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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74. -1 -9.16 BOX 28 03532 vil . , , N i +; Ion ,, r , r .' r , ;Z . .1 ` r 03532 TNAM COUNTY DEPARTMENT OF MEAL CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT PCHD CONSTRUCTION PERMIT # /Py / — jj 3 Located at eia Cott W Owner /Applicant Name /�� riv a Formerly Mailing Address l �`� / ��✓�r �'' S i Date Construction Permit Issued by PCHD S, Town or Village l' c> Aa I - W c, Tax Map 7d Block Lot f i.6 Subdivision Name C� ce Subd. Lot # 6 Zip/' 7 Separate Sewerage System built by O W'W e� Address 3.0 "VVe Consisting of /,-,j Gallon Septic Tank and V� P- t° e j�� Other Requirements: `/� Water Supply: Public Supply From, Address or: , Private Supply Drilled by1i'���/'; �� Address ✓-gip t^���f /�%� Has erosion control been 601ripieteil? Ve � - Number of Bedrooms Has garbage grinder been installed? p4l& I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: / l Certified by �" Address Any person occupying premises sere y the P.E. /-' R.A. License # promptly take such action as may be necessary to secure the correction of any unsanitary condi such usage. Approval of the separate sewage treatment system shall become null and void as s 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, modification or change is necessary. By: �� Title: �' Date: Whi 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 NylFl( . rOM P>l .lfi'.Tlfti N 1R71PO RT Webl Locfitif o'n 91766 es : ' -- - - � n/Villa .� , Tax Grid # -� Map 124< Block 1 Lot(s) ,9/4 Well Owner: Na 7 e: Address: >(1se of Well: I- primary 2-secondary Residential Public Suppl Air cond /heat pum Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment _Z< Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _2!<, Open hole in bedrock . Other Casing Details Total length .z/ ft. Length below grade /9 IYft. Diameter ('' in. Weight per foot /G lb /ft. Materials: _2(_ Steel _ Plastic _ Other Joints: _ Welded _X Threaded — Other -. Seal: � Cement grout = Bentonite Other Drive shoe: Yes No Liner _ Yes J%eNo Screen ][Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) 'Developed? First Yes—No Hours Second Well Yield Test _ Bailed Pumped Compressed Air Hours 2 Yield /o gpm ][Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 1 Well Log If more detailed information descriptions or are available, please attach. )[Depth From Surface Water Bearing Well Diameter(in) )For atio ][Description fft. ft. Land Surface If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Typ pacity Depth D ` Model SS'o1,1r Voltage2iLv HP ! Tank Type X5C 30 Volume� Date Well Completed 03 Putnam County Cert ification No. IM/ ell Driller (si ature) lNu i t: txft location of well with arstances to at least two perman&nt/landrr*k, to be provided on a separate sheet/plan. Well Driller's Name c �/ Address:��Y �.. Signature: o Date: . White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 mi-iY-2,-I-'*%-_,10q 12;fig r ROM: PUTNM COUNTY DEPART 845-278-7981 I ' .0 BA 11. FOLEY k Av 93TARTMINr OF EBAIIH I' Genva Road - Brewstrj- Novi Y&k 111509 UvIrontucAbil Health (914)279.6130 Fv, (014) 27(1.7921. TO: 4MVITER!".1, ANN.:. Dix . ... ....... Al-TECYRIZED 7OWN. OFF ICUL:., L4 IrAt Pubutin County Department of Health NY91 wt j. It C'I 400, (.0hiplia N! S.S C 0Ve a is corap] utei, 4_,, a iltiab i 'fan"'' addrems.[s ivsii ;used by an Ru*ih'o*'xiz(,,d taw n'dficiaJ. T' Ids formi, btolp.e.-inji ull'Ti!d ...with the alp -A a C"ficite,Df C0149tll7 'a I Ictioll 3) lvpip Cie. 0 YML ENVIRONMENTAL SERVICES 321 Kear Street g . -�- (914> 245-2800 | Albert H. Padovani, Director | LAB #: 32.405083 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CLIENT #: 57700 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NOW 5TAT PROC PAGE: 1 VAZQUEZ, MANUEL DATE/TIME TAKEN: 07/20/04 08:35A 128 PUDDING ST ' DATE/TIME REC'D: 07/21/04 09:46A PUTNAM VALLEY, NY 10579 REPORT DATE: 07/28/04 PHONE: (845)-528-1158 �� SAMPLING SITE: 16 NORTH MEADOW RD ��� -" SAMPLE TYPE..: POTABLE : PUTNAM VALLEY NY ���� � PRESERVATIVES: NONE COL'D 8Y: MANUEL VAZQUEZ TEMPERATURE..: < 40 NOTES ... : KITCHEN ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLlFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE PUTNAM CNTY PROFILE 07/21/04 MF T. COLIFORM ABSENT /100 ML ABSENT 07/21/04 LEAD (INS) 1.6 ppb 0-15 ppb 07/21/04 NITRATE NITROG 0.66 MG/L O - 10 07/21/04 NITRITE NITROG <0.01 MG/L N/A 07/21/04 IRON (Fe) 0.103 MG/L 0-0.3 mg/l 07/21/04 MANGANESE (Mn) 0.014 MG/L 0-0.3 mg/1 07/21/04 SODIUM (Na) 3.69 MG/L N/A 07/21/04 pH 7.O UNITS 6.5-8.5 07/21/04 HARDNESS,TOTAL 42.0 MG/L N/A 07/21/04 ALKALINITY (AS 40.0 MG/L N/A _07/21/O4,,.,,�'.