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Home My WebLink About3617DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.10 -1 -44 BOX 28 03617 I Is Is Is �i ` jr T • rl Ass, � `' I '. �• r. , ir ;r Is t"�"4 b 03617 I .. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR- SEWAGE-�TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 1�< �r/� Town or Village Owner /Applicant Name__ l ktiG Tax Map7j /y Block / Lot Formerly Mailing Address e- Date Construction Permit Issued by PCHD /°- &0 3 Subdivision Name Subd. Lot # Separate Sewerage System built by a q,-yh egr- Address �aM � Zip / Consisting of /z- -3 ?r Gallon Septic Tank and �% G a� ��'' y✓�� r�� Other Requirements: , 11;v /'17 /�r i 0 Water Supply: Public Supply From Address or: 1^ Private Supply Drilled by A . , ;& Address Building Typei1 44' n Has. erosion control been completed? Number of Bedrooms Has garbage grinder been installed? 1 Gf Yr � 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 plains and the standards, rules and regulations of the Putn�ty Department of Health. Date: l3 d Certified by P.E. J"" R.A. �-- Address 9-972--l' te - --v ��rG� L ! A/'� G c � o #- License # 2-9 Any person occupying premises served by the above take such action as may be necessary to secure the correction of any unsanitary conditions usage. Approval of the separate sewage treatment system shall become null and void as soon a puc ssewer 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: L� Lo � Whit copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 BRUCF1-* R. 1``01 `Y LORETTA NIOLJN,! RI Public Yealrh Directol, Associate Filblic Director of DEPARTMENT -OF 14.,AL TH I Geneva Road Brewster, New York '10509 Liwirunment-al 11culth (914)M-600 Fwx (914) 278 - 792 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (9) 4) 278 - 6014 Preschool (914) 278-6082 Fax (914) 278 - 660 E911 ADDRES—.-'S VEMIETICATI )D� FOLIM TAX N11A1'' MINIBER: E, 9 1 t A, 3'.) 1) R E SS: 'I"'OWN: ALFFHORIZED'I"OWN OF DA11'. VA A 'Ch e Putnam COUTICY Departnient of' 1-teaftft will not issue a M., t.'oll:i Compliance unless the above form is completed, i.e., cress is assityned by an authorized town official. This form is tc �UVCLALNI,� wit-11 the applice-4tion for a Certificate Of Construction Compliance, 0, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location S ' reet Address:'7i y' Milo T n/Village: cue Tax Grid # Map7¢.,lo Block Lot(s)41- Well Owner: Na e: Address: Use of Well: 1- primary 2- secondary K, Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment _>I— Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing •� Open hole in bedrock Other Casing Details Total length I ft. Length below grade Diameter �` in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded (Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: X Yes No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped X' Compressed Air Hours Yield �D gpm Depth Data Measure from land surface - static (specify ft) - 3b During yield test(ft) Depth of completed well in feet i -3vo Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 9 `' _ o If yield was tested at different depths during drilling, list: Feet Gallons Per Minute 1114s Pump /Storage Tank Information Pump Type 3,U�,Q, Capacity _ /D�OScs Depth Mode. Voltage 2,30 HP t Tank Type ty L -fo Volu e Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) NOTE: hRact location of well wttn atstances to at least two ermaneT ianaiparKS io De provtueu on a separa�c snccvpia.1. Well Driller's Name / Address: Signature: Date. 1 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 � / � YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y., 10598 (914) 245-.2900 Albert H. Padovani, Director LAB #: 32.310307 CLIENT #: 12591 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MJD CONTRACTING-CORP. 1290 WILSON RD. YORKTOWN, NY 10598 DATE/TIME TAKEN: 12/30/03 04o00P DATE/TIME REC'D: 12/31/0301:00P REPORT DATE: 01/08/04 PHONE: (914)-245-0880 SAMPLING SITE: 288 BARGER ST PUTNAM VALLEY NY SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE COL'D BY: BEN COZZI TEMPERATURE..: < 4C NOTES...: NAIN BATHROOM SINK COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE RESULT NORMAL - RANGE: PUTNAM CNTY PROFILE 12/31/03 MF T. COLIFORM ABSENT /100 ML ABSENT 12/31/03 LEAD (IMS) I <1 ppb 0-15 ppb 12/31/03 NITRATE NITROG 5.13 MG/L O - 10 12/31/03 NITRITE NITROG <O.01 MG/L N/A ` 12/31/03 IRON (Fe) <0.060 MG/L 0-0.3 mg/1 12/31/03 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 12/31/03 SODIUM (Na) 74.7 MG/L N/A 12/31/03 pH 6.9 UNITS 6.5-8.5 12/31/03 HARDNESS,TOTAL 43.0 MG/L N/A 12/31/03 ALKALINITY (AS 26.0 MG/L N/A 121/31/03 TURBIDITY (TUR 1.2 NTU . 0-5NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDII�:)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. . -iblic schools are set at 15 ppb. Rule for Public System-, 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 ` .� YML ENVIRONMENTAL SERVICES 321 Kear Strebt Yorktown Heights, N.Y. 10598 (9-4)-24` 8(40�--~'��`��-'`'`�-^`~-~'^�' Albert H. Padovani, Director | LAB #: 32.310307 CLIENT #: 12591 NON STAT PROC PAGE - 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MJD CONTRACTING CORP. 1290 WILSON RD. YORKTOWN, NY 10598 DATE/TIME TAKEN: 12/30/03 04;00P DATE/TIME REC'D: 12/31/03 01:00P REPORT DATE: 01/08/04 PHONE: (914)-245-0880 SAMPLING SITE: 288 BARGER ST PUTNAM VALLEY NY SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE COL'D BY: BEN COZZI TEMPERATURE..: < 4C NOTES...: NAIN BATHROOM SINK COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE 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 TO 8.5. . H 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 MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER ,. SUBMITTED BY: ` Director ELAP# 10323 DIVISION O ENVIRON MENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE Y. A`..I,IE TR EATM ENT SYSTEM Owner or Purchaser of Building Building Constructed by Location--/ Street Building Type 7-4,40 l 411--14 Tax Map Block Lot TownNillage / 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 system The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the buil ng utilizing the system. Dated: Month Day 1-3 Year D General Contractor er) - Signature Signature: Title: /" „e S v Corporation Name (if corporation) Corporation Name (if corporation) Address: c ,,,A M _r c ¢— S51 State ti" Zip c� S Address: State i Form GS -97 PUTNAM COUNTY DEPARTMENT OF. HEALTH • .A DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: [ o Inspected by: Jsp Street Location S v Owner, 1,,,,,�4 ` - -, .$ _ . Town _ ... :��,;.._. ,>, . �._ � Permit # �� - �2 s TM # Subdivision Lot 7ke j.4 6 0Y 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........;..... :...... .. :........... d. Distribution Box -/ j/4 1. 1 outlets at a evation -water tes ed ....... :........ 2. Pr et Blow frost .................. ............................... f�3.i mum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. Trenches, Length installed S !� 2. Distance to watercourse measured Ft, � 3. Installed according to plan .... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft, from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................; 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends ca ed ....................... .•:.....:..,._...... pp ....... v......g. Pum or Dose Systems -::. ; 1. Size of pump chamber . ................ 2. Overflow tank...... . ................... ............................... 3. Alarm, visuaU io ........:........:.. ............................... 4. Pump ea ' accessible, manhole to grade ................. 5. Firs x baffled .......................... ............................... 6. cle witnessed by H.D.estimated flow /cycle........... III. House udding a. house located er approved plans . .......................:....... b. Number of bearrooms .................. ............................... IV. Well Well located as per approved plans . ......:........................ P. Distance from STS area measured 1106 - ft....:..... . c. Casing 18" above grade ................ .............:................. d. Surface drainage around well acceptable ....................... V. Overall Worlananshiu . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfll material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :.......................... i. Erosion control provided .................. ............................... Rev. 12102 10%27/2003 05:25 9149624248 JOSEPH SULLIVAN PAGE 01 Y csa* that the emm(sl as titled, a4 tho *m p imim bu tm cmkuoW aoW I bm bspeoW ad valued their compWan Na accordsm with the W* Pm c"Wadva %t sad approved p 'mW the SU*4uds, R" and RMpAidw of the !uAm CoWy DqwWW ®f OCT -27 -2003 MON 06:55 TEL:845- 278 -7921 elk 0 Q NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 ,`PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM �o PERMIT # � 03 Located at Town or Village /'y /;�/ 41177 )o Subdivision name Subd. Lot # 57 Tax Map A� / Block / Lot -,*t4 Date Subdivision Approved if12-/1 9� Owner /Applicant Name a/, Ire, CP rl Mailing Address /r-7 fe Renewal Revision Date of Previous Approval Zip'*0; Amount of Fee Enclosed 3 ,0Q Building Type & i,Awee Lot Area 2,611 No. of Bedrooms Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S/� sy te-m to consist of % �/ <ti gallon septic tank and Other Requirements: az3 To be constructed by f w 19 e- /-,- Address e Water Supply: Public Supply_ From Address - or: - Private Supply l7rihed bye 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 agcordance 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 approval of the Certificate of Construction Compliance of the original system or any repairs thereto. of WtV co ��,pNC1SSG Signed: ,,c� �/✓ E. R.A. Date 1 '� Address 2 9 7 ,V- License # APPROVED FOR CONSTRUCTI R a2xpires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and. is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. Approved for discharge of domestic sanitary sewage only. By: Title: !-Fe&a fmineer- Date: 7/3 10 3 copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUT NAM (COUNTY DEPARTMENT 07 HEALTH H SDI[ gSffON OF ENVIRONMENTAL HEALTH H SEI[8V CES APPLICATION TO CONSTRUCT A WATER WELL :. please prin 6r type HD 1'ermlt # WeH Location: Street Address: Town/ Tax Grid # /Village ✓ �''7'- I�t /��'r,? l�c�� 1 Map 7-�-, 1 Block 1 Lots) ,,U Weep Owner: am : Name"' /iJ1,7 C,�� Address: 1�� -� yZ�; / �J / �� /� ��l�il Al Use of WeRl: "esidential Public Supply _Air/ConcMeat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondalry Industrial Institutional Standby Amount of Use Yield Sought r gpm # People Served 4 Est. of Daily Usage d e;z gal. Reason for Replace Existing Supply Test/Observation Additional Supply Dripping New Supply (new dwelling) Deepen Existing Well Detailed Reason for IID>rilping Wen Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ....................................... ............................... Yes I," No Name of subdivision 1-/i e,.,w -o �� 1 /z� Lot No. Water Well Contractor: �L''/ i�ul�� d,-, Address: /9-0 r' -LL— /— �V' Is Public Water Supply available to site? .................................. .............. .................. Yes No jv Name of Public Water Supply: Town/Village Distance to property from nearest water main: "041-'`AS Proposed well location & sources of contamination to be provided on separate sheet/plan. `J Date:.�� -. Applicant Signature: `,_,` - 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. A Date of Issue 3 /0 3 Permit Issuing Official: Date of Expiration d Title: As5i5lZ ub rec ed need Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM' COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT: SYSTEMS REVILW SHEET FOR`CONSTRUCTION PERMIT f y NAME OF OWNER: ETLOCATION:d'-'� J� REVIEWED.BY: RM, GR, Aff, SRDATE: J 3 TAX MAP#.: (CONFIRMED) � -1 Y /� DOCUMENTS Y /N (REQUIRED DETAILS ON PLANS CONT'D1 (� )PERNIIT APPLICATION t - )HOUSE SEWER -'/." FT. 4 "0'; TYPE PIPE. CAST IRON L )� WELL PERWr OR PWS LETTER (�UNO BENDS; MAX BENDS 45' W /CLEANOUT (__- )a�C 97 RE (�!