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74. -1 -9.14
BOX 28
03530
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03530
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\� PUTNAM COUNTY DEPARTMENT OF HEALTH
XME' L MAITY :.s 'ORYWE$
CERTIFICATE OF CONSTRUCTION COMPLIAANCE e ;IR TREATMENT SYSTEM
PCHD CONS RUCTION PERMIT #
N Nf- J
Located at e-w C/ o a✓ a h C Town or Village
Owner /Applicant Name�,� e A"W;a a t� Tax Map.' ;- Block / Lot
Formerly — Subdivision Name
Mailing Address
I'Ah fir
Subd. Lot #'
noll 21v- IIS40 av xw
Date Construction Permit Issued by PCHD V % F
Separate Sewerage System built by Address g ce.n -e
Zip /as 7
Consisting of 1 ,2�U Gallon Septic Tank and 'o o /• , I d /– 'z/ " W,,
Cif?" * SYSTe" ' LT I ►vgd f cam;
Other Requirements:
Water Sunnly:
I ee4 /' -4 1v 42-a ""�/ y G
Public Supply From
Address ?1Z'A0---- Tu
or: � Private Supply Drilled by /4/. �O e 0,1-e�S o V Address /ate 'w- .S ✓ N y
`..�.__• _ - t .�•. _' /�i ��Q� ��.y?��. I'r/' Maser ninr� ,q/�ri� n ";t i. mra- t �� c�.
8� ��Z19 -TYT
e. / '�. � �. aiiJ ioJiJ.i ' o.ix l'.b - r.e e.l :
Number of Bedrooms
Has garbage grinder been installed?
Ald
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 regulation &of the Putnam County Department of Health.
Date: / � a*° Certified A4�
�� P.E. � R.A.
y fessional) '
Address 7 9 7,7
License #
/01cculip;ing " %Y �i/ ��
=Wtem(s) Any perso premises se shall promptly take such action as may be necessary
to secure the correction of any unsani esulting from such usage. Approval of the separate sewage
treatment system shall become null and Vol aas 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 modificatio or change when, in the judgment of the Public Health Director, such
rev cat* odi do c an s e essary.
By: Title: Date: I �/
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
'Welf'n: icdt;m ''° _°
' tr ef' diir ss: �. ..:
ge: ",:� -
Tax CJ'rid'#
Map - Block % Lot(s)D+
Well Owner:
Nam Address:
!Use of Well:
11- primary
2-secondary
esidential upute Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling )Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length
Length below grade �
Diameter '� in.
Weight per foot lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded � Threaded _ Other
Seal: Cement grout _ Bent6nite ' Other
Drive shoe: _Yes No
Liner Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes—No
Hours
Second
Well Yield Test
Bailed Pumped V- Compressed Air
Hours
Yield /0 gpm
Depth Data
Measure from land surface -static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
stove -analyses`
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
]Formation
Description
ft.
ft.
Land Su e_
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per-Minute
Pump /Storage Tank Information
Pump Type 5,201q,/Capacity
Depth '. -D Model 0&S LA 9
Voltage ->-3 O HP
TanIcrUJ� �� Vol e T 7� 7
G
Date Well Complete
o"Z d 0
Putnam County Certification No.
Date of Report
�� OD
Well Driller (signature)
rs'771
NO'B'LE: a location of well with distances to at least two permanent landm ks t be provided on a separate sheet/plan.
Well Driller'$ Name Address: 0 Y
Signature: Date: / v v 7%,
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
•�n•. ..._ r .: A_ .t?l•�..:c'... -.. r°"',�'.. v�- .�� _rte .'"'.t..'_. ,.� ,�l:,:s�•.: .`�. �m• . "r °l..r. i'_. '7'4`: ;_ .,,-•: r�`�. r.�. _^., •'v: "n.••�;, "II=I• r .5�• ..