�TURBIDITY <TUR '��2,4 ��TU,�, `_ <)`�� NTi ---_-_~- _ --~_ COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT S NDT) OF A SATISFACTORY SANITARY QUALITY ACCORDIP���[�°�HE 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. ublic schools are set at 15 ppb. ` Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium that for people on a contain no more than moderately restricte' is suggested. are proscribed. Suggested guidelines state sodium restricted diet,the water should 20 mg/L of Sodium. For those on a diet, a maximum of 270 mg/L of Sodium METHOD 1008 9101. 9139 9l46 2037 2037 9043 `�� � YML ENVIRONMENTAL SERVICES 321 Kear Street ,orx Albert H. Padovani, Director LAB #: 32.405083 CLIENT #: 57700 NON STAT PROC PAGE: 2 VAZQUEZ, MANUEL DATE/TIME TAKEN: 07/20/04 08:35A 128 PUDDING ST DATE/TIME REC'D: 07/21/04 0906A PUTNAM VALLEY, NY 10579 REPORT DATE: 07/28/04 PHONE: (845)-528-1158 SAMPLING SITE: 16 NORTH MEADOW RD : PUTNAM VALLEY NY COL'D By: MANUEL VAZQUEZ NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: Ml:-' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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 OH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM 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 .' TELY_ HARD, WATER q 7PY10O.MG /L. /-- �---l--'—�-- | I grain/gallon nn = 1/.2 MG/L) _/ ` ' SUBMITTED BY: `~ Director ELAP# 10323 PIJIFNIAM COUNTY REPARL C'M ENT OF H:lj'E�;.!I,,:'!I., "J.'4� 1[ ..;� b .:gib~ .�:g. .�: �..: �,,,,,�.....,..� �!+�, � �yh :� :56• -�?�e� T�i^: 1 � I�; `� -t' � ` i�.. -�� r•- ;:�...:.� �.� . � :ate =r -.�: C.11rARANTEE OAF' SUBSURFACE SE`NA.C-lE 'll'II'.EA7CMAEN"11 111) q.'�:)'I ":l Al VO 7.1 01.1rner or krercha.ser of Building Tax. , al, 1? ltwo'c. Building Constimcted by /� / I-OWe ,_ Stree Bi.uilding 'Type Town/'Village ..Ye Subdivision t\` amel ell Subdivision Lot I represent - fiat.:[ am wholly. and completely responsible for the location, � ;vs:►:r'srR�a:i::,lltp, r1,:�,t�,ri�rl, ccnstr.iction x,ld drainage of the sewage treatment sy..tem servivg prop-en .y, and the t; :is :ha: been c:o:astructed as shown or the approved plan or a,.pproved l:t?t rcto, a .,A in accordance:,?Ath the standards, rules and ::egulations o'the Pixtna::n County De :l��xr >.vicul c - CH- a.11h. u.:nd lucrebil vi.amritee to the owner, his successors, heirs or assigns, ::o place is go :A ts ? fw;rie. iron aVy part of said system constructed by ruse which fails to operate for a ptxiod% of Vva yt,7rs inarnediately following the date of approval of the "Certificate of Constructior. C oni- o:ii;:rnce" ar:: the sevI ;q;e t:ree.t:metit system, or any repairs made by me to such sys-tern, except ;Axa–r: fa.d ".1rc to _CCE:ratt' ► 1:, r + r n t us,^ used by the �villfiu. or :nt, _gligent .t o ' ►e;c�.,,�ti�►arit of tlj,_ ¢;iq. systen:i. . . The undersi;rtees to accept as conclusive the determination of he FOI c 1-1calth i D =rector of-the Putnam County Department of Healt.1 as to whether or not thf .ilifi -1 e i�ft:l:tr::. �atktirn to opc:rat:e'vvas caused by the willful or negligent act of the occupartt: ofthe: lr:il�l.itu,�; ga3ilihi tr Q.e systt�ra. . Dated: Pvlonth. 0 Day -Year y,44 �J :aeral Col.tractor (Owner) - Signature- Corporation Naunte (if corporatiort) Address: i, a, e State -,! �,� �!; %orb � j9 %�'97'19. Sigma-ure.: Tithe C:orl�orattio:ri t�ian:►.� (' i:ot��� >a�:ttior�} State z ip Forin GS-97 UTNAM COUNTY DEPARTMENT OF HEALTH VISION OF ENVIRONMENTAL HEALTH SER r CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT It �%' / — e -3 Located at ✓ /o n e, Town or Village ATLdh -t P/ Subdivision name � el- Subd. Lot # �_ Tax Map � Block / Lot 91,C Date Subdivision Approved z 19 qrs'° Owner /Applicant Name --'� h u0/ Y G = g uCz Mailing Address a i' ,o Renewal Revision ✓ Date of Previous Approval 'Au )0(a-1zy1 kl� /J. Zip Amount of Fee Enclosed 2 4 0 Building Type ��� !i„ roc Lot Area �• %o. of Bedrooms _� Design Flow GPD Y� Fill Section Only Depth - Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12 gallon septic tank and S' 7 L ' Ovc Other Requirements: // -* /?!