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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.17 -1 -28 BOX 29 03696 o �4 _ 1v PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES r CERTIFICATE OF CONSTRUCTION COMPLIANCE F GE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 3t icy �� Located g31 P 7,V 1,0 a r= Town illage dl-XJjm Owner /Applicant Name J_ �i y Iy pe 4 Tax Map � Block _� Lot Formerly 41 c y n r'" 4• Subdivision Name-SA Subd. Lot # Mailing-Address g / �Y {s sj -�'; �4i �rri Zip Date Construction Permit Issued by PCHD O� Separate Sewerage System built byc,, 0-,—,y ,M Address ��,�' <rr G?-J �}L �� o�/i Consisting of Lb 60 ^ Gallon Septic Tank and � %° �� � � r.� ,�� /•��� Other Requirements: ih 41-4 dt Water Supply: Public Supply From Address or: Private Supply Drilled by �1�rrh Address F�it'� Building Type_,( %�t��i/�J -ri Has erosion control been completed?--'- Number of Bedrooms _ Has garbage grinder been installed? Ad 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 Putnam Co !�Pepartment of Health. Date: % -' / G Certified by P.E. R.A. Desi Prom sional) 1� Addresses L rfG' -� /1 �� JPe� 02�&O A�c 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 or change when, in the judgment of the Public Health Director, such revocatiom modificati ch ge is necessary. Y• B `L� . Title: i Date: 1 Z 3 0 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 a PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT ' 7 4J7 7 r I -Z .8 Well Location.. St tAc�dress;........... _ ('V7 ' 3� /V:illage:. arc Grids #. 'p— A ap7q.f-7 Block Lot(s)2j Well Owner: Name: ci a Address: O�M�" 31 ?0,,A-2 -i ,) tit. Lr r Use of Well: 1- primary 2- secondary _�Z- Resident' 1 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 _2 Open hole in bedrock Other Casing Details Total length Length below grade �� tiff. Diameter L " in. Weight per foot _jjLIb /ft. Materials:" Steel _ Plastic _ Other Joints: _Welded 7< Threaded Other Seal: Cement grout — Bentonite Other Drive shoe: Yes No Liner: Yes _�10 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 :Zt Yield _1<) gpm Depth Data Measure from land surface -stati c(specify ft) During yield test(ft) Depth of completed well in feet 30 0 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 '3 ell , (} 2e) p If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth 5afv ' Model 5S' -0 !�' 13 Voltage 2-30 HP - -- -by. Tank Type �-S'� Volume y " Date Well Completed Putnam County Certification No. q Date of Report �0 Well Driller (si ature) NOTE:/ Exact location of well with distances to at least two permanent landmarks to be provided on a separate sneevpian. Well Driller's Name Address��"�� Signature: Date: -A G l White copy: HD File; Yellow copy - Building Inspector; Pink'copy - Owner; Orange copy - Well driller Form WC -97 I . YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 ('714> 245-2800.. -t' H.' �' Vahi, LAB #: 32.103761 CLIENT #: 13436 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ` GUMINA, ANTHONY DATE/TIME TAKEN: 06/04/01 03:00p 32 PARTRIDGE LANE DATE/TIME REC'D: 06/04/01 03:40P PUTNAM VALLEY, NY 10579 REPORT DATE: 06/28/01 PHONE: (914)-528-1491 SAMPLING SITE: 31 PARTRIDGE LANE PUTNAM VALLEY, NY, 10579 COL'D BY: NOTES—: WATER TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SAMPLE TYPE..: POTABLE � PRESERVATIVES: 1 .� ' TEMPERATURE. COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ , DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/04/01 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 06/04/01 LEAD (IMS) <1 ppb 0-15 ppb 9101 06/04/01 NITRATE NITROG 2.15 MG/L 0 - 10 9139 06/04/01 NITRITE NITROG <0.01 MG/L N/A 9146 06/04/01 IRON (Fe) 0.060 MG/L 0-0.3 mg/l 2037 06/04/01 MANGANESE (Mn) 0.061 MG/L 0-0.3 mg/l 2037 06/04/01 SODIUM (Na) 20.3 MG/L N/A 06/04/01 pH 5.7 UNITS 6.5-8.5 9043 06/04/01 HARDNESG,TOTAL 124 MG/L N/A 06/04/01 ALKALINITY (AS 38.