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631- 589 -8100
83.66 -2 -80
BOX 31
.o
f
PU NAM COUNTY HEALTH DEPARMU
jDIVISION OF ENVIRONMENTAL HEALTH SERVICES
' ."1C. r'R.'l. ..i`3W�VL\ _ _ ... -r __- ... ... ..:. .! _ .•3^Y t T: lv)r.. ^li
`S�"IIISP(�AY; 'SYSTEM R�PA'IIt.
OWNER'S NAME Ro e) e;e s Sc_Nu�; i l�,i 5Z.8-77/5
SITE LOCATION 2,^ LAy,E WQF_ LAY.F_ FEE KSKI L L TO 93,66) &-2- JorRO
MAILING ADDRESS E �2_�� _ . >>21v E , l �c —EV- SKI L-.44 105 3 7
PIIiSarl INTERVIEWED PCHD Complaint #
Name &Relationship (i.e, owner, tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
M
Proposal Disapproved
Proposal approved with the following conditions: �EE �Ls
1. Procurement of any Topermit, Town pe if apple blca e.
2. Submission of as built repair sketch in duplicate showing: �Ey�2
a. Owner's name.�
b. Site Street Name, Town and Tax Map number. I rC
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions. y
SIGNATURE TITLE J f &<-e it DATE Y / 7
I1�LE11: V&te (PM); Yellow (Tapm ffi); Pink (gZaint)
PC -RP 97
MARVIN O'DELL
Bldg. inspector
JOHN MAHONEY
Deputy Zoning Inspector
0
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
June 17, 1998
Mr. Robert Shubin
82 Lake Road
Lake Peekskill, New York 10537
Re: 82 Lake Road
TM#83.66-2-8
To whom it may concern:
TOW 113 HALu
PUTNAM VALLEY, N.Y.
(914) 526 2377
BETTE STOCKINGER
Bldg Dept Clerk
This is to advise that above referenced premises at the time of demolition was declared
a two bedroom dwelling.
If anything further is required, please let me know.
Very truly yours,
Marvin O'Dell
Building and Zoning Inspector
Beyer and Associates
4 Brookdale Road
1Vlahopac, New York
TeL(914) 6214756
Fax. (914) 628 -1905
June 18, 1998
Mr. Adam Stiebeling
Putnam County Department of Health
4 Geneva Road
Brewster, New York 10509
Re: 82 Lake Drive, Lake Peekskill
Tax Map 83.66 Block 2 Lot 80
Putnam Valley, Putnam County
Dear Mr. Stiebeling:
Enclosed please find a copy of the following items for your review and approval:
• Letter from Town of Putnam Valley building inspector
• Date of Fire —May 5, 1997 (see enclosed Article)
• No plans for the exisiting house are available.
I trust the above materials are adequate for your approval and complete the submission for the above project,
However if you have any questions concerning this project, please do not hesitate to call me @ 621 -4756.
Very truly yours,
ic. ae Leyer, P k.
. Oahn6ftN(
.. — I
. RDP
I Ne' ws
Local Echx Call Gonnan: 678-2104
4?.3. 66-
ay, May 6,1997
p f
e�av�ng e ts - don survive ire
Peekskill. He went to bed around the'- fire' extinguishers he Luongo said, there were no other
Lake Pec*slum Cats awaken homeowner, 9 p.m. u kept in his house, "but I couldn't casualties in the fire. Priam
but after two tries, he couldn't rescue them He was'roused. sometime be- use it," ,'he said. "I couldn't see Among other things ;Putnam
,
to use it on." Shubin
was able to salvage a pair of
eyjer.�Gleoson afternoon outside the charred fore 6 a.m. by the cries of his two anythini,
Staff Write, ruins of the two-bedroom, wood- pets. When he opened his bed- Neighbors called emergency steel-rim eyeglasses, a soggy VJ '1/
room door, he found thick clouds' services, and the Putnam Valley -.0V
checkbook, and his wallet con-
frame house at 82 Lake Drive.
Robert Shubin credits his pet of smoke. Wearing only a long T- Fire Department was summoned taining some melted credit cards. Ph1110ii
chtA'Alax and Duncan with rous- A man in his early 50s, Shubin shirt and a pair of slippers, Shu- at 5:52 a.m. Chief Louie Luongo He said he was grateful to the 2.
teaches special education at a bin fled out the front door and said lie I arrived three minutes Shayers, with whom he would
ing him, from bed. before smoke New York City public school in
and flimes 'from his burning ran to his next-door neighbors,- later, followed by about 40 de- .staying While. making. ,arrange Lake Dr.