}(_JLETTER OF AUTHORIZATION GE) L �(�DESIGN DATA SHEET (DDS) FILL SYSTEM ( �_•/_)/ CORPORATE RESOLUTION La/SO'HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (( !: — SHORT EAF PLANS -THREE SETS U ' s ECSlrFII;L NOTES -1 =5^ r/ (�kTOUSE PLANS - TWO SETS C % � L PROFILE & DIMENSIONS VARIANCE REQUEST `�� --)'L IN EXPANSION AREA (---)U FILL GREA TER THAN FE SUBDIVISION '(_�)C:_j CLAY BARRIER �LEGAL SUBDIVISION 1 ?�1"�1 UUFJLI _CERTIFICATI TE SUBDTVISION APPROVAL CHECKED., j-bla- WFILL PERC RATE WD - vUVO GA REQUIRED DEPTH -JL_ )VO LAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS CURTAIN DRAIN REQUIRED Lj PARATION DISTANCE FROMTOE OF SLOPE __ TRENCH U �✓ ATED .IN NYC WATERSHED LF TRENCH PROVIDED 60FT MAX. Jr % PARALLEL 'TO CONTOURS (_ PLANS SUBMITTED TO DEP 100% EXPANSION PROVIDED UD LEGATED TO PCHD DETACAUST FREE CRUSHED'STONE OR WASHED GRAVEL EP APPROVAL, IF REQ'D UGEOTEXTILE COVER. L__)pEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROMISSTS (�U // PERCS TO BE WITNESSED (t� 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL SSDS ADJ, LOTS (� `� , 20 TO FOUNDATION WALLS �_)L',-��-Fx--APPROVAL ETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 200' IN DLOD,150' TQ PITS �ATA ON DDS PLANS & PERMIT SAME . (_)C!: )PRE 1969 NEIGHBOR NOTIFICATION 100' TO STREAM, WATERCOURSE, LAKE Inc. ez a 50. TO.CATCH BASIN, 35 STORMDRAIN; WPED. WATER -- - TO WATER LINE (Pits - 20') UC� :•- FLOOD'ELEVATIOI�fV�l�' 200'.• �• _.. � , `� (J50 INTERMITTENT DRAINAGE COURSE (� SOM TESTING LOTS>10 YEARS OLD (200'/500' RESERVOI t, ETC. 150' GALLEY SYSTEMS REQUIRED DETAILS ON PLANS- : 0' MIN TO LEDGE.OUTCROP C_j (SEWAGE SYSTEM PLAN - (NORTH ARROW). SEPTIC TANK SDS HYDRAULIC PROFILE (_JU10' FROM FOUNDATION; 50' TO WELL ( lt% )GRAVITY FLOW 7( }U WELL — CONSTRUCTION NOTES 1 -15 (-� DDIMENSIONS TO PROPERTY LINES (� ✓DESIGN DATA: PERC &DEEP RESULTS U — LOCATION OF SERVICE CONNECTION .(�2' CONTOURS EXISTING & PROPOSED �� 15' TO'PROPERTY LINE (DRIVEWAY & SLOPES, CUT SLOPE U(,)FOOTING/GMER/CURTAIN DRAINS �&-RE OPE IN SSTS AREA / (S20 /o) (-JL,JUSDA SOIL TYPE BOUNDARIES o UUT.ITLE BLOCK, OWNERS NAME ADDRESS U GRADED TO 15 %, IF REQUIRED TM#, PE/RA; NAME, ADDRESS, PHONE# ' . DQSEmuw SYSTEMS-.-- (-JL_,)DATE OF DRAWING/REVISION UUPUMP NOTES . UUDATUM REFERENCE . UUDOSE 75°/ VOLUME/DOSE VOLUME NOTED L_JLJLOCATION OF WATERCOURSES, PONDS U AIL FOR FORCKMAIN, (PIPE TYPE, ETC.) LAKES,WETLANDS'WTTHIN 200' OF P.L. IT AND D -BOX SHOWN & DETAILED UUPROPOSED FINISH FLOOR AND U 1 DAY STORAGE ABOVE ALARM BASEMENT ELEVATIONS CURTAIN DRAIN (_JU,WELI,S & SSDS'S WAIN 200' OF SSTS STANDPIPES, 5' BOTH SIDES, DETAIL L JL _PROPERTY METES & BOUNDS 15' MIN to CDS=>S %, 20'-4%,15'-3%,35'-l'/'o, 100%.<I% (-J(_JEROSION CONTROL FOR - HOUSE, WELL & 0' MIN to CD DISCHARGE/100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE (_)(_J10' MIN to NON - PERFORATED PIPE EVSHMT)09 /01/00 jMs N 1.' ,i i ! o)) ID v,{+ tai F/F N, P. ENVIRONMENTAL HEALTH SERVICES RE-. Property of LETTER OF AUTHORIZATION 141 Or V a,� Located at /5 a r ti T/V�c�i' Tax Map # Block _Z Lot Subdivision of Subdivision Lot # Gentlemen: This letter is to authorize Filed Map # 26 3410 Date Filed a duly licensed Professional Engineer v� 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 .14.7 of.the Education,Law,:the. Public Health Law, and the Putnam County Sanitary (:ode. r ante si e P.E.,R—A., # 7 Telephone: 19--12— % Z Very truly yours, Signed: Mailing Address: State 2, / Zip Telephone: Form LA -97 R JET ID NUMBER 817'20 SEQR P O C APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only _ - : • ...�..'. _.:. mow.. ��.. •.w,: .:_,. r•:D -... PART i - RR-0JEiGT- F0KMATION ^' (�'To'be completed by Applicant or'Project Sponsor)_ 1. APPLICANT /SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: Municipality TJ / f �JlfA�! l� v�� County 4. PRECISE LOCATION: Street Addess annc Road In erseLtions. Prominent landmarks etcG• or provide %OOtI `GriT�'y/ T% t�G�1�1 CZ /ice G� 5. IS PROPOSED ACTION: New Expansion a Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: g�� `� / �� /• „��,.'