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PUTNAM COUNTY DEPARTMENT OF HEALTH
_......_:.... JVISION: OF F -
EN�RON�!IX.I.INT.P. M r.:k .l..I. , I L .H.. SE • YvY� . -
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT #
Located at PgRk �R / "� Town Village
Owner /Applicant Name If /U Tax Map %�,, /v Block Lot
Formerly
Subdivision Name A //' � of
Subd. Lot # 4
Mailing Address a-Y /p- .- "r.6... U U 'g A - Zip
Date Construction Permit Issued by PCHD
Separate Sewerage System built by /°%U✓ r, 41 d Address / "r Z���� ~' "/ ."f°l
Consisting of /l Gall Septic Tank and eQ Z_ d %
Other Requirements:
Water Supply:
Public Supply From,
or: Private Supply Drilled by
Address
Address
B !ding =l � � - �� /• 0a �'
Has erosion control beer. con.pleied?
Number of Bedrooms !!f� Has garbage grinder been installed?
/VC
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 P tnam County Department of Health.
Z
Date: _i/ y G Certified by P.E. R.A.
(Design Pr essional)
Address ���� d df -girl. �f ti e/
441- - -- License #
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 of change when, in the judgment of the Public Health Director, such
revoca 'on, modification or change is necessary.
By: Title: A-k:� Date:
White copy - HD f ile; Yell'oWcopy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
ION OF ENVIRONMENTAL HEALTH SERVICES
V?l 31'02- __.. WELL COMPLETION REPORT
Well ILticatA- _2
eet Address:
park b �jv�°
To` )re. /
GC IIGaIq► (Oa e, �
Tax Grid # ,
Map �, /OBlock / Lot(s)
Well Owner:
Name: / Address:
1/a c6h Strut 6 K
Use of Well:
1- primary
2- secondary
Residential Public 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 ft.
Length below grade ft.
Diameter % in.
Weight per foot _L7_lb /ft.
Materials: _ Steel _ Plastic _ Other
Joints: _ Welded . Threaded _ Other
Seal: _ Cement grout Bentonite Other
Drive shoe: -X 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 _X Compressed Air
Hours _(5
Yield _ gpm
Depth Data
Measure from land surface - static (specify ft)
`44 na
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
si66"_a.lysee
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
-f-
�j
%/
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type r,,Capacity i_ZP%
Depth 3 _60 Model 261-0 7
Voltage 0,6 HP -�
Tank Type �c- I Volume
DateWell omplet d
/
Putnam County Certification No.
067
Date of R port
i e3' a�-
Well Driller (signature)
NO'1(T .V: Exact location of well with distances to at least two permanept IanatnarKS to De provtaea on a separ snucupla,l.
Well Driller's Name )#J) GU Address: zo `
Signature: Date: a
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Public Health Director
January 23, 2002
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
L•61 `fT'A• MOLINAPULIZ::�T:;
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 (845)278-6014 Fax(845)278-6648
Preschool (845)228-5912 Fax(845)229-6113
Dan Donahue, PE
120 Breckenridge Road
Mahopac, New York 10541
Re: .Field Inspection - Sunset Hill Developers
of Putnam Valley Inc., Park Drive, Lot A
TM# 74.10 -1 -21
Dear Mr. Donahue:
The above referenced separate sewage treatment system can be backfilled. The following
comments must be corrected in the field:
1. Grading around the well needs to be completed. Please note that the well casing must
maintain eighteen inches above grade.
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
Very truly yours,
Gene D. Reed
GDR:cj Environmental Health Engineering Aide
YML ENVIRONMENTAL SERVICES
321 Kear Street
N.Y. 105913
| `'^^' 245-2800 |
Albert H. Padovani, Director
LAB #: 32.201982 CLIENT #:'55136 ' NON STAT PR[KC PAGE 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~°~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
OTERO,SOCORRO DATE/TIME TAKEN: 03/18/02 11:10A
P.O. BOX 125 . DATE/TIME REC'D: 03/19/02 12:10P-
SHRUB OAK, NY 10588 REPORT DATE: 03/20y02
PHONE: (914)-962-9844
SAMPLING SITE: 40 PARK DR,PUTNAM VALLEY,NY SAMPLE TYPE..: POTABLE
: KIT TAP PRESERVATIVES: NONE
COL'D BY: TEMPERATURE..:
NOTES—: COLIFORM-METH: N/A
DATE FLAG PROCEDURE RESULT NORMAL -- RANGE METHOD
03/19/02 TURBIDITY (TUR <1 NTU 0-5 NTU
,
.-'- -~
SUBMITTED
AfF)ert H.
' Director
ELAP# 10323
YML ENVIRONMENTAL SERVICES
321 Kear Street �
Y�� ,_ _��;� � =���.���`��=����
Albert H. Padovani, Director
LAB #h 32.200779 CLIENT #: 55136 NON STAT PROC PAGE 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~'~~~~~~~~~~~~~~
OTERO,SOCORRO DATE/TIME TAKEN: 02/04/02 03:451::'
P.O. BOX 125 DATE/TIME REC'D: 02/04/02 04:20P
SHRUB OAK, NY 10588 ' REPORT DATEt 02/09/02
PHONE: (914)-962-9844
SAMPLING SITE: 40 PARK DRlVE,PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE
: BATHROOM TAP PRESERVATlVE5: NONE
� � ' ' ' � �
CAN BY: SOCORRO OTERO TEMPERATURE..: < 4C
NOTES...: COLlFORM METH: Ml::'
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
`
PUTNAM CNTY PROFILE
02/04/02 MF T. COLIFORM ABSENT /100 ML ABSENT 1008
02/04/02 LEAD (INS) <1 ppb 0-15 ppb 910).
