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HomeMy WebLinkAbout3977DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.58-1-38.1 BOX 31 03977 ! r1 T . ,} •r.. �� - T kQ • ■ tiIr. � 'h yr' ' i IN ' � r� F Ill IN low IN :- 03977 PUTNAM COUNTY'DEPARTMENT OF HEALTH `.IFLIO:O". °Fut'i= ta�J,.'N P1iENTAr. H�. iAFi1T.H'DJ�1R= 1.�C ":/A�:::'. :•vim. •... .. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR AGE -TRE TMENT SYSTEM PCHD CONSTRUCTION PERMIT # 3 - vim - Located at Town or Village DQ -0i4M Get Tax Ma 83,68 Block Lot Owner /Applicant Name i 2M c- ; p Formerly l; Subdivision Name &i9-g5 .,ego JgW Lam IcA Mailing Address Subd. Lot # ZI Ks iLL 1-�CL aW (2c)A,(.). WVAM Vt Date Construction Permit Issued by PCHD 60' ' q 1 0 Zip /c6 -7gf Separate Sewerage -System built by LaA ' �Z, "i� , 1NC - Address 0,r,3,I+V'A \IA LLe- 4, Q/ X)541' Consisting of Z 5� Gallon Septic Tank and +AL9 Lr � 72 { ki uj i 5 a Other Requirements: Water Supply: Public Supply From. Address or: )( Private Supply Drilled by 0;Z4VW r )'4G• Address '3i VULCN, -My X6`61 LxW d ng..T -ype- - IZ -5 0%. i H�.s erosion control been completed? Number of Bedrooms Has garbage grinder been installed? `I96 Nu 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 a Z I �Z Date: Certified by & (Design Professional) Address County Department of Health. P.E. 4 R.A. License # C)G75L 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 revocation, modification or change is necessary. By: e copy - HD File; Yellow copy - Building Inspi Title: le-i+.I' 6- Date: u �� ctor; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF ]WEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Str ,� Ad ess: =wnNyag AMap85,58Block Tax Grid # ( ' Lots) 3 Well Owner: & a Address: �-rrLe.. Z ( ?ice- U- l�� J Q--WO, P.r, m4^ V,t-Ue-e, Y Use of Well: I- primary 2- secondary X Residential Nblic Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade ,���yft. Diameter in. Weight per foot _ZLIb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded k Threaded _ Other Seal: 2!�_ 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 ,i' Compressed Air HourQ•�- Yield 2� gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet 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 $' C f '2 gap If yield was tested at different depths ' during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth 2 fD Model AiTe 5 /3 Voltage :g-3o HP y Tank Type i,>X zj o Volume C/�I, ) Date W I( Completed Putnam County Certification No. Date of Report Well Driller (signature) 0 NFTE:/Exact location of well with distances to at least two permat dnt 1pdmarks to be provided on a separate sneevpian. ix, Well Driller's Name�ir,�t e Addressf.� Signature: �1 -4,9 Date: T mil' White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 BADEY & WATSON LETTER of TRANSMITTAL - - in ring;­. Siir-veyznk'-­ &: Eng *' ee RC 3063 Route 9, Cold Spring, New York 10516 Date: 17 Jun 2003 TO: Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Department of Health 1 Geneva Road File No. 02.165 W. O.# 15538 RE: Certificate of Construction Compliance Greencliff Homes Gilbert Lane Rose Marie & Michael Burns and Subd. Lot No. I Tax Map 83.58-1-38.1 Permit/Title/PO # PV-3-02 Sent via: Brewster, NY 10509 I US MAIL ❑ UPS-NIGHT ❑ MESSENGER ❑ UPS-2 DAY ❑ PICK-UP UPS-3 DAY FAX ❑ UPS-GRND W We are sending: UPS-COD ❑ copies date description of document 711 117-Jun-03 I [Application Fee - $200.00 V F-11 117-Dec-02 lCertificate of Construction Compliance for Sewer Treatment System F 11 117-Dec-02 -71 JE91 1 Address Verification Form F-31 117-Dec-02 = IGuarantee of Subsurface Sewage Treatment System F-11 102-Jun-03 I Well Water Test Results F11 116-Jun-03 Well Water Test Results (re-test) 1 fl-itin-03 'r ell Completion 74 117-Dec-02 Fs-s—T§7 �As- Built" F-1 I I F-1 I I REMARKS: Copies to: File Yours truly: Jason R. Snyder, Jr. Engineer Tel: (845) 265-9217 ext 13 Fax: (845) 265-4428 Email: jsnyder@badey-watson.com 40 40-05 490400 624800 21666 COG BRTJCER FOL Ev.., _ -: LORETTA 1� OLINARI R.N., M.S.N. Public Health Director _ cn YoQ` Associate Public Health birector Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road -- Brewster, New York 10509 Environmental Health (914) 278,- 6130 Fax (914) 278 - 7921 Nimsing 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 E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: 'TOWN , AUTHORIZED TOWN OF (Signature) DATE: Greenclifff Homes, Ltd. 83.58-1-38.1 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. (E911VERFRM) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALT H SERVICES ;, . :,- ...z:.... G1JA1�AlVTPIE,d�1 +.SIJBSLTR'4,C SEWAGF..