() MG/L N/A 06/04/01 TURBIDITY (TUR <1 NTU 0-5 NTU -'' CQMMENTS.C: BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIM�-7O THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. � Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. 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 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. IC . ` ^ ' YML ENVIRONMENTAL SERVICES ' . i 321 Kear Street ' 'Yorktown Heights, N.Y. 10598 ' - (914) 245~^280O' ' - � . LAB #: 32.103761 CLIENT #,.- 13436 NON STAT PROC PAGE 2 8UMINA, ANTHONY. DATE/TIME TAKEN: 06/04/01 03:00P 32 PARTRIDGE LANE DATE/TIME REC'D: 06/04/01 03:401-" PUTNAM VALLEY, NY 10579 REPORT DATE: 06/28/01 . PHONE: (914)-528-1491 SAMPLING SITE: 31 PARTRIDGE LANE : PUTNAM_VALLEY,. NY, 10579 COL'D BY: NOTES...: WATER TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: PRESERVATIVES: TEMPERATURE..: COLIFORM METH: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE POTABLE NONE < 4C ` MF ' ~~~ MET 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. ' Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESSMAY 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 HARD WATER: 140-300 MG/L (-1 grain,/gall�o?�`�=.17,2!'|iG/L-) " SUBMITTED BY: Albeu.�-H. Padov , M.T.(ASCP) Director 7 Doi PUTNAM COUNTY DEPARTMENT OF ItEALT D1V1S10N1'0F'EXV1k0SME* NTAL HEALM, SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENt SYSTEM J Owner or Purchaser of Building Tax Map dock Lot Building Constructed by - _EL A J6 Location Street :S) ti� 64in� _TJi'►') .. .......... -To *Am rr A TownNillage il iii I ) I ;Nj Sit ,pion I ame :...�on Lot 0 .4 ,�11 '1 1 .7, * . ; - 1 I'll . . I repi-es,=i-a am wholly afi,l i-tsi"01,95111C 410n. Workmanship, material, Cori S tructl on 0.]Ad di-ainage of the svxage treatriienz above-described property, and that 1�. i lu tCn con.5truC-I~k-A, 35 shc)tvn on ?k �, e nn,. ""lan, arnemdrn,mt thereto, and in ol-naf .n i o D. t Y "", palirntnt of Health, and —u De the owner, his successors, gns, to place in gobd operating condition system constructed by me t74 i �:o operate for a period of hvo years j1C1`.!,.ng the date of approval of F Con -5tructim Compliance" for t1he rn exce t where the. fallure lo evva-,r-.a t,.,.;;-atrnent system, or m rep.airs 0 N't h 1 -1 the a f" 7-"-Perk� is�catjsed-b!N�'the -oidl-fil"'Or aeg paiiz'Of-tho bUll"d zir g P .t-nn of the Iublic Health a�:)rees to accept as conclusive the d( i --�datio Futnan-, County Department of Health as to whether or not the failure of the system to cperai_- vva.; caused by the willful or negligent Act of the,.-,,-Xupant of the b o.-,Odlng utilizing the Dated- Month 0 Dav Zte Year 0_1 Signavir Title: %*D Signat ire (Owner) H -)n) W orporatic am- orporation Name (if corporation) mss- 3 -Wdress:47 L-3 _f -Q_v��1.--__.&__A State J/d. _ —Zip Lo��07 IV-c-- vL-' TV�_ Form GS-97 BRUCE R FOLEY - - LOF.E1i'A MO�LrNARI R-N., M.S.N. Public fteQilfr ' 1irector - __ -• Associate Public Nealtk Director Director of Patient Services DEPARTT/f-ENT OF ` HEALTH 1 . Geneva Road Brewster, New York 10509 Environmental. Health (914)278-'6130 Fax (9.14) 278-7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 ISAMU OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS:. TOWN: ]�APbL,I _J�oI{n( 'e� ll� 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. (E911 VERFRM) October 11, 2001 DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road r IN,ahopac N.Y 10541"• • ,,, . �.. h , w ._ } , 845- 628 -7576 Putnam County Department of Hgalth Geneva Road Brewster N.Y. 10509 -. Att: Mr. Adam Steibling RE: Certification -of Construction Compliance Property of Anthony Gumina Partridge Lane Putnam Valley Dear Mr. Steibling: Enclosed please find: 1. Certification of Construction