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
_ cv5e- /,?e; W. '0 Grre- -,-, -
Owner or Purchaser of Building'-'
Building Constructed by
Location - Street
Building Type
Tax Map Block of
Town/Village
Subdivi on Name
4
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 %, Day ) Year ,, c/ Signature:
1
a�
r� Title: e
General Contractor Owner) - Signature
Corporation Name (if corporation)
Address:
State
Corporation Name (if corporation)
Address: ;W-Ale A /%tea ",ee
Zip State r �� 6'al p
Form GS -97
Public Health Director
LORMA'MOLINARI ^R.N., "M.S.N.
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
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
OWfgERS NAME:
TAX MAP NUMBER:
E911 ADDRESS:
TOWN:
AUTHORIZED TOWN OF
(Signature)
DA'V'E:
MING e
The Putnam County Department of Health will not issue. a Certificate of
Construction Compliance unless the above form is completed, i.e., a legal 1E911
address is assigned.by an authorized town official. This form is to be submitted
with the application for a Certificate of Construction Compliance.
(E911 VERFRM)
0
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YML ENVIRONMENTAL SERVICES
321 Kear Street
.
Y�o`r ' t N.T. 10�198
Albert H. Padovani, Director
�l��f''.
LAB #: 87.000955 CLIENT #: 12690 �
~~~~~~~~~~~~~~~~~~~~~~~~^~~~~~~~~~~~~~~
DONINGUEZ, JOSE
188 UNION AVE.
PEEKSKILL, NY 10566
�
74- / ~- �.l 3�
NON STAT PROC PAGE 1
~~~~~~~~~~~~~~~~r~~~~~~~~~~~~~~~~~~~~~~
DATE/TIME TAKEN: 09/25/00 12:00P
DATE/TIME REC'D: 09/26/00 10:50A
REPORT DATE: 10/05/00
PHONE: (914)-739-6576
SAMPLING SITE: 24 NORTH MEADOW LANE SAMPLE TYPE..: POTABLE
: PUTNAM VALLEY, NY, 10579 PRESERVATIVES: NONE
COL'D BY: JOSE DOMINGUEZ TEMPERATURE..: < 4C
NOTES...: KIT TAP COLIFORM METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG
PROCEDURE
RESULT
NORMAL - RANGE
PUTNAM,CNTY PROFILE
09/26/00
MF T. COLIFORM
ABSENT
/100 ML
ABSENT
09/26/00
LEAD (IMS)
<1
ppb
0-15 ppb
09/26/00
NITRATE NITROG
0.53
MG/L
0 - 10
09/26/00
NITRITE NITROG
0.01
MG/L
N/A
09/26/00
IRON (Fe)
0.075
MG/L
0-0.3 mg/l
09/26/00
MANGANESE (Mn)
0.025
MG/L
0-0.3 mg/1
09/26/00
SODIUM (Na)
1.86
MG/L
N/A
09/26/00
pH
6.4
UNITS
6.5-8.5
09/26/00
HARDNESS,TOTAL
30.0
MG/L
N/A
09/26/00
ALKALINITY (AS
22.0
MG/L '
N/A
(.!J7/26 /0C
TURBID1T _
- 1'7.NTU�'
-_-
� -
� {+`5`NT��' `
.
COMMENTS:
BACT THESE RESULTS
INDICATE THAT THE
WATER
WAS
NOT) OF A
SATISFACTORY
SANITARY QUALITY
ACCORDIN����THE
NEW YORK STATE
AND EPA FEDERAL
DRINKING WATER
STANDARDS, FOR
THE PARAMETERS
TESTED, AT THE
TIME OF COLLECTION.
Pb/Cu LEAD limits for-p
EPA Lead & Copper
than 10% of their
than 15 ppb and a
treatment must be
potential. /
tblic schools are set at 15 ppb.
Rule for Public Systems requires that no more
distribution points have a LEAD value of more
COPPER value of 1.3 mg/L, else water
undertaken to reduce the waters corrosive
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
Na No limits for Sodium are proscribed" Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg/L of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg/L of Sodium
is suggested.