�C A,;TMK _T._SXSTFlY1- Greencliff Homes, Ltd. Owner or Purchaser of Building Greencliff Homes, Ltd. Building Constructed by Location- Street 1 Gilbert Lane Residential 83.58 1 38.1 Tax Map Block Lot Putnam Valley TownNillage Rose Marie & Michael Burns and John Lenich Subdivision Name Building Type Subdivision Lot # 1 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. -he undeAi ed furtlYer agrees to accept-as' conclusive the determinations 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 building utilizing the system. Dated: Month December Day _ 17 Year _ 2002 Signature: Title: President General Contractor (Owner) - Signature Greencliff Homes, Ltd. Corporation Name (if corporation) Corporation Name (if corporation) Address: Address: 21 Pe&AW Hollow Road, Putnam Valley State Zip State NY Zip 10579 Form GS -97 ' ] . l y � YML ENVIRONMENTAL SERVICES 321 Kear Street | \ Albert H. Padovani, Director | LAB #: 32.304069 CLIENT #: 56580 NON STAT 1::'ROC PAG� GREENCLIFF HOMES DATE/TIME TAKEN: 05/28/03 03:30 21 PEEKSKILL HOLLOW RD DATE/TIME REC'D: 05/28/03 03:50 PUTNAM VALLEY, NY 10579 REPORT DATE: 06/02/03 PHONE: (845)-528-8560 SAMPLING SITE: 1 GILBERT LANE SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COWD BY: JAMES SCHMITT TEMPERATURE..: < 4C NOTES ...x COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE RESULT NORMAL - RANGE PUTNAM CNTY PROFILE . 05/28/03 _MF T. COLIFORM ABSENT 000 ML ABSENT 05/28/03 -LEAD (INS) 15.5 ppb 0-15 ppb 05/28/03 -NITRATE NITROG -1.03 MG/L 0 - 10 05/28/03 -NITRITE NITROG ~<0.01 MG/L N/A 05/28/03 -IRON (Fe) ~0.088 MG/L 0-0.3 mg/l 0508/03 -MANGANESE (Mn) '<0.010 MG/L 0-0.3 mg/1 05/28/03 -SODIUM (Na) '7.73 MG/L N/A 05/28/03 -pH ~7.0 UNITS 6.5-8.5 - 05/28/03 -HARDNESS,TOTAL ~92.0 MG/L N/A 85/28/03 ALKALINITITYY JAS, NIA`-.--�-' ---~ ---- ^~-'~-� - � --'-7-4-,,0��-'MGY116`-- -- ---'`-'' �--~-- COMMENTS: � BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDif�7�HE Iy� � 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 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 METHOD 1008 9101 9139 9146 � � 2037 2037 9043 -0 ` YML ENVIRONMENTAL SERVICES 321 Kear Street N.Y. 1059B | ,,Y�o�- r ' k Heights. � ��� : __ � _���'�'�������`�����: � | | Albert H. Padovani, Director | LAB #: 32.304069 CLIENT #: 66580 NON STAT PROC PAGE R GREENCLIFF HOMES DATE/TIME TAKEN: 05/28/03 03:30 21 PEEKSKILL HOLLOW RD DATE/TIME REC'D: 05/28/03 03:50 PUTNAM VALLEY, NY 10579 REPORT DATE: 06/02/03 PHONE: (845)-528-8560 SAMPLING SITE: 1 GILBERT LANE SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE OOL'D BY: JAMES SCHMITT TEMPERATURE..: < 4C NOTES_,: COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANSE METHOD ` moderately restricted diet, a maximum of 270 mg/L of Sodium is sug-' ted. _ 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 WTTH 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 HARDNESS MAY RANGE FROM.0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND-TBEATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. - - . - -''- SOFT-WATE]��`��70-MG/L -^ ' - - 'VER\'RARD WATER&ABOVE^3UO'MG/L' ~~ MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 170 MG/L) SUBMITTED BY: Albert H. raoovanz, n./.(ASCr) Director ELAP# 10323 ') YML ENVIRONMENTAL SERVICES 321 Kear Street - Yo q kt wn 1 , . . . �`�����������=����.��, � Albert H. Padovani, Director | GREENCLIFF HOMES DATE/TIME TAKEN: 06/12/03 02:59 21 PEEKSKILL HOLLOW RD DATE/TIME REC'D: 06/12/03 0405 PUTNAM VALLEY, NY 10579 REPORT DATE: 06/16/03 PHONE: (845)-528-8560 SAMPLING SITE: LOT #1 GILBERT LANE, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE C{]L'D BY: JAMES SCHMITT TEMPERATURE..: NOTES...: COLIFORM METH: N/A ~~~~~~~~~~~~~~ ~~~~~~ ~ ~ ~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ � ^ DATE ALAS PROCEDURE RESULT NORMAL - RANGE METHOD 06/12/03 -TURBIDITY (TUR -<1 NTU . 0-5 NTU SUBMITTED BY: A I b er At H 4.P a c o v a Qni .. M I . T . ( A S C P Director . ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: .,_.14444 ;. � ......._ Inspected by: - Street Location t Y 1 Owner 6, - / -`- Town Permit # �'- TM # S S - i - 3 �' . Subdivision Lot # 1. Sewage System Area a. STS area located-as per approved plans ... .. .................... :.. b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil.not stripped..;....., .......................................... d: Stone, brush, etc., greater than 15' from STS area.......... e.. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size - 1,000 ...:.... .1,250.::.other ....:..........: b. Septic tank installed level ............... ............................... c. 10' minimum from foundation .......... ............................... d. i t 'bt i n Bo 1. All outlets at same-SW -wale t ..... 2. Protecte��Ifftt.voorn-Gisr t .................. ............... ................. 3.- ' 0 0 0 al s oil.between box &trenches Junction Bo roperly set required . " ........... ....ng....t... h ...:........:..::... ti . en �t Le installed G! 2. Distance to .watercourse measured Ft ........ 1�%,� -� 3. Installed according to plan.: ....... ............................... �N 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 =1' /z" diameter clean .........:.......... 9. Depth of gravel in trench 12" minimum.. : ................... _ W.. 'Pi. pe,en Gapped. ..................................................... -..w . �. g. gump or Dosed Systems . Size ot pump chamber ......... .: :........ 2. Overflow tank..;,.,~ - . j ......................... ............... 3. 'Alarm, ' audio .................... ............................... 4. P easily accessible, manhole to grade ................. First box baffled........ .....:............. ............................... •6. Cycle witnessed by H.D.estimated flow /cycle........... M. Hogsefflgild' . a. house lo cated per approved Wan s.. ........... ..............................: .. IV. a: Nell located as per approved plans . ............................... b. Distance from STS area measured ft ........... c. Casing 18" above grade..... .............. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship .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 & dinto exist watercourse g. Footing drains discharge away from.STS area............... h. Surface water protection adequate... .... .. .......................... i. Erosion control provided ................. ............................... Rev. 1/97 VO V, l ►LU US 0j. go T 'd d0 1N3W18Ud30 A1Nnoo WUNind :3WdN T261- 812-Sb8 :-131 ST :ZT 03M 2002-SZ -030 T0'd_ 1d101 r ......::.:, :. _ : - . _...... - •� .�Il� :C I£?NTYP, ®Ffid - DMSION. ®F ENVIRt®lolWNTAL HEALTH SERVICES REQUEST FOR FINAL, - INSPECTION Date: 12/11/2002 PCHD Construction Permit # PV -3.02 For: Fill Trenches Located: 1 Gilbert Lane Cif-. Pamarre valley Owner /Applicant Name: ,__..._Greeneliff Homes, l.t� TM 83.53 Block ...J L.ot 38.1 . Formerly: RUB! Subdivision Name: Rwe Dane a WOW ams wd John knish Subdivision Lot # Is system till completed? MIA Is system complete? yea Is system constructed as per plans? ___ -� yes_.�_. Is well drilled? _..._.. -__ -- NO Is well located as per plans? NIA Are erosion control measures in place? yes bate: MA Date: Bate: 12/17/2002 M I certify that the systems), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. /211712002 Certified by: John P. Delano PE RA Design Professional Address: Badey & Wifton, P.C. 3063 Route 6, Cold Spring,. NY Lie. # FOR: ® ADAM ❑ GENE @ Joe Pasavati (NAME) 062505 Form FIR -99 TO /T0'd Od 'NOSiUM I AMUE EZ:9T Z00Z- 8T -03a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. : a .. ,r -- .. .. - r : y: i i - .Y7w: a�i , ..... •-, .. . . i - .. .. . �..,q't.. .. ....�i, CONSTRUCTION PERMIT FOR WAGE TREATMENT SYSTEM PERMIT # 01 2- Locatedat &N-RE0, Lgk'E Subdivision name 1?> i.tkAjt s Subd. Lot # Date Subdivision Approved _T /, /, 0 /01 �orVillage f:�v{T/JA/4 V ALLg ►_ Tax Map 193.5 Block I— Lot 3$ - I Renewal Revision X Owner /Applicant Name C�E+i; ,U�,i,i ;= �-IuM�S, L7°7. Date of Previous Approval 1 ag ua� Mailing Address d21 0t Q6K4 L L. PO �W QV Py rAJ Aot V&LL -E1 Zip I G Amount of Fee Enclosed ISO . © Q Building Type 5 "c Pq,-i , ° j Lot Area , 6 4-�- No. of Bedrooms 1-/ Design Flow GPD Roo Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1,2S0 gallon septic tank and yy� Lf� o � � y �. '7,2r,✓c,it Other Requirements: /. S' pG noCS �'� ` E 7, (3 0 r ffyf [ q #9'r#4 •J .DA,4t ,%) To be constructed by Address A4'r1vr^-- t14c -i.cy Water Sunuly: Public Supply From Address or: ­ t� Private Supply Drilled•by (lfJeM✓t 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 aystem 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. y Signed: P.E. R.A. Address 1,� a �� �= G�c �� Q �� �'A r�� ��9� �° License # Date 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 by the Public Health Director. Any revision or alteration of the approved plan requires a new p rmit. Approved r discharge of domestic sanitary se ge only. By: Title: Date: CD White copy - HD File( Yello c y - Building Inspector; Pink copy - Lr;Q�nge copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT 07 HEALTH ➢DIIVIIffiIICgi OF IEIdWIliOPIlbH1ERT'Il'AlL, ffIIEAII.7CffII SlEE2VIIClES �:. ... �'.m •.. �,. .._.... •1 _ _.......,z. ... _. ;.,. L1���LI..CA >r " - :C "A_ iJ�Yi' r '"Y .