nr �/ � combined shall not exceed 0.5 mg/L SUBMI[TiED BY: Albert H. Padovani, M.T.(ASI � Director PUTNAM COUNTY DEPARTMENT OF HEALTH GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM DAAIIEL 0U /JSF_cC. Owner or Purchaser of Building llAtJI E c MCAU X6 L C Building Constructed by I(K ✓q vy 6RS f6,, o Location - Street S11j64-E rr jl- y re S"a6,0JCE 73./9 1 .3�L. Z Tax Map Block Lot Cu -r4,1 r. Vp t Z ow illage sut3o�vispow OF PROP6Ri �' �o R Ev7 rhE rT �d � �' ®Eh'TE7Z Subdivision Name Z Building Type 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 pr�nerly. is_cause hy.the willful or negligent act of the occupant of the buildin utilizin the _ "-�' � no- • y �.._ v......- . .. - nom..... -.,.. as + >,4- ...... .... ... -�_ _._ _-` -"+'°- ra•.-- ....v...es:�..+... a.- o-- .- •'tF +- °r••= -.za.« oe = Ya- ,.o�...: -.w .... �"'..0...:yvv.. system: The undersigned further agrees to accept as conclusive the determination of the Public Health Director bf 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 M,4RC14 Day '7 Year Z 000 x -W �"1/ General Contractor (Owner) - 'Signature Corporation Name (if corporation) Address: 31 PYO R 20- 6 C State /J E P YO PK Zip 1056'Z Signature: " Title: co, .DAM- Fl rJ o Cod s Tn U c i 10/J Corporation Name (if corporation) Address: 1060 0IZ666P RoA,0 State EEKSK 14 C , N; `, Zip I o S 6� Form GS -97 ::,�_ r rg•= �F,J<�svw.� - .�,; 9':vstv::i3 t' ` �._` o�i� 3r��arJlld(�E:T- 1:'.:r+'� .. cr Public Health Director 04 Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914)278-6130 Fax (914) 278-7921 Nursing Services (914)278-6558 WIC (914)278-6678 . Fax (914) 278-6085 U9. Early Intervention (914)278-6014 , Preschool (914) 278 -6082 Fax (914) 278 - 6648 March 6, 2000 Ken Murphy, PE Cronin Engineering The Lindy Building, Suite 200 2 John Walsh Blvd. Peekskill, New York 10566 Re: Application of Certificate of Construction Compliance, Munsell, Kramers Pond Road (T) Putnam Valley, TM# 73.18 -1 -34.2 Dear Mr. Murphy: This office has determined that the above referenced Certificate of Construction Compliance application, received by the Department on March 3, 2000 is incomplete. Please be advised that the f lowing information is required before the Department may commence its review. D uments Completed Guarantee of.SSTS. L Z* Oriwginal. enclosed. _ r_ ;__ Cll9; iI—I rVV G11FCU111J1C L1Vil i\Gp171L lL UIl`ea: Well Completion Report must be completed, (see attached). 4. Original Water Quality Analysis required. Test for Iron results higher than maximum contaminate leve1.313 mg/1 > .30 mg/l. As -built plan to show property in its entirety, plan can be at 1"=100'. As -built of system to be 1" = 30', as shown. All comments pursuant to PCHD Bulletin ST -19, Policies & Procedures. This office will continue its review upon receipt of the above mentioned comments. Please feel free to contact this office if any questions arise. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj encl. Cronin Engineering PE PC n'''" ;a.`.• �.•L1 riaC -n-R �771"Ui"�' ��Lltkl i,n' i D.r.,- - y.,c..7.<...a^ •.,J�J 2 John Walsh Boulevard Peekskill, New York 10566 Telephone: (914) 736 -3664 Fax: (914) 736 -3693 TO: Adam B. Stiebeling Assistant Public Health Engineer Putnam County Department of Health Department of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: o.r__1Ga 11TTAL Location: EKA0 6-21-s tea" Town: `�RJMJAM 1_W&42' j E I WE ARE SENDING YOU: Copies Date No. Description 3 AS -BUILT SEPARATE SEWAGE DISPOSAL SYSTEM PLAN -9' 3 GUARANTY OF SEPARATE SEWAGE DISPOSAL SYSTEM 1 WELL COMPLETION REPORT 1 WATER ANALYSIS REPORT ;�SF �. St tfTT IP FOR: �RE1I?EI?4' 11 .. A�DPR()vA?,.' CONEM ENTS: \NE Ate. 2 -� u��'iTrrJr� �(L f;ppkV41- t -s t� 0--J Wa-y - i E INE0 BLS 445V L*n.�V . 7V4Ad k S COPIES TO: L SIGNED- M An nicchiarico o Putnam County DOH TRANSMIT.doc 02/24/00 ' THU 14:07 FAX t;v *99M I 39 P&aC161f6V AJD — 1D y CT 06911 EAM (203) 748 -7903 - FAX (203) 748.0652 NY Cer¢: 11471 qA %$ wF ?y �"`[ i. rs � �.. ^r m�P '�`r pr t rt e ,a'° � °. ��` .�l �°^' � �� " -�L f � �w"PJ F��;� •� '�ir;' 'i'� y „` � - f "` 1..� . �...� ��i P' a � .. �,.. 3 � e -, h, a. _T `R. A - o �,p �. _ .� P. :.. °f+ � ,1._ e _�`�.. � �4..• a. .P,. .1 U � n S.,.S ; MRT TO; P.F. REAL do SONS DATE SAWMra COLLFMD: 113!2000 4 PUTNAM AVENUE Tilts COLLECTED: 10:30 A.M. BREWSTER., N.Y. 10509 COLLECTED BY: PL3 BATE RECETVED @ LAB: 1/342000 IDATI TESTED: 1/3/2000 TESTED D BY: LA13O11.471 REPORT JDATS: 1/10/3000 . SAX&E Sl[T'.L; 10Q1(WN'SIELL, 70 OL4141M POND ROAD, MTNAM VALLEY, N.Y. S L 1 D>lNle: ROSE M @ TA NDIC S 1 LR ° WELL 7(it1EAT MNt': NONE Q003 DAI H tfil'�,19 ; Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml Chlorine Residual ND mg/L - - - -- ml = milliliter mg/L = miffigam per Liter ND = none detacted RIESU'ILTS BASED ON SAIbTUS SUBM=1 D:1/3 /2000 SAMPLE, AS TESTED ABOVE: DOTABLE on° DIMPOTABLE (PER STATE OF NEW YORK DEPT. OF HEAL.T11 SERVICES STANDARDS FOR POTABLE WATWO r iIi Labormnr Director NORTHEAST LABORATOPY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9781 - FAX (860)829 -1050 TOLL FREE WTTH[N CT: 800 -826 -0105 o OUTSTDE CT: 800-(154 -1230 K, 02/24/00• THU 14:07 FAX �J004 Iv G+. • .. - i �.�g. ..�p• . AVA NEAMEM 39 Di ML PLM Ro" - DANSV1nt, CT 06811 Cr Cent: PH-W's (303) 748 -7903 - M (203) 748 -0652 NY Cett: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING RSPORT T0: P.>:.