METHOD
1008
9101
9139
9146
2037
2037
9043
I
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YML ENVIRONMENTAL SERVICES
321 Kear Street
K! ho�������`�������
014' -'- --''
| Albert H. Padovani� Director. |
| - --- |
LAS 4:47.000955 CLIENT #k 12690
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
'
DONINGUEZ, JOSE
188 UNION AVE.
PEEKSKILL, NY 10566 `
SAMPLING SITE:�24 NORTH MEADOW LANE
: PUTNAM VALLEY, NY, 10579
COL'D BY: JOSE DOMINGUEZ
NOTES...: KIT TAP
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
NON STATPROC PAGE 2
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE/TIME TAKEN: 09/25/00 12:00P
DATE/TINE REC'D: 09/26/00 10:50A
REPORT DATE: 10/05/00 '
PHONE: (914)-739-6576
SAMPLE TYPE..: POTABLE
,PRESERVATIVES: NONE
TEMPERATURE..: < 4C
COLIFORM,METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~=~~~~~~~~~~~~~
RESULT NORMAL - RANGE METHOD
pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5,T0 8.5.
Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE
HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L
-1���EE��1��Z£]�''_-�.�_-�-��
HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) |
SUBMITTED BY:
D i r Sit. o r
ELAP# 10323
:1 PUTNAM COUNTY DEPARTMENT OF HEALTH
.DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-r. CONSTRUCTION F
PERNIIT #
Located at % e-o W,- � �0
Subdivisionname - ��' •'v =/ csSubd. Lot #
Date Subdivision Approved 1,99-3--
E TREATMENT SYSTEM
Town or Village P, "4arn xyf `%-�-y
Tax Map 141. -J Block �' Lot
7 A - c�-- 1
Renewal
Revision
Owner /Applicant Name s /Qd en /v Date of Previous Approval
Mailing Address
Zip o
Amount of Fee Enclosed 3 d a
Building Type Lot Area ,Z No. of Bedrooms .44 Design Flow GPD ?ey
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage Sxstem to consist of l 2 SV gallon septic tank and -
d�
Other Requirements: 7 �z9 / ,'r�^�, �' �;►
To be constructed by v Address
Water Suanlr Public Supply From Address
ot:• - private Soppily railed by ..' .t/' c U ,;'G :,. Address y
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
parate sewagt treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his. successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed: e` u � ! � �C �.--� _ w /I)—,,/ r
P.E. pNCI Date SG �
Address �? %`7� ifaCr�si� J�%i1 re- ) //' )vwo i # a y Js
APPROVED FOR CONSTRUCTION: This approval expires two o, sued unless construction of the
sewage treatment system has been completed and inspected by the PC cause or may be amended or
modified when considegd -nec ary.by the Public Health Director. Any rev' eration of the approved plan requires
anew permit. Ap oved to mastic- sanitary sewage only.
B Title: `�i�i. Date: -2
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Desig rotes
Form CP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLI<CATIOR1 TO CONSTRUCT A dYA'1('IER WELL _ g�
lease d of a.,..e's.
Weill Location:
Street Address: Tow Tax Grid #
fn/V,illllage
He. �r t l e�ae t.. la/ Map 14,-1 Block Lot(s) ' f
WeR Owner:
Name:
�e�/!a Jh� G �
Address:
% � � !r! Y! ° 6` ✓a �1`^L', %r(,7T: � /�-' �i�S�/
e�d J° GJ e�
A a
Use of Wefl:
t/`Residential Public Supply Air /Cond/Heat Pump Irrigation
I- pn°imziry
Business Farm Test/Monitoring Other (specify)
2- secondanry
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served Est. of Daily Usage Fc o gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
IIDntilli mg
k 'New Supply (new dwelling) Deepen Existing Well
IlDetafled Reasoun
for DrMinng
WeH Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes ✓' No
Name of subdivision s n�,�a ��' '� m� r " ¢� s Lot No. -4-
Water Well Contractor: N Address: �� �� Ol ec�c A/
Is Public Water Supply available to site? ....................... ..............................: ........... Yes No v'
Name of Public Water Supply: --. Town/Village •-
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date: A.nplicant, Signature:
PERMffT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED .70R. CONSTRUCTIION: 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 Issues �' Permi
Date of Expiration f Title:
Permit is Non-Trans fferirs Re
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278 - 6130 Fax (914) 278'_ 7921
July 22, 1998
Frank Sullivan
2972 Ferncrest Drive
Yorktown Hgts, NY 10598
B/ /RUCE R. FOLEY
Re: Jose Dominquez
TM# 74- 1,9.14
(T) Putnam Valley
Dear Mr. Sullivan:
This office has received and reviewed the most recent set of plans for the above mentioned project.