02/04/02 NITRATE NITROG 0.60 MG/L 0 - 10 9139
02/04/02 NITRITE NITROG <0"01 MG/L N/A 9146
02/04/02 IRON (Fe) 0.085 MG/L 0-0.3 mg/l 2037
02/04/02 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/1 2037
02/04/02 SODIUM (Na) 7.07 MG/L N/A
02/04/02 pH 7.2 UNITS 6.5-8.5 9043
02/04/02 HARDNESS,TOTAL 154 MG/L N/A `
02/04/02 ALKALINITY (AS 128 MG/L N/A
.,. 2/04/02 ,.� .��]RBIDJT`Y'(Tl]R�� .'' '^6.E�-NTU -='
��, .� ` - ^` ' .�
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATE S NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDIN�*�f�-f|E NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE TIME OF COLLECTlON,,
Pb/Cu LEAD limits for public schools are set at 15 ppb. 04
EPA Lead & Copper Rule for Public Systems requires that no more
than 10% of their distribution points have a LEAD value of more
than 15 ppb and a COPPER value of 1.3 mg/L, else water
treatment must be undertaken to reduce the waters corrosive
potential.
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 sodi 're ed diet,the water should
����_ }��y
contain no more than p��ae/� C"of'^'Sou�um. \For those on a
moderately restricted diet, a��a��i of 270 mg/L of Sodium
^*..
is suggested.
� t
DIVISION OFENVIRONMENTAL HEALTH SERVICES......
GUARANTEE OF SUBSURFACE SE WAGE TREATMENT SYSTEM
4 o2
Owner or Purchaser of Building. Tax Map Block Lot
I , �r/Y4 v/; /4 0 v o� e�� 1i-�
Bu ding Constructed by To illage
4 P, e,
Location - Street
� / z %
Building Type
Subdivision Name
0
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 7 buil ' g tilizing the
system. �i
a2
Owner) - Signature
Corporation Name (if corporation)
Signature:
Title:
Corporation Name (if corporation)
Address: ell 4/5 �4cle 111�fllr/�,>Address:
State Zip State _
Zip
Form GS -97
BRUCE R:. F,SJi.ly1'...,....... r
Public Health Director
,. ., LOP ETFA,..P. OLiNARI- R id.,- M.S.N.-v, -
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 (9I4) 278 —6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 .
E911 ADDRESS VERIFICATION FORM
OWNERS NAME:
TAX MAP NUMBER:
E911 ADDRESS:
TOWN:
AUTHORIZED TOWN OF
(Signature)
DATE:
4
7.10 -I -41
40 aRK, )IR/ ViC
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.
(E91 l V.ERFRIv1) .
-
DIVISION ®.,- F - ENVI R - Er.. a.T. A — _L Ew., AvL T.H .. ..S.-E...Z..V. Ia? C.r ES
LETTER OF AUTHORIZATION
RE: Property of
Located at �� D W/
�"/ 44, i x Map # 2�fb Block _ Z Lot �-
Subdivision of /N
Subdivision Lot # 14 Filed Map # Date Filed 11161x
Gentlemen:
This letter is to authorize
a duly licensed Professional Engineer or Registered Architect to apply for the required
wastewater treatment and/or water supp y 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 14�7�of the Education Law, .the Public Health
_.. �.... _ .. _. __.._ ........ ,a - -. _ ...
Law, and the Putnam County Sanitary Code.
Countersigned:
R.A., #
Mailin g Address l0ly
Very to
Signed:
Mailing Address: -V. J, ) dk
State Zip State `%� Zip 1 O.SeC
Telephone: ��' ��F'f Telephone: 76
Form LA -97
,1:
0
O
Form LA -97
•a
pioDANIEL J. DONAHUE, P.E.
CONSULTING ENGINEERS
,..L. _ .... _.. 12,0.•B zeake-?mdge,:ltoad • . -. ... M.Y. ..v v. ,....
Mahopac, N.Y. 10541
845. 628 -7576
February 19, 2001
Putnam County Department of Health
Geneva Road
Brewster, N.Y. 10509
Att: S. Rogan
RE: As Built SSTS
40 Park Drive
Putnam Valley
Dear Mr. Rogan:
Enclosed please find: l 3/ar
1. Certification of Construction Co r9pliance
LA
2 figj Lg Bacti Results 6 U 44-4-t-
3.
Guarantee and two copies
4. Three copies of the asbuilt plan
5. Filing fee of $200.00
- 6. E911 Verification. Letter :. : _ . , ....
Your prompt attention would be appreciated.
Since
el J. Donahue, P.E.
Site - Sanitary Environmental
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