-Y.'�.yL�tl.,. ,/:.t•. �:�•.:•• ::v �. ... please print or type PCHD Permit # PV Well Location: Street Address: �illage Tax Grid # 6,-1L ISC2t I- oq,.;E 00,TVA..%_ V A Map93.5� Block I Lot(s) Well Owner: Name: Address: 60CEnIaiFf Poor -5 ? t &aSkJj,,J, Har,ww Use of Well: r- Residential Public Supply Air /Cond/Heat Pump Irrigation rinn�ry Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _ gpm # People Served V 6EOA-LEst. of Daily Usage JZ _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason ✓e A tiiEw 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 8.44/0 Lot No. j Water Well Contractor: nlo,Q. -not.J Address: (�,LTa4t,- 0-L Is Public Water Supply available to site? .................................. ............................... Yes No �r- Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be rovided on eparate sheet/plan. • � - Date': /> Si nay ► : -- . _. .......: _ .... __ _ _ ._ _ .. r, Applicant g 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 & 4 -0 Permi Date of Expiratio Title: Permit is lion- Transff rrablle White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller t Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of 6 k'C1-7"i "I rl� -�LM C5 Located at k (_C,e-r t I- 14n)c T/V Pvlt )40';� V aL-Lo) Tax Map # !S3 - S_� Block 1 Lot 39 — 1 Subdivision of 3 L $2.nJ Subdivision Lot # S Filed Map # Gentlemen: Date Filed This letter is to authorize X17. '_D0/,M OLA G PE-, 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 treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health _.: I,�w;-and., the- Ptitnam -C- dusty- Sapita- y- Codo:- _ _ ...:. -. -... Very truly your . Countersigned: Signed: T. P.E., R.A., # ��` (Owner of Property) G jQG:pJL0 YC /- L-vtCS LTD Mailing Address ly �� d��ey —r� eft -�'°� Mailing Address: �2 1 46-Ls+<«` Haj L0,j 2p.. State Zip Telephoner State _ Zip ! v S Telephone: 5.;�e- .5yy8 . Form LA -97 PU'TNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEN'TA]L HEALTH SERVICES AFMA FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: Consrtuction Permits for Sewage Treatment Systems & Water Wells I, Steven Lealydi represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Greenefiff Hones Having offices at:. 21 PeekskiRl Hollow Road, Putnam Valley, NY 1 0579 Whose Officers Are: President = Name: Steven Leardi Address: 21 Peekskill Hollow Road, Putnam Walley, NY 1 0579' Vice President - Name: Daniel Romanello Address: 21 Peekskill follow Road, Putman Valley, NY 1 0579 Secretary -Name: Address: Treasurer - Name: Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: Title: Firesidennt Sworn to before me this tl day of (month) D ar) Notary Public MARIANNE S. DINATALEYork Corporate �al Public, State of New Notary No p1D15020567 Qualified in Westchesoter county commission Expires N Form CA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PE ® o PERMIT # Located at nl<- Subdivision name Rfeh')V---r / Subd. Lot # Date Subdivision Approved AGI 'TREAT'1VIEIVI' SYS`I'E1Vi[ own Village �Oo Tax MapY fl Block !� Lot 3 oo-/ Renewal Revision Owner /Applicant Name APG J'-e /v/. #, i < P.)&227 IX Date of Previous Approval Mailing Address!,/j. J ��. �J �i %G� %%fib/) �✓ ?��� rf�GfC �/f Zip 0 S-P,( Amount of Fee Enclosed , Building Type W4414* tlt- Lot Area No. of Bedrooms Design Flow GPD_jE Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and 4. r Other Requirements: 41;:/,e C I�AI,0 Q -U d ee 1, e `°4 % 4zAr (fix y To be constructed by -7-plp Address Water Supply: Public Supply From Address or:- %/.: Private-Supplx Drilled b - Address- I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: P.E. R.A. Datei Address la U 47, -04 kc rW,1_i dj^ e ee 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 modifie when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p rmit. Approved for discharge of domestic sanitary sew ge only. By: .'� Title: Date: �z White copy - HD File; ello co y - Building Inspector; Pink copy wn - ange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT ®IF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ., . A]EnPLICA'I IQN TO CONSTRUCT A WATER WELL s .. Please print or type - . a Pow Permit #1 Weill Locatlnon: Street Address: illage Tax Grid # 3 / er�iS�/l�7 !,/�t��� Map(. ,r�' Block r Lot(s) WeRlOwne>r: Name: Address: Use of Weil: Residential Public Supply Air /Cond/Heat Pump Irrigation >rimary Business Farm Test/Monitoring Other (specify) 2- secondairy Industrial Institutional Standby Amount of Use Yield Sought gpm errve"(( Est. of Daily Usage If gal. Reason ffoir Replace Existing Supply Test/Observation Additional Supply IlDirffing New Supply dwelling) Deepen Existing Well 1<Detailed Reason A(new ,�7 !