We would like to offer the following comments for your consideration.
1. Please split system as shown on attached copy of plan. This will provide for field testing in
both proposed primary and expansion areas of the system.
.:__r;r, ti .��..__1fis office will coiifinue'its review -and grant approval upon consideration of tTie above ^mention-eTY
comment. Please feel free to contact us if any questions arise.
Very truly yours,
I
s•
Adam B. Stiebeling
ASB:dk Assistant Public Health Engineer
Eric: Plan
-.,A
t 7
I -cj
It
qw, 4
ie
N X.
F"
BRUCE R. FOLEY
Public Health Director
...::�+�a:� m. >: � r .. `�.d:�� .r��%.iy�i:.. --�� �- �::..'"'•.is.�. -. _• •{r3 ;.,�`.= v.:.f•T d
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914).278-7921
Joseph F. Sullivan, P.E.
2972 Ferncrest Drive
Yorktown Heights NY 10598
Dear Mr. Sullivan:
June 24, 1998
Re: Domingurs, Meadow Lane
TM# 74 -1 -9.14
(T) Putnam Valley
This office has received and reviewed the most recent set of plans for the above mentioned project.
We would li to offer the following comments for your consideration.
lease show construction conditions of drainage easement, SSTS must be
minimum distance of 35' from a storm drain or pipes water.
Drainage easement should also be shown on 30 scale drawing.
Pl°ase:shRw-la ation of C>?'$ -at- .Meadow. Lane minimum :_distance...of.50'__�:..,,.__. _
must be maintained.
appears proposed SSTS is shown more to south, than as located on filed
subdivision plan, please clarify.
Please correct all application forms, with correct tax map number.
This office will continue its review upon consideration of the above mentioned comments. Please
feel free to contact us if any questions arise.
ASB;tn
enc. All Application Forms
Very truly yours,
�j
Adam B. Stiebeling t
Assistant Public Health Engineer
S •L I,ti'V 6 [InP E6
a't
E! i 1 0 - '
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERK RT
REVIEWED BY DATE S TAX MAP # ?1
DOCUMENTS
APPLICATION
:RMIT PWS LETTER
OF AUTHORIZATION
DATA SHEET (DDS)
ATE RESOLUTION N' 7,
,AF
THREE SETS
'LANS - TWO SETS
CE REQUEST t4 It
MPEGASUBDIVISION
SUBDIVISION
SUBDIVISION APPROVAL CHECKED
L
RATE
woo L REQUIRED DEPTH
CURTAIN DRAIN REQUIRED
GENERAL
CATED N NYC WATERSHED
ANS SUBMITTED TO DEP
LEGATED TO PCHD
DEP APPROVAL, IF REQ'D
D EEP TEST HOLES OBSERVED St'
ERC_S WITNESSED, IF REQ'D. N_4
Y
EROSION CONTROL:HOUSE,WELL, SSDS
PERC & DEEP HOLES LOCATED
REPRESENTATIVE OF PRIMARY & EXPANSION
LOCATION MAP
E XK AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
F PUMPED, PIT & D BOX SHO & DETAILED
OUSE - NO.OF BEDROOMS
tz LLS & SSDS'S W/IN 200' OF MPOSED SYS.
ROPERTY METES & BOUNDS
11OUSE SETBACK NECESSARY (TIGHT LOT)
OUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE
NO BENDS; MAX.BENDS 45° W /CLEANOUT
FILL SYSTEMS
CLAY BARRIER
FT. HORIZONTAL;SLOPE 3: GRADE
FILL CS FILL NOTES
STANDPIPES FILL CER ITI A OTE
DEPTH GUA
FILL P LE & CA D , NSIONS
FILL N EXPANSION AREA
TRENCH
F TRENCH PROVIDED L3DJ 60 FT MAX.