-BEAL & SON'S 4 PU'i'NAM AVENUE BREWSTER N.Y. 10509 DATE SAMPLE COLLECTED: 2/912000 TIME COLLECTED: 9;3 0 A.M. COLLECTED BY: PLH DATE RECEIVED a LAB: 2/9/2000 TESTED BY: LA13011471 REPORT DATE: 2/15/2000 DAN 1MUNSE11., RRAMERS POND RD., PUTNAM VALLEY, N.Y. HOSE BIB WRLL -NEW NONE RESULT: Color 5 Odor 3- METALLIC pH 6.29 Turbidity 1.4 NTUs 15 3 Units no designated limit 5 NTUs +Y: Nitrite N <0.005 mg/L as N 1 mg/L as N Nitrate N 3.72 mg/L as N 10 mg/L as N Alkalinity 92.0 mg/L no designated limits Hardness 126.0 mg/L no designated limits 0.30 mg/L [Note: Combined Lirr_it for Iron plus Manganese = 0.50 mg/.] Sodium 11.8 rng/L. 20 mg/L ** Lead 0.003 mg/L 0.015° ** ml = milliliter mg /L - milligrams per Liter ND none detected NM=Unb "Notification Level ** *Action Lcvcl RESULTS BASED ON SAMPLES SUUBAUTTED:219/2000 (PER NEW► YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POT.l M WATER) Iy� Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828-9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826- 0105.OUTSIDE CT; 800 -654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH 1 IVISION OF ENVIRONMENTAL HEALTH SERVICES , _.� �.. , . �.;� - -,. � , >_ .M�.�,. -_ %;..�:-�:. :" �_. ;:�„ _ ..'rya. ._ • -- .� < >_, GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM N�JIEZ �IJIJSE-Z C Owner or Purchaser of Building Building Constructed by k'I?p 1P o�j0 7O qQ Location - Street 7S. � 3$� 2 Tax Map Block Lot VFW L L 4• ow illaI sJ;Tgit/ISlo.J of Pt20PE'7: `1 FOR e/''7MG TT Poi ,0 TdcfiTr7Z_ Subdivision Name Building Type 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 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 _CTK = Day 2 (� Year Title: General Contractor (Owner) - Signature Y1� Corporation Name (if corporation) kz _ Corporation ( corporation) e , Co oration Name if co oration Address: O S S I Address: uLL^ State /J E P Yd R K Zip I State Zip Ch in 4.! L U ra. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES L�lj.). - C-omPl(�1�':�n�I Ma •.: y�- ^a�_i. -�' =1 : �. _w...wi Y• J u b -.� iry .1 �,; .�- .!t!- . --`.C� �iL._>, •l!! -n uF. ,`%s:f,^� ,.•rt^'.[ r±! l ""' ' S.^• s- ^- '1•Lt-�`•�h-?S'p�G7 "'.'f�' •.1�_'iIA7�� ?t fi Well Location Street Address: lTownNillage: Tax Grid 0 Rramers Pond Road ( #20) Putnam Valley Map73. J$ Block I Lot(!):; Y 2 Well Owner: Name- Address: 20 Aramers Pond Road Dan Mansell Putnam Valley, PIT 10579 Use of Well: X Residential Public Supply Air cond/heat pump irrigation 1- p&imary Business Farm Testtmonitoring Other(specify) 2- secondary Industrial Institutional Standby , Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Op= hole in bedrock Other Total length 32' ft. Materials: X Steel _ Plastic _ Other Casing DetaBs Length below grade 311- ft. Joints: _ Welded X Threaded _ Other Diameter 6 in. Seal: X Cement gout Bentonite Other Weight per foot 19 lb /ft. Drive shoe: X Yes • No Liner:_ Yes X No Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Screen Deta& First _ Yes No Second Hours Well Yield Test Bailed X Pumped X Compressed Air Hours f! Yield 5 gpm Depth Data Measure ftom land surfacrrstauc (specs ) During yield tesr(tt) -lDcpth of completed we]) in fat 204 540' 605, Well Log Depth From Surface Water Well Formation Tf more detailed ft. ft. Bearing I Diumctcrliu) • Description information Land Surface 10 Drilling in over urden clay and boulders descriptions or 10 at 10' sieve analyse-S in. !'ocl� ..sctt, are available, 32 6U5` I Dr ilia in rocks 1 'ranite please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths ump TypeSub Capacity 5q= during drilling, Depth 560' Model 5GS10412 list: Voltage 230 HP 1 Tank Type Vol Datc Well completed Putnam County Certification u. Dan: ofRepm W 12/7/99 002 1 /11 /00 a INV JLZ: rxaet location of well with distances to at i9W two permanent landmarks to be prgy)ad on a separate she"lan. 4 Putnam Avenue Well Drille?s Name P , Inc. Address: Brewster, NY 10509 Signature: Date: 1111 Zoo Pe L. Beal White copy: fID ,Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- WeIl driller Form WC -97 INV JLZ: rxaet location of well with distances to at i9W two permanent landmarks to be prgy)ad on a separate she"lan. 4 Putnam Avenue Well Drille?s Name P , Inc. Address: Brewster, NY 10509 Signature: Date: 1111 Zoo Pe L. Beal White copy: fID ,Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- WeIl driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNMENTAL HEALTH SERVICES FINAL SITE I\SPECTION' Date: ! 7. j 6 cl S[re�t :to -a U'a_'�Ai_'�� Town Permit r 0, TiM 3 : i $ — l —, Z Subdivision Lot r 1. Sewage System Area YES KO COMNfEi1'TS a. STS area located as per approved plans ..........:................ b. Fill section - date of placement 3:1 barrier Lgth. Width Avg D �n • i? e. 'Na, al soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area ......... e. 100' from water eourseA etlands ...... ............................... II. Sewaae System a. So§tic tank size - 1,000 ......... 1,250 ......... other .... � b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box n{� outlets at same elevation -water tested ................. 5T tS. C 2. ' Protected below frost ................ .. ............................... 3. Minimum 2 ft.Original soil between box & t_enches Junction Box. - roperly set ......:.............. I . Long required to Length installed _ 2. Distance to water arse measured Ft.......... 1�� �- 3. Installed accordi , to plan ............ ... ................ 4. f . nch ccept e 1/1 1/32 f ` ........... I /3 1 ft. o pr e E e ft. found . Depth f t n inche fro surface .................. 7. Room llo� e or expansion, 10 /o ..................... 8. Size gravel 3/4 -1' /2" diameter clean .................... I De a of gravel in trench 12" minimum ................... J?u mp or Dosed Svstems a Size Ot pump c am er .............................. ....... 