%%� � /V for 1ZDriIlling WeH Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes !/ No Name of subdivision R± /C '01 Lot No. / Water Well Contractor: ?p Address: " Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to beyrovi ded o parate sheet/plan. 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 ' E8 FO 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 Countv. 4 - Date of Issue 1-79 '0 2 Permi Date of Expiration °-D W Title: Permit is Non- Tiransffenrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller 1� Form WP -97 r BATH •A r BEDROOM 4 OAESSING• 9* -8' x 12'•0' .. BEDROOM 3 . ,WALK 13' -0" x 10'-O' �� „I IN CLOSET • r 1 , MASTER SEOROOM BEDROOM 2 OPEN 17' -0 ; 16'•8' 13' 0” x IS' -8— i — PUTNAM COUNTY DE" ARTMENT OF HEALTH < Ft0 SE PLANS APPROVED F�0 BEDROOM COUNT ONLY, Z/ _ ` i BEDROOMS ' /v/ 3,-!N-00 —/-" 3 • / SECOND FLOOR 1 ALL SUBSEQUENT RFV1S11ONjALTER�ATION;S, T04`aT2�i', ;�13�,44S F PLANS MUST ICE SUBi1LTTED TO THE PCDOH FOR Apj1JR0V j cr � . KITCHEN i - lA4M DINING HOOM p �� MORNING HO.OM ~� r 13'0** a 12' -0" L-- J. LIVING ROO 1�'•0" x 11'•0" FIRST FLOOR L -f OPEN ABOVE M w FOYER �• r -- FAMILY ROOM 13' 0" a 17' 0" 4828 = 1'144CF i PUTNADI COUNTY DEPART,-,IF,,T OF HEALTH DMSION OF ENVIRONMENTAL HEALTH L\- DTVIDUALWATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR;CONSTRUCTIO_N P•ER►IIIT , v.. NAIVE OF O' NER: &c rAJJ STREET LOCATION: REVIEWED BY: R%L OR, AS, &ATE: 9� a°�' TAX (CONFIRMED) 1' N DOCU`IEN`TS (,!!!��PERIITT APPLICATION ( AUWELL PERDIIT OR PW S LETTER ( f�UP C -97 (/)ULETTER OF AUTHORIZATION U )DESIGN DATA SHEET (DDS) (J(UCORPORATE RESOLUTION (UUSHORT EAF ((__)PLANS -THREE SETS (___)HOUSE PLANS - TWO SETS U(f )VAK NCEREQUEST SUBDIVISION (,,}(JLEG.kL SUBDIVISION �(_)SUBDIVISIO\ APPROVAL CHECEED UPERC RATE , n•.•.� (. j)(UFML RE QUMED b S" DEPTH (_/)U CURTAIN DRAIN REQUIRED 7 , x /6v � GEti L ' U(�LOCA L� NYC D (_)SANS s D TO DEP LE ED TO. HD (__)( DPROVAL, ff 'D UUDEEP TEST HOLES OBSERVED UUPERCS TO BE WITNESSED ,()(__)EX- APPROVAL SSDS ADJ, LOTS ( J(_,e!!5VETLANDS (TOWN/DEC PERMIT REQ'D ?) (.,,eJlUDATA ON DDS PLANS & PERMIT SAME (_J( _ZPRE 1969 NEIGHBOR NOTIFICATION U( dLETTER.BUZBA ... - "'•" - (�`j(�100�CR- _:FI:00'D Ei:EVAT %iN W /T2Uu °" _:. °.:. (J(/JSOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS 9 (___)SEWAGE SYSTEM PLAN - (NORTH ARROW) ( JSSDS HYDRAULIC PROFILE UGRAVTTY FLOW (JCONSTRUCTION NOTES 1 -15 (/J(__)DESIGN DATA: PERC & DEEP RESULTS UU2' CONT.OURS_EXLSTIXG & PROPOSED (Zj( _JDRIVEWAY & SLOPES, CUT (&(JFOOTING /GUTTER/C'URTAIN DRAINS (Z(___)USDA SOIL TYPE BOUNDARIES - ( /)(_)TITLE BLOCK; OWNERS NAME ADDRESS TN&4, PE/RA; NANIE, ADDRESS, PHONE4 (­!�J( _JDATE OF DRAWING/REVISION (!)( _JDATUZI REFERENCE (Zj(-__)LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P -L. _JPROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS ( I(_�)WELLS & SSDS'S W/Il't 200' OF SSTS (_Zj(_JPROPERTY ii1 ES &BOUNDS COtiIb1ENTS: 'Y N (REQUIRED DETAILS ON PLANS CONT'D) UUHOUSE SEWER -' /�" FT. 4 "0'; TYPE PIPE CAST IRON U(_JNO BENDS; MAX BENDS 450 W /CLEANOUT - NEW LS UUSTTE NOTE (NO NGE) ILL SYS Eti1S �( )l0' HORIZONTAL; PAST TRENCH SLOPES,11 -T_0 GRADE U)UFILL SPECS/ FILL NOTES 1c5' ( )(__)FILL PROFILE & DNS (�(JFILL Di EXPANSION AREA FILL GREATER TA-4 ` 2 FEET UU CLAY B. UUFILL CE R ICATI N NOTE U )DEPT A ES UU��O .ON PLAY FOR RO.B., UNCLASSIFIED & �IPERVIOUS U( )SE ARATION DISTANCE FROM TOE OF SLOPE TRENCH (� (,LF TRENCH PROVIDED Yl K 60FT MAX. (%IUPAR4LLELTO CONTOURS (•,)(_)100% EXPANSION PROVIDED. (/)UDETAILDUST FREE CRUSHED STONE OR WASHED GRAVEL (Z)UGEOTEXTILE COVER SEPARATION DISTANCES O FROM SSTS (e/!�)U10' TO P.L. WAY, LARGE TREES, TOP OF FILL (�2VTO- UNDATION WALLS (,,!6 (__)100' TO WELL, 200' IN DLOD,150' TO PITS (,t!j0100' TO STREAM, WATERCOURSE, LAKE (inc. espan) (v(J50' TO CATCH BASIN, 35' STORItiIDRAIN, PIPED WATER 10 TO WATER LI`rE its 20' (1JU50' I`iTERIUTTENT DRAINAGE COURSE ((_)200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (,t3U10' NIINTO LEDGE OUTCROP SEPTIC TAB l�JU10' FROM FOUNDATION; 50' TO WELL WELL ( /L_)DLtifENSIONS TO PROPERTY LINES ((LOCATION OF SERVICE CONNECTION _... - ()MIN 15' TO PROPERTY LINE / SLQPE (__)USLOPE LY SSTS AREA %Y0 %) C_)L REGRADED TO 15 %, IF REQUIRED UUPUMP NOTES (�UDOSE 75% OF V LUME/DOSE VOLUME NOTED (__)(JDETAIL FOR F CE IN, (PIPE TYPE, ETC.) UUPTT AND D -B O N & DETAILED UUl DAY STO ABOVE ALARM CURTAIN DRAIN (�6STANDP ES BOTH SIDES,'DETAIL 5'. b _„ td;: : S=. >S %, 2014%,251-3%,351-1%, 100 % -<1% U( 0 C__) X20' IIN to CUDISCHARGE /100 "With 182 cons day discharge G—it )10' MLY to NON - PERFORATED PIPE BRUCE R FOLEY Public Health Director 0 �vc-... .c .. �. ...,�...: .:.x^r:,...