%%3 i // To be constructed by & him 0/' Address Water Sunaly: Public Supply From Address or: Private Supply Drilled by �' , fyli� �►� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance- of the original system or any repairs thereto. Signed: /� /�'j Address APPROVED R CONSTRUCTION. his a R.A. Date T/ 910 t License # 2 y Y•9s'' )m the date issued unless construction of the sewage treatment system has been completed and inspe is revocable for cause or may be amended or modified when considered necessary by the Public Health ision or alteration of the approved plan requires a new pe t. Approved for discharge of domestic sanitary s nly. By: f Title: ,"%�-�� Date: -7 AP ( /0 el Whit opy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pro essional Form CP -97 •^ �. e•';,, 'L,�i::..:�%c.,w.,�'r= .o..,Y�;� 1i..,k:, 1-. ... :rne =. �+�.�.'tt',, : rte, Ki -;` >. LORETTA MOLINARI Public Health Director June 23, 2004 :;j.:I:e��w�.:::..,9i.`v" -,.•.: t:'a+T �:'.4C'r.i:: , v;. e`+ te- i' m, �: hl. ye` f. �' �i� .i.'c:����''.�.q= + °.s.,!:ri.'.. %+� DEPARTMENT OF HEALTH[ 1 Geneva Road, Brewster, New York 10509 ]Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 OFFICIAL REQUEST FOR STOP -WORK ORDER Iry Sevelowitz, Building Inspector Putnam Valley Town Hall 265 Oscawana Lake Road Putnam Valley, New York 10579 Re: Dear Mr. Sevelowitz: ROBERT J. BONDI County Executive Stop -Fork Order Request: Vazquez North Meadow Lane, (T) Putnam Valley TM# 74 -1 -9.16 The permit PV -1 -03 for the above regarded project has been suspended by this Department for the reasons noted below: 's ed k P � ✓` �.a� M;t � L Septic system was not installed according to the approved plan. There,does not.appear to be room for 1Q0% expansiar!-.area -..:.. _systemnee s t6bVReinoved.. ....... .. _ . _, . ,. "-t w 1/ There appears to be no fill at the top of the system. 5. Revised plans showing new layout are required, including $200.00 certified check or money order for revision to approved plans. Please be advised that an additional comment letter not associated with the permit suspension will be forthcoming. It is respectfully requested that a Stop -Work Order be issued until these items have been satisfactorily resolved. Should you have any question or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. Thank you in advance for your cooperation in this matter. „ Sincerely, ? seph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj Cc: M. Vazquez Frank Sullivan PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �'���•- �w iU `'/� FINAL SITE INSPECTION 9� t d b: spec e y. Street Location _ __ u.. � Town (/ Permit # U ! - d 3 TM # - l - 4l . C L Subdivision Lot # 1. Sewage System Area a. STS area located as per approved plans .......... ................ . b.. Fill section - date of placement (� 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ........................ d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank size - 1,000 .... ..... 1,250......... other ................ b. ' Septic'tank installed level ................ ................................ c. 10' minimum from foundation ...............4sd./ d. Distribution Box 1. All outle ts at sam on -water ........... 2. Protect o w frost .................. ............................... 3.. um 2 ft.Original soil between box & trenches e. Strnction Box - properly set .......... ............................... 6. Length required - Length installed 2. Dis an sta ed according to p ............................. 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5, 10 ft. from property he - 20 ft.- foundations.......... 6. Depth_o trenc < 0 ' ace .................. Room allowed for expansion, 100% 8. Size o grave - 2 tameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... nds..za ped.,,..:- .:..,::;:: ..... 9. 2 3 4 5 Size of pump ctia er........... Overflow t .......................... ........................ I......... Alarm, aUaudio .................:........... . ..................... Pu easily accessible, manhole to grade ................. first box baffled ........................... ............................... Cycle witnessed by H.D.estimated flow /cycle........... �a. house located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured cOo ' - ft........... c. Casing. 18" above grade ................ ......... ..... ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... bacl6 -- ............................... es flush wi�in�id�ebo . ...... ......................... d. Backf maten ces <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f j f. outfall - rotected & dint xist watercourse " s discharge away om STS area .............. h. Surface water protec ...................I ............... i. Erosion control provided ....................................... Rev, 12/02 COMMENTS LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ]Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing services (845) 278 - 6558 WIC (845).278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 279-6648 OFFICU L NOTICE OF PERMIT SUSPENSIO N CERTIFIED RETURN RECEIPT R]EOUESTFD June 23, 2004 Manuel Vazquez 128 Pudding Street Putnam Valley, NY 10579 Dear Mr. Vazquez: ROBERT J. BONDI County Executive Re: Suspension of Permit: PV -1 -03 North Meadow Lane, (T) Putnam Valley TM# 74 -1 -9.16 Please be adv_i sed,th9.1.1?e. Permit PV 1 -03. for-the above regarded project has been suspended by.E, s . :I Uepartmeit for the reasons noted 1. Septic system was not installed according to the approved plan. 2. There does not appear to be room for 100% expansion area. 3. The large tree in the middle of the system needs to be removed. 4. There appears to be no fill at the top of the system. 5. Revised plans showing new layout are required, including $200.00 certified check or money order for revision to approved plans. Please be advised that an additional comment letter not associated with the permit suspension will be forthcoming. The suspension of the permit will remain in effect until these issues have been satisfactorily addressed. t Furthermore, pursuant to Article III, Section 3, paragraph d, of the Putnam County Sanitary Code, whenever inspection indicates. construction to be otherwise than in accordance with the permit all work shall cease upon written notice served upon any person connected with or working in said system. 1. b ..... ....... ._ .. _ _ .. __....__. ... .. .. �• - Please be advised that appropriate steps must be taken immediately to resolve these issues. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2157. Sincerely, Ale" - 2 Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj cc: BI (T) Putnam Valley R. Morris M. Budzinski Frank Sullivan LORETTA MOLINARI Public Health Director June 23, 2004 1 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 ROBERT J. BONDI County Executive Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Re: Field Inspection — Vazquez North Meadow Lane, (T) Putnam Valley �- TM# 74 -1 -9.16 Dear Mr. Sullivan: �L1 A site inspection was made for the above referenced project on June 18, 2004. The following comments must be corrected in the field. Cast iron pipe needs to be fully exposed for inspection. Septic tank needs to be exposed. .3 The pipe in 'unction box #•1 reeds tote- fled.—t—: -, 54 The pipes in box # 2 need to extend so they are flush or into the box about 1/4 of an inch. Please check all box covers, some appear to be cracked and need to be replaced. A bedroom count needs to be done. The well casing needs to be raised 18" above grade. will vl� The discharge pipe for the roof leader /footing drain should extend to the ground to avoid erosion (%5 of the property. Please be advised that there are additional items associated with a Suspension Of Permit and Stop Work Order that need to be addressed. If you have any further questions, please contact me at (845) 278 -6130 ext. 2157. Sincerely, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj cc: Manuel Vazquez 06/14/2004 06:30 9149624248 JOSEPH SULLIVAN PAGE 01 IPITNAM COUNTY DEPARTNM OF BL4LT11 DIVISION OF ENVMONMFMAL HEALTH SERVIcEs ATMNTION O*bAbr 0 GENE. RMIIUIIMMALD12ECTION Tor: Till All infoaution must be. My completed prior t6 any inspe,-tiou beh;j made., PCHD Comtructiouftuit # )e Locued: 0vmar/AppUcwN&ma: 7: 131ock Subdhision Lot Is synew fAl completed?. Diner Is Sy I-Lem complete? Is system consvuCted as per OW Is w,-.0 dzilied?. . Is well located aspeplans? Are arosi.ou coutrol.,ummres in placi Date; Date. I certify that thasysum(s), as listed, at the above prengses has I mu comMicted sad I hal) BI- q-) e4 ted and verified their completion it accordance with the inmd PCIM Consuvdon il."rJ tom. huu;m Date:. el Certified by. PE DcWp ?Wadotwl Lk, cor=euts: FOIMFGL.99 JUN-14-2004 MON 08:03 TEL:845-278-7921 NAMP , P; 1TWQM rn WTV MPOOTMCKIT n= 0 !PUT TAM COUNTY DEPARTMENT OIF HEALTH HDHW510- 071EKWRGT�MI 7AI� I�HIEAIL'�`II - . - -s r ♦.. yi'�i ..�4 -� Ii •. i s .Y..u: �•.-[a rw. r ,. ...