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HomeMy WebLinkAbout4068DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 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 saa.he ruper3ede�ayralr ..4thar:li►vfteLd aggnfy ❑ 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 rl . .il n u Ilr�twnu r �� �•nr Signature of reparer (If aiffefent from responsible officer) 10537 IArPT/%AT 11AD Q P•i .I PnB F V) w w 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 .... E 69 PUTNAM COUNTY CLERK. ICE TO EXISTING FIRST FLOOR. 98 Outlet El. 96.25 \ Q 3 � wJ E3 El I I I I Expansion I PT "A'� I Area o I I 97 N4'52'00" W 40.14' x g1 LAKE DRIVE JNTY HEALTH DEPARTMENT - GENERAL NOTES tV n O N a 110 UK$ 90; I 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