Compliance 2. Well and Bacti Results 3. Guarantee and two copies 4. Four copies of the as -built plan 5. Filing fee of $200.00 6 E911 Verification Letter Daniel J. Donahue; P ..E. a Site • Sanitary • Environmental _ _ UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONAIEh"IAL HEALTH SERVICES FINAL SITE INSPECTION .r . Date: Inspecte y: IVA Street Local po_?'k 1) 14 L ►./ Owner Totivn r s Permif ,��! ZC, T'M # _ . /��• �`i 2_ Cd Subdivision Lot #T c,r ''► 1. SeNvage Svsterin_Area YES O COMMENTS 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. SeAge Sy:nTMsilr aseptic t .. .....1,250 .........other ................ / b. Septic t s e ................. ..............................� c. 10' minimum from foundation.. ... ............................... d. Distribution Box . ` . All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. Trenches / T- Length required 37> Length installed )!a 2. Distance to watercourse measured Ft.......... 3. Installed according to plan .. .... 4. Slope of trench acceptable 1/ 6 -1/32V ' . 5. 10 ft. from pro a line - 2 ft.- foun atio ........ 6. Depth of tr ch < ches om surf ce....... ..... 7. Roo 11 we or sio ,100 ° / ......................... 8. Size f ave13 /4 =1' " i e clean .................... 9. Dept o gravel in tre ch minimum ................. 10. Pipe a capped....... ..... ....... .......... .. ...... .... .. $ .. um o S stemsQ ., ..j ........I .................. .... 2.Overflo ta.................... ........, 3. Alarm, vis ... .... ... .... ..4. Pump easily e, anh e a e ................ 5. First box baffled ............... .. ........................ 6. Cycle witnessed by H.D.est ate flow /cycle......... III. HouseBuildin a. house located per approved plans ................. . ....... ....Z b. Number of bedrooms ... ............................... IV. Well ............ a. 9✓ell located as per approved plans....................... b. Distance from STS area measured t7 O ft......... c. Casing 18" above grade ................. ............................... d. Surface drainage around well acceptable ..................... V. Overall Workmanshin. a. Boxes properly grouted ................. ............................... b. All pipes partially backfilled ......... ............................... c. All pipes flush with inside of box ... ...:........................... d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... _.. <<c%, lmm °E '0 iter. iii E�� Y v f 6mzl- 7f r� - r, 1 4 2 � r� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENTS STEM* ` ' .-..: - .- - PERMIT # f ► ` �" O 0 11-0' Located at P47M,9l00,r e 4d:&j0_-*_ Town Village ��,o�if�> ���'/��► Subdivision name P,01 aim ,9r rxf Subd. Lot # ! ,S Tax Map ,9Y. 1`7 Block l Lot e� Date Subdivision Approved Renewal Revision Owner /Applicant Name dj ,& / i4 A, Date of Previous Approval Mailing Address Pfr d f A. -P, 101-f I /e�f _ Zip Amount of Fee Enclosed p -I r Building Type 1P4Xy1 �7 Lot Area / _'_ No. of Bedrooms -9 Design Flow GPD 41e e e� Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of l,o o ® gallon septic tank and l ly-e iy 7-r-04 e Other Requirements: ilt �/ /! % 19i?/g i� 0 & % 4 � r� To be constructed by =23> P Address .--_Water Supubu Public Supply From Address or: ( Private Supply Drilled by -` :. -:. Ad&ess. 