9�� u ►v� 2. Overflow ta ... ............................... ............. 3. Alarm, visual/ di ......... ... .......................... 4. Pump easily ac ble to grade ................. 5. First box baffle .................... ............................... 6. Cycle witnessed y D.estimated flow /cycle......... III. HouseBuildin_,.g a. house located per approved plans ........................... b. Number of bedrooms ....................... ............................... Ii'. a--Well Well � ... o� b. Distanc c. Casing Surface V1 V. verall W a. Boxes 1, b. c. All pip; . All pip d. Backfti e. Curtait f. Curtail g. Footin h. Surfac i. Erosio. Rev. 1197 . Ari R Diu +A' ARV /MrC1.uWK�f[`rZF'�r;,D r4yb�ly ����'�r1K�YrH �9/er".'NNC alp: a'r� •..` .... '.. ' �:� -ter ^y. - �. ...- .. .... PUTNAM COUNTY DBPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ;1 Q7 FOR flIIAL �L�i'iON For. Fill . Ti+eaches �� PCHD Construction Permit #� P V16 -- q Located _ejWnEc" ?Oti0 Qwnet /Applicant Name 1�A i� �+� S L L: 7 ..1$ Block _I _Lot FornuCtly i�► T. P6iA)o!K-r6 t &*&visi=Name S�3 F oP' foie t"o lN��k � Subdivision Lot iii 2�_______�____.__r_r Is system fw completed ? M-4 1' Data Is system complete? V tr S : Date is system eonstrwed es per plans? Is well dn7lod? V.S _ Date Is wall tcated es p ph=? (fir f Are erosion control maagto" in place? I cenify that the system(s), as listed, at the above premises has been cons m and and I have insEected and verified *eir completion in accordance with the issues PCHD Const meson Permit -: ;sub i:�_�• �vrC�e^? �i.,+ti�e Se�31 £'�LLt�tIA?S ofu PiltTt CQ1wty Cnt Of Health. - ., • ; .. � ti...,., ......�,.,,..�:_ ...: w. a.::' :.•.: ' •._. Date: / Cetdited by: PE�t IZA Design Profession[d 2 �sott�J Wpt,�'N. '�`LU0 Address �EK.fY�� N� to�C� Lic.# ©�Z°!�U Comnem FOR: ADAM 13 GENE . Form FM-" t d 176LLL -GV 161 'ON Pf 111Y 1 AXI M- MA A XY W L 91 66 -Lt -150 02/24/00• THU 14:07 FAX Qooi a. F. BEAL & SONS9,9MC. A PU'jWAm AveNuo WATER SVWMMS COMMERCIAL WATeft SYSTEM japut" 2 i t. d4 A W, /*Y/ - ow, // 4. 10 am, a e NVOROMACTURING SUUM810fte Pumps TEL. 279-2460 • 2461 WATER CONDMOHM EQUMERT FAX 279I 6613 C0MP6C&Tr& INSTA"ATION. Ries-LACEP41ENT &NO REPAIR SERNICE FAX TRANSMITTAL SHEET DATE: 2/24/00 TIME:— . 1:10 M TO. Dan Mmseli. COMPANY: FAX PHONE NO.-736-3693 FROM -. pffm -= EgKKZ-L-. Beal - TELEPHONE NO: 279-2460 Pond Road, Putnam Valley, NY _ NUMBER OF PAGES INCLUDING TRANSMITTAL: 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVLSION .OF..ENVIRONMENTAL_HEALTH. SERVICES v.iHiii iia•cr'- .- •sstic,•....v '.. ^i'�e::;�.'%.•i!-� +�G +. ... rj.;. "\j :�. ,. ".'r:v ....• i"-< e^ „�sv.•,�:;�i',ti�jo..e ^.,v:a.:: tires. er' �svt::-•' .•''�.�.��..� ✓�-:.�- ;�:.p..�e.� s ...,.. >.« �r;.�.iiw :i..fn,. ?.4y'•x'�z;, : CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at K iq me p� S COO D ?,O A D own r Village Pu'T�,1(h VA LL q/ Subdivision name Po i P Dc K,TVf2 Subd. Lot # S Tax Map 7-3. 0 Block I— Lot 3q.. 2 Date Subdivision Approved MA K C H 36 1990 Renewal Revision Der/ pplicant Name DA fJ 16 L N O t� S E- L Z Date of Previous Approval Mailing Address I 19 )1V E K 1<640 0 S S 1 P I A 6 O. 10S-62- Zip i m a 62 Amount of Fee Enclosed Building Type Si j6E4'- Fr�r A- Lot Area N.'3 ac No. of Bedrooms _5” Design Flow GPD O6v Fill Section Only Depth 12 Volume 375- cc), YO, PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of I O G gallon septic tank and S 6 L • F O F y_ F C i7 w TE..D tP V G ?,?C f C / ^) 1%C L 7-1-2 t; /`I Other Requirements: To be constructed by Co S ► A r'E121ZC i RM, WC. , Address 6 b 199G yL Z 141/6 �J_`�J CW4ce '.,:- WatQ*- Sun t•�d..'- z. _ Puhlic..Suppi From Address v: =rte s _ : _ y.., .�_. ......- ..p- ..... -•f-c mu...-. .. - ....r.n...+�+n.f..: -.. .... .. �....�:�. -.. .w•� .0 �.sv ...-+�v.- '.�...►_.r_- �.- .:..�.�..r* `r.; m... �.e w- .. _.�...��. « ».. ... ...r�._..�.r. - _ :H.�. .....-wr.y. .or.- X Private Supply Drilled byf- F CFI L Somas rJC, Address �}F' d�S`T ^�y. 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 sx is em 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 ConstructiotpjiplC►c�epR isfactory to the Public Health Director will be submitted to the Department, and a written guarante `�vi�l�k� firth weer, his successors, heirs or assigns by the builder, that said builder will place in good operati coo cji ion any p f ga \ sewage treatment system during the period of two (2) years immediately follo a date o rthe u appr vai. f the Certificate of Construction Compliance of the original system or any Signed: Y W tu .�' E. R.A. Date �_' S .-15 Address ` Z-00 Z�c" VI OJJUhi EES � X'y l Q License # 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 Public Health Director. Any revision or alteration of the approved plan requires anew it. Ap ved o dis ar of domestic sanitary sewage only. ny: Title: Date: L� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design ProTessional Form CP -97 PUTNAM COUNTY DEPARTMENT T O F HEALTH I ngSffG N OF ENVIRONMENTAL HEAIL'll'IHI SERVICES .�...., ,..... - -- - ^-- ^ ._•-.. '-, °.._.......•.... - aannev as�r. a rn+v.rex�r rm.n, s- �wwx�rc� .mirn�r,.-..n.- .x- R.c.- e.+mc.� .ra.s...r w:.�......._r�.