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HomeMy WebLinkAbout3781DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83. -1 -28 BOX 29 96 IN IN IN J II IN . IN q ,� IN r 16 IN . . TO -'-. L.D . 03781 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -0F ENVIRONMENTAL_ HEALTH SERVICES._, CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TIRE NT SYSTEM a PCHD CONSTRUCTION PERMIT # _5 VV 2 Lt - Located at K 9 v Town or Village ;,Z V� l l e_ Owner /Applicant Name -�J C.a 4 4!�v r-1 -5 �-, Tax Map 7_25, Block / Lot 217 Formerl Subdivision Name Mailing Address Subd. Lot # �� Y7 �+ ✓ G' ,� r:' vim' t�;t '� r�t� i�1 t� cr. �� �J4 Zip ) ,a_Z; ' Date Construction Permit Issued by PCHD /v �. Separate Sewerage System built by % � rr� A er W Al Cra4h`,/Address Consisting of Me C Gallon Septic Tank and 3 vo e'.. F ej Other Requirements: 5 / y,) !} 'T M 6 la r c' y Water Su®oly: Public Supply From, Address or: Private Supply Drilled by %�e,-e Address - Buii in �'3��e'--- �.,` �- e=� e-.ev . _ :Has- erocior&.con.trnlhenn conipsetecl ?�__:- Number of Bedrooms Has garbage grinder been installed? A10 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 Putn OF Date: `Z124&3 Certified by Address -)-V 7 "Z- Any person occupying premises served by the above Department of Health. P.E. cam' R.A. License # 2 y1j take such action as may be necessary to secure the correction of any unsanitary conditions resufWch 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 revocation, modification or change is necessary. P I By: Title: �f f v! J Date: �_714 > W rte copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT �' e117L+o tavif; -.- Street Address:"" a:: 611 Sprout Brook Rd – Lot,,, #1.,.; TovvnlVillage - -: - Putnam Valley Tak`Grid;# =: Map g3 Block I Lots) 2g Well Owner: Name: Address Scott Carlsen, 37B West Shore Drive, Putnam Valie , NY 10579 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 X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: —Welded X Threaded _ Other Seal: X 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 X Pumped X Compressed Air Hours 6 Yield 15 gpm Depth Data Measure from land surface- static (specify ft) 90' During yield test(ft) 120' Depth of completed well in feet 185' Well Log If more detailed information descriptions or sieve.a_nalyses ... are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 5 Dril ' 1 5. 32 185 Drillina in roc If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 10anm Depth 140' Model IOGS07412 Voltage 230 HP -3/4 Tank Type wX250 Volume 44 gallons Date Well Completed 3/13/03 Putnam County Certification No. 001 Date of Report 4/25/03 Well Driller (signature) Adam L. Beal NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's Name P. F. Bea Address: 4 Putnam Aye., Brewster, NY 1(Y(x3 Signature: a .. Date: 4/25/03 Adam L. Be 1 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 1/1 FROM :.Panasonic FAX SYSTEM PHONE NO. : Apr -24 -03 06:57A Sett /Diana Carlsen May. 19 2002 03:38PM P1 8465260076 P-02 +.....• ^ry.. •.w.f. '.'c.'i.. i �. PUT NAM COUNTY DEPARTMENT OFR_EL TH XT 'SER A USYDl I R NMENr yLKE A r,LTAR& ITEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM r5- e, -i ,!tf 4, .,.;, �, �? - - Owner ar Purchaser of Building{ Building Constructed' by Location Street .� Building Type Tax Map Block Lot Totivn.�'V'illage Subdivision Name Subdivision Lot ; ~ I represent that 1 am wholly and completely responsible for the location, workmanship, imaterial, consttuetion 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 &- -:rcrN aft IP accordance with the standards, rules and regulations of the Put uni County Deparlm=l t„ teiiith, hereby guarantee to the owner, his successors, heirs or assigns, to place in good operEtir•` c, ndltion ": any part of said system constructed by me which fails to operate for a peri-->c of viii yem immediately following the date of approval of the "Certificate of Construction CoLtpliarice ". for the sewage. treatment system, or any repairs made by me to such system, except where the `iiilure 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 c - �,, ..ht Pt:'* 'Mil V. a men to operate was caused by the willful or negligent act of the occupant of the building utilizing the' system. Dated: 'Month _ y _pay 23 year 2, Signature: ! ✓ s Gini eral Contractor (Owner) - Signature Corporation Name (if corporation) . Address: Cs? 1 I S fc t -061 State -?tk-b,%A m vai i e v _ zip % .5- Corporation Name (if corporation)" Address: Mate Form 93 -97- 10 002 ®5/12/2003 09:55 2039619919 Pp Mailing Information: Mama: Pi= Beal & Sons Address: 4 Putnam Ave City*. Brewster State: NY Telephone: 845- 279 -2460 Sample's Information, Client: Scott Carlson zip: 10509 FaX: 845- 279-6613 Collector's information: Ham'. Adam Address of site: 611 Sprout Brook Rd City: Putnam Valley State: NY Zip: Tebphoaa., Site: tank Cate Collected: 5/6/03 Date Received: 517103 PmeriaMa: HNO3 Time Collected; 13:30 Time Received: 13:45 Temperature: <4C Lab No.,. J03291S Date Analyzed Test Name Result WCL Method 5/7103 15,00 Total Collform Absent Absent SMMN 92228 517/03 Chlorine Free Residual <0.1 mg/L N/A SMWW 46000IG 5/9/03 Color ND 15 Units SMWW 2120 8 519103 Odor NO 3 TONs SMWW 2150 B 5/9/03 Iron 0.048 mg/L 0.3 mg/L SMt 31118 519103 Manganese <0,01 mgtL 0.3 mg/L SMWW 3111B 5/9103 Sodium 7,47 mg/L NIA SMWW 31116 S/9103 Chloride 19 rng/L 260 mg/L SMWW 4500 CI C $19/03 Hardness 84 mg/L N/A SMWW 2340 C 5/9/03 Nitrate 0.662 mglL 10 m911` SMWW 4500 NO3E 5/9/0310:00 .__-= •.5/7103 _ ,... .._ .. pH _ - -• .._ ......_ . _x --- 7.07 S.U- 6.5 -8.5 S,U. SM11uU►14500 ii B 5/9/03 Sulfate 39.1 mg/L 250 rng/L SMWW 4500 SO4P 5/9103 Turbidity 1.1 NTU 5 WTUs SN" 2130 8 519/03- Alkalinity 42 mg/L NIA SMWW 2320 B 5/9103 Lead <1.0 u9IL 15 Ug& SMWW 3113 6 At the time of analysis ft sample was acceptable for total conform r4 1A = Not Applicable mqX- milligrams per Liter MD -tone Detected S.U.- 818n lard Unit NTU- Nephelornatric Turbiidity Unit MCL- Max. Contaminant Level TOM- Threshold Odor Number ugiL- micrograms per Liter Signature: 3t2 PH -0218 Mictmal I-apman ELAP M 11715 President BRUCE R. FOLEY LORE` MOLNARi R.N., M.S.N. P] e o I th Dire caw 4- j�sQ iqte �t� C -;Pubtic—. feu i %,N I-FJ,0 Public Director of i'afi-m Service,-: DEPAR17.N.I. -AL "I -H I Gtneva Road Brewster. New York 10�09 Envirunumit -a I I Ica It I 1 (1) 14) 278 - 0130 I"(914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Pax (914) 278 - 6085 Early Interventiun (914) 273 - 6014 Preschool (914) 278-6032 Fax(914)278-6648 E-1911 ADDRESS VERIFICA rj,j ON 14"ORM 0 W N V, RUS NL A NIT" - TAX NIA P N U N.] 13 ET: E91 t ADDRESS- '1.-'(.)WN: AUT1101-tIZED "FOWA Of (Signature) The Vatnalu DOI)MIRMIt of ffeafth Wiff 110t issue a Certificate COMI)1i41111Ce unless t1fic, above. form Is commlete(i, i.e., zl F0 'Iddress ls ass',.Ylied by an authorized town official. 1"his form is to be submitted with the application for a Cel-tificlate of Coils tru C boll Compliance 0") LORD TTA.:141�OLINARI,1k. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 : k06ERT r. County Executive Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 April 17, 2003 Frank Sullivan, PE 2972 Fernerest Drive Yorktown Heights, NY 10509 Re: Field Inspection - Carlsen 611 Sprout Brook Road, (T) Putnam Valley TM# 83 -1 -28, Permit # SW -24 -02 Dear Mr. Sullivan: A site inspection was made for the above referenced project on April 16. 2003. The following comments must be corrected in the field. 1 2 3 5. 6. 7. 8. 9. 10 11 Clay barrier needs to be finished on the west side of the system. The cast iron pipe contains 45° elbows, which require cleanouts. The 90° elbow on the SDR -35 plastic pipe needs to be removed and replaced with either a 45° elbow and cleanout or a series of 22.5 °.elbows. - -_- -�The-45'el'uow un t$e SDR =3-5- plastic pipe needs a cfeanout` v Fabric material is acceptable. Drop boxes # 2 and # 3 are in backwards. The lengths are not installed according to plan. It appears the system is short. All end caps need to be exposed. Bedroom count needs to be done. Has seepage pit been installed for roof drainage? Silt fence needs to be fixed in certain areas. If you have any further questions, please contact me at (845) 278 -6130 ext. 2157. Sincerely, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ' FINAL SITE INSPECTION Date: Street ocation 4�y' Ins ectedby: fiS� 0 lime% /] itut Owner S t'' - .50 -Town r :Permit - TM # �, l '"a-k� Subdivision Lot # 1• Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of plac7Aent I/ / 3:1 barrier Lgth. V Width l/ . Avg.Dpth v c. Natural soil not stripped ................. .. ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / Wetlands ...... ............................... II. Sewaze System a. Septic tank size - 1,000 ... , 250 ......... other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. 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 ........................ 6. Irenches � fj 1. Length required Length installed j . 1r1sta11eCt nnnor incr to lan...�w .s ..!�v�` ..c<,,.... �--� y� 4. Slope of trench acceptable 1 1 - 5. 10 ft. from property line - 20 ft.- foundations.......... tf 6. Depth of trench <30 inches from surface .................. 0 7. Room allowed for expansion, 100 % ......................... f k�+J 8. Size of gravel 3/4 - 11/2" diameter clean ...................: f 1,9, Depth of gravel in trench 12" minimum .......:........... 0. Pipe ends ca ed .............................. g. Pump or Dose Systems 1. Size of pump chamber . ............ ............................... 2. Overflow tank .. ........................ ............................... 3. Alarm, audio ........:........... ............................... 4. P asily accessible, manhole to grade ................. 5. rst box baffled .....:.................... ............................... 6. Cyycle witnessed by H.D.estimated flow /c cle........... M. $use/Building d (ve6c-e a. House located per a PP roved plans ............ IAI ... -. .. . b. Number of bedrooms ....................... ............................... IV. Vi41 Well 1!cated as per approved plans . ............................... b. Distance from STS area measured _j-/,9Z) - ft ........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Otrall Workmanship . a. Boxes properly grouted ................... ............................... b. All, pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d.kckfill 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 ............... ka. Surface water protection adequate .... ....:.......................... i.- Erosion control provided ................. ............................... Rev. 12/02 LYESI,NQ COMMENTS v'h Lt j V�1e I s�� ��' ;Z -M ✓ILµ �� =/i•LS ifs` `Gi=�.�s e X c 471-l' ZI 177 Dr je (n r Form S773 04/15/2003 14:05 9149624248 JOSEPH SULLIVAN PAGE 01 F "OTNANI COO NTY DEPAWFMIN'T OV UFXLTR DIVISION OF .EN VIRONMENTAL HEALTH SERVICES Z-;,3m� A"I"FENFION MI-QUi �ILIS"LEOR--L-aL&L-IL.'2"i-l'L'ji-(2N All MfOITMIti011 ITILISt be fUlly wniplewd prior to any hispec,tions bellig made. El GENE For Fill Trenches 11C'HD Cot"itruction Permit A P1.1 +" et rvi Va (T) (V IF --- 17N * .6tv-1 -4e-n Fm S Block Lot (CLY"_(Wn SL&.Imlou Nam(;-. J'04 CL",k Subdivisioo Lot Is systenl fill completed? Is System uImpIcte? Date:. IS3.)'StCr1I Q01IStRicted as per plaus? k well drilled? I-Ve erosion CO.-It.rCl MWISWCS iLl f?hLL:C-'.) I certify that thesystefn(s), as listed, at the above pren scs has been constructed and I have inspected and verified the.ir Completion it a(;C0Y6,1AW With the; iS_sUed PCHD Constniction Permit and approved plazis and the Stanclaf(IS, RdlleS mid Reyvlatluns 01" 01C PLA1421n County epa D t i TW 0 rit of 1•jo-Mth RE R -6 , < A C fied by Addt,ess-. C`__ —Liz.. .4 — C,ofI11fx,j1.t:i. Fqrfm FQR­()�) - ____ -1 it 4 A. -2" 7M - OA�_97Q-7qp1 NOME• P1 ITNOM rni wy npPOPTMPKIT np o 1 Scott & Diane Carlsen efts rive Putnam Valley, NY 10579 845 -526 -9076 December 20, 2002 Putnam County Health Dept. 21 Geneva Rd. Brewster, NY 10509 Please stamp the original copy of these house plans and keep the copy for your records. The Permit 4SW -24 -02 was on the BOHA papers and would help to reference this land (tax map #83- 1 -28). Please mail the stamped original back to us at 37B West Shore Drive, Putnam Valley, NY 10579 as soon as possible, Thank you, w A Diane Carlsen CONSTRUCTION PERMIT FOR SE-GIE ARE— - AT MlENT SYSTEM PERMIT # - .� ;t Located at - lon'tf A/�� ( fie Gy -�' 3� or Village G Subdivision name /d � � .� �/` Subd. Lot # Tax Map 973 Block / Lot 2- ' Date Subdivision Approved' Renewal °' Revision 0 Owner /Applicant Name S Ae .4 0" iq.ca" Date of Previous Approval Mailing Address A/ Amount of Fee Enclosede�� Building Type s igiee Lot Area 4� 9. 