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: P.E. R.A. Date &_9z_16r_ Address �i,:�� �- r" �t� %'�e,� License #/ APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary ty the Public Health Director. Any revision or alteration of the approved plan requires anew . Appr ved d' har of domestic sanitary se ge only. By Title: Date: ge/Z3100 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr ession 1 Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPL,II�A'I'dO�1 TO CONSTRUCT A. WA'D'ER WELL 1/ -,` cIIPermit please print or type # Well Location: Street Address: iNillage Tax Grid # -(Towr x, t/W Map �f% %� Block C Lot(s)2.gP Well Owner: N e: Address: Use of Well: Residential Public Supply. Air /Cond/Heat Pump Irrigation rimary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm erve Est. of Daily Usage A� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ......................... ............. ............................... Yes Y No Name of subdivision s Lot No. :r— Water Well Contractor: �j"`� Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: ` i 141 TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to be vided on se arate shpt/plan. bate: '- 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 utnan County. Date of Issue 23 Permit Issuing Offippial: Date of Expiration 191 Title: 4 Ile Permit is Non- Transferrabl 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 ENVIkONMENTAL HEALTH SERVICES �a 1 APPLICATION FOR APPROVAL OF PLANS FOR :....: _: A WASTEWATER T— REAT- MENTF- SYSTEM, 1. Name and address .of applicant: A-0 y14- - i 2. Name of project: i,yzo- 3. Locatio n �/.✓��� 4. Design Professlortai:,Dgn Do.�ANuEyR� 5. Address: 6. Drainage Basin: 7. Type o pRigct,: _ t� Privatdt*sidential .Food Service Commercial Apartments..:) Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... /Vo 10. Has DEIS been completed and found acceptable by Lead Agency ?. ............... /Y /,q 11. Name of Lead Agency nl /.Q 12. Is thisproject in an area under the control of local planning, zoning, or other officials, ordinances? ........................................................ ............................... I so, have plans been submitted to such authori ties ......... ............................... /✓d i 14. Has preliminary approval been granted by such authorities?/ i Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water X' groundwater 16. If surface water discharge, what is the stream class designation? .................... N/ff 17. Waters index number (surface) :.......................................... ............................:.. /Y /'41 18. Is project located near a public water supply system? ....... ............................... ND 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ /VO 21. Name of sewage system // Distance to sewage system 9ZAY 22. Date test holes observed d 23. Name of Health Inspector -0� 14,e ' 24. Project design flow (gallons per day) ......... x ................ ............................... �1 a( 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... A& 26. Has SPDES Application been submitted to local DEC office? ......................... RIO _ 2 27. Is any portion of this project located within a designated Town or State wetland? ... .. 25: Wetlands 1) 29. Is Wetlands Permit required? ............ .... .11 ............. ............. ..........I.............,...... — Has application, been made to Town or Local DEC office? ............................... , 30. Does project require a DEC Stream Disturbance Pcrrnit? .. ............................... Al® 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 6o 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? ............................... Ye&92 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... G 35. Are an sewage treatment areas in excess of 15% slope? . ............................... &6 36..E _� ._.. Tax Maps ID Number .......................... ............................... Map Biock__Z Lot 37 Approv`d plans are to be returned to . Applicant Design Professional NOTE All•a$lic at ons for-review and °approval of a-66 v -SSTS to be located within the NYC Watershed shall be sentto:thel3epartirent, and need not be sent in duplicate to the DEP, although the project may require DEP approval of t11 SSTS prior to final approval by the Department. Projects within the watershed may also require DEP eview and approval of other aspects of a project, such as stormwate�,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. 