Len and Jackie Shayer.
the South Bronx. He had lived A
Lake Peekskill home could over - partment members. The fire was ments with his insurer:
me hi�n yesterday morning. intermittently*, at -his -.family's s' out in - less than an hour, he said. ..H
co home since 1963, and. moved in "My wife was jelling, 'Bobby;" e was -real lucky,"
.4uongo J'
S
Lake
adly � Shubin was unable to full time 10 years ago after his, house is on fire!"' Len Shay& MemLers of the Putnam Coun- Said. 2()
rescue the animals, although he parents died.
said. They gave ,him a pair 'of ty Bureau of Fire were still in- - So; apparently* were the Shay- Staff graphWlAarco DoefflM;
re-entei,6d the burning house Shubin had come home Sun- sweatpants and he returned to vestigating what caused the fire. trs
. Their house IS about 30 feet
twice to,* search for 'them. Both day night after volunteering as his house- It appirently started in an en-
from Shubin's, but the only dam- blowing before firefighters ar-:
.cats: were found dead after the stage manager at a Peekskill Inside; he called out his pets' closed Mir porch before spread- age it sustained was some warp- rived.
extinguished. - pe ing into -the rest of the building,
1ID6.Was Repertory Theatre production of names but couldn't summon the 1: ing of its yellow vinyl siding. —Until those hoses were going,
'.4'11 can'be; thankrul they saved "84 Charing Cross Road" at the frightened animals -1hrdugh* * the • the chief t;aid. . 'Shayer said the story might have I couldn't be sure about any
one. of Aside from Shub n s two
Shubin said yesterday Paramount Center for the Arts in smoke. Shubin .grabbed pets', been different had the wind been thing," Shayer said.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of [Lo3E2e S6 2 %%N
Located at S Z- LA6 -�—.
T/� k7krk N� V k-wfe Tax Map # Co% Block 2. Lot O
Subdivision of
Subdivision Lot # Filed Map # Date Filed
Gentlemen:
This letter is to authorize � —te ._. j WrX
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
Law, and the Putnam Cciunty Sanitary -Code:
Countersigned:
P.E., R.A., # 0 7yS9 Z
Mailing Address, / zeole /,?—p
State . Ai y Zip
Telephone: 21 Y
Very truly you at
Signed:
(o. ner of Property)
Mailin g Address: `�� i
._
State Zip
Telephone:
Form LA -97
1
Mike Beyer
4 Brookdale Rd.
Mahopac, NY 10541
Dear Mr. Beyer:
DEPARTMENT OF HEALTH
Division of Environmental health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
July 24, 1998
Re- Shubin, 87 Lane Dr., Lake Peekskill
TM# 83.66 -2 -80
(T) Putnam Valley
BRUCE R. FOLEY
Fui -lic Health .Direetdr
F�� F
eo�Y
This office has received and reviewed the most recent set of plans for the above mentioned project.
We would like to offer the following comments for your consideration.
This. proposed repair, to the existing system, is going go be considered that; a repair.
Please submit a "Construction Repair" permit (enclosed).
In order for bedroom count to remain the same please resubmit plans showing the "living room" as
the dining room and current "study" as the living room. Plans will be approved as a two bedroom
residence.
This office will continue its review upon consideration of the above mentioned comments. Please
feel free to contact us if any questions arise.
Very truly eyours,
Adam B. Stiebeling
ASB:dk Assistant Public Health Engineer
Enc: repair App.
Mike Beyer
4 Brookdale Rd.
Mahopac, NY 10541
Dear Mr. Beyer:
DEPARTMENT OF HEALTH
Division of Environmental health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
July 24, 1998
Re- Shubin, 87 Lane Dr., Lake Peekskill
TM# 83.66 -2 -80
(T) Putnam Valley
BRUCE R. FOLEY
Fui -lic Health .Direetdr
F�� F
eo�Y
This office has received and reviewed the most recent set of plans for the above mentioned project.
We would like to offer the following comments for your consideration.
This. proposed repair, to the existing system, is going go be considered that; a repair.
Please submit a "Construction Repair" permit (enclosed).