•-a*•.i i^: ^fa ••^n�""i+4ti a'oa•..w..; :z,;.:,�: ••�• 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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845),228 - 5912 Fax (845) 228 - 6113 January 8, 2002 Daniel Donahue, P. E. 120 Breckenridge road Mahopac, NY 10541 Re: Proposed SSTS: Burns, Gilbert Lane (T)Putnam Valley TM #83.58- 1 -38 -1 Dear Mr. Donahue: 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: Provide erosion control just below the SSTS area, and around the proposed well. Z. Provide a 20' separation distance on the plan between the foundation-and absorption trenches. _ -- Provlde--,two-sets -of -stand pipes for the curtain - drain with detail skefcl%` Provide curtain drain detail. Show a minimum 15' separation distance between the curtain drain and absorption trench, and 20' from the discharge to the absorption area. Plans specify a "Geo web" swale detail yet one does not exist on the plans. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Shawn Rogan`` Public Health Technici SR/jp SiJU11. ENGINEERS - - _ icl ).Donahue, P.E. '.i i . v.. , ... ��c.Y�'•'... rn:� -.�'- ..: q , "' ..:� r : d:n =1'a. �' r.a. %.�.r,:.z. 200 Breckenridge Road Mahopac, N.Y. 10541 _.__. ____ _.__._._..._._........ 914 - 628 -7576 TO DATE ` roo reo. ATTENTION I / _ DESCRIPTI ON • As requested ❑ /_ /� -C / [a 6��11 �T BRIE ARE SENDING YOU Attached G Under separate cover via —the following Items: O Shop drawings ❑ Prints ❑ Plans O 'Samples ❑ Specifications O Copy of letter O Change order ❑ COPIES DATE NO. _ DESCRIPTI ON • As requested ❑ /_ /� -C / [a 6��11 �T O _ �// ► &I% % f ! 40W 61 ell THESE ARE TRANSMITTED as checked below: REMARKS CV For approval • For your use • As requested ❑ For review and comment O FOR BIDS DUE N ❑ Approved as submitted ❑ Resubmit_ . - copies for approval ❑ Approved as noted ❑ Submit copies for distribution O Returned for corrections O Return corrected prints 19 O PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: I 200 Breckenridge Road Mahopec, N.Y. 10541 . ............ 914.628-7576 TO lei XM 00 NO. ATTI.T1 pit Ino Z_A* & 7- "M . WE ARE. SENDING YOU V Attached 0 Under separate cover via --the following Items: [I Shop drawings Lj Copy of latter 0 prints ❑ Plans 0 Samples 0 Specifications 0 Change order, 0 COPIES DATE NO. DISCAI►TICIN _4466- do _fA&r4,?_ i 2-,o h en— el /* /* THESE ARE TRANSMITTED as chocked Wow; �r For approval L' Approved as submitted 10 Resubmit--copies for approval 0 For your use 0 Approved as noted C3 Submit copies for distribution L7 As requested 0-.Returned for corrections C1 Return corroded prints 0 For review W comment E3 FOR BIDS DUE 19 0 PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO- SIGNED: -M &* INWed. hiAdIV ro*10Y 416 orefte: 'r%LJTNAM COUNTY DE A .T° ENT° OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES "...,vy- :..��. --; .._ %i�►fi'. .. .;.;- '- tr_-s�.c a.�= i��:y <`:.,- .Fair:_.'. ,r .. .a. ... ... -- � ..- _ '_. LETTER OF AUTHORIZATION RE: Property of /V e, "'r Located at 611, /94�fl �✓�+/� Pv'-(Xlpf -�n ax Map # _602f Block �-- Lot 3 �' Subdivision of /?A-;f A)'X' Subdivision Lot #. Filed Map # � Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer 4--"' 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 tretrnent and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health the.Putnarn_County Sanitary Code. .�. rw b..e...� :.v _..... n an. ;. .. J'. � ._. _�.�a w_.r a .:.:. .. .... :.. .a;.. ur .. Y -. .. • v ti- -..+- w.. .v- _ a- �.w ... .� a. _ . s X ..s .... -. .Y ...s w .. -- .. Countersigned- P.E., R.A., # ..�„.4 Very truly yours, Sagned:ll�'� (Owner of Property) _ & o' Mailing Address A7 -fjG�{;L� WZam; State Zip 1,6rW State M Zip `6' Telephone: �%�- ��� I% Telephone: Form LA -47 14-164 M87)—Text 12 PROJECT i-D. NUMBER SEOR APP*ndlx C ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS. Onty PART I—PROJECT INFORMATION (To be completed by ftollearit or Prole6t soonson 1. APPLICANLille PONSOR ov PROJECT NAME 3. PROJECT LOCATION: Municipality z z County A. PRECISE LOCATION (Street address and road Intersections,' prominent landmarks, etc,, of provide map) k4w /15- S. IS PROPOSED ACTION: QO C3 ❑ New Ex;vsIon M"adificationlatterstion 5. DESCRIBE PROJECT BRIEFLY: 6'V 7. AMOUNT OF LAW) AFFECTED: 61 Initistly acres Ultimately jr acres 6. W!L PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ❑ Commercial 0 Agriculture LJ ParkiForostio;4M space other Describe: A PERMIT APPROVAL, OR FUNDING, NOVI OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FE ERA) -!' 1C. DOES ACTION INVOLVE STATE R LOCAL)? y#$ ON 0 If Yes, list agency(s) and pormittapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes 19NO It Yes, list agency flame And p4mivapprov#1 12. M A RESULT OF PROPOSED ACTION WILL EXISTING PERMI'TIAPPROVAL REQUIRE MODIFICATION? Yes Vi No PROVIDED ABOVE 13 TRUE TO THE BEST OF My KNOWLEDGE I CERTIFY THAT THE INFORMATION d Vol 4 u 1 9 Date: AppliClintlSpOnUt flame: Sigmstufs: It the action Is In the Coastal Area, and you are & state agency, completefthe Coastal Assessment Form before proceeding with this assessment OVER PART, I1- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION Ex EffD ANY TYPE 1 THRESHOLD IN S NYCRR, PART 817.1x? If yes, coordinate the review process and u_aa the FULL EAF. Q- - :.._ Yes NC -s^ .1 4' _r_ `sal r-• B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 8 NYCRR. PART 817.ti? It No, a negative declaration may be superseded by another invjived agency. ❑ Yes C• COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WRH THE FOLLOWING: (Answers may be handwritten, If logtble) Ct, 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 neighkorhood charactea lcxplaln briefly: �oiv ar C7. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangored species? Explain briefly: /V a N� 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? Eitgdain briefly /V Al r° t C3. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. v �. �- .! Cb: Long term, short term, cumulative, or other effects not identified In CI-CS? Explain briefly. - CT. Other impacts (including changes in use of alther quantity or type of energy)7 Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? C1 Yes' Z No It Yes, explain briefly i PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse elfect Identified above, determine whether it Is oubstantial, large, Important or otherwise significant. Each effect should be assessdd In connection with Its (a) setting p.e. urban pr.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 detall to show that all relevant adverse impeeto have been Identified end adequately addressed. C� Check this box If you have Identified one or more potentially large or sigrif scant adverse Impacts which MAY 0 ur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. !'Check this box if you have determined, based an the Informatlon and analysis above and any supporting documentation, that " proposed action WIi.L NOT result In any significant adverse environmental Impacts AND provide on attachtnents as necessary, the reasons supporting this determination: Name of Lead 'Asencv `? v � aL it 0 OT 2�spOn4i lure o reparer III iliffaterit from response e olficQri PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ F..._.... ...._ .....__.. APPLICATION Ti ON FO R - - A PPR VAL.�OF LAN S' F-O :R. WASTEWATER TREATMENT SYSTEM t 1 - 1. Name and address of applicant: e& ,r 2. Name of project: SiWs e FA"ii r ,aF r 3. Locatic& 0700. orz- 4. Design Professional: MAt IoL 4. aoN.4Hvr 5. Address: _lea &0 6a- FNR�oa . o 6.' Drainage Basin: Af e -44 Oiyn 4 ,QrdVic d-"" y 7. Tyge of Project: _ k Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status check one ...... . Type I Exempt Type II Unlisted _L__ 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... _m� ..- 10. Has DEIS been completed and found acceptable by Lead Agency? ............... All 11. Napie of Lead Agency _ ' 2. 'Is this p;ojict in an area under the control of local planning, zoning, or other _... _ ... officials,- ordinances? .w. >,................: ... .................... .. :r _ ... ...... 13. If so, have plans been submitted to such authorities? ........ ............................... No 14. Has preliminary approval been granted by such authorities? Date gri rated: 15. Type of Sewage Treatment System Discharge ................. surface water Y groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ...... ... ............................................. I.................... . AIM 18. Is project located near a public water supply system? ....... ............................... /Y/J 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A/O 21. Name of sewage system A Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector��iv� 24. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... IV-0 26. Has SPDES Application been submitted to local DEC office? ......................... /V le _ Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? Ala 2$.. .Wetlands ID.:Number. _ _ ... ........ .... 29. Is Wetlands Permit required? .. .............................................. ............................... N y Has application been made to Town or Local DEC: office? ............................... 30. Does project require a DEC Stream Disturbance Permit? ... ..............................� 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? .................. I......... Yes(d 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 DESCRIBE: 33. Is there a local master plan on file with the Town or Tillage? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... /V d C? 35. Are any sewage treatment areas in excess of 15% slope? . ............................... Alb 36. Tax Map ID Number .......................... ............................... Map_ 3 rkBlock Lot — J 37. Approved plans are to be returned to..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS. to be located within _the NYC.Watershed AM be sent to the Department, and need not be sent in duplicate to the DEP, although the project -nay 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 Tor 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 - 1.,thd application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the- rejection of any submission. I hereby affirm, under penalty of 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. SIGNATURES ali ®FF'ICUL TITLES.- 2) 4uiF (,4- Mailing Address: ................................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner k9ttS E 1t,q ?1 j 6 VV A)f . Address IQ !2 11AW I r-yo, 40; !/,BiPi�ild� Located at (Street) 4:714 Tax Map 3 S Block l Lot (indicate nearest cross street) Municipality PLrr) d& Watershed OJT �''�,�►d.vQ ,�C'�C SOIL PERCOLATION TEST DATA Date of Pre - soaking 1z Ov Date of Percolation Test / 60 Hole No .. .:. .., ...:..... Ru— No.. .... ..... Tiiate.. Start Stop E!a 4' (PMin:� . De� `th to'Water ]E�rom Ground .: Surface (Inciyes) : °Start Stop '�VY�tter Level :. _ rop Ia nohes Perc6l8tp g�to M.in/I6. .2 � 35- Ar a a ,..3 " Is Z a ' . �s a C2 *7 67 24A 4 7 of � 3 l , 2 3 144 /bj40j#fdTK 4 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 triin/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 840.100 A.) LOT p ®�'I'ES1' PiI' DO'H'A e® ,✓,� �e DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES � D t.�Y.p +t w.. . "NLLE :' �i.• . ^110E ®• '.. 'R.®LL 11 •1V.•�•�- _. .n r r1 o r� _ r •!� G.I . 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.51 7.5' 8.01 8.5, 9.0' 10.01 Indicate level at which groundwater is encountered .6 o LW ma _ Indicate level at which mottling is observed Indicate level to which water level rises after being encountered e Aj g e ..- Beep hole observations made by: - Date Design Professional's Seal J. n y�Ak,Mo O 0 m O O rn x w 0 z U_ a Q 0 0 0 w 0 00 M i m 00 m N to I N O O wz J >I Q r m Q 0 EL r m w AS 'BUILT RELOCATION -DI MEN SI DNS 1B 27.0' SEPTIC TANK 1C 18.5' SEPTIC TANK 2B 20.5' SEPTIC TANK 2C 25.1' SEPTIC TANK 3A 53.4' DROP BOX 3B 29.5' DROP BOX 4A 56.2' DROP BOX 4B 34.9' DROP BOX 5A 59.5' DROP BOX 5B 40.2' DROP BOX 6A 64.3' DROP BOX 6B 47.7' DROP BOX 7A 75.6' DROP BOX 7B 52.6' DROP BOX 8A 25.0' END LATERAL 8B 71.4' END LATERAL 9A 31.0' END LATERAL 9B 73.9' END LATERAL 1OA 36.9' END LATERAL 1OB 76.4' END LATERAL 11A 43.4' END LATERAL 11B 81.1' END LATERAL 12A 49.2' END LATERAL 129 85.5' END LATERAL 13A 103.5' END LATERAL 136 47.0'• . _,. END. LATERAL 14A 105.2' END LATERAL 14B 51.0' END LATERAL 15A 107.4' END LATERAL 15B 55.6' END LATERAL 16A 110.0' END LATERAL 16B 60.1' END LATERAL WC 72.8' WELL WD 28.9' WELL P w Q O J N \ J Z Q y v \ O 2 Q � Q �- Q O Z Q O Jw o N �- R N 1., ^W O CL ^. \,,_ 2 'N EAsEMENT CONsER VA T1 ON YN CL 1-54,59 S17350 00 E O I 1.609 Acres (70,105 S.F.) Pde < 43.1� wnTr poia pave IdocadoM m pole SEPTI TANK 1 11 2 [4431 Cl.ABSCR- P,ON LATERAL (TYP) I WI ri prop• po%. Mon. LANE D --JJC 2 St Fl. (Fovmaaebn U. c- 2 45.34' PORCH 6" SDR 35 SLEEVE 4* SDR 35 DROP 8 X (TYP. 3 48 L. 49 LF. 8 L.F. 4 49 L.F. 9 48 L.F. 5 49 L.F. 1 49 L.F. 6 49 LF LF 1 C4 100 Exp!S!170N t C4 I QL cl O wnTr poia pave IdocadoM m pole SEPTI TANK 1 11 2 [4431 Cl.ABSCR- P,ON LATERAL (TYP) I WI ri prop• po%. Mon. LANE