$'AKAL1,Ei1T0 CONTOURS -
:.._
ETLANDS (TOWN/DEC PERMIT REQ'D ?) SEPARATION DISTANCES SPECIFIED
kTA ON DDS PLANS & PERMIT SAME ON PLAN - FROM SSTS
;.E-1969 NEIGHBOR NOTIFICATION 0' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL
FrFER BUZBA 7.9,20'TO FOUNDATION WALLS 15' WELL TO PL
kYk. FLOOD ELEVATION 100' TO WELL, 200' N DLOD, 150' PITS
MR REQ'D PERMITS) 00' TO STREAM WATERCOURSE LAKE (inc. expan)
REQUIRED DETAILS ON PLANS 0' TO CATCH BASIN, 35' STORMDRAN, PIPED WATER
:WAGE SYSTEM PLAN - (NORTH ARROW)
;DS HYDRAULIC PROFILE_ GRAVITY FLOW
INSTRUCTION NOTES
ESIGN DATA: PERC & DEEP RESULTS
CONTOURS EXISTING & PROPOSED
UVEWAY & SLOPES, CUT
)OTNG /GUTTER/CURTAN DRAINS
COMMENTS:
10'
50' INTERMITTENT DRAINAGE COURSE
200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS
15'min to CDS= >5 %,10'- 4 %,25'- 3 0/o,30'- 2%,35' -1 0/a,100' - <I%
20'min to CD discharge/ I 00'with 182 cons day discharge
SEPTIC TANK
Ffl 10' FROM FOUNDATION; 50' TO WELL
`� 1 ` 1` FORM 5T -2
• —r, rA "'n. �.e �... ..a ry ."��.I ►• ✓Y.a r�r.! neer+r.0 .:u4..r
@i BRUCE R. FOLEY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New . York 10509
Tel. (914) 278 - 6130 Fax (914) 278 - 7921
June 24, 1998
Joseph F. Sullivan, P.E.
2972 Ferncrest Drive
Yorktown Heights NY 10598
Re: Domi.ngurs, Meadow Lane
TM# 74 -1 -9.14
(T) Putnam Valley
Dear Mr. Sullivan:
This office has received and reviewed the most recent set of plans for the above mentioned project.
We would like to offer the following comments for your consideration.
A. Please show construction conditions of drainage easement, SSTS must be
minimum distance of 35' from a storm drain or pipes water.
_ :._... B.. Drainage easement. should also be shown. on. 3.0 scale ,drawing..: .
C:' ika- se`show location of CB's of Meadow Lane, minimum distant c6 of 50
must be maintained.
D. It appears proposed SSTS is shown more to south, than as located on filed
subdivision plan, please clarify.
E. Please correct all application forms, with correct tax map number.
This office will continue its review upon consideration, of the above mentioned comments. Please
feel free to contact us if any questions arise.
Very truly yours,
U � t
Adam B. Stiebeling
ASB:tn Assistant Public Health Engineer
enc. All Application Forms
PUTNAM COUNTY DEPARTMENT OF HEALTH
bmSION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION ION FOR
APPROVAL
�j OF PLANS
j�FOR
_��Ln ^� w.�+,-.rayg•w .-:- r. _ ;yerC.'.z:.:At�AU' ll'lLJ,ILJ.R TEA tl'liJ�IJ
1. Name and address of applicant: `,lea Ilv s''�'p
/ f : tltr /' ei "7 LA
2. Name of project: S�''� 3.
4. Design Professional: ; T r S.
6. Drainage Basin: /guy's/
7. Type of Project:.
Private/Residential
Apartments
Office Building
Location TN:
Address: -Z yV 7L f���a r��T�s '%fir•
Food Service Commercial
Institutional Mobile Home Park .