�. � -.. v.; may`.. .. CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM P ERr,0T G ` _....... W. n , j) a � Located atd�s�G� Town or Village 1U4®`4711' Subdivision name _ Subd. Lot # oV*' Tax Map Z:�: Block -,[— Lot %'ie-, Date Subdivision Approve / Renewal Revision Owner /Applicant Name r7ve,' ;x Date of Previous Approval Mailing Address y Zip Amount of Fee Enclosed �d Building Type ✓ , ;j dl,lye e Lot Area l No. of Bedrooms 4 Design Flow GPD Yelp Fill Section Only Depth Volume Selgairate Sewerage System to consist of gallon septic tank and .r1---7 / . z— Other Requirements: To be constructed by rafe /—G" /;vim /4's-'-e ef is/ Address �te� upply.Fr�m,..- .:.__...._...: Address . ..... _ - or: Private Supply Drilled by Y7 ��� Address. -ye, e,-'e, 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 s,, 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 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 origina system or any repairs thereto. cV Nri I Signed: 0) l In- � R.A. Date "-p ! Address _ 2 7 2— C fps' ,?.- I License # APIEDI[8 ®V]E ®I� C ®lYS'g'Il3tiTC'1cII ®IY Aa!�'roval °ie >two years from the date issued unless construction of U 7s 1� sewage treatment system has been completed and inspect.e�-"e PCHD and is revocable for cause or may be amended i modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requiri a new pe it. Approved fo ischarge of domestic sanitary sewage only. By: Title: Date: h /c, -3 copy - HD File; Yellow copy - uilding Inspector; Pink copy - Owner; Orange copy - Design Pro essional �I Form k PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL fJ��` n - .. •. a ; ° :� �.�:pVea a jTri'rii or.tYp.� PCI, ID, P&M- ifok r' `� l . l ti Well Location: Street Address: Town/Villa a Tax Grid # Map Block Lot(s),9 Well Owner: Name: Address: Use of Well: esidential Public Supply Air /Cond/Heat Pump Irriga on 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought —67' gpm # People Served Est. of Daily Usage dcl gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling P14ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type _/brilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes ` No Is well located in a realty subdivision? ...................................... ............................... Yes t/ No Name of subdivision d urn zr Lot No. Water Well Contractor: Address: /30 psi-/ jJL !?i'`•' 11Z 'Is Public Water Supply available to site? .................................. ............................... Yes No 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. I?ate:...�`.�' L : ^plicant_Signahue: ZG Z% ti"f'�.^— PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 3 D Permit I sum Official: Date of Expiration Title: c Permit is Non- Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE R FOLEY Public Health Director IDEPARDMENT OF B EALT H 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 January 10, 2003 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Dear Mr. Sullivan: Re: Proposed SSTS - Vasquez Meadow Lane, (T) Putnam Valley TM# 74 -1 -9.16 This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. 1. There are no deep holes or percolation tests in the expansion area. The dr?veway._grading.needs to be—shown since it -may aBeet the pr.oposed,SSTS.. ys` S.` _ .. - "T1fe proposed floor plans contain 5 bedrooms.'-'-' This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, 1 Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj 14.164 CA7) —Text 12 PROJECT I.D.NUMBER � 617.21 - -" ._ SEQR -..•'+-,; III•,. ;, s Appendix C �y� ....::: Stvte tcr+litsarinteni�t'Qiirfity low SHORT ENVIRONMENTAL ASSESSMENT FORM... For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLi A /SPONSOR 2. PROJECT NAME. 3. PROJECT LOCATION: z p/� Atunicipaliry � Q 116 County 4. PRECISE LOCATION (Street address and road interse ons, //prominent landmarks etc., or provide map) ��•-- 5. IS PROPOSED ACTION: 'e•x ❑ Exaa.islon ❑ Mcdillcationlalteration 6. DESCFUBBEPPROJECT BRIIEEFFLY:/� / / Ci/�l /ice /� /%�G'.�/ d 't/flG�' %Y', +� /! /r/- '''it ✓ /GEC/ %'Y�ti�� 7. AMOUNT OF LAND AFFECTED: C Initial!y G acres Ultimately acres 8. WILL PROP ED ACTION COMPLY WITH EXISTING ZONINd OR OTHER EXISTING LAND USE RESTRICTIONS? MoL-s [ No It No, describe briefly 9. WHAT S PRESENT LAND USE IN VICINITY OF PROJECT? n sidentia! EJ Industrial C1 , Cl..Cemmerciai - Airiculture -_._ . OPa1JFore it 10o +_.spat^ -.-:. C I Otbe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATEJOR Yes OCAL)Q No It yes, list agency(s) and permitlapprovals 14� 11. DOES ANY ASPECT OF THE ACTION HAVE A. CURRENTLY VAUD PERMIT OR APPROVAL? Yes ❑ No It yes, list agency name and permitfapprovai . = u 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMRiAPPROVAL REQUIRE MODIFICATION? ❑Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applica .Usponsor name: " "� Date: �n 2— Signature: ry.. 