In order for bedroom count to remain the same please resubmit plans showing the "living room" as
the dining room and current "study" as the living room. Plans will be approved as a two bedroom
residence.
This office will continue its review upon consideration of the above mentioned comments. Please
feel free to contact us if any questions arise.
Very truly eyours,
Adam B. Stiebeling
ASB:dk Assistant Public Health Engineer
Enc: repair App.
'Beyer and Associates
Mahopac, New York
Tel.(914) 621 -4756
Fax. (914) 628 -1905
August 17, 1998
Mr. Adam Stiebeling
Putnam County Department of Health
4 Geneva Road
Brewster, New York 10509
Re: 82 Lake Drive, Lake Peekskill
Tax Map 83.66 Block 2 Lot 80
Putnam Valley, Putnam County
Dear Mr. Stiebeling:
Enclosed please find a copy of the revised first and second ,Moor plans for the above project and a
"construction repair "permit.
I trust the above materials are adequate for your approval and complete the submission for the above project,
However if you have any questions concerning this project, please do not hesitate to call me @ 621 -475. Please
forward the approved construction permit to Beyer & Associates.
Very truly yours,
Michael Beyer, P.E.
f!
}i�,r Associates
i d
Mr. Bill Hedges
Putnam County Department of Health
4 Geneva Road
Brewster, New York 10509
Re. 82 Lake Drive, Lake Peekskill
Tax Map 83.66 Block 2 Lot 80
Putnam Valley, Putnam County
Dear Mr. Hedges:
_ 4 Brookdale ft-ad
Mahopae, New York
Tel.(994) 629 -4756
Fax. (994) 628 -9905
May 29, 1998
Our client, Robert Shubin, proposes to construct a two bedroom single - family residence at the above address
to be serviced by an individual subsurface sewage treatment system and a private drilled well. Approximately a
year ago afire consumed the two bedroom residence at the above location. The foundation, well and septic
system is all that remains. The original subsurface sewage treatment system consists of a septic tank (size
unknown) which discharges to a gravel pit and has been in service since approximately 1926 with full time
residents since 1971. The system has no history of failure and appears in good working order. We propose to
upgrade the system to include a 1000 gallon septic tank and an 8' dia. seepage pit. Due. to the small lot size we
were only able to maintain a 10' minimum from the foundation setback for the septic tank.
Enclosed please find a copy of the following items for your review and approval.
o Construction Permit for Sewage Treatment System
o Letter of Authorization for Design ,Professional. ....
o " Application for Approval of Plans f or a Wastewater Treatment ,system.
o Short Environmental Assessment Form
o Plan and Profile- Separate Sewage Treatment System (3 copies)
o House Plans (2 copies)
o Design Data sheets
o Fee — Certified Check in the amount of $300
I trust the above materials are adequate for your approval and complete the submission for the above project,
However if you have any questions concerning this project, please do not hesitate to call me @ 621 -4756.
Very truly yours,
Michael Beyer, P E
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET- FOR,'CONSTRUCTION'.PERMIT
STREET LOCATION LA_, NAME OF OWNER i- f-ULll %'e
REVIEWED BY ��" DATE to OI .5S TAX MAP # 93 06�
Y . DOCUMENTS
ERM APPLICATION
P
LL PERMIT P PWS LETTER
LETTER OF AUTHORIZATION
qkSIGN DATA SHEET (DDS)
CORPORATE RESOLUTION
SHORT EAF
LANS - THREE SETS
LISE PLANS - WO SETS
VARIANCE RE UEST 'T
SUBDIVISION
LEGAL SUBDIVISION N A-
SUBDIVISION APPROVAL
P C RATE 13 . ?j
F REQUIRED DEPTH
CURTAIN DRAIN REQUIRED STANDPIPES
GENERAL
ATED IN NYC WATERSHED
' P NS SUBMITTED TO DEP
�PLEGATED TO PCHD
D ,F,P APPROVAL, IF REQ'D
EP TEST HOLES OBSERVED
P-'RCS WI'T'NESSED, IF REQ'D
-APPROVAL SSDS ADJ. LOTS
ETLANDS (TOWN/DEC PERMIT REQ'D ?)