Realty Subdivision Other (specify)
g. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status check one .. ............................... Type 1
Type I1
9. Is a Draft Environmental Impact Statement (DEIS) required? ...................
10. Has DEIS been completed and found acceptable by Lead Agency? ...........7.
11. Name of Lead Agency
Exempt —
Unlisted
12. Is this project in an area under the control of local planning, zoning, or other
....w...,.a.... ...wp os r..a _,_.a •,,. __....s_ -s.. ..�....�— e.....a�:v...... � .... ..-=+e �.x ...�.rtao n.T,.. �- .c.... ..... -- - c..._. »..- vim. -� -.. .. ��..ra.a.�.. -,. .- - «.:.w +d.. +.+a. �...s�.
13. If so, have plans been submitted to such authorities ?�
14. Has preliminary approval been granted by such authorities? s •,Date granted: J19f4
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? ....... ............................... Al. e
19. If yes, name :bf water supply Distance to water supply mil•/
20.
21.
22.
Is project site near a public sewage collection or treatment system? ................Al
Name of sewage system Distance to sewage system A -:�.o
Date test holes observed / 23. Name of Health Inspector
•v P
24. Project design flow.(gallons per day) ........................... 4f" °c)
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?.._.
26. Has SPDES Application been submitted to local DEC office? _
Form PC -97
z
d7.a any portion of this project located within a designated "Town or State wetland?
28. Wetlands ID Number .... ...............................
. ........................ ...............................
1! nd. P��it p q0, reds..,
Has application been made to Town or Local DEC office? . ...............................
30. Does project require a DEC Stream Disturbance Permit? .. ............................... /V-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
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 /Nom
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? ... ... .................... Ald
34. Are community water and/or sewer facilities planned to be developed within
1.5 years in or adjacent to project site? ................................ ............................... A141
35. Are any sewage treatment areas in excess of 15% slope? . ............................... A'a
36. Tax Map ID Number .......................... ............................... Map 7W •-/ Block_ Lot , 1,01
37. Approved plans are to be returned to ..... Applicant t' Design Professional
NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall
.be sent -to the.:De_partment; and- need.n_ot'.be - ent.in duplicate to-tl;e_IEP; althoug,h-the—project niay..r«auirc
approval of the SSTS prior to final approval by the Department. Projects within the �%atcrshed may also w
require DEP review and approval of other aspects of a project, such as stomm titer pLu►s or the creation ot'
impervious surfaces, and the project applicant should obtain the appropriate forms ti)r 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.,thc application n►u�t
be accompanied by a Letter of Authorization (Form LA -97). I'ailure to comply with this prop isioii
may be, grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information Provided on this f urin is true
to the best of my knowledge and belief. False statements made herein cure punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.'
SIGNATURES & OFFICIAL TITLES:
Mailing Address: l
I'" I I NA 'F 1 COUNTY DEPARTMENT 01F I HEALTH
AI I i
DIVISION O ENVIRONMENTAL HEALTH S I '
A'SHE �: �'. SUB S��i[ �' �C�'.. �E'' �v�� 'YTIAA`7ildi[)�l`dT's STEM
Owner Address /�' /�:-� ;`�� ►�'� -%��
Located at (Street) - w- -2,ri-,, e Tax Map % Block _j Lot
(indicate nearest cross street)
Municipality ,/; /��e;;'/7�7 Drainage Basin
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Date of Percolation Test
Hole loo.
Run No.
Time
start - stop
>Ela se Time
�M1in.)
IIDe th to Water
)N rom Ground
Surface (Inches)
start Stop
Water
]Level
gDropp In
Inc�nes
]Percolation
hate
Min/Inch
2
3
4
Pe, 7e9I*v
c
t"
5/�`✓`
%� �UGo
s
3
4
5
l
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. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
4.. ' . _-..
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
2
_' ...'.'. _:. -,.. ...'. � ...�.: - •�. . , . v:'. :::. ": -'w'- tip' /� _ ... _.: °.. c- ..e. ,. _-. 'r.• _. $L;a :�.. i:: Y:..: . +_a.. �is':_^rt.:..: 4 L •�..]:. rir ... ,a. �.,..
DEPTH HOLE NO. ~ HOLE N--O. HOLE NO.
G.L.
0.5' °
1.0'
1.5' �;n j
d?i
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0' .