.•� j�� „ J' j1� • 7. AMOUNT OF LAND AFFECTED: Initially f acres Ultimately / acres 8: WILL R'OPOSED ACTION COMPLY' WITH EXISTI G ZONING OR OTHER RESTRICtION$ ?. • : ` Yes 0 No If no, describe briefly: , e as man'as appl .) 9. WHAT IS PRESENT LAND USE IN VICINITY OF . PROJECT? •(Choos y Residential Industrial Commercial Agriculture' 'Park / Forest / Open Space E] Other (describe) •. 1.0. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY.OTHER .GOVERNMENTAL. AGENCY (Federal, State or Local) / >1 �• ' �� { XIYes El No If yes, list agency name and permit approval: 11. DOES ANY ASPECT OF THE ACTION HAVE' A CURRENTLY, VALID :PlrftMlT OR•, APPROVAL ?....,. Yes No -If yes, list agency name and permit / approval. 12. AS A .RE ULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? QYes No I CERTIFY THAT THE; INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Cdr% �"� Date: 'Alit/ _/ Signature---- _�y?i✓�t�''= �i�f�� If the action is a Costal Area, acid you are a state agency, complete the Coastal Assessment Form before 'proceeding with this assessment ..•PART II..- I.MPACT-A.SSEa .5 IFNT (Tcs.b�.campleted by Leac.Agency A. DOES ACTIENO CEED ANY TYPE 'l THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN•6 NYCRR, PART 617.6 ?.' If No, a negative declaration may be superseded by another involved agency. -• Yes. No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing'traffic pattern, 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 comaiLihity or neighborhood character? Explain briefly: - N, 4 C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: N17e 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'actiorY? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: Nolte C7. Other impacts (including changes in use of either quantity or type of energy? .Explain briefljr? ' D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL — ENVIRONMENTAL -AP.EA (CEA)? (If yes, ex Lain brieFl -' Yes" No E. IS THERE, O,R� IS,(THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex lain: Yes N0 PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impactof the proposed action on the environmental characteristics of theCEA. Check this box if you have identified one or more potentially large or significant adverse impact's 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 actin WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency ° ; �� Date ,, �6�eeZ Print 6r Type Name of Responsible Officer i e110-1 ° ail Title of Responsible Officer, wvtana i 75ignature of Responsible Officer i Agency Signature of Preparer (If different from responsible officer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address 12-?-dk11/,<e,,7 Al Located at"(Street) -TaX.Map 74.E -Block : -*/ Lot .44- (indica't'e' nearest cross street) Municipality L244 M -f Watershed— /45a rjf 41 SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test . ........ ... ....... . .... ...... ...... ....... ... .................. ............ .. ... ........ ... ....... ............ I .......................... . ......... ........ .... .... ... ........ ... ....... M --th e p t at ate Hole No Run No ..... ..... ........ T�we ........ Ala se Time From .. Surface : A ac es) Level I ID I Inches erco A on .............. : 0 ...... ..... . ...... .. ... ... : 3e, -2 2- 0- � - 3z ?1 . 2– 3 2� .3 4 5 367 lk5 2 ;? --a 2- V 3 3o z0 2-v 4 5 2 3 4 NOTES: 1. Tests to'be repeated at same depth until approximately equal percolation rates are obtained at each r[" test :5 hole. (i.e. 1 min for 1 -30 s perc�Ia ti�o min inch, 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. % HOLE NO. � HOLE NO. 1-10 0.5' 1.0' 1.5' 2.0' 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' --9.0' 9.5' 10.0'. Indicate level at which groundwater is encountered 'Ole Indicate level at which mottling is observed a �� Indicate level to which* water level rises after being encountered Deep hole observations made by: - , f1;Y¢;;5;, Date d-� Design Professional Name: //i ✓cs� AAA - 'K,— 7 Signature: ..M. c Z'' Indicate level at which groundwater is encountered 'Ole Indicate level at which mottling is observed a �� Indicate level to which* water level rises after being encountered Deep hole observations made by: - , f1;Y¢;;5;, Date d-� Design Professional Name: //i ✓cs� AAA - 'K,— 7 Signature: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT. SYSTEM.. 