7 No. of Bedrooms Design Flow GPD -0 Fill Section Only I Depth Volume PCH D NOTIFICATION IS RE UIREID WHEN FILL IS COMPLETED Separate Sewerage System to consist of `-d v -!:7 gallon septic tank and � ° �� -A - � a F j' .4 Other Requirements:�°-� To be constructed by Water SUP91v• Public Supply From Address Address ham- _: P*hate:Si�ply:�r- illed.by..:: address,. -r ^� Itrepresent 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. �� pF NElti y ANC /s 4� Signed: �' -'` : �< R.A. Date Address ' ,rep °�— '�s License # 9 0�F ;9 ' APPROVED XR COht3 RgTCTION- aaaro ars from the date issued unless construction of the sewage treatment system has been completed and inspected HD and is revocable for cause or may be amended or modified wh considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. pproved for discharge of domestic sanitary sewage only. By: Title: () j f `�-- a !' Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type. Well Location: Street Address: Town/Village Tax Grid # f j1 �s ap ,7.�R . Block Lot(s) V Well Owner: e: Address: Use of Well: residential ` Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage 4ow', gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _ Z New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type ko' Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ..................................... ............................... Yes P" No Name of subdivision /'cy L, � ` . Y Lot No. Water Well Contractor: ��, -aac� Is Public Water Supply available to site? .................................. ............................... Yes No' ,4-o' Name of Public Water Supply: = Town/Village �- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: F 445-ez' 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 well driller certified by Putnam County. Date of Issue Permit Issuing- pfficial. Date of Expiration _() I ; I ! ,) t j Title: Permit is Non- TradsferrWe White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ,i °�': � z, � Li A NEW YORK STATE DEPARTMENT OF HEALTH Specific Waiver Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR ..dha.ldusl HoUSSIa old SevaagA Treatment 3 yy4arns fo�t� Name of Applicant 6 C II A- 6 Address a4 r No. Street City/Town St Zip Site - Location 1. Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)): Separation distance cannot be achieved. i"Axcessive slope. High groundwater. 7 Inadequate depth to bedrock or impermeable layer. Soil unsuitable Other (explain) ...: ......... ........... . ........ . ......... . V`:....... ............................... ...../.............. .... - - - -- ---------------------------------------- ----- ------ ------------- .. .' ............................................................................. ............................... . 2. Proposed design or conditions of waiver: 4 C �....... ..... '........... .. ............. ... ..................... '. ..............:.............. -. ........... ...........................�`.. �.................... �....G............. ....... .... . `................. ..............................: ......................... ............................... .......................................................................................................................................................... ............................... 3. The proposed design may have the following limitations (check appropriate box(es)): __! Increased risk of well or spring contamination. Increased risk of surface water contamination.- L] Expected design life of the system will be diminished. Operation of sewage system is subject to mechanical problems. Other (explain) .............................. : ............................................. ...................................................... Additional information attached Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. in accordance with New York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver may be revoked by t wing official fora change in conditions for which this waiver was granted. . s ..................... .................... ............................... REPRESENTATIVE COMMISSIONER OF HEALTH ORIGINAL - Local Health Agency / Z COPY - Applicant/Design Professional �� DATE" ..................................................................... ............................... y DOH -1326 (7/92) (GEN -152) 14-164 (21117) —Text 12 PROJECT I.D. NUMBER s1i.2i SEAR Appendix-C.'