— please print or type PCHD Permit # r N - 9 & — Weflll Location: Street Address: < To illage Tax Grid # �Izmvl-S di'Np 0. VA14 maP'71-19 Block i Lot( ,9)34/ Z WeRl Owner: Name: pej N i e L- Address: ,� j �'�' ®r� R r4 a A .0 Use of Wen: Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secoandairy Industrial Institutional Standby Amount of Use Yield Sought .5— gpm # People Served Est. of Daily Usage S gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling __ �' New Supply (new dwelling) Deepen Existing Well Detailed Reasons Wpq 'Tc g S u r F c Y O /J E w Rc7siloiEwcc for IIDrWing WeR Type X Drilled Driven Gravel Other Is well site subject to flooding? ................... ............................... .............................. Yes No jam_ Is well located in a realty subdivision? ...................................... ............................... Yeses_ No Name of subdivisionSui3n a r Ma?- r-oz CMMC -T-T" Po t i- JOCKTEC Lot No. q rurN11n, v uC- Water Well Contractor: P L 9CAL � S &J s j ra c • Address: _ 67 P 11.). !e Is Public Water Supply available to site? .......... ............................... ��, �r °Rk� es. No � Name of Public Water Supply: '�P 111ag9ti� Distance to property from nearest water main: '. Proposed well location & sources of contaminati to a prov &.1 o s Meet/ fin' i3dYC: /::. G`t ='� 'App 11LQ111 J1`ilittill:.`•_, ✓, 62980 PERMIT TO CONSTRUCT A WA - This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 1 n 17 Permit Issuing fficial: Date of Expiration I 0 o Title: Permit is Non- Transfferr bi White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH D SIO.N OF ENVIRON —MENT ' �' ' � - ' . .__ .� .. _ „ _. ... m�..•rl.�.u..R.,:.ra. yG3•�.:t:i�. r r• `?ii .�...!�..L'.ra�..•�v�. ..w H.s.. «�a:'y -• , t t �' c . .._ _ �: o.• ria'd".•7 .- --ice LETTER OF AUTHORIZATION RE: Property of DAN) E L j} tJ 0 S H A 90,0 M 0 tJ S C Z L Located at }'�tA mEgx' 110 rJD gorq p (P I vTN N ti 1f►9 (.l ax Map # 7:9 , 1 8 Block Lot -3'/, Z SV�LOT �Z, Subdivision of PRo('L-'fl T j' MFAj1ZC-t0 F'o R C rift --T W. Po IN P I X T &?L Subdivision Lot # z Filed Map # ?,4-64- Date Filed t 4W C /J 30 1.i 10 --T Gentlemen: This letter is to authorize T m o-rH w L. C rz o i-j (h1 a duly licensed Professional Engineer y)e' 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 mattte�lr and to supervise the construction of said wastewater treatment and/or water supply systems .v Z:ctiii J.ti„1.tv:wit!.i i.11"�J '..,.�a. �Yyl•IiSP..-1>'��,.nr., /�, •I���i',f ws- wni t �r;'r,: f. _ . sr.• O•i i ..�%�1 xnsl Law, and the Putnam County Salt Jr N y019, ti %v t ry truly yours, Countersigned: P.E., 4aL, # (Owner of Property) Mailing Address S ui T t J ® P� ailing Address: DA h' E 1. i✓1C�r1 SE C C, 2 T6K� W1�C S'H �L. PC E-ksK I L C.. 3 � '� ®� � 0 r� JD. State tJC W oiu< Zip 1 o S6.c State O S S ► N G , /.1, V/, Zip 109'6' �. Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS .} ;:.: :�+i,.i�wJ.'�'�"C"';..�c ...,t.: �.r•- is -ti._ . - � �. � -\ tom. � ...-51' I' ,�ei'�_. +�L �a'bfi�•'x..+��:.c•s.'.:r ���.. ^:. .:.:t.r.•.�'r.�:ia°�•^ . ±•i'�- ' %� / STREET LOCATION V 2 u/iS '`�� NAME OF OWN R 11 � t REVIEWED BY R-NI, GR, AS, IB, BH TAX iyiAP # Y N DOCUMENTS Y N 73 r p PERMIT APPLICATION EROSION CONTROL:HOUSE,WELL, SSDS . C3 0 �,3� ; WELL PERMIT _ P WS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS - THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST FEE fi SUBDIVISION AL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE I FILL REQUIRED t DEPTH �A CURTAIN DRAIN REQUIRED I STANDPIPES GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PPECS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT HOUSE SEWER -1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED Q.N. g4AN - F.80 ,SSTS .,., Ei1 •rrl,•L.,i.vc'i'i�%...,-;v�`vt iriLi; PRE 1969 NEIGHBOR NOTIFICATION 20' TO FOUNDATION WALLS _15'WELL TO PL LETTER BI/ZBA 100' TO WELL, 200' IN DLOD, 150'PITS 100 YR. FLOOD ELEVATION 100' TO STREAM WATERCOURSE LAKE (inc. expan) OTHER REQ'D PERMIT(S) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER REQUIRED DETAILS ON PLAINS IV TO WATER LINE (pits -20) SEWAGE SYSTEM PLAN - (NORTH ARROW) 50' INTERMITTENT DRAINAGE COURSE SSDS HYDRAULIC PROFILE 200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS GRAVITY FLOW CONSTRUCTION NOTES 15'MIN to CDS= >5 0/N10'- 4 %,25'- 3 0/o,30'- 2 0/o,35' -I %,100' - <1% DESIGN DATA: PERC & DEEP RESULTS 20'MIN to CD discharge /100'with 182 cons day discharge 2' CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES; CUT m 10' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES ® DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET mPROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: DEPM. AN* NP. HOLE ND. 2 HOLE NO. G.L. 21 4q 31 41 51 61 71 81 go 10, 11' 129 131 is W.'? INDICATE LEM go wm= WATER LEVE L RISES AFM BEING DEEP HOLE* bum BY: DATE: Ag DESIGN Soil Rate used 7 Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity gals. Type -`1 Absoacption Area Provided By 67 L.P. x 240 width..tiench Other Nam Signature Address MISSFACE KM USE BY'R11 Soil Rate AWoved WA W OW: 10 eq.ft/gal. Checked by D te PUTNAM COUNTY DEPARTMENT OF HEALTH I... D I IVIS21ON OF ENVIRONMENTAL HEALTH SERVICES Subdvo Lot # Filed Map Gentlemen: Date This letter is to authorize* Wej-eW) ,.7 a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the'Putnam County Department of Health, and to sign all necessary papers on my behalf in —dlid tibrjvubakvfs�� c nnec ion with t is wo system or systems in conformity with the provisions of Article 145 or 147,.Educ . ation Law, the Public Health 14aw9 and the Putnam County Sani- tary Code. Very truly yours Signed Owner of Property Countersigned: OF N /V POE p 0 Address Ll' flIV(- 79)(A -7 72 Address Town Na 2 4� 0907 Telephone Telephone • m PUTNAM COUNT' DEPARTMENT OE-IEALTR....: ' ' 140N~C� ;' iVV�Il NIVIEIYTAL HEALTH�SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: D'fV /X6 MPR/SOEGG 5-7 2. Name of Project: 3. Location: T/V: P` L vll-e-•� 4. Design Professional: STWNsN r�eziE141 5. Address: 20 xG� z4eS 91w 1240N 6. Drainage Basin: Vivid SGN l�t�k/L 7. Tvve 0 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/ Type Status check one .............................. Type I _Exempt Type II'. Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yesk 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yess 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials,... . _:.... :..:..:' :...`................................................................ i io o/#Nk T Od444 13. If so, have plans been submitted to such authorities? ... .............................(!gKo 14. Has preliminary approval been granted by such authorities? 1✓S Date granted: 2,10 15. Type of sewage treatment system discharge ........................ 'surface water groundwater 16. If surface water discharge, what is the stream class designation? .......................... 17. Waters index number (surface) 18. Is project located near a public water supply system? . ............................... Yeso 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? .......... Yes/ I-0) 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector �' .0 19 24. Project design flow (gallons per day) ................:............. ............................... 25. Is State Pollutant Discharge Elimination system ( SPDES) Permit required? ... Ye3&�b 26. Has SPDES Application been submitted to local DEC office? .......................... Yes, Rev. 11/02 Fomi PC -97 Pg. I of 2 27. Is any portion of this project located within a designated Town or State wetland ?... Yes _ + t L .. "i —•T i ". 1.:4%','.Buw�:K. L. d R3 sre'T'�,Ttt rl�m,t5�^ V+1-Ey y?s�.i1 i.`] � .'.A••.+. ...- -. -s .. _.. --.� _ �� � .1 E,s- �-K .{fTar..o --:.< �a >.:�, K r S �. d�. dr. a,.,."rt .W ..ta • '.�.z\ I 1 �. t 28. Wetlands ID number.................. ................................................................................ 29. Is Wetlands Permit required? ........................... ............................... Has application been made to Town or Local DEC ..............'............. 30. Does project require a DEC Stream Disturbance Permit? ........... Yes& Yes/10_ ... Yes/lVo _ 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? ........................................ ...........................Ye4g_ 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 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ........................ee No 34. Are community water and/or sewer facilities planned to be developed within ....Yesl� Yes, Lot 15 years in or adjacent to project site? ........................ ...............:............... 35. Are any sewage treatment areas in excess of 15% slope? .................... 36. Tax Map ID Number p 1 Ma Block 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 shall �F 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, underpenalty 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 tlae Penal Law. SIGNATURES & OFFICIAL TITLES: S' �U 6ft4 -, Mailing Address. `.....: =. !' .. q- C6 7^7 Form PC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL .HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A:.G . NERAL INFORiN�IATION Name of Project 0(MTAU ( T County 4 Site Location Building construction begun VICp Extent Is property within NYC Watershed ? ................. Yes No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. F� Hilly F7 Rolling F-� Steep slope F--J . Gentle slope Flat 2. F--J Evidence of wetlands Low area subject to flooding Bodies of water Drainage ditches F-� Rock outcrops 3. Property lines or comers evident ....................... ............................... ❑ Yes N 4. Do water courses exist on or adjoin the property? .............. F--] Yes No S. Will these affect the design of the sewage system facilities? ..........: - F Yes .-No - 6. Do watershed-regulations apply in this development ? .................:.:.. Yes No 7' Will extensive grading be necessary•? ................. ............................... Yes r No 8. Will extensive fill be necessary for SSTS? ......... ......:.::..................... F Yes E240 • � 9. -Do• f,�l ?dare��'P�.:�t�Vi•'�th1.Il iI12. �c.l'..2 Yrpc%. °.', ........ ........ ................ ...... Y.. 1T�iJ " V 11(7.._.,c..�..x-: r ., -.. .�t. ..w� . .. �. L• If yes, what is the condition of the fill? SECTION C. SOIL. OBSERVATIONS 10. Appearance of soil: 0 Sand F� Gravel F� Loam F-� Clay E:] Hardpan F—� Mixture 11. Observed from: . 0 Borings Bank cut F-� Backhoe excavations 12: Soil borings %excavations .observed by on 13. Depth to groundwater 14. Depth to mottling 15. Are test holes representative of primary & reserve areas ..... ............................... 16. Soil percolation tests made by 17. Soil percolation tests witnessed by SECTION D (on back) on on on on Yes . 0 No Form ST -1 '4 SECTION 'D. DRAINAGE proposed - ading materially alter the natural drainage in Us or adjacent areas"".?F-] Yes N gr cre require special consideration? ................... ... ❑ Yes N30 19. Will groundwater or surface drainage F "o Z 20. Will gullies, ditches, etc., be filled and watercourses be relocated? .......................... Yes No SECTION E. RENURKS 21. If a common water supply is proposed, has an inspection ection been made of the existing or P roposed source and facilities ?........ `: ............ .......................................... Yes Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................................................... s ❑ No 23. Additional comments 24. Site observer/inspector and title-- 25. Date(s) of observation(s)inspection(s) -7/0 c7 9 TEST PIT PROFILES Hole P Lot 9 Hole r Lot = Hole A' � Lot JF' Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling , ' -!).epjh k di-M -D liEp G.L. G.L. G.L. 0.5 Tbp Som. 0.5 1.0 1.0 44 2.0 2e, SL-- 2.0 3.0 4.0 5.0 6.0 7.0 8.0 M 10.0 3.0- 4.0 5.0 I L-lull 7.0 8.0 9.0 10.0 0.15 O!f D 1.0- 2.0 3.0 . 3.p 4 4.0 5.0 6.0 7.0 8.0 ffil 10.0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4 S DSURFACY&EWACE TREATMENT NT S`YS' EIVI .3 1, iA y'DE� 13�►�ib. Owner D Ark 16 L M uN S EL L Address OS S 1 N G f N. y_ 10,7-6 S Located at (Street) e-gA 1r✓ 115 Porgy b g c A-p Tax Map 73- IS Block I Lot .3l*. Z (indicate nearest cross street) S u II L oT : 2 Municipality (jr. \/A L ix-YDrainage Basin fC C K S K 1 L L N o LLo U 13800 K SOIL PERCOLATION TEST DATA Date of Pre - soaking SO L Y 1, J i S Date of Percolation Test -TV 'L Y 2, I SS Hole No. Run No. Time Start - Stop Ela se Time (PMin.) De th to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 1001. 2, _ o .s 0 '1 6 2 3 4 s, �s IDS IZ 2 l_ ,bu i�23 IZ iS 21 ,. I "d 1 I u. 3 's 110-7 'L q S 4 11 0 � I'131 2'f y 5 2 3 5— ' NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each ;,percolation test hole. (i.e. s 1 min for 1 -30 min/ `s 2 min for'31 =60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 2 TEST PIT DATA IDESCIZIPTION OF SOILS ENCOUNTERED IN TESL' HOLES - -- .. .✓ -._ <' .,.,. .. ... _ ..'..z.. _ .tti,4iwf�+�= {c.a' :}aw =� .5.- :a:�.= .:,.:. ..- .- -.e-.. :w- :�_ = +....- .w. _.,..v .. •r,.,r-•.tw -yf: -'t DEPTH HOLE NO. D HOLE NO. D Z HOLE NO. 3 G.L. --r o Q S 0 1 L-- -1,6 iS a 1 C. ---T"6 r o t 0.5' S A rj.D Y. ; L 'st-4, 6 Y L o O rk., s'�9a1b � Z. o oi r 1.0' 1.5' 2.0' 9grJb Ah1b 6r4h)0 /q/h3D SAP" ArJO sTLAVC L 612r -)V C 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0 Zo c 9< 1R0 c K 6:5' 7.0' 7.5' 8.0' 8.5' _ 94U-h -, ,. �� ...,��- _ -,: _�.r+g o. �WY...o.t.r.w+r.. � - �........ •. :- ��+�a.•_a.�.. 9.51 9.5' 10.0' Indicate. level at which groundwater is encountered tJOA) g,J c o Uti+TC2ED Indicate level at which mottling is observed f'1 a N E Indicate level to which water level rises after being encountered ti t Deep hole observations made by: Ti M a i Owl Y L- Date 6 2 $ .51 Design Professional Name:. ( ji m oTN y 4.. e`rZON of U- Address: -T )46- C j b Y TU I C,D) r4 6 S'U i -c 26 0 Signature; bF NE4V r� \ L. CnC� /� -Is 62980 v� \N�OFES5%0 / =?�--Twt 12 PROJECT I.D. NUMBER 617.21 Appendix C State Envftnmento! Ousill -Re-418 M y SHOO ENVl[A0NMENf-_A['A89t9W ENT FORM For UNLISTED ACTIONS, Only PART 1— PROJECT INFORMATION (TO be completed by Applicant of Piolect sponso► SEAR I - APPLICANT ISPON30R 2. PROJECT NAME 1>141J11EL 1—jU^1.SEL1_ ISEWAGE E>I.Sfo! AL SVX-rern 3. PROJECT LOCATIOK- 'VA L'C!2z county Pu Trjr4 r1l .4. PRECISE LOCATION (Strom aft*" and mad Intaraeetlona, prominent la wmarka. ate., or pmwe map) AOTZ-r" SIDE 6 v)�iqmf-as Foriv, go iq-b S. 18 PROPOSED ACTION: ON@w ❑ Expansion ❑ Madificatlordalteriallon 6. DESCRIBE PROJECT BRIEFLY: G 0,0N) S U C-. T 10 fo OF 14 sl^i '1'7 1 1QESID"ct'i S6-w)4 D) S P0 _S,/q I- S's - Y _r6_/'7 AND PR I L L 15't> W 45L L 7. AMOUNT OF LAND AFFECTED. Initially — I I - U' 1'1. act" ultimately act" S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? o ❑•No if tft describe bialy 9. WHAT 18 PRESENT LAND USE IN VIONfTY OF PROJECT? ArAlsoldmIlIal ❑ InduaulI&I ❑ Cammemial (3 AWIcultuts ❑ Pa&FomVOpw spaco ❑ Ottw id's 6,1_7;j7_,7 -6- to. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAQ? Ary. ❑ No if yea, list low"s) and wpivapprmals S65-WA C67 P:)SP0.Sr9L &,9,D P,-'C - b -13U I LD 10 6. Vcf)Ml -r Pu-!-/,j iq ' Vt9L4G)wL 11-, DOES ANY'ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ yes If yes. IN agency name and parnwapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISI NO PERMFTIAPPROVAL REQUIRE MODIFICATIOINI? Ely" I CERTIFY THAT THE INFORMATION PROVIDED ABOVE 93 TRUE TO THE BEST OF MY KNOWLEDGE C wJ 0-3 CI-J 0 AJ CET I tJ 6' F. ✓C, oats: 116 -95 P silptatum in I the action I Coastal Area, and you are a state agency, complete the Coastal Form before proceeding with this assessment OVER 1 M PART I0— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN ti NYCAA. PART 617.177 It yea, coordinate 1119 revioer proem and use blur FULL EAF. CJ Yea ❑ No ®. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS;IN 6 NYCRR, PART 017.137 If No, a negative declaration may be superseded by another Involved agency. ..a 1'cu rJ ie0 ' Q COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (lanowere may be handwritten, If legible) C1. Existing air quality, sudece or groundwater quality or quantity, nolso levele, existing traffic patterns, solid waste production or dlspml. potential for aroslon. drainage or flooding problema? Explain bristly: C,2. Aesthetic. agricultural, archaeological. histodc. or other natural or cultural (oaoareao; of community or neighborhood eharacia? Explain briefly: C9. V00018110e1 of fauna, fish. aholllleh or Wildlife ap®cl®s, significant habitoto, or threotonod of andangatred gpecles? Explaln bristly. C4. A community's oaistlng plans or Vote as off dally mdoptad, or a change In uo@ or Intonolty of uoo of land or othor natural resources? Explain CS. Growth. subsequent devolopmol, or related oetivitlos likely to be Induced by the proposed action? Explain briefly. Ca. Long term, short term, cumulative, or other effects not Identlflod In C1-CS? Explain Malty. C7. Other impacts pnciudlng changes In use of olthor quantity or type of @porgy)? Explain Malty. D. 18 THERE. OR IS THERE LIKELY TO SE. CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yea ❑ No It Yea, axplain oroafly FART W—DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSYMWIXINS: For each adverse effect Identified Above, determine Whether It Is €luubettantlal, large, Important or otherwise No.nlf cant. Each effect should be aseossed In connection with Its (a) setting p.o. urban or rural►,; (b) probability of occurring;.