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 PART II-- ENVIRONMENTAL ASSESSMENT (To be completed by agency) A. DOES ACTION EX_ CEW ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.12? if yes, coordinate the review process and use the FULL EAF. Cl Yes B. WILL ACTION RECEIVE COORDINATED A- .VIEW.AS:PROVI.P?E0 SOP UNUZTED ACTIONSiN 6 NYCRR„ PART 617.6? It No, a negative declaration JTay.bo apersedzd iititfitet'trevblv6d`ag4n °cy:`�.` , ❑ Yes dGlF1b ' 1 C. COULD ACTION, RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential forr erosion, drainage or flooding problems? Explain_ brletfy C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood eharacteR Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: / U O A'R_. C4. A community's existing plans or goals as officially adopted, or a change In use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. A YLL . C6. Long term, short term, cumulative, or other effects not identified in Cl-CS? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. G: is TH`cRE; OR IS TH RE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? CO] Yes o It Yes, explain briefly DART 111 — DETERMINATION OF SIGNIFICANCE (ro 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 ((.e. urban or.tural);_ ti) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (1) 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 QkF and /or prepare a positive declaration. heck 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: ti A�- 5 d row lint or Type Name of Respo le Officer in Lead Agen y Tf e of Responsible 011icer ignature of Res nsi le Officer in Le Ag y Siguture of Preparer (ir diffefentTfom responsible officer) 3• n ate I X � ,\ol. PUTNAN[ COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS,_ .. ; . • • _ � . CONS f IcLc�'il)i � F§�13nl�inr'". ~ ` NAI 2 OF OWNER: = ^ V Z �Z STREET LOCATION: / ' ! vv JV REVIEWED.BY: RM, GR, AS, SRDATE: llqlo3 D -7 4i- : (1 Yf N DOCUMENTS PERMIT APPLICATION j�(,_JWELL PERMIT OR PWS LETTER UPC =97 k D(_)DESIGN ETTER OF AUTHORIZATION DATA SHEET (DDS) / C—) �� SHORT EAF ANS -THREE SETS (cJ U HOUSE PLANS - TWO SETS -U(DVARYANCE REQUEST SUBDIVISION ✓(�;�)LEGAL SUBDIVISION ' ( �/ -)SUBDIVISION APPROVAL CHECKED (� PE CRATE d-O � /�}F�L REQUIRED O DEPTH ' UUCURTAIN DRAIN REQUIRED GENERAL C_)L_JLOCATED IN NYC WA D UUPLANS sumrrnmrTO DEP , /Q� L_)C:_)DEbVAM TO PCHD f v / /'I P APPROVAL, IF REQ'D EEP TEST HOLES OBSERVED (___)(t:�)PERCS TO BE WITNESSED UU -APPROVAL SSDS ADJ, LOTS (� WETLANDS (TOWN/DEC PERMIT REQ'D ?) (__)L'ATA ON DDS PLANS & PERMIT SAME (�U// PRE 1969 NEIGHBUR N TIFICATION NPR _ '(-._ �" li :. �' SOIL TESTING LOTS>10 YEARS OLD REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS UUV-CONTOURS EXISTING & PROPOSED iFOOTING /GUTTERICURTAIN DRAINS USDA SOIL TYPE BOUNDARIES TITLE BLOCK, OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE • LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (WELLS & SSDS'S W/IN 200' OF SSTS ►PROPERTY METES & BOUNDS - JEROSION CONTROL FOR.HOUSE, WELL & SSTS, EROSION CONTROL NOTE lonwlms: in tEVSHEET)09 101/00 (REQUIRED DETAILS ON PLANS CONT'D} HOUSE SEWER - V," FT. 4 "0'; TYPE PIPE CAST IRON Ct�AUNO BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS * AJ FILL SYSTEMS (U�(-)10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (✓� FILL SPECS / FILL NOTES 1 -5 FII,L PROFILE & DIMENSIONS L IN EXPANSION AREA - 'UU CLAY BARRIER U(rjFILL CERTIFICA UUDEPTH G �(,_}V0L� -WPLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS �(� SEPARATION DISTANCE FROMTOE OF SLOPE %% TRENCH ID LF TRENCH PROVE 60FT MAX. 'PARALLEL TO CONTOURS 100% EXPANSION PROVIDED DETAIIJI)UST FREE CRUSHED'STONE OR WASHED GRAVEL -ZJJ(--)GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM -SUS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 'L�100' TO WELL, 200' IN DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan). ,:L�50' TO CATCH BASIN, 35! .STORMDRAIN, PEPED. WATERS (r/:1(.r'_�1�L..T4 a- �•t:'�.�- (piis = 2v`)� .:... •. .... - (')50' INTERMITTENT DRAINAGE COURSE tV200' /500' RESERVOIR, ETC. 150' GALLEY SYSTEMS IO' MIN TO LEDGE OUTCROP SEPTIC TANK (J10' FROM FOUNDATION; 50' TO WELL WELL (-I�C_JDMNSIONS TO PROPERTY LINES ( -�JLJLOCATION OF SERVICE CONNECTION CCUMIN 15' TO PROPERTY LINE SLOPE (, jz(__)S 0PE IN SSTS AREA (520 %) U��REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS UUPLMfP NOTES (_J _)DOSE 75% OF P�IP OSE VOLUME NOTED (_( )DET =JFORCE.MAIN, (PIPE TYPE, ETC.) //. U D-BOX SHOWN & DETAILED (/ 1 DAY STORAGE ABOVE ALARM CURTAIN D U(__)STANDPIPES, 5'B0-Tff8ffflff, DETAIL (x(_)15' MIN to %, 20'4%,1S1-3%,35'-1b/., 100%-<I% LJC—J20' CD DISCHARGE/100' with 182 cons day discharge U 'MIN to NON - PERFORATED PIPE s � � rte. i�� �'�'� utp��' • II "� � ,� •�t4 � �,�k �'� � b &��L j�t•�e�4 � ��I � � (,�� IB� '�a a dFI III) I E a, �G... jai-. ,...,yT.