. _ .. EnirFr6irtlt9itClit'tOu'Ilty R64 SHORT ENVIRONMENTAL ASSESSMENT FORM.. For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT !SPONSOR 2. PROJECT NAME_ .3. PROJECT LOCATION: / Municipality /� �l�� County t. PRECISE LOCATION (Street address and yroad IntersectioKs, prominent landmarks, etc., or provide map) 5. IS PROPOSED AST10N: NeW ❑ Expa:ision ❑ Mcdifcationtalteration 6. DES/C� SSE P_Roj =_CT BRIEFLY: I � 7. AMOWITi OF D AFFECTED: lnitia:ty acres Ultimately acres 8. VA I P-nO--Ot=D ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? es n No It No describe briefly S. WHAT IS PRESEIT LAND USE IN VICINITY OF PROJECT? esidentia! C Industrial El ❑ Agriculture ❑ ParklForest/Open space.... ;. ©Othe, - AR. - 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STAT E OR LOCAL f / tAYes ❑ No If yes, list agency(s) and permiUapprovats ,P, 11. DOES ANY ASPECT OF THE ACTION HAVE A. CURRENTLY VAUD PERMIT OR APPROVAL? Aes ❑ No If yes, list agency name and permitlapprovai 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITlAPPROVAL REQUIRE MODIFICATION? ❑ Yes 2W I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponscr name: Date: 71 Signature: rr• If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding'with this assessment Lj� %-�z. PART Il— ENVIRONMENTAL ASSESSMENT (To be completed by Rgency) A. DOES ACTION FXCELED ANY TYPE I THRESHOLD IN 6 NYCR% PART 617.12? It yes, coordinate the review process and use the FULL EAF. ❑ Yes o B. WILL ACTION AECEIVE COORDINATED REVIEW.AS PROVIDED:F.OR UNLISTED AC11O.4S;1N 6RYCKf PART- 6"17.6? it No, a negative declaration a rnay.be- s;rryerse another itrm ed agency: ❑ Yes ®'No '- C. COULD ACTION'RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) Ci. Existing air quality, surface er groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character/ Explain briefly: �J C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 'a 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 X/v C5. Growth, subsequent development, or related activities likely to be induced'by the proposed action? Explain briefly. 06. long term, short tern, cumulative, or other effects not identified In C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type or energy)? Explain briefly. h A 9 _ D: 'IS THttR= 'Oa IS .. HERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes o It Yes, explain briefly PART 111 -- 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. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY r occur. Then proceed directly to the FULL EAF and /or prepare a'posit(ve declaration. Check this box if you have determined, based on the information and analysis above and any supporting, documentation, that the proposed action WiLL NOT result In any significant adverse environmental impaci_s'' AND provide on attachments as necessary, the reasons supporting this determination: _- Name of Lead Al Rig Foaq not or Type N e t Responsible 0 icer in Lead Agency rr. 51 na re of Res risible 0 icer in Lead A ency Date 71' 'W i nature of Pre aver (it different from responsible officer) t 14 -16-4 (2157)-Text 12 PROJECT I.D. NUMSER 617.21 SEAR Appendix C _.:. ;:. ..: ... • .., S4ate- EnvH •ot�ritentalQualltjll�evTew SHORT ENVIRONMENTAL ASSESSMENT FORM . For UNLISTED ACTIONS Only. PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. P iCANT !SPONSOR J f� 2. PROJECT NAME. e—r� 3. PROJE T LOCATION: ko'l ��kx Municipality '> % County / (� I I 4. PRECISE LOCATION (Street address and road inter (clions, prominent laadrnarks, etc., or provide map) .-jam �✓,�� �� /�� .!�orr� " 5. IS PROPOSED AvTiO4: IaNex 0 Ex;,ass:on 0 Mcdificationlalteration a. DESCRIBE PROJECT BRIEFLY: `//gel P"e zl 7. AMOUtrr OF LAND AFFECTED: � ¢ inival!y acres Ultimately acres a. WILL.PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes r No It No, describe briefly S. WHAT IS PRESE`N'T LAND USE IN VICINITY OF PROJECT? identia! C 0 Commercial 0 Agriculture ' O ParklForesfJOpen.sttaca— - •- QOther~~ 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAL)? ,Yes ❑ No if yes, list agency(s) and permitlapprovals III. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? Yes ❑ No It list and yes, agency name permitlapprovat Al /v 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? 0 Yes .KNO • I I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE ABOVE �i�,t�/f L� ✓% / PiY /ri fj�JGIt%� Date: / ej L . Applica .Usponscr name: Signature: rr. If the action is In the Coastal Area, and you are a state agency, complete the - Coastal Assessment Form before proceeding with this assessment PART Il— ENVIRONMENTAL ASSESSMENT (To be completed by Rgency) A. DOES ACTION EXCEED ANY TYPE i THRESHOLD IN 6 NYCRR, PART 617.12? It yes, coordinate the review process and use the FULL EAF. ❑ Yes .) No _ - _ - -.• _ B. Ylilt ACTION RECEIVE C90RDINAT> i? REVIEW AS PROVIDED FOR UNUSTEG ACTIONS (N 6 N`1tF r , PAAT 617.6? It No, a negative declaration : -'rsy Gc'supeBedetl "by itTt6t`ner involved agency. . ❑ Yes , CkNo ' 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 patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. VeSetation or fauna, fish, shetifish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A connunity'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 iii ely to be induced*by the proposed action? Explain briefly. 06. Lon., term, short tern, cumulative, or other effects not identified in C11:5? Explain briefly. C7. Other impacts (including Changes in use of either quantity or type of energy)? Explain briefly. too D. 'IS THERE, OR IS THERS LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ] No It Yes, explain briefly PART ill — 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. ❑ Check this box If you have identified one or more potentially large or"significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a•positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WiLL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency T e olC'v WL' 14� LJyPCdP'lerj , Print or Typ. Nz a of Responsib 0 icer in Lead Agency = licit of Responsible officer 5 anature o Respo 'b e Officer in Lead Agency 5ignature of PreparerIli different from responsible officer) BRUCE R, . FOLEY 'llcf'alth''`DfPi�ctvr"'- ,. . 2— -. LORE rA;:.MOLINARt RN.-,- M:SNI. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York. 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER NAME: ADDRESS: SITE LOCATION: DATE: STAFF PRESENT: SPECIFIC WAVIER REQUEST: Q. h -- - 1prewdk gre* L. 14,E , P. d ( X53. -1 -Ice) l ;c/ % l u'r / rS ....: _. ..- ..'.DOES T =I3E PROPOSED VARIIANCE REQUEST POSE A HEALTH HAZARD OR ENVIRONMENTAL CONTAMINATION PROBLEM? YES NO WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP? S NO DISCUSSION REQUEST APPROVAL OR DENIE 6Kv APPROVED REASON F R DENIAL DATE: OF PUBLIC HEALTH (SPECWAIVER) DENIED PUTNAM' COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEM$ ... REVIEW SHEE "T.FOR GONS'I'fili)CrION'PEtm.....a : `: Q NAME OF OWNER. STREET LOCATION: to 1- -. REVIEWED BY: RM, GR, AS,(�WATE: TAX MAP #: (CONFIRMED) 0 e i/ Y N DOCUMENTS (_ZL�PERMIT APPLICATION CZ (_JWELL PERMIT OR PWS LETTER �LUPC -97 4 C,6 _LETTER OF AUTHORIZATION C::fnL__)DESIGN DATA SHEET (DDS) C­J( CORPORATE RESOLUTION (�USHORT EAF L_)PLANS -THREE SETS (U(_JHOUSE PLANS - TWO SETS VARIANCE REQUEST SUBDIVISION L JLEGAL SUBDIVISION -)SUBDIVISION APPROVAL CHECKED L)PERC RATE FILL REQUIRED 3 DEPTH UUCURTAIN DRAIN REQUIRED GENERAL C__)(_JLOCATED IN NYC W D UUPLANS SUB TO DEP DUDE ED TO PCHD EP APPROVAL, IF REQ'D (JDEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED Lam(_ , EX- APPROVAL SSDS ADJ, LOTS )(,�ETLANDS (TOWN/DEC PERMIT REQ'D ?) (/�(� ___)DATA ON DDS PLANS & PERMIT SAME ( _J(RE 1969 NEIGHBOR NOTIFICATION (LETTER BI/ZBA 1100 Y& FLOO]VFLEV.AT .ON W/I ZOO'— OIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS L SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE (___)GRAVITY FLOW ( --W )CONSTRUCTION NOTES 1 -15 (_)DESIGN DATA: PERC & DEEP RESULTS ,(f::::)7L_)2' CONTOURS EXISTING & PROPOSED (�j- DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS ( J ___)USD,C SOIL TYPE BOUNDARIES (,/(�TITLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# ()DATE OF DRAWING/REVISION (�(_JDATUM REFERENCE je:::j-(_JLOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. (}PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS WELLS & SSDS'S W/IN 200' OF SSTS PROPERTY METES & BOUNDS (��EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE OMMENTS: EVSHEET)09 101100 �N (REQUIRED DETAILS ON PLANS CONT'D) )HOUSE SEWER - %" FT. 4 "0'; TYPE PIPE CAST IRON (J_)J LINO BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS ((_)SITE NOTE CHANGE) FILL SYSTEMS ( J10' HORIZONTAL; PAST TRENCH SLOPES 3 :1 TO GRADE (FILL SPECS/ FILL NOTES 1 -5 C,:::::5-C-_)FILL PROFILE & DIMENSIONS ( L_)FILL IN EXPANSION AREA FILL GREATER THAN 2 FEET (UCU) CL Y BARRIER _, R.O.B., UNCLASSIFIED & IMPERVIOUS --JL_)$KPARATION DISTANCE FROM TOE OF SLOPE (/ TRENCH LF TRENCH PROVIDED J� 60FT MAX. )( )PARALLEL TO CONTOURS C/f )100% EXPANSION PROVIDED Cl )DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL ( j('JGEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM 'SSTS C�E 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL �C20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS __)100'TO STREAM, WATERCOURSE, LAKE (inc. egpan), -- �50 TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER - .�1 10' ' (,-501 INTERMITTENT DRAINAGE COURSE (efjC )200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (_,)t__)10' MIN TO LEDGE OUTCROP jj SEPTIC TANK (�(--)10' FROM FOUNDATION; 50' TO WELL WELL (,fy(�:JDIMENSIONS TO PROPERTY LINES (�L_)LOCATION OF SERVICE CONNECTION (.,e�MIN 15' TO PROPERTY LINE /SLOPE U(_)SLOPE IN SSTS AREA k0' (520 %) ( f: REGRADED TO 15 %, IF REQUIRED C-JC__)PUMP NOTES (_)C_)DOSE 75% OF P OLU OSE VOLUME NOTED C-JL_)DETAIL FOR FO E' MA (PIPE TYPE, ETC.) UUPIT AND D -BO SH & DETAILED (�(_)1 DAY STORAG ABO ALARM T DRAIN C-JC_JSTANDPIPES, OTH S ES, DETAIL (_JL-)15' MIN to C ->5% -4 %, 25' -3 %, 35' -1 %, 100 % - <1% J20' MIN to C DISCHARGE /100' with 182 cons day discharge (__ _)(___)10' MIN to N - PERFORATED PIPE • - � "B.-RJCE °R:' FOL'EY" " Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI} R.N., M.S.N. - Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 -7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 20, 2002 Joseph Sullivan, PL 2972 Ferncrest Drive Yorktown Heights, New York 10598 Re: Dear Mr. Sullivan: Proposed SSTS - Seligman Sprout Brook Road, (T) Putnam Valley TM# 83. -1 -28 Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: Current codes require that a SSTS be constructed on site with a slope of _< 15 %. Since the proposed site is ± 20% slope, this project is denied. It is your right to request a waiver to be able to .regrade to _< 15 % slope with the addition of R_ OB fill ,by- completing the enclosed waiver request and sending it back to my attention. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, 5� C., 5-- --- Shawn Rogan Public Health Technician SR: cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR ° A'WASTE'WATtlt TREATMENT SYSTEM 1. Name and address of applicant: G/�'d,� �- ,mac a%Gd 2. Name of project: ?� 4. Design Professional: �Ut / %it'C9r� 6. Drainage Basin:,Qsa ?����� 7. Tyne gf Pr2ject: Private/Residential Apartments Office Building 3. Location TN: ; cam �i' `1 =f% e-: V 5. Address: 2-9�'�U'r3�*r. Food Service Institutional Realty Subdivision Commercial _ Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Ale Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... ^•'y 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? ............................................................ _ . .. T� 13. If so, have plans been submitted to such authorities? ........... 14. Has preliminary approval been granted by such authorities Date granted: I-eJ 0/ 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ..................................... .............. ................... 18. Is project located near a public water supply system? ....... ............................... Ali' 19. If yes, name of water supply — Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A4) 21. Name of sewage system Distance to sewage system 22. Date test holes observed ` T 23. Name of Health Inspector- ��,��. / ?e eel 24. Project design flow (gallons per day) .................. ... ............................... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.:. We/ 26. Has SPDES Application been submitted to local DEC ofl:ice? ` - ......................... Form PC-91 2 27. Is any portion of this project located within it designated Town or State wetland? 