(e) duration; (d) Inewslblift. (e) geographic scope; aid M magnitude. If necessary, add attachments or reference supporting materials. Ensure that 01to iinatlons contain sufficient detail to ohm that ail relsmil OWN Ifapsele halve bssrt identified and ar!degtlately addressed. ❑ Check this box If you hate identified one or more potentially large or significant advem Impabcb which MAT occur. Then proceed dlrectiy to the FULL EAF andfor prepare a poeltin declaration, ❑ Check this box If you have - determined, based on the Informatlon and analysis attars and any supporting documentation, that the proposed action WILL NOT result in any significant adverse emrironmiental Impacts AND provide on attachments as racessairy, the reasons oupporting thlo detsrrninatiolrL Name or Luail Agency Ypt NBMQ Of 1050001S*10 Kar In Le . AVMV Resoonuble Officer soratum of Responsible liar 0 Load Agency Signature (19 diffel BRt fom o icarl ,e Date L PUTNAM COUNTY DEPARTMENT OF HEALTH ' DIVISION OF ENVIRONMENTAL HEALTH SERVICES .� m' � T T: '4� '¢ i �. ^._ n�� ti: - r.- ; �..,;,-.,r iq.,=: mn. nP49. n ..w..:,.�,.�..+a'•:A�rry�,..a.. :a�a::'�'''��t�` °•'sw ;. i'. �r: �' a'.: �..:.:' a�; �' �:. iwc�xe" R9st._' 2� ''fi,_•.•.3i,5�i°�.���'�'4-'i�t. �i'aii���S7�1'V���1� A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: D A nt 15 L jv o s Hn (lON M yn2 s E L L S1 RyDig 904D O SS 1rJ 14 G nl. Y, 2. Name of project: S S D S 3. LocatiorAv: Qu-TIJA rl 1%A z LC' y 71 f 6 L NOy IZL b 6 4. Design Professional: --rtrl CROfJO 5. Address: Su i fie Zdo 2 -ISO H.*i WA t.s't9 t�C un 6. Drainage Basin:' EEKSKI1.L P0CL6 LJ M20b1< ?66eX KILL, 7. Type of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... :. .I ........... ................. Type I Exempt Type II Unlisted 9 Is a Draft Environmental Impact Statement (DEIS) required? ......................... 110 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of,local.plan�iin zoning �or_nther v ;C .ais ~c,causat i,cS ............: '°°..... ..... ...................................................... p ..... 5= .• -_.-- - - .�. , . 13. If so, have plans been `submitted to such authorities? ........ ............................... /JO. 14. Has preliminary approval been granted by such authorities ?d L4 Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water ✓groundwater 16. If surface water discharge, what is the stream class designation? .................... ti 1,4 17. Waters index number (surface) ............................. ............................... 18. Is project located near a public water s�Pll ly system. do 19. If yes,.riame,of water'supply Distance to water supply 20. Is project site near a public. sewage collection or treatment system? ................ N o 21. Name ;off sewage system N A Distance to sewage system 22. Date test, holes. observed 7•-gM 23. Name of Health Inspector S T 1 C 3 E L INC 24. Project design flow('' ow (gallons per day) ................................. ............................... g Od 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NO 26. Has SPDES Application'been submitted to local DEC office? ......................... Form PC -97 1 2 27. Is any portion of this project located within a designated Town sp Sam wetland? YffS 28.- Wetlands, ID N..umbe ..: .;,i.S:...n.r_+ -. . _..,.� v,+ - }r�`ic: a'>:.; .,.'.v', .`,t...rt,• °. %e1;r.'.:�ss+ "� 29. Is Wetlands Permit required? .............. ........... ............. ............................... tJ d Has application been made to Town or Local DEC office? ............................:.. nJ } 30. Does project require a DEC Stream Disturbance Permit? .. ............................... /J 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 130 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 /Jo DESCRIBE: 33. Is there a local master plan on file with the Town :or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 0 35. Are any sewage treatment areas in excess of 15 % slope? . ............................... o 36. Tax Map ID Number .......................... ........................... .I... Map °73,18 Block_ Lot _11K Z 37. Approved plans are to be returned to ..... Applicant ve— Design Professional -- __NOTE:.�ll:aprlic,- tigps fCr rev. a<i 1va:� si � 8 S1eJV 11,E `i `lt ii rat r� �xrith h�: iL�v a1 �o 'j _ 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 l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, underpenalty of,perjury, that information provided ' is true to the best of my knowledge and belief. Pals . tements made h a are P ' h e as a Class A misdemeanor pursuant to Se on 2 0.41Spf them q � SIGNATURES & OF'F'ICIAL TITLESe Pai A_ ",rwwl lh o Tf9 CIQO�IidJ � Gt[J ....................... %HE LI[JDV 1311>[_D1 &C Z So kN WA L-YH EL N611�s W I L c.. n�.y /ci -K 6- PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit I on CERTIFICATE OF COMP CE CONSTB ON PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit Ii - � Lext.d /GI/ G9j a/% -- '_>,- •`�+.,a:.0 .: --:v ... ... _:. •.,�...