1 hereby affirm, underpenalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.4j4phe Pe l Law. SIGNATURES & `OFFICL4L TITLES. Mailing Address: ................................... at? _rat P tC Ad Pe i D 09A) • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA - SHEET`- SUBSURFACE- SEWAGE'TREATMENT'SYSTEM "7"- Owner. L) )W Address Located at (Street) ,, <��.l .� Tax Map ,/q Block Lot ,,,2-._ (indicate nearest cross street) Municipality 'i /-/d/h /12G40 i— - Watershed 13 g�,,, 2 t- - -y it/ or SOIL PERCOLATION TEST DATA Date of Pre - soaking 1� Date of Percolation Test e-'�De l 1 g3v 2 e 3 3 f-17 Y - 02-1 4 5 1 av 3 p L fro 3 36 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole.. Form DD -97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH .-,-...--HOLENO. HOLE NO. HOLE NO. G.L. 0.5 mum 1.01 1.51, swry 2.0' 2.5' 3.0' 3.5' 4.0' Cl AIP V 4.5' 5.0' .0 5.51 6.01 6.5' 7.01 7.51 8.01 8.5' 9.0 965- 10.0 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Depp hdfe observations made Date ARld Design Pr-ofessional Name: 0414 ,r "Address,-- Ir"t, "t C Signature: Design Professional's Seal y.F'SS10 D A 418 u -164 (2187) —Test 12 PROJECT I.D. NUMBER 6!7.21 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL APESSl l 'NT. FORM,.. FoiINLiSTEO ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLI NT /SPONSOR _. PRO�JJy NAME 3. PROJECT LOCATION: Municipality county 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) S. IS PAOPOSED ACTION: New ❑EYpanslon ❑Modificationlalteration 6. DESCRIBE PROJECT BRIEFLY: Pi6)u 11* T /O N o /51 qtr t �iNA S r ?= '4 eOe kAl ? nr ,vVrrL ,Q ors 4r c 7. AMOUNT 0." LAND AFFECTED: lnitiai!y acres Ultimately acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING. OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly g. WHAT IS PRESENT LANOO USE IN VICINITY OF PROJECT? �Rasidentia! 0Industrial 0 Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. ODES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAL)? / Yes El No It yes. Ilat agency(a) and permit/approvals L 4� � f� it. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes 14 No If yes, list agency name and permlVapprovsl 12. AS A RESULT OF PROPOSED ACTION WILL OUSTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes ftfNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Q Date: v �� Applicant/sponsor name. Signature: , It the action Is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 .o 2 27.. Is any portion of this project located within a designated Town or State wetland? 28.. _ W. ctlands -ID Nutxtlier _ . .:.............a...,..;:.:; _ .a . ... i . /ai to a -a l:.ai8i:::.:... a.a a.a aaaa..ra a.♦a... aa.a •�-: 29. Is Wetlands Permit required? ... ........,a ..................:....... a.............................. Has application been made to Town or Local DEC office? 30. Does project require a'DEC Stream Disturbance Permit? .. ..............................a R/a 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or.other crops, solid or hazardous waste disposal, landf•illing,.sludgle application or industrial activity? ..................a......... 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 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? ................................ I'Ve 36. Tax Map ID Number .......................... ............................... Map Block Lot 37. Approved plans are to be returned to..... Applicant _Design Professional NO All applications for review and approval: of a new-SSTS to be located within the NYC tershed shall ue 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 stormwaterplans 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 ',gr(Rds for the rejection of any submission. :::I fierey affirm, under penalty of perjury, that information provided on this form is true `to" he,biftl of my knowledge and belief. False statem`e'nts made herein are punishable as -Clas s misdemeanor pursuant to Section 2d 0.4S of the Penal Law.. SIG'NA;TURES & OFFICUL ?TITLES. CD Mailing Address :.... ............................... Ai 4'W'0 14's A/ V a� 2� Oca PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH._.SERVICES RE: Property of Located at LETTER OF AUTHORIZATION (9V k - /'i/PO 6iAk Tax Map # 7 Block Lot t Subdivision of Subdivision Lot # Gentlemen: 'S's— : �T vtck wt x4 J ?' 5 oS�? �t Filed Map # Date Filed �J 0 cl This letter is to authorize rA U l s2 L ,, _ .00 \/\ a 4 U --Q-. , F,> L , 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 - confor- mity.with -the. provisions- of Article 1.45- and/or -1 "47 of the Education.Law, the- Public - .Health - . Law, and the Putnam County Sanitary Code. � ._ . _ _.... _ _ ... ........ ,... _ .._...._. _. _ . , . _._ _ . "" � _ Countersigned: P.E., R.A., # Mailing Address�hi %�i- sG�•►,;� State Zip Telephone:% Very truly yours, Signed: (Owner of Property) Mailing Address: . tGl 1.-_ (A- ��`�a-VcfRpc,, State ( ti Zip C7 Telephone:) t 5 rj 65 Form LA -97 PUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL I1`DIVII)VAL /COMMERCUL SITE INSPECTION- FORtI�I SECTION A. GENERAL INFOIUMATION Name of Project G-V w� 04 A (T)(V) County -r. Site LocationA��at L►.t . Buildinq construction begun 1 Extent Is property within NYC Watershed ? ................. F Yes No SECTION B. TOPOGRAPHY (Please check all appropriate bomes) 1. F7 Hilly F-1 Rolling F� Steep slope e slope Fl Flat 2. ❑ Evidence of wetlands Loin area subject to flooding ❑ Bodies of water ❑ Drainage ditches ❑ Rock outcrops 1 3.., Property lines or comers evident ....................... ............................... -EYes ❑ No 4. Do water courses exist on or adjoin the property? I .......................... 5. Will these affect the design of the sewage system facilities ?............ 6. Do watershed regulations apply in this development ? ...................... 7 ' Will extensh-le grading be necessary? ................. ............................... 8. Will extensive fill be necessary for SSTS ? .................................... 9. Do filled areas exist within the SSTS area? ........ ................... ............ , If yes, what is the condition of the fill? L Yes -b< No ❑ Yes �o Yes �.No ❑ Yes Wo Yes No Yes No SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: d vel am ~ ❑Clay Hardpan ixture 11. Observed from: ❑Borings ❑ Bank cut �Backhoe excavations ` a 12. Soil borings /excavations observed by Z �p on (3 13. Depth to groundwater 6 on 14. Depth to mottling t'fo on 15. Are test holes representative of primary & reserve areas ...... ............................... Yes No 16. Soil percolation tests made by on 17. Soil percolation tests witnessed by on _ SECTION D (on back) Form ST -1 • 7 SECTION A DRAINAGE Will ptoposed�grading materially alter the natural drainage in this or adjacent areas? Yes 19. Will groundwater or surface drainage require special consideration? ...........::. es No 20. Will gullies, ditches, etc.; be filled and watercourses be relocated ? ......................... Dye SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ...... . ............................ FlYes No Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ............................... Yes a.No 23. Additionalsomments l� r 24. Site observerlinspector and title DAL., 9 t 25. Date(s) of observation(s)inspection(s) 8 TEST PIT PROFILES Hole r _Lot r Hole 4. of - Hole-," Lot r ht Depth to wate Depth to water Depth to water Depth to mottling X77! Depth to mottling O- Depth.to,.mottlin;..:: Dzptn to'rock/imp. `i " " Depth to rock/imp.