-�.Lah. a': n.:. .. �:'r -. . -" r.. ...a���i .. �ar: -.. r..r- %i• --�.. � ♦'ter•. rw ..:.-- +a:�v%+�7+r v +c-...a K ;.'.p' ^�:;� -. r. _ �... 4 .. r. ,..:.a.- 7i..� =,L:. �_. LETTER OF AUTIDHORI[ZATffON RE: Property of Located at T /V'a e Tax Map # %� Block I Lot Subdivision of �,, �✓�`J'r 117 Subdivision Lot # Filed Map #/ 7A Date Filed Gentlemen: This letter is to authorize ..1 c 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 tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health ; .. .. . .. Co,...oand tic 'ulna rrCounty ariiG ary . � p -. _ �. . r -r . 0 n � • +�°Y�+....x .h a.6.'o�C« , - _ . .. .a�r • -• -Oy . Countersigned: P.E., R.A., # Mailing Address State i Ell 1� z Gies .00,9 Very truly yours, i Signed: (Owner of Property) Mailing Address: d , vi S� ,I,c � &LilaW _ State Zip D S 7 Telephone: '/�' z Z % Telephone: 2 l� s Form LA -97 02/03/2003 11:23 9149624248 JOSEPH SULLIVAN PAGE 01 PUTNAM COUNTY DEPARTMENT OF HEALTH E r DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner, &mve-1 L,;� W c-r— Address 2- 0_147o e4J,-,j:j Located at (Street) 67 Tax Map 7,04 Block Lot 0/ 6 (indicate nearest cross street) Municipality _PV1txA= 211"ile4v Watershed. SOIL PERCOLATION TEST DATA j6/%bWiV--*7 '4Z_e_49_ Date of Pro-soaking Date of Percolation Test percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60:min/inch) All data to be submitted for review. 2.. Depth measurements to be made from top of hole. Form DD-97 FEB-5-2003 WED 11:48 TEL:845-278-7921 NAME:PUTNAM COUNTY DEPARTMENT OF P ....................... R -RA 'E"i tM, oxi n .9 1 Jed /4 21 .2 2 3 5 2 3 4 2 3 4 NOTES: I Tests to be rcmted at same death until avoroximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60:min/inch) All data to be submitted for review. 2.. Depth measurements to be made from top of hole. Form DD-97 FEB-5-2003 WED 11:48 TEL:845-278-7921 NAME:PUTNAM COUNTY DEPARTMENT OF P l!"s F 1EA J .1 NA.M., CGOTY DEPARTMENT 0. .7%;LTH 'E -1 S -13 2AC A612- r Su' S R1 Owner ax Map Block Lot Lo ca (td ..I( ".SV",eet T e- (lid' to 11F1W*Q.5t or SStj,0et ly Ile- y Watershed SOIL PERCOLATION TEST DATA Dat e t -'s C) a <. In R Date of Perco'lationlut 77 71" . . . . . . . . . . . . Dqth 4Q W*t` xe� I 111m( from Gro Surface 961, iy 1� 1 1. 144.. N_q URO 1" -`$top: 4p st :411, Start st -V_ 3 47 4., .i*'(,'Stst()t)01'ei)etitedat swine dei)-tli U11til t1DDl-0X1'1Y1,1t01V COLIal Dercolatlon rates m abuind as Percolation test hole, -(i.e. $ I min liar 1-30 min/inch, s 2 min for 31-60-minhat) AU ftfobe sui�rnitted for review, to be made from top oftolQ, F©= DD-97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 4. ,.. .... .E'an�:��:..•ITOLEN0. G.L. 1.0' _ 2.0' I 'I 2.5' l 3.0' j 3.5' ! ' 4.0' - - - -- I 4.5' 5.0' ` 8.0 9.0' Indical e.. l.cvel at which groundwater is encountered indic-irre level at which mottling is observed Inclir•,.d.c (evd to which water level rises after being encowitered Deep Bole observations made by: Date Deslj :c,n 1= 'roR��,ssional Name: 412 - a ` l'�/G�� Design Professional's Seat 02/03/2003 11:23 9149624248 JOSEPH SULLIVAN PAGE 02 . DEPTH G.L. 0.51 fl.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.01 4.51 5.0' 5.3' 6.®' 6.5' 7.0' 7.5' 8.0' 9.5' 10.01 TEST l?ff DATA p gON w gg WNR7E N HOI{ TE � y..1 '..•t" t,... b't.aT+S n:`o..,if "tom. :.m.'.. a> ...... N. ..•.H.i...y '. .•, HOLE No. HOLE NO, HOLE NO. Desip Fr®fessu®ma09s SuR FEB -5 -2003 WED 11:49 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCQUNTERED IN TEST HOLES i Pa.�` -..1�; 14.Alrry,..er'+.e. +::'r G.L. 05O 0.51 1.0' J 2.0' 2.51 3.0' ©�� �bL✓� v 3.5' 4.0' Owd 4.5' 5.0' 5.5' 6.0' e 7.0' .5';; 8.0' 8.5' 9.0' 51 , o r .. .. .. _.. -.�. ..�.... �-..r -�.e �..... _ .. ....- .. v .. .. a .. .. .... .. .... v, 10.0' Indicate level at which groundwater is encountered,% Indicate level at which mottling is observ6 &" Indicate level to which water level rises after being encountered lJ Deep hole observations made by: Bp f.A, -r12 !)r w8ttUpw► Date Design Professional Name: Address: Signature: Design Professional's Seal 03 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAIL'II'IHI SERVICES �- �! v b � � f L"9�J OV ;-r L3l Y1 IA' `IY bO •-• rr .. v.i.c, •il�w.:;y." -..