DATA ON DDS PLANS & PERMIT SAME-7
PRE69 EIGHBOR NOTIFICATION
LETTER BUZBA
100 YR. FLOOD ELEVATION
OTHER REQ'D PERMIT(S)
REOUIRED DETAILS ON PLANS
SEWAGE SYSTEM PLAN - (NORTH ARROW)
SSDS HYDRAULIC PROFILE GRAVITY FLOW
CONSTRUCTION NOTES
:SIGN DATA: PERC & DEEP RESULTS
CONTOURS EXISTING & PROPOSED
UVEWAY & SLOPES, CUT
AIN DRAINS
Y N'
EROSION CONTROL:HOUSE,WELL, SSDS
PERC & DEEP HOLES LOCATED
REPRESENTATIVE OF PRIMARY & EXPANSION
LOCATION MAP
EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
IF PUMPED, PIT & D BOX SHOWN & DETAILED
HOUSE, NO.OF BEDROOMS
WELLS & SSDS'S W/IN 200' OF PROPOSED SYS.
PROPERTY METES & BOUNDS
HOUSE SETBACK NECESSARY (TIGHT LOT)
HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE
NO BENDS; MAX.BENDS 45° W /CLEANOUT
FILL SYSTEMS
CLAY BARRIER
10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE
FILL SPECS FILL NOTES
FILL CERTIFICATION NOTE
DEPTH GUAGES
JFILL PROFILE & DIMENSIONS
VOLUME
FILL IN EXPANSION AREA
TRENCH
LF TRENCH_ PROVIDED—. i T MAX., ,
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
ON PLAN - FROM SSTS
10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL
20' TO FOUNDATION WALLS 15'WELL TO PL
100' TO WELL, 200' IN DLOD, 150' PITS
100' TO STREAM WATERCOURSE LAKE (inc. expan)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER.
10' TO WATER LINE (pits -20')
50' INTERMITTENT DRAINAGE COURSE
200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS
15'min to CDS= >5Vo,10'- 4 1/o,25'- 3 0/o,30'- 2 1/o,35' -I %,100' - <I%
20'min to CD discharge /100'with 182 cons day discharge
SEPTIC TANK
m 10' FROM FOUNDATION; 50' TO WELL
FORM ST-2
BRUCE R. FOLEY
r Public Health. Director..
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278 - 6130 Fax (914) 278 - 7921
Date:
To: � ��GtZ "-� IEZ
FAX COVER SHEET
Fax #: ( 213 r i � ®1
No. Pages I —
(Including cover sheet)
From: -
Adam B. Stiebeling
Asst. Public Health Engineer
For your information Please respond_
For your review Attached as requested
As discussed
Please call
�2
„ �t-r-�3tnc
Notes/iNIessa g es
c,o�� �• �-�' ®!' u �. �v ST'i rcc� i�. °�i � .- 5 c�et:r wc'c.— � t�ev� S
r _ 1
CT) C), r, �-r' V
In the event of transmission /reception difficulties, please contact this office at
(914) 278 -6130 ext. 157.
�{Z �7vrLDS
Vt;D M it &Z'tT-LL15
E,:. .
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_.:........., '� .._ a�.. ROYAL OF'PEA!?VT@ F'OR. .
...: P� •iC� �DN Fi oR APP. ,
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: _ Ro ee:T s- t gi iJ
rDa
��CE14SOLL i.lsd
2. Name'ofproject: SIAO &vy ( y,F -VIC C 3. 'Locat ion
T
4. Design Professional: HI C14fict 96VFIL 5. Address: !f &Z Z1 -00Ar p /Zn
6. Drainage Basin: v/L
7. Type of Prokct:
_ 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
T eII
Exempt
yp Unlisted �
9. Is a Draft Environmental Impact Statement (DEIS) required? ........................ r,
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 .
c fi gals; ordinances`? ..........................................
.................
13. If so,' have plans been submitted'to such authorities? ........................................
14as prelimH nary approval been granted by such authorities? Ff�. bate granted:
15. Type of Sewage Treatment System Discharge :................ surface water _.X 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?
......................... ........ Rio
19. If yes, name of water supply Distance to water supply
20. Is project site near a public sewage collection or treatment system? :..:::.:...::...' /V0
21. Name of sewage system Distance to sewage system A
�- P E,S►sw g RoFftxsl�mrt� .
22. Date test holes observed 0 a 23. Name of Health Inspector
24. Project design flow (gallons per day) ................. ........... g�x ..:Q,.........................
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N 0
26. Has SPDES Application been submitted to local DEC office? .........................
N
Form PC -97
2
27. Is any portion of this project located within a designated Town or State wetland? tland? '/J o
28. Wetlands ID Number.
29. Is Wetlands Permit required? .... ............ . ... .................
.............................