� Depth to rock/imp. . ; z G:L G.L. G.L. 1.0 1.0 1.0' AF 2.0 , V WA-fl 2.0 ' Z ��- 2.0 �Sli 3.0 3.0 4.0 .4.0 4.0 5.0 ! r _ _ `�,; 5 5,0 0-7 " 5.0 6.0 6.0 7.0 vim,' } 7.01 ' �% 7.0 8.0 A,0., 8.0 tL '8.0 9.0 9.0 A+Z • 9.0 10.0 10.0 10.0 D ... •BRUCE publk Hefikk D(recter DEPARTMENT OF HEALTH 1 Gencva Road Brewster, Now Yak 10509 ATTENTION: A ADAM STIEBELING )dGENE REED LORE7TA MOLINARI. ILK. - KS.N." Aso cW PWk lid D Ddr~ q/ pa*w swwda AU information below must be A& completed prior to any scheduling. DATF%L4#kL^ ENGINEER OR FIRM: ,$Iti� J% N444"effir PHONE as ,&af - -712 REASON: DEEPS: PERCS: '! PUMP TEST: o ROAD/STREET: ,tf a�F _ : •y �- TOWN: ._ .fir . P4T0V*,* TAX MAP#: 7! J'* ,tX W y SUBDIVISION: A" LA4 LOT#: zL OWNER: R 00ft a ,1^ - YES NO o !t' a Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. Proposed SSTS within 5W feet of a reservoir, reservoir stem or control labs. Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ---Proposed SSTS design flow greater than IM gallons/day or SPDF3 Teriaat rewired: Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yA to any of the questions, NYCDEP must witness thq soil testing. This Department will coordinate a mutually suitable time for field testing with the PCWH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the "go professiopal to scbedule re- witnessing of the soil testing with NYCDEP. 1 a1 (t,DSESrI L 8 DANIEL J. DONAHUE, P.E. - CONSULTING ENGINEERS - 120 Breckenridge Road Mahopac, N.Y. 10541 914.628 -7576 August 9, 2000 Putnam County Dep�rkment of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Adam Steibligg RE: SSTS Permit..& Well Permit Property of.Anthony Gumina Partridge Lane Putnam Valley Dear Mr. Steibling: Enclosed herewith ple4se find the following: 1. Form PC -1 2. SSTS application 3. Well permit application 4. Design data sheet 5. Letter of authorization 6. Neighborhood Notification receipts 7. Short EAF 8. =Three copics.ofcon�truction plans -= Comments: Fee and house plans were submitted with the original application. By: Daniel I Donahue, P.E. Site • Sanitary o Environmental 120 Breckenridge Road Mahopac, N.Y. 10541 914. 628 -7576 August 21, 2000 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att:1&. Adam $teibling RE: SSTS- Permit & Well Permit Property of Anthony Gumina Partridge Lane _ Putnam Valley Dear Mr. Steibling: Attached herewith please find the five original return receipts for the neighborhood notification process required by your department for processing the above application. Sincerely, ikY1fMM1a_ Site - Sanitary • Environmental I� tea, . v r Q0 d-z? \ 164 ■ !y • 2� X f g I Lotwt&' 43714 -02- SO- 1.0635 QTR,. J r � S 76 028100'► T' 39.54' L� i ti kn cs o It •C I� tea, . v r Q0 d-z? \ 164 ■ !y • 2� X f g I Lotwt&' 43714 -02- SO- 1.0635 QTR,. J r � S 76 028100'► T' 39.54' L� TT T13' I'L fi �4 . 160,001 y utility pole Phone box 1 F —81on Of*E4lvironmebtal�Health Serdioe&. �!_$�'°�� approved as noted for oonformagoa -pith" `' f3,0 able Rules. Regulations Of the Co al Department. l p L 3 1.6 ASBUILT PLAN 'ianature a T1 +7a A ro . G C t� / SEWAGE TREATMENT SYSTEM 1`14 Property of A. GUMINA IN SSTS TIE.- INS URED BY TAPE) PARTRIDGE LANE OF TRENCH UNIT A B LENGTH 74.17 -1 -28 PUTNAMVALLEY(T) SEPTIC TANK' 15 50 �OpESSIO yq� JUNCTION BOX _ p `� DOnq FZ DANIEL J. DONAHUE, P.E. A 82 99 m� e� CONSULTING ENGINEERS 1 82 98 M 628-7576 2 88 94 _ t M, tiMAHOPAC, N.Y..,105 I 85.. ,. -91 .. OCTOBER 11, 2001 .. ' .4.- :. ' . 87 ...._. 87 DATE °SCALE 1 - 30 END OF TRENCH �y R'0.4E4R1 Orc� SURVEY" BY: RRAYMOND1Cff MIRE, L.S. 5 137 142 55 npr.� 6 138 141 55 7 140 140 52 8 142 135 55 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED SUBSTANTIALLY AS INDICATED ON THIS 9 36 35 b0 PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER THE SYSTEM WAS CONSTRUCTED AI ACCORDANCE WITH All. STANDARDS, RULES AND REGULATIONS OF THE PUPNAM COUNTY DEPARTMENT OF HEALTH 10 31 42 55 _ AND THE NEW YORK STATE DEPARTMENT OF HEALTH 11 29 55 60 N 3 TT T13' I'L fi �4 . 