6.5'
7.0'
7.5'
8.0'
8.5'
10.0'
Indicate level at which groundwater is encountered T1 o n
Indicate level at which mottling is observed .'7j
Indicate level to which water level rises after being encountered �- �✓� ��
Deep hole observations made by: yt,,� 4 /2;p -; %v,� Date % c
Design Professional Name: - g i
Address: 7. ^,1 `-ri ✓�
jr
a
Signature:
Design Professional's Seal
of NEW
S.
G
IFUTNAM COUNTY DEPARTMENT OF HEALTH
DIIVffSffON OF ENVIRONMENTAL HEALTH SERVICES
.,.c: .,e'�:t� ".. �a....yetl' -ars;a '..-.y '�vx S. �:- +�.�••r rah �:.r r ^�i r. u�:�:v<id:::.�w.a c:. ..eC::is '1 v�.:.'�p .r. :o. -....�. � ^v. ... "r.;.�i .r :.:-�:.r.i:v: �•ni �..
LETTER OF AUTHORIZATION
V
RE: Property of
Located at %1C =67
T/V c$� /e, Tax Map # 7d, -° / Block _ Lot s f
Subdivision of ` 0_.; .
Subdivision Lot # - Filed Map # Date Filed �'dfgd
Gentlemen:
This, letter is to authorize ,;5 Y
a duly licensed Professional Engineer or Registered Architect to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the 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 treatment and /or water supply systems
in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
aw and .,- the --Pu:tlarsa County: - nt any :.6&,'.
- 7 _:Zo I � 0 � FILI /,I,/— —
Countersigned- NEW
P.E., R.A., #
Mailing
Very truly yours,
Signed: _
(Owner of Property)
Mailing Address: % �a �� �`dd��►
State State Zip
Telephone: Telephone: % -3
Form LA -97
14-164 (2187) —Text 12
PROJECT I.D. NUMBER 617.21 SEOR
q Appendix C
- .. State. Erttrlra�nno�ntsl;A�allty
SHORT .ENVIRONMENTAL ASSESSMENT FORM,
For UNLISTED ACTIONS Only"
PART 1— PROJECT INFORMATION (To be completed by Applicant..or Project sponsor)
1. APPLICANT /SPONSOR
2. PROJECT. NAME,
3. PROJECT LOCATION:
Municipality' �j�j�d, u /er County
4. PRECISE LOCATION (Street address and road Intersedilons, prominent landmarks, etc., or provide map)
9
5. IS PROPOSED. ACTION:
New ❑ Expansion ❑ ModificatioNalteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
Initially j acres Ultimately ' acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑
Yes No If No, describe briefly
8. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
jKlResidentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
Yes, ❑ No If yes, list agency(s) and permit/approvals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
as ❑ No If yes, list agency name and permiUapproval
KY .
���� % %vas %��r /�- ��r�.��.i•
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes No
1, CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
ApplicanUsponsor name: 1 t7
,. .Date:
Signature:����
If the action Is In the Coastal Area, and you are a state agency, complete* the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
Yes ❑ No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS-IN 6 NYCRR,.PART 617.6? If No, a negative declaration
.n.u.il'6:1'rJerEcy_ ... ... - Jf n .... ..
❑Yes No
C. =
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED.WITH THE- FOLLOWING: (Answers may be handwritten, if legible)
Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain 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, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly
C5. Growth, subsequent development, or`related activities likely to be induced,4y 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.
co
C-
`5 D 'IS'TfiR°OFY j XitiF�iC,Llf} Y.T 7 RK;ytiEi��Qv'.cii Y iL?n�C�: ITi�Tf /Efi�ll�SE�,.h�V.E�NfviFaT4i `IMP .ACTS ?''.
❑ Yes ❑ No If Yes, explain briefly 17.
<.
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
co
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 oP more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and /or, prepare a'positive declaration.
❑ Check this box If you have determined, based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts
AND provide on `attachments as necessary', the reasons supporting this determination:
Name of Lead Agency
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Off icer
Signature of Responsible Officer in Lead Agency Signature 'o Preparer (if different from responsible officer)
Date
2
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