Has application been made to Town or Local DEC office? ................................ Al.
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? ............................. Yes/No /JO
32. Is project located within 1,000 feet of existing bra'bandone'd landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially. known source of contamination? ............................... . Yes/No /J 4
DESCRIBE:
33. Is there a local master plan on file with the Town '6`r Village? ......................... /J 'o
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? .............................................................. Alo
35. Are any sewage treatment areas in excess of 15% .................................
36. Tax Map ID Number ................ * ................................................ Map_ 3G(v Block 2- Lot 190
37. Approved plans are to be returned to ...... ApplicantC Design Professional
app "-''o�-an-..e:w.gs.m.io&lo'eated-vNi� -the N-Y-C,-VJat6rsh6d--eiiall--
NOTE: All
be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department. Projects within the watershed may also
require DEP review and approval of other aspects of project', such as stormwater plans or the creation of
impervious surfaces, and the project applicant should 'Obtain the appropriate form's for such activities from
DEP and submit those forms to PEP for review and approval.
If the application is signed by a person other than the applicant shown in Item I.,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.
1hereby affirm., underpenalty q 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.
aA SIGNATURES& OFFICIAL TITLES.-
Mailing Address: ................................... Hftol-c— /OEIV
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIROMENTAL HEALTH SERVICES
DESIGN DATA SHEET' -SiSkjj CA '1: WAI 7CR19ATF"NrSV STEM.. - -�:4
Owner ROBERT SHUBIN Address 82 LA" DRIVE
Located at (Street) Chester Place Tag Map 83.66 Block 2 Lot 80
( indicate nearest cross street )
Municipality PU MAM VALLEY - Drainage Basin LUMS IV RLM
SOIL PERCOLATION TEST DATA
Date of Pre - soaking May 9,1998 Date of Percolation Test May 10, 1998
Hole No.
Run
No.
Time
Start - Stop
Elapse
Time
in.
Depth to Water
From Ground
Surface (inches)
Start Stop
Water
Level
Drop in
Inches
Percolation
Rate
Min/Inch
A
1
5:28 - 5:58
30
21 23
2.25
13.3
2
5 :59 - 6 :29
30
21 23
2.25
13.3
3
4
5
"
2
3
4
5
1
.
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. ( i.e. 5 1 min for 1 -30 min/inch, Smin for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of bole.
Form DD -97
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED 1Il1 TEST HOLES
DEPTH
HOLE NO. 1A HOLE NO. HOLE NO.
G.L.
Grass
0.51
Top Soil
1.09
K u
Il 9
^
Light Brown Sandy Loam
with traces of Silt
99
2.09
2.59
3.09
3.59
4.09
41.59
5.09
5.59
6.09.
..
6059
7.09
7.59
Q8.09
8'
.59
::•.., ...
9.59
¶
L 0.09
Indicate level at which groundwater is encountered No Water ]Encountered
Indicate level at which mottling is observed No Mottling Observed
Indicate level at which water level rises after being encountered None
Deep hole observations made by: Michael F. Beyer Date: Mgy 10, 1998
Design Professional Name: Michael F. Beer
Address: Bever do Associates
Signature:
4 Brookdale Road
m4hopac, New fork, 10541
Design Professional's Seal I �
14-16-4 (2107)—Text 12
f1ROJECT I.D. NUMBER
617.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT
For UNLISTED ACTIONS Only
PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
SEAR
FORM.
1. APPI:18 /SPONSOR
N tc %W(- 13 F-Y FL,
2., PROJECT NAME
126S1AD.=,AXF-
3. PROJECT LOCATION:
Municipality g Z LAW-WILVIL P(fit AWW, Vfdj_,(!f County J7V7— p"Vr%e
4. PRECISE LOCATION (Street address and roa6 Intersections, prominent landmarks, etc., or provide map)
LAk(r= WIve-
5. IS PROPOSED ACTION:
❑ Now . ❑ Expansion 9ModI lice tionialterat Ion j2e&%t_p>
6. DESCRIBE PROJECT BRIEFLY:
w 11-j+- .0 LnX.G. uc
2-
7. AMOUNT OF LAND AFFECTED:
n /0
Initially — 1 acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑ Yes No If No, describe briefly
2_or-atwi VW ( " C*C5 PK4157n r4jrjcv4r.,.� 5er bN Ic S
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
*esldentlal ❑ Industrial ❑ Commerdlal ❑ Agriculture ❑ Park/Forest/Open space ❑ Other
Describe:
5L &i,
10. DOES ACTION INVOLVE ,A PERMIT APPROVAL, OR FUNDING, NOW.OR ULTIMATELY FROM ANY OTHER qoVERNMENTAL.AGENCYJEEDERAL,
'S TATE-OR-LOCAL)?- TI -OR-LOCAL)?-
Man .