160,001 y utility pole Phone box 1 F —81on Of*E4lvironmebtal�Health Serdioe&. �!_$�'°�� approved as noted for oonformagoa -pith" `' f3,0 able Rules. Regulations Of the Co al Department. l p L 3 1.6 ASBUILT PLAN 'ianature a T1 +7a A ro . G C t� / SEWAGE TREATMENT SYSTEM 1`14 Property of A. GUMINA IN SSTS TIE.- INS URED BY TAPE) PARTRIDGE LANE OF TRENCH UNIT A B LENGTH 74.17 -1 -28 PUTNAMVALLEY(T) SEPTIC TANK' 15 50 �OpESSIO yq� JUNCTION BOX _ p `� DOnq FZ DANIEL J. DONAHUE, P.E. A 82 99 m� e� CONSULTING ENGINEERS 1 82 98 M 628-7576 2 88 94 _ t M, tiMAHOPAC, N.Y..,105 I 85.. ,. -91 .. OCTOBER 11, 2001 .. ' .4.- :. ' . 87 ...._. 87 DATE °SCALE 1 - 30 END OF TRENCH �y R'0.4E4R1 Orc� SURVEY" BY: RRAYMOND1Cff MIRE, L.S. 5 137 142 55 npr.� 6 138 141 55 7 140 140 52 8 142 135 55 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED SUBSTANTIALLY AS INDICATED ON THIS 9 36 35 b0 PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER THE SYSTEM WAS CONSTRUCTED AI ACCORDANCE WITH All. STANDARDS, RULES AND REGULATIONS OF THE PUPNAM COUNTY DEPARTMENT OF HEALTH 10 31 42 55 _ AND THE NEW YORK STATE DEPARTMENT OF HEALTH 11 29 55 60 N •C TT T13' I'L fi �4 . 160,001 y utility pole Phone box 1 F —81on Of*E4lvironmebtal�Health Serdioe&. �!_$�'°�� approved as noted for oonformagoa -pith" `' f3,0 able Rules. Regulations Of the Co al Department. l p L 3 1.6 ASBUILT PLAN 'ianature a T1 +7a A ro . G C t� / SEWAGE TREATMENT SYSTEM 1`14 Property of A. GUMINA IN SSTS TIE.- INS URED BY TAPE) PARTRIDGE LANE OF TRENCH UNIT A B LENGTH 74.17 -1 -28 PUTNAMVALLEY(T) SEPTIC TANK' 15 50 �OpESSIO yq� JUNCTION BOX _ p `� DOnq FZ DANIEL J. DONAHUE, P.E. A 82 99 m� e� CONSULTING ENGINEERS 1 82 98 M 628-7576 2 88 94 _ t M, tiMAHOPAC, N.Y..,105 I 85.. ,. -91 .. OCTOBER 11, 2001 .. ' .4.- :. ' . 87 ...._. 87 DATE °SCALE 1 - 30 END OF TRENCH �y R'0.4E4R1 Orc� SURVEY" BY: RRAYMOND1Cff MIRE, L.S. 5 137 142 55 npr.� 6 138 141 55 7 140 140 52 8 142 135 55 THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED SUBSTANTIALLY AS INDICATED ON THIS 9 36 35 b0 PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER THE SYSTEM WAS CONSTRUCTED AI ACCORDANCE WITH All. STANDARDS, RULES AND REGULATIONS OF THE PUPNAM COUNTY DEPARTMENT OF HEALTH 10 31 42 55 _ AND THE NEW YORK STATE DEPARTMENT OF HEALTH 11 29 55 60 B U M P OU � °�s` $GF I �TP Cwt 24 - W36 x 636Dw2a '. sea eaa ' DI NETTS 3 M� �. M - N1 w .IEw�A \tlC�, SS01I Ftu3KLa1v1 i 3 --z x10 (-T"-) + �-0 B i0P ��iRAt�F1M �q Myv1y r KITCHEN, �`/4'xo11k'• oU 24 :24 W F. 36 36 D24 5836. 6 24 GF _ GF l3AR FAMR -Y ROOM \rL! - - - - i r HALL . 3r, 48. 24" 24� D Ptn NAM CO O DE MTM£NT OF LTH N .3 PA RECY ' O HO A s FOR nimooM 3 IT ONLY, A ' I - .__ _ m o, N ti ff � ✓ 3 £ ooitirs s' b � * ► -�° 3`-OO '� V� - - r - ALL SUBSEQUF'NT REVIS N�ALTERAWONS I4ESE sE $ "E�.. OPEN fA - MUST 5U MI TO TF1E PC v APP - c� HALL gsov ► fA DINING ROOM �� Fu►sN 3-�-_ _-�- cd �'Ji yz BA Y E R �e. 111►ur»w C = 9 ` 0 VF _ ' ti 3 nm �) p �' f ci GF ;t I ZLU ,, ► © P.T. FARMER'S OK PORCH AREA C C ° D i p S AL 4t O _ P � L V - r- c: ._ D j v I .P 71 LTJ zo r� Imo' r 4 -c P ip y a -4 w 2' -B" :. r � D a N v 3 J'U' D I =m I - 0 1 Q 4p r I n _ — PUTNA➢I COUNTY DEPARTMENT OF HEALTH - HOUSE PLANS PLANS APPROVED FOR BEDROOM COUNT ONLY, BEDROOMS ALL T REVISIONIALTERATIONS TO THESE HOUSE --PLAN SUBMITTED TO THE P C DO FOR APPROVAL. - SIGNATURE & TITLE DATE HAVE BEEN DEVEWPED AND DISTRIEIITED WITHOUTIWOWLCDGF. OR REFERENCE lY1 A SPQCIFIC GEOGRAPHIC LM'ATION. 'STRUCTIgN RICNT9 7'O THE PURCHASFR'OF THIS HOUSE DESIGN, I.E.:'HIS /HER r r — rr... n.-... .. DFCI(:N RI'q HiRI`v'•rrry rrnn.. n ............ ..