1. Name and address of applicant: 2. Name of project: 3. 4. Design Professional:, >�, ��i 1�� 5. 6. Drainage Basin: 7. T e of Project: . Private/Residential Apartments Office Building Location T/ V: L, lweg � Address: Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review ,(SEQR)? Type Status check one : Yp ( ) .....................: .............. .................. Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ............. ............. �a 10. Has DEIS been completed and found acceptable by Lead'Agency? .. .............. 11. Name of Lead Agency -- 12. Is this project in; an area under the control of local planning, zoning,-or other, officials, ordinances ...................... .. ......� -:.. • . .....: 13. If so, have plans been submitted-to such authorities. e� 14. Has preliminary approval been granted by such authorities? Date granted: 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) ..... .................................................................. ..... A 18. Is project located near a public water supply system? ........................... :............. Ale 19. If yes, name .of water. supply Distance to water supply h5 4V 20. Is project site near a public sewage collection or treatment system? ................ .moo 21. Name of sewage system Distance. to sewage system /5% 22. 'Date test holes observed :� �' .23. •Name of Health Inspector ` °''a 1A/ 24. Project design flow (gallons per day) ......... ............................... ............ zGa 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... Ale' 2 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC- 97 -27. Is any portion of this project located within a designated Town or State wetland? All' 28. Wetlands ID Number...: ........ .•... _ 29. Is Wetlands Permit required? .............................................. ............................... Ale Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? ... ............................... Ales 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfillingi sludge application or industnal'activi Yes/No A& 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 known source of contamination? Yes/No f�/D 'DESCRIBE: 33. Is there a local master plan on f le with the Town or Village? ....................... ... A/a 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? ....... .- ........................ :a. 36. Tax Map ID Number .......................................... .. .......... Map k.% Block / Lot 37. Approved plans are to be returned to ..... Applicant P"besign'Professional ...N -.A cfor :_review and'approval of new- SSTS`to be located-widdrrfthe NYC watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other.aspects of a project, such as stormwater plans or the, creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I herebpy of rm, under penaltny of perjury➢ that information provided on this form is true to the best of my knowledge. and belief.. False statements Made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SICNATURlE'S A OF'FICI L TITLES. Nnr . xas Mailing Address ; Z�1?0`11� 433. l • PUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES• �r•.. �y�.':::.' r,,.:: ITIAI.• AA; YB!-. B+ T�YI'Sc1.4JSSi:J /ti��1�ll�i.iJi \VIAL SIT.L:/INSPi%IVN'1' 0R1, I.i'i :.'..:: .,,.•,•r..••. ., ••�, ••••!�•�• SECTION A. GENERAL INFORMATION Name of Project.2. �' (T)(V)' 1+ County . Site Location • Building construction :begun Extent . Is property within NYC Watershed ? ...........:..... a Yes �-No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. F-1 'Hilly.' --0 Rolling a Steep slope Gentle slope Flat ' 'N 2. evi�exi • ee.of wetlands a Low area subject to flooding L Bodies of water Drainage ditches Rock outcrops I, Property lines or. corners. evident ................ :......................... :..:.............. des No. 4. Do water courses exist on'or adjoin the property ?.. ..........:................ Ye No ; 5. Will these affect the design of the sewage system facilities ?.:......... Y s No 6.. Do watershed regulations apply in this development ? .. ...................... F7 Yes No 7 Will extensive grading be necessary? ................. ............................... Yes. i No. 8. Will extensive fill be necessary for SS` TS? .................... . ................ :.. n Yes No'. ... ..... w_ n.... .r ..... _ •fit • L� • - -- �- ��, .'W.:�_ ..... ... ..... ..._.. ._ �. - . , 9" Do filled' areas exist th"mi. the S S T S area? ........ ............................... Yes No If yes, what is the condition of the fill? SECTION C: SOIL OBSERVATIONS 10. Appearance of goi . d Gravel oam . 0 Clay _ Q Hardpan Q Mixture 11. Observed from: a Borings F_� - Bank cut.' ackhoe excavations.. 12. Soil borings /excavations observed by (:J� on v 13. Depth to groundwater on 14. Depth to mottling /.,�' on 15. Are test. holes representative of primary & reserve areas ...... ............................... EYes El No 16. Soil percolation tests made by Soh on 17. Soil percolation tests witnessed by /[,� on SECTION D (on back) Form ST -1 SEcnmmn, IlPQATW,&G1E- 2 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes 1 19. Will groundwater or surface drainage require special consideration? ..................:... Q Yes E Fo 20. Will gullies, ditches, etc:, be filled and watercourses be relocated ? ......................... F-� Yes �[O SECTION E. &tEMA,RK 21. If a cominon water supply is proposed; has an inspection been. made of the existing or proposed source and facilities? .............. ................................... .................... Q Yes KN o, Inspection data 22. Do adjacent wells- and /or sewage systems 'exist? ..................... ............................... �j'Yes a -Na 23. Additional comments :. 001 ( /o .24. Site observer /inspector and title 25. Date( s ) -of observation(S)inspection(s) 41,11d 'TEST PIT PROFILES Hole # Lot # _ Hole #_ Lot # .-Hole # Lot # Depth to water All Depth to water Depth to water Depth to mottling Depth to_mottling Depth -to °mvttlirig �• Depth to rock/imp. l/v -' Depth to rock/imp. Depth to rockhmp. .G.L. Q��j G.L. G.L. _ I 10 L 2.0 Lnav►^ 4.0� e, 0.5 .. 0.5 1.0 2.0 3.0 4.0 .1.0 2.0 3.0 4.0 5.0 5.0 5.0 6.0 9.0 6.0 6.0 7.0 r � 9.0 .9.0. 10.0 10.0 10.0 ■ XX ION PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES o WELL COMPLETION REPORT Well Location S 'reet Address: �� Ally T Nilla e: Tax Grid # Map -74,jo Block Lot(s) .4.* Well Owner: N e: Address: Use of Well: 1- primary 2- secondary X Residential . Public. Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing X� Open hole in bedrock Other Casing Details Total length / ft. Length below grade >/ft. Diameter Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded (Threaded _ Other. Seal: Cement grout _ Bentonite Other Drive shoe: X Yes No _ Liner Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test Bailed _ Pumped _x Compressed Air Hours �- Yield 7,0 gpm Depth Data Measure from land surface- static (specify ft) 1 3� During yield test(ft) ]Depth - of completed well in feet � moo Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land-Surface 9 " . 1- ri-a If yield was tested at different depths during drilling, list: Feet Gallons Per Minute 1114.5 Pump /Storage Tank Information Pump Type-3AZLg, Capacity Depth •:Xn Mode Voltage 2,30. HP Tank Type —LS�o Volu e _� Date Well Completed o Putnam County Certification No. Date of Report Well Driller (signature) N?TE: hkact location ot-well with distances to at least two ermane7 lan4arks to be provided on a separate sheet/plan. Well Driller's Name _ I Address: Signature: Date: Date: / !��i White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller