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HomeMy WebLinkAbout3990DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.64 -1 -10 BOX 31 I I 16 r 116 03990 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION .:0 -,. I V �. H .RY� ,—�� ' 4H� e T ����. :.._ CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR ..SE �' ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # –eel Located at e C re ->/ d- Town or Village Owner /Applicant Name CGe rg ��a r ;` Tax Map ,�?,3. d 4 Block Lot Formerly Mailing Address Date Construction Permit Issued by PCHD Subdivision Name .-1 Subd. Lot # Xie a e' /'r fir= e' Zip Separate Sewerage System built by �/ ��� `� % dam Address /fie li ?,d X / Consisting of / d' L' Gallon Septic Tank and 3e e Other Requirements: Water Supply: Public Supply From Address or: Y Private Supply Drilled by /1,4r,o-,;4" 4 &3,0 /7Address a3ui- '.ding All e � %, J' - y= 't` - ;: erasion contral been con��pl: tc3? = - Number of Bedrooms j3 Has garbage grinder been installed? Ale 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 Putnam County Department of Health. —T N 3 6� Date:i/ Certified by P.E. R.A. � SDe o sG � Address 2– 9 7 i` E License # l� Any persoXoccupymg premises served-Wy a above ptly take such action as may be necessary to secure the correction of any unsanitary conditions re h usage. Approval of the separate sewage treatment system shall become null and void as soon as a pu tary 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: Title: ` s` �� (f Q Date: Whi 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 Well - L ®eatuon St et Address: /•�•s- --"uo u i : _s= - Tax Gr-si� d # ap '�` ` Block / Lot(s) /0 Well Owner: /�-� Address: LL ! // �Ga rCg�i i� %i "t'G%r'risl jc>t` Nse off WeRh I- primary 2-secondary Residential Pu lic 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 4. Open hole in bedrock _ Other Casing Details Total length 4ft. °ft. Length below grade Diameter in. Weight per foot alb /ft. Materials: Steel Plastic _ Other Joints: .Welded X Threaded Other Seal: >e 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 (Compressed Air Hours 2 Yield.-5- 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 analysis_... are available, please attach. Depth From Surface Water ]fearing Well Diameter(in) ]Formation Description ft. ft. Land Surface If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Types , , iLL Capaci _S Depths Model 'S10 Voltage -,)3 6 HP Tank Tye olume 4, Date Well Completed Putnam County Cert ification No. Date of Report Well Driller (signature) iNa ii e:: rxact location of well wttn aistances to at least two permanent landmarks to be provided on a separate?sshhe'eet/plan. Well Driller's Name - r-en -0 Address: /3/ �y Signature: Date: U S 7 c White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 YML ENVIRDNMENTAL SERVlCES 321 Kear Street N.Y. 10598 .`�����a������'���.���r�����' '- - Albert H. Padovani, Director | LAB #: 32.304020 CLIENT #: 56577 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~ - | RUSH, FRANK III (�'����� '' � | -~",",�,",,� ~� ~- - J1 rk IvpMLInMo/ LAKE PEB<SKILLv | $3 Zd/-/-.)-" NY 1 �= y°�,� NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~ ... ~~~~~~ ... ... ~ ... ... ~~~~~~ DATE/TIME TAKEN: DATE/TIME REC'D: RB,ORT DATE: PHONE: 05/27/03 1J.:00 05/27/03 11:40 06/02/03 SAMPLING SITE: RlDGECREST, LAKE PEEKSKlLL, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COL'D BY: SARAH ANDERSON TEMPERATURE..: < 4C NOTES...: COL 11: METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURZE- PUTNAM CNTY PROFILE 05/27/03 MF T. COLIFORM 05/27/03 LEAD (IMS) 05/27/03 NITRATE NITROG 05/27/03 NITRITE NITROG 05/ 2 7/03 IRON (Fe) 05/27/03 MANGANESE (Mn) 05/27/03 SODIUM (Na) 05/27/03 pH 05/27/03 HARDNESS ,TOTAL 05/27/03 ALKALINITY (AS 05/27/03 TURBIDITY <TUR ABSENT /100 ML 1.2 ppb 0.59 MG /L. <0.01 MG /L <0.060 MG/L 0.012 MG /L 6.56 MG /L 6"0 UNITS 42.0 116 /L 36.() MG /L NORMAL - RANGE ABSENT 0-15 ppb 0 - 10 N/A O-0.3 mg/l 0-A.3 (ng/l N/A 6"5~f)"5 N/A N/A METHOD 1008 910l 9139 9146 2037 2037 9O4": COMMENTS: PACT THESE RESULTS INDICATE THAT THE WATE NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDINZ)�HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS 'TESTED, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits, for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 27O mg/L. of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street (914) 245-2800 Albert H. Padovani, Director LAB #: 32,304020 CLIENT #: 56577 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RUSH, FRANK III �_����� ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ �� /��~.7"!nq DATE/TIME TAKEN: 05/27/03 11:00 RIDGECREST ~' DATE/TIME REC'Dv 05/27/03 11:40 LAKE PEEKSKILL, 0-:� .�x�~�— /u/ NY 10537 jrell�y 411" REPORT DATE: 06/02/03 PHONE: SAMPLING SITE: RIDGECREST, LAKE PEEKSKlLL, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVESt NONE COVD--B% SARAH ANDERSON - TEMPERATURE..: < 4C NOTES..": ------- m --- ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLlFORM METH: M1:- DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested., pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. . WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER:'0,70MG/L�_ NOW AWL WATER:��ABOVE.3(X)^MG/L,� -'- ;Ob-R�\T-f\rT�-riWATER� ��-14O MG/L ' AG/L�'i1{ PB LITB� HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Director ELAP# 10323 Jun 24 03 06:22p FRANK W. RUSH III 8455261958 p.1 Qty CoG k3kCJC6 ~ k? FOLD Y LORFTTA MOLTNARI R. N M.S,N. PYolic Health Director ti� Y OQ-� Associatc Public Neak/a Director Director of Patient Scrvleer DEPAazt'I N ENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Eaviroatacat :l llculth (914) 278 - 6130 Fax (9.14) 278 - 7921 Nvrsiag Scrvicu {914) 278 - bSSB WIC(914)278-6679 Fax V 14) 278 - 6085 Ddy loterveadoa (914)278 -6014 1'rcRboo1 (914)2786082 Fsx(914)278.6648 OWI-EHs NA:N: TAX MAP NUMBER: E411 ADDRESS: TOWN: AUTHORIZED TOWN OF (Signature) DAM 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 to-w-n official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 V) u-PA DHVHSION OF _ ENVIRONMENTAL _HEALTH EIRY GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building ,, Building Constructed by 2 �. "�.-�� -vim Location - Street Building Type Tax Map Block Lot 0 J-757 )�J /e_ ;o TownNillage Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam. County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me. which fails to. operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage, treatment system, or any repairs made by me to such system, except where the failure. to operate properly is caused by the willful or negligent act of the occupant,of the building utilizing'the = _system;_ _ ..`..._. P.. _ ..._ .... _... _ .. __ - __ .. _.._ u _ _ _ __ The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the bfilding utilizing the system. Dated: �� 1 �.� Year 2— `5 eneral Contractor (C caner) - Signature / fix/ 7 Z�e Corporation Name (if corporation) Address: 25 c y & State zip Si Title: Corporation Na4ie (if corporation) Address:)' e'y /_17N 177a� U� /may State -- -- /Zip /'s"79 Form GS -97- -""- -_ :- `Y,OI�T'I'A`•IviOI.INAItT R.N','1vI.S�.IV. Acting Public Health Director Director of Patient Services April 7, 2003 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 /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights, New York 10598 Re: Dear Mr. Sullivan: ROBERT J. BONDI County Executive Field Inspection — Hozim Ridgecrest Road, (T) Putnam Valley TM# 83.64 -1 -10, Permit # PV -13 -00 A site inspection was made for the above referenced project on April 7, 2003 1 r co ents must be corrected in the field. The following cast iroi. pip e.thaf aTp:less -than .' /a ". per - foot.. -T here also appears to be a downward facing 45° elbow. Pipe pitch must be corrected and a cleanout provided. A reinspection is required. X71. It appears that the house is occupied and the system is being used without compliance. If �( this is the case, it is a violation of Article 3, Section 3.2.5 of the Putnam County Sanitary r_ Code. A compliance must be issued by April 23, 2003 or further action will be necessary. 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 DEPARTMIENT OF HEALTH 1 'r , � `�'.J'G' DIVISION OF ENVIRONMENTAL HEALTH SERVICl✓�_' FINAL SITE IN SP>ECTION Inspected by: .1k Street Location � � �1;�,. ��( Owner h/a ,'.a,. Town Av .,fK Permit # - I T_ o TM # 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 ...... ............................... 11. &wage System a. Sep-tic, t size - 1,000 ....... 1, 250 ......... other ...:............ b. Septic tank installed level ................ .................... ............ C. 10' minimum from foundation .......... ...... .......................... d. ]fDistribtuion Box 1. All outlets at same elater tested ................. 2. Protected below ....... .............lv ./. . - ................. 3. Minimum riginal soil.between box & trenches Junction Box - properly set .............. .................: :........... 1. ength required, '3� Length installed `,t7 2. Distance to watercourse measured Ft.......... 'V� 3. installed according to plan..:. : .............................. 4. -Slope of trench acceptable 1/16 -1/32" /foot ...:......... 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 %...... .. .................. 8. Size of gravel 3/4 1' /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ......::........... ends caliped .:...::..................................................... g. Pump or Dosed Systems Size ot pump chamber ................ ............................... 2. Overflow tank ......... .................... . 3. Alarm, visual/au ' .................... .�............................. 4. Pump easilya cessible, manhole to grade ................. 5. First) box`�,affled .............:............. ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildin a. House located per approved plane, �.........._ _ -- - Number of bedrooms ...... ............................... ......... :..... IV. nWe e ll 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. 6j� f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... e_v NCO. r "M INN Mum RVL e_v NCO. 12/04/2002 14:15 9149624248 JOSEPH SULLIVAN PAGE 01 PUTNAM COUNTY DEPARTAIENT OF SMALTB DrVMOX OF ENMOMMENTAL NZALTR WIMCES g',o e- ATTENTION k8 13 C*P.NE R �i T FQA 71�IAt 1�LL�P d� For: P'i11,, 4:tg c3" All iafonadon mast be Uy completed prior W any • Tmwbu intOns batng >mad0. . { PCHD Construction Permit 0 -- t'3— A 0 Located. " M (v) Owner /Apphcant Name: Coat , *Cz ed ► TM� s r BICok . .. %ot Subdivisloa Naw; ~' Subdir iou Lot * Is system 511 completed? Date:.��„ !�' � �• _., Is system complate? Date:..__.__!.' e� Is system constructed ss per ? Is well drilled? d Date. Is well Waled as per pim? Are erosion control Mu mu is place? I tb A tbo syr*s), as lis* at the dxm premiss has been owed and I have is qw tsd and va lfied their completion in accordance with tbt issued PM Commu bm Parana and approved plans sad the Staadatds, Rules ud Regulatinns of the PAc m County Dapartmao of Date. /3� f' o..� CerJR d by: rte; P A-7" DiOp Profess<wd . 11111 T .11 . /� Z. � I azzz r 1,y 1149fe Ul ovi iw 1(�G�u a Cr�ST �vwt, lbw �Trlp,�' Form Flkt"99 PUJ7['NAM COUNTY DEPARTMENT CIF HEALTH _ - DRVIISffGN_ OIF IENVRR(DNMENTAIL IHIEALTIHI SERVRCES CONSTRUCTION PERMIT FOR ATMENT SYSTEM u PERMffT # E✓- 13 - Located at �i % �j /r Town or Village OAOW X I/ Subdivision name '-" Subd. Lot # Tax Map$3.� Block Lot le Date Subdivision Approved Owner /Applicant Name Mailing Address Renewal Revision ��'d y e'- ff ,p ---7 rn+ Date of Previous Approval Amount of Fee Enclosed ., e a Building TypeAjll2rW�C' Lot Area No. of Bedrooms 3 Design Flow GPD Fill Section Only Depth Volume PCH D NOTR FICATIQN IS REQUIRED WHEN IFML IS COMPLETED Selparsate Sewerage fystem to consist of /a 00 gallon septic tank and -3 0, / -10'-�7 e /- 741 " . , L- &:�)q Other Requirements: To be constructed by Address -Waiteir_S.unto�ly:_ Public Supply.From.._ _ _Address ou•: Private Supply Drilled by r ._. - 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: Address ;z �J ��'vii Al1nPl[8® ®I1� ® S�'t8U sewage treatment system has been c P.E. R.A. Date License # ._ eof s two years from the date issued unless construction of the �v the PCHD and is revocable for cause or may be amended or modified when considered necessary i is Director. Any revision or alteration of the approved plan requires anew pgrqvt. App ved fo d' char o� itary sew ge only. By: Title: thQkff Date: /IZ�/QD White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professi nal Form CP -97 , -1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT, A WATER WELL z. e ' please print or type _.. a < T- i PCHD'Permt Well Location: Street Address: Town/Village Tax Grid # i �� Maf-5"�*' Block Lot(s) /L7 Well Owner: Name: Address: i' a il'J'I O d °�vp�6w Use of Well: esidential Public Supply Air /Cond/Heat Pump Irrigat' n 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 o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type KDrilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: lVd.,we'/! 42j?, —p� Address: may Is Public Water Supply available to site? ............... ............................. -. Yes No 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 . _ o o ' Applicant Signature: 61-0- _ - 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 certifie by Putnam County. Date of Issue -7)IZ,1001 I Permit Iss 'ng Official: Date of Expiration 7 1 if -02. Title: Permit is Non - Transferrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller ' (" ] a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM fl . Name and address of applicant: e 2. Aflame of project: _;�5.2t— 3. Location T' s 4. Design Professional:. i 5. Address: t�a- b. 1%f Proicpl: Private/Residential Food Service Conunercial .Apartments � Institutional Mobile Home Park Office Building Realty Subidvision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted g. Is a Draft Environmental Impact Statement (DEIS) required? 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 07/�% 10. Name of Lead Agency 11:. I thgs ° rojec is�att area unu�r the con rdl -6f 1oeaa pig 8i ng';'zo`�f; br'bth'e officials, ordinances? ......................................................... ............................... 12. If so, have plans been submitted to such authorities? ........ ....... /....................... �i 4 13. Has preliminary approval been granted by such authorities? — Date granted: 14. Type of Sewage Treatment System Discharge ................. surface water �oundwater 15. If surface water discharge, what is the stream class designation? .................... 16. Waters index number (surface) ........................................... ............................... 17. Is project located near a public water supply system? ....... ............................... M 18. If yes, name of water supply Distance to water supply /%f 19. Is project site near a public sewage collection or treatment system? ................ 20. Name of sewage system Distance to sewage system 21. Date test holes observed 22. Name of Health Inspector Ponta PC -97 2 23. Project design flow (gallons per day) ................................. ............................... _J�-- =; : '�s ta�e`I'b�Iiit`a� t i isclia�ge�El`irtiinatiu�n Systersi-(SPDES)ar nriit regw 25. Has SPDES Application been submitted to local DEC office? ......................... N�o 26. Is any portion of this project located within a designated Town or State wetland ?__,&�w_ 27. Wetlands ID Number ........................................................... ............................... 28. Is Wetlands Permit required? ........... ........I ........ I ..... .. .... ......I........................ Has application been made to Town of Local DEC office? 29. Does project require a DEC Stream Disturbance Permit? .. ............................... �o 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity ............... Yes/No y� 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? Yes/No DESCRIBE: 32. Is there a local master plan on file with the Town or Village? ......................... 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... y _ ;.34:r . z.—any. sewage treatment areds. in, excess .of 15% :ope ?. 35. Tax Map ID Number .......................... ............................... Map _ Block 1 Lot /p 36. Approved plans are to be returned to.—. Applicant PDesign Professional 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, under penalh, 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 & OFFICIAL TITLES: 21YMailing Address: ............ ...................... ) /% .� T r 1. APPLICANT r$ ONSOR / f S. PP44SCY NAME 3. P CTL?Cy tiOfi , �g. . "u"o f4rv'-'fry 60 d Pf?ECIGR LOCATION (Eticst address and road IAW6tWne, Prominent la ndly oft. cc.. or ®rouldo Ir�m S. 15 Pf1A a ACTION Petra ;J 0^ Ese0n610n ®)IA"Ilr:Bt+ORl8kwa116r+ 0. DASCRImQ PAWtECT fI01(1110 AMOUNT OF LAa10 APPECTED. --- - -- _.__ imti®Ily _ .._ C acme IfY onev®ly >� _ egos _ $_ WI SI ACTION COMPLY WITH EXISTING $0 Id® OR OTHER dXIETIN LAND Use RII�YIwfCTlOele37� - _•— _..... /gYeo G N* II Pe ®, �I®Ily e iWMAT 16 PDIf: W; LAND uss IN HK:twry OF PpOJEv? ~�rr _-•_ ewoomco; r-J lndUQtrletl COi41MOM101 ❑ A ftuttyro L Porwor(mcp3a or= O owu i09 10. DOES ACTION INVOLVE A PERMIT Ar1'MOVAL, OR FUNDIPtG, NOW OR ULTIMATSLd FROa Ar4- OTHSR 8OVEIRIIaAEWTAL AGENCY IFFOERAL. STATE OR LOCAW Am 0 PD9 It vn. IM4 ©fie) end parmluaopWala 11. 0093 ANY ASPECT OF THE ACTION HAVE A CURRIENTLY VALID RRAVIT OA APPP.W4 ❑ Yoo ,(des® If V09, l►e1 &SORGy F*fft afod 12 A6 A RESULT OF MPOSiO ACTION WILL EXISTING P9111MITIAPOPIOVAL REOUIR11 00DIFICA.TION- 1 - V ®a -PIb9 I CERTIFY THAT THE IOdP IWATW ®ROVIOID ABOVE !S `OVR TO THE 61 3T OP ICY KWOLIDGE Aea1tc0AvDp poor norm: l�i!�c9r'! el .ra!f .� _ _ _ ... _ Doto /-7o'/ Ot Me *0111WIN 8s 10 OhO C488t8i AM&, Gr+d YOU sty» 0 sat9100 860W, DOWI O ) OWEN 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner e-- -- %Address A,01 Located at (Street) Tax Map Block Lot le-2. (indicate nearest cross street) Municipality. A I�4244Z Watershed SOIL PERCOLATION TEST DATA Date of Pre-soakine A m-lv �Oel Date of Percolation Test A% ............... ... .... .. . .............. .....X ... . .............. ..... ................................ . .. ...... th t D e Water erVrom Ground Level Percolattpp .. . .. ..... 'N , -... Apse Time Surface (Inches')' roD1 n Rate * 0. Mi. tg ft Stop tart S to Inches C ....... . . . . Ire 2 3 'ev A ->w 4 5 2 3 V 4 5 2 2-. 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained - at�.,each percolation test hole. (i.e. s I min for 1-30 min/inch, 15 2 min for 31-60 min/inch) All data,to, be submitted for review. 2. Depth measurements to be made, from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES l� F`IIi %I I;1✓ Vii: r ,.. , =DLIE NO. "ids. _ G.L. `i' / — rot)� 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered dV.4 ,t2 Indicate level at which mottling is observed Indicate level to which water level rises after being -g encountered Deep hole observations made by: 6 -��i �/�`J Date Design Professional Dame: Address: �9' 7 -)- Signature: Design Professional's Beall K jvgfjo v M4 2',,ByS r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... .. ., ... _ ,. .., a .. - ._ ..... . • . o .. +r � .. .... ... ..9 ., - � �.. ♦+a '�7 "mil a '-Y'�•' LETTER OF AUTHORIZATION RE: Property of nj Located at TN & Avm Yax Map # ' 3. �d 44r Block ! Subdivision of Subdivision Lot # Filed Map # --r Date Filed Gentlemen: Lot lo This letter is to authorize /Z/ 1/'�%__ a duly licensed Professional Engine"er �A '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._ 7_;� � `11 Countersi ei P. E., R-A-, # y� P. NC Mailing A ddres RoFess, State ip Telephone: 2'1 _Z �p 1' Very trul urs, Signed: ,� \ (owner of Prop'- ) Mailing Address: ' K SM ti7 LN LC MILL N� State - 'I Zip (� Telephone: G Fonn LA -97 t r' M-2c -70 SAT c:19 A1...4 PUNAh CT's EIG '.HEAUH . FAX uc. 19142727921 BRUCE R. FOLEY Public Health Director IDEPARTNMNT OF HEALTH I Geneva Road Brewster, New York 10509 LORETTA MOLINARI K,N„ M,S.N. Associata Mile Health Director Director of Patient Senicet A'I"i"IwNTION: ' kDAM STIEBEIANG ❑ GENE REED All information below must be —& ! completed prior to any scheduling. DATE. ENGINEER OR FIRM: � - � " t' J Za �) �'� cys �n � FHO_NE 9: RE, ASON: DEEPS: A� PERCS: Q PUMP TEST: ❑ ROADISTRE,ET: TOWN! / k �t�ri�_1���_ __ 'TAX W#: SUBDIVISION: OWNER: ae 6' A4 2-tl le' rT2 LOT #: YES NO ❑ .,9 Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs, b Proposed SSTS within $00 feet of a reservoir, reservoir stem or control lake. -- :,�;:.� _- _� Prap�sed �S1�;S vwikhin. BOO feet•of a watercaurse or a- DEC.wetland. . �- - ❑ Y Proposed SSTS design flow greater than 1000-gallons/da— or 9VIXES!?ei=mi.CHqui ed "— -- O Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered Xa to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsecluent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR C'OUN'TY USE ONLY DA'1'E -15—;0 J (6 IDTEST) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIA.L SITE INSPECTION FORM SECTION A. - GENERAL INFORMATION 9 �, Name of Project C1 in ;��i.i, (T)(V) // y Coup h' Site Location 11>61t C'�z•;� -s,— Building construction begun a Extent Is property within NYC Watershed ?... .. ............. Yes U N' o SECTION B. TOPOGRAPHY (Please check all appropri oxes),�' I. ❑ Hilly F-� Rolling F--] Steep slope G ntle slope Flat 2. , Evidence of wetlands ❑ Low area subject to flooding Bodies of water ❑ Drainage ditches Rock outcrops 3. Property lines or corners evident ....................... ............................... ❑Yes 4. Do water courses exist on or adjoin the property? ............................ Yes 5. Will these affect the design of the sewage system facilities ?............ Yes 6. Do watershed regulations apply in this development ? ..................... ... ❑ Yes 7 Will extensive grading be necessary? .............. .................................. Yes 8. Will extensive fill be necessary for SSTS? ......... ............................... ❑ Yes R...Do.iilled.areas exist_within•the SSTS area? ::::�.;.: '. —es If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS • i �No N i V NN 10. Appearance of soil: and ravel Loam Clay Hardpan fixture 11. Observed from: Borings . ❑ Bank cut I . E( Bickhoe excavations 12. Soil borings /excavations observed by T67 Kc.— L. on l 13. Depth to groundwater �A4��A on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas.......... 16. Soil percolation tests made by 17. Soil percolation tests witnessed by SECTION D (on back) WX on on Yes ❑ No Form ST -1 SECTION D. DRAINAGE 18. ) ili proposed grading materially alter the natural drainage in this or adjacent areas? ❑ Yes 12 19. Will groundwater or surface drainage require special consideration? ..................... F-� Yes F� 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... Yes 3<0-, SECTION E. REN,1ARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities ? ................. .......... ............................... Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist ?.... 2' ). Additional comments .................................. I............. ZYes F-� No 24. Site observer /inspector and title 25. Date(s) of observation(s)inspection(s) E' ©( . TEST PIT PROFILES Hole Lot Hole 9 Lot T Hole A Lot 9 Depth to water ',c M Depth to water Depth to water Depth to mottling ��'�'� Depth to mottling Depth to mottling Depth to ruclJino..: < ,:�.._Derth -to Toclv`ir, �y:- -._ __.. _ _ _ Depth o rock/imp. G.L. G.L. G.L. 0.5 CJ S 0/L- 0.5 0.5 1.0 1.0 )9---1 t .0 2.0 2.0 ---2:0 3.0'r2 3.0 r'� `''s 3.0 4.0 L 4.0 �' .-' ` 4.0 5.0 d t-�' 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 y r 1 2 ,2a 3 l l 9 u 24 Al • i j r d ,~� -,� �•"'�' ��{ ♦ A�'^•... :..�yYrWnrs�+�w'►i!'wMey.a4�.. .�.+w.- n..- ........ ..� —.�„� �. Iry 9441 t •K . �J i L1 L r �t t ,- d ruiea ring. segulatiAOn8 of the Put-mm Co►>>ty Department of gmlth and the Now 'f*VV SUMO Dapnatmt 'at of Health_' f'y► SV)V 35- P: .VP . . r J �_� J /s�z•r1/, CorJ.f�Jf: C� /QPi pia: 300 �,f sue` '�1" lw' /d• }�'y°is L. e�r�'r/'. .. +.fir., r 1 �r r f� d 4 j �Q S '•u x r d /74' X70 .ot Ae 6 2 P P 112 i ��`Ji � • ? L Q ..7 ! /T 1 Y l9 9 200 >Q 2 /,P I + r J �_� J /s�z•r1/, CorJ.f�Jf: C� /QPi pia: 300 �,f sue` '�1" lw' /d• }�'y°is L. e�r�'r/'. .. +.fir., r 1 �r r f� d 4 j �Q S '•u x r d