El No If list
a s yes; agency(s) and permitlapprovals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
[]Yes - Mlo 11 list agency name and
yes, permItlapproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑ Yes �40
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
AI e & W-- & 6—e1—F< D .
Appllcantisponsor name: ate:
Signature:
.If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this -assessment
OVER
1
-PART It— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
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. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? It No, a negative declaration
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❑ Yes ❑'No
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'quanlity, nolse 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 brlefiy:
C9. Vegetation or fauna, fish, shellfish or wildlife species, signlflt:ant habitats, or threatened or endangered species? Explain brielly:
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
C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not Identified In C1 -05? Explain briefly.
C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly.
Di iS THEM OR,IS•THERE LIKELY TO 9E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yes �] No If Yes, explain briefly
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether It is substantial, large, Important or otherwise significant.
Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
Irreversibility; (e) geographic scope;.and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed.
❑ 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.
C Check this box If you have determined, based on the 'information and _analysts above and any supporting
documentation, that the proposed actlon.WILL NOT result in any slgnlficant adverse environmental Impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Print of typo Naun• Of Itegwa1d r e Offia r•r in I ead Avency
Signature of Responsible Officer in Lead Agency
Name of Lead Agency
Date
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Signature of reparer (If aiffefent from responsible officer)
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EXISTING WELL
PROPOSED
2 BEDROOM HOUSE
ON EXISTING FOUNDATION
FF. ELEV 100.0
BASEMENT ELEV. 92.08
4" Cast Iron Pipe
Slope = 1/4" / ft
1000 Gallon Septic Tank -
4" Dia. Solid PVC
Slope = 1/4" / 1
8' Dia. Seepage Pit (see Detail) -
SILT FEN
(SEE DETA
FROM A JUNE 23, 1956 SURVEY DESCRIBING
N ON SECTION "A" OF LAKE PEEKSKILL ....
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LAKE DRIVE
JNTY HEALTH DEPARTMENT - GENERAL NOTES
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V 10 FEET OF THE PROPOSED SUBSURFACE SEWAGE TREATMENT 9. CUT OR FILL IS NOT PERMITTED IN THE SSTS AREA, EXCEPT IF SO SPECHM ON
THIS PLAN.
w ED BY T71E Idmso DESIGN PROFESSIONAL AND THE4PUTNAM IO.AFTER BACKFD.LING THE SYSTEM, TIN SST5 AREA SHALL BE COVE= WMI A
KPARTMENT AFTER CONSTRUCTION AND PROD? TO BACKFILL. MINAIUM OF 6' <TOPSOIL,.SEEDED AND MULCHED.
SHALL BE STAKED AND ROPED OFF SO THAT NO TRUCKS, MACAIRgWY, 11. OCCUPANCY OF TINS STRUCTURE WILL NOT BE PERMITTED UN77L 77M CONST.
4 NOR EXCAVATED EARTH SHALL BE ALLOWED DV TEE SM AREA. COMPLIANCE APPLIC477ON HAS BEEN RECIEVED AND APPROVED BY THE PUTNAM COt�
HEALTH DEPARTMENT AND FORWARDED TO TIN BUILDING INSPECMR OF THE
VTROL MEASURES SHALL BE INSTALLED PRIOR TO THE START OF ANY RESPECTIVE MUMCIPALITY AS PART OF THE CERTIFICATE OF OCCUPANCY APPLICA"i
12. THIS PLAN IS APPROVED FOR SEWAGE TREAn91MT AND /OR WATER SUPPLY OKI
OF SS7S TO BE IN ACCORDANCE W77H 771ESE PLANS, ANY REVISIONS AND ALL OTHER'REQUMED PERMITS AND /OR APPROVALS ARE THE RESPONSIBILITY ;I