- e.r^,:n�is:- .,.,..,:,em -. a '':'.:..�? =.n...::.,_..- ._.sa, �yyrld SubdlvWon Name sh s f ! n d a: J' -ubd. Lot !! Tax Map ' Block t t t)wneriAPPllcluo mt Nuae ��i�Le- 0, �.,0,1164 o:,, d` Renewal_ ❑ Revision ❑ ,t ,/ _ / Data of Previous Approval MaWng Address _ `�' ¢ �� �r✓o a � / /QO C Town Zip ale lx • J�3 id,cncC 7. 7-d 7f -- Building Type Lot Area Fill Section Only Depth Volume Number of Bedrooms -3- Design Flow G P D 'AOA PCHD Notification Is Repaired When Fill is completed Separate Sewerage System to consist of ZOO C' .Gallen Septic Tank and 2 � a 4. 04" v i Je To be constructed by Address Water SaPPiyt Public Supply From Address or: P^ Private Supply Drilled by i3 _Address Other Requirements 1 represent that 1 am wholly and completely responsible for the design and location of the pro system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in a he standards, rules and regulations of e Putnam, County Department of Health, and that on completion thereof a "Certificate of Con - satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the o �pi or assigns by the builder, that said builder Will � Place in good operating condition any part of sold sewage disposal system duri th piod of t ) y rs immediately following thetlate of the issu- ance of the approval of the Certificate of Construction Compliance of the origi no em to th sto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be Installed In cc w t dar s, ru s and regu aia173 oof the Putnam County Department of Health. ti� " r,► Date Z1,, L / / O Signed .:. P.E. R.A. y�J, License No Ito, 9_93 APPROVED FOR CONSTRUCTION: Th approval expires two years from the date is 2%411).:0011 on of the building has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Co salth. Any change or alteration of construction requires a new Permit. Approved for disposal of domestic sanijarW sewage, a r Private supply only. Date _Z2 &0e /ZS�7 BM AV— Title R �v. 3186 PUTNAM COUNTY PEP.. - Tr uK tWALTIi Division "of Environmental Health Servl, Carmel, N.Y. 10512 .- r� Engineer Mast Provide : m P.C.H.A. Permit I 3 RTIFIC kff CONSTRUCTION COMPLIANCE FOR SEWAGEDISPOSAL SYSTEM � /4' d� yaz )_ } Town or V Located at Tax Map Block Lot NWHng Address Separate Sewerage System built by C4W / Cy c— VZ W7 Consisting of ! eJ a y Gallon Septic. Water Supply: Public Supply From 6 or: �X Private Supply Drilled by i Building Type 'CS i °e Has Erosion Control Been I Number of Bedrooms Has Garbage Grinder Been Other --f I certify that the system(s) as listed serving the above premises were of which are attached), and in accordance with the standards, rules and Putnam County Department Of Health. 1 Date / 7�� 2- ZZ Certifled by Addressd y fJ"7��fl Subdivision Name Subdv. Lot N o7 o Date Permit issued 12. /,I My i, and ff LL Any person occupying premises served by the/above system(s) shall promptlyv� conditions resulting from such usage. Approval of the separate sewerage sy R available and the approval of the private water supply shall become null and vo subject to mo ication or change when, in the judgment of the Commistkoner of Date Address Address NC, as shown on the plans of the completed work I copies ce with the filed plan, and the permit issued by the ar y� P.E. R.A. '' �• License No.. 4'610 be necessary to secure the correction of any unsanitary I� ce ll and void as soon as a Dubt% sanitary aawer becomes mbflc water supply bosoms available. Such approvals are such revocation, modification or change Is necessary. k L, h yo 2. IS jc1LZ1.0 MAP NF I912 QL, 07 L07 / / CFI*33 '/If `%w 28.60' s 014 773/, lf9 ld 4 'd If 'Ile 94.0/ X/ o06,1,5 2.26. t 7.34' tl hl, \... 460 I � , l'--1 767 PRO DWE FIF 54.3.99' R=, M, 0 Ire ,J ,o °E�K 11.87' /0 FOR i� 50 411( 7',( Jr ?6 /Y '90. jj I *32 *44'50,,,V . 772, 411, r so 020 c P, C, D I hqbl 45.09'— Al'�' IVEXTER SUBDIVISION" Filed Afap NO 241 Lot I , :,T— t f A104-14 '00,,E (T° a. U..d) sky! I c C it NVP05'15-E - 51.85' jv2117,14-E NOMS'15-E Nfr55 f.4 J'05��3 f5.62 fO5.9,� Lot 2 Pr.p—d a'" 57. E B. 4234 Act, AV, 93 3 34. f2. NVO'59'46-ir 84. P a~ D'" AVf-45'15_Sj1.74' GEMMED N SEE PLAN m df' Pn~ Vh. SO17ll,i!F'f5-)Ol 21734' j S00,02,ts"Ir 7 so '15-)V 207.12 YGQ so ff8.46' S09'34'46-E 34.01-' i 5-46%511; f2.64' NOW sky! I it Lot 2 Area= 366,924 .5 B. 4234 Act, GEMMED N SEE PLAN df' YGQ so ff8.46' SOO -03 'ss°n t. NOW 7 Li OW 49#77 LOCATIONS A B c D E 1 31.5' 48' AM f D Yorktown Heights, IVY 1 'i 0598 22 JA' 2 38' 53' 3 43.5' 58.5' 4 50' rA 5 13 6 14 '1 19, 7 53' 41' 8 56' 46 9 590 50.5' 10 of 56' 11 99.5' 80, 12 1001. 82' 13 102', 101 14 104' 87" 15 (WELL) 38.5' 41' SCALE- f, - 80' THE OWTS HAS BEEN CONS' THE RULES AND REGULATR RESIDENTIAL SUBSURFACE PUTNAM COUNTY, NEW YOA TBEDESIGNPROFESS1011 CONSTRUCTION OF TRE, INSTALLATION TO BE IN i?UCTEDJNACCOJ ; FOR THE DESK SEWAGE TREATM iSSUPERWSED AND CERTIFIES RDANCE WITH "NO GARBAGE GRINDER WAS IN; a AS-BUILT SURVEY I )TION. INSTI Donnelly Land Surveyidg�,. P.C. LICEN I It,.- 1929 Commerce Street';' AM f D Yorktown Heights, IVY 1 'i 0598 22 JA' ,;i CORI Phone/ Fax: (914) 96", 2215 "NO GARBAGE GRINDER WAS IN; a Q P s,sr. 232.ad' a S- Qa 5c 70 } Y � 2 —. •" dam' 0 . S p - 37 3 .3 Y 'd 4.6 , a/ 7 0 �1/1�s�1 Ga•r.) 3�9 e� /SiG� y %oir sr.rs�'a �`��% .' '. X /K . . , Putnam County Department of-Health Avi � n ol Environmental Health Se;viog. :gproved as noted for con ormanoe with .pplicable Rules and Regulations Of thx r �atnam'.County Health Department. :tpnntura a. T .� +p AS -BUILT SEWAGE DISPOSAL SYSTR SUB -.DIV. T. M. N0. DATE. J �oFS JOSEPH F. SULLIVAN P.E. YnNTAWN HFICHTS.AEW YORK