� . ►7C4.xr r -�.;. y A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: e. W 2. Name of project: .j 3. Location TN: m G 4. Design Professional: 5. Address: zz 6. Drainage Basin: ,��;� r ��� ✓� �/�i o/ fir' ,17 7. TvDe ofPro'ect: 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)? /'cc' Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... AL&___ 10. Has DEIS been completed and found- acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is" this.pzoject in an area under" the control of- local planningzoni� officials, ordinances? ......................................................... ............................... ye 13. If so, have plans been submitted to such authorities? ......... ..... ...... ................. �. . 14. Has preliminary approval been granted by such authorities? )I- te granted: mss' 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? dl°° 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ............. `� 21. Name of sewage system Distance to sewage systemh�/J� 22. Date test_holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) .. ' .J.� (.. ..z.......... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?. ... Ale 26. Has SPDES Application been submitted to local DEC office? ......................... d4# Form PC -97 2 ti 21. 'Is' any portion of this project located within.a designated Town or State wetland? A"I 28. Wetlands ID Number .......................................................... ............................... 29. Is Wetlands P ...................................................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Ala . 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/No Al o DESCRIBE: 33. Is there a local master plan on file with the Town or Tillage? ......................... Alo 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... � 36. Tax Map ID Number .......................... ............................... Map Block Lot ^ /� 37. Approved plans are to be returned to ..... Applicant 1,"4 Design Professional NOTE:. All applications for review and approval of anew SSTS to be located within the NYC Vdatershed-shall be sent to the Denartment, and need not be sentint duplicate to`t.he Psi?; aithougli tne'pidject may require DEP ro -. -- ,apprdval "of ,the_SSZ "$ 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, under penalty of p erjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: telr,-7 Mailing Address ..................... 0 W.01 CrY ]PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Iau -1eu>m ' �teei` i nNill Tax Grid # Map ,�, Block ` Lot(s) ,91G Well Owner: Na e: Address: Use of Well: I -primM 2- second2ry >c Residential Public Suppl Air cond/heat pum 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 _2!<, Open hole in bedrock Other Casing ][Details Total length .21 ft. Length below grade Iq 7". Diameter 4 `' in. Weight per foot /G lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded _, Threaded � Other. .. Seal: � Cement grout .. Bentonite Other Drive shoe:. ,-< Yes No Liner: Yes k'No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) 'Developed? First Yes—No Hours Second Well Yield Vest Bailed Pumped Compressed Air Hours Yield � gpm Depth Data Measure from land surface - static (specify ft) D During yield test(ft) Depth of completed well in feet � Well Log If more detailed information descriptions or sieve analyses are available, please attach. I[De th From Surface Water Bearing Well Diameter(in) Fornfiatiod Description ft. ft. Land Surface 3 d GJ ... . _ ...... . =' 1 v If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Typ - pacity Depth t ` Model 'r ,901 —/'r Voltage O_,i5 J HP Tank Type J 3� -4olume t Date Well Completed a o3 Putnam County Certification No. Date o7Re or ' 0 ell Driller (si ature) NOTT: Exafct location of well with dtttances to at least two perman6n0'landttYaticl to be provided on .a separate sheet/plan.. Well Driller's Name A4 Address: /r?� Signature: 1:24 /I A Date: 0 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 }17.7-- "2 !° tip^ -:Acs i - J` 1 % � %L9 3 ` rte' � - " - �'� �Y••' /`' . �.-•:a --� a i T 9 171 170 i �� �. � , . � � - ry '` �' \• /, � x,22. /� ' j�` Q "Oe5 .77 XP zo r. � +•;tfJ }`3 t53 �, t ; ,0 y` \. :..f••� '- f. � mil'" pY�^ • _. '��.. f - �`�•: 1 -- �- :.:. __.G [i - -mow. - - _ _ - i - '( ��:/9�/�T, S / 0/ y rJ...^ee, n::�ZiiAr.�ef �orr i r i✓ ' it i