28. Wetlands ID Number .......................................................... ............................... -- 29. Is We�ands Permit required? ......- ...:,........... ;.v .:.:�..:a.:: . ::..:::.. ........:" application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Ad 31. Is or evas project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, !ale landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ....... ........................'Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... A10 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project s ite? ................................ ............................... 35. Are any sewage treatment areas it. excess of 15% slope? . ..........:.................... 36. Tax Map ID Number .......................... ............................... Map_Z,3 Block % Lot. 37. Approved plans are to be returned o ..... Applicant b'' Design Professional NOTE: All applications for review and approN al of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project m .r,;:quke DEP. approval of the: SSTS p6or.twfina-L approval 1: ;7 the Deliartm�rit. Prrojects"within the watershed may also " iequire DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l.,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, an der penalty of perjury, that inaformation provided on this forts is true to the best of pry knowledge and belief. False statements trade herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: or Mailing Address :.... ............................... COUNTY DEPARTMENT 01FREALTH "'VIRONMENTAL HEALTH SERVICES -U(,--JON'OF EN DXFA SHEET- i (l,v Add o, � T a x M, I P.'3 Block i Lot On 'Qato fiew-O'st Cross SU-000 037 rj,// • SOIL PERCOLAT ION 'TE ST BATA -'s ou,K IX1g Date of Percolation Tut ;,-,L.i LU vo ropQ-titec, at Same depth until approm I m! !eiy equal percolation rates vs.* percOlation W.A 1101c�, mbi (Or 1••30 mirdii-ich, s 2 rain for 31-60 min/Lwh) UL "W* Depih MOULINfrierItS to be made from top o•fiolo. Foam DD-97 ..... ..... Depth to w Il, Time $urfftc- n Start 2 4 5 -3 I'Ag & 3 5 ;,-,L.i LU vo ropQ-titec, at Same depth until approm I m! !eiy equal percolation rates vs.* percOlation W.A 1101c�, mbi (Or 1••30 mirdii-ich, s 2 rain for 31-60 min/Lwh) UL "W* Depih MOULINfrierItS to be made from top o•fiolo. Foam DD-97 TEST TITDA'rA D D.I,'SCIU'P]'IONO.FSOI.LSENCOUN'rE It E, INTESTHOLES GIJi* -2*7 0.5 IS 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5; 6-V 6.5' 7.0' vm Z,-r, 074 Z zea 8.0, 8.;j1 . ..... ........ 9.011 Ic%,d at �;vhich, -oundwater is enc,(),u-ntercd ,46 - e- Indic,itc llclvt.i at w1iian ja-iouling is observed lie e- Indlui.o,,. to vvhich water lc rises alle.j: being CflcOLffllcreu o'servIl ti oils 11-lacle by: -I mllNarnei ve Desig.11 I)rofessional's Sea]. I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of ')�/_ LETTER OF AUTHORIZATION ev�r J��% Located at 5 0-'-6 0 -1-4 a d 3-7 Q&D0 g'-9 — \ - -a$ Tax Map # Block Lot Subdivision of Subdivision Lot # Gentlemen: Filed Map # 2 9Z / Date Filed �' / ��� Gr/ This letter is to authorize 7 7 S -e v l ;Z 1/n� a duly licensed Professional Engineer t/' or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law,, the._Public Health., . L.aw and =the Putnam County Sanitary Code: Countersigned;--, P.E., R.A., # ,) vA Mailing State Telephone: Very truly yours, Signed: (Owner of Property) I Mailing Address: 49, LO GC.) c, C PDAD State Zip d �i Telephone: —q Form LA -97 toposal system was .nd that the system iovered over. The with all standard inty Department of ;nt of Health. " _4 o- a a 7 4.7' s °a s� yr �7..C_'6 .�. _ - _� _ ... ...♦ .�. �8 /od X03 Ids /08 4 100 411., r t 13. G 4 .f J PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF EN I ONN4NTAL YLTH SERVICES. APPROVED AS NOTED FOR CONFORMANCE WITH APPLICABLE RULES AND REGULATIONS OF THE PIMAM COUNTY HEALTH DEPARTMENT. M b lui L) we N �- / - -<i3 ,J f i 771- 2 2,3' 3 2S S 3S �' la 8a ♦/ 77 a 7 4.7' s °a s� yr �7..C_'6 .�. _ - _� _ ... ...♦ .�. �8 /od X03 Ids /08 4 100 411., r t 13. G 4 .f J PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF EN I ONN4NTAL YLTH SERVICES. APPROVED AS NOTED FOR CONFORMANCE WITH APPLICABLE RULES AND REGULATIONS OF THE PIMAM COUNTY HEALTH DEPARTMENT. M b lui L) we N �- / - -<i3 ,J f