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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -1 -16.2 BOX 33 1 ' WWI go �r FL_ . 04310 . PUTNAM COUNTY DEPARTMENT OF HEALTH r 'DIVISION-OF ENVIRONMENTAL HEALTHSERVICES, CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TM SYSTEM PCHD CONSTRUCTION PERMIT # PV— 2A A lb �'� Located at 131mW�-, Rs�� Town or Village i�li`1 1 i�� Owner /Applicant Name INZJOkFftkS, M"Al s''"Tax Map ?— Block I— Lot _1 (o.2 Formerl Subdivision Name ftJWLL- @; j7! ffl 9A,5T- Subd. Lot # 2- Mailing Address 3W WE55 49 �j, �5( �°C32iL Zip 00 (o Date Construction Permit Issued by PCHD 1,2,12410116 ` Separate Sewerage System built by 5A7F4 t U`Tt 11� Address f'c.l" iiiu� Consisting of 2,50 Gallon Septic Tank and 5 02.1i LF - 24 tt XkC w t OF-- NR>5311? i i orJ 'TiZ p- ,Math 5P� Al- fir, f-':T- C'), -C,. Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by wOZnAiQ MDefzsok) 114'C- Address Q�,li'4•� l l�� Building Type (�S D t� ht, Has erosion controfbeen completed? Number of Bedrooms Has garbage grinder been installed? ? 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. Date: 10 Zo Certified by Address .G. P.E. %" R.A. License # ('S0290c;' 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 revocatio modi- ti or c g is necessary. By: Title: Date: ll White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �k 9 PU NAM COUNTY DEPARTMENT MENT OlF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well cation Street Address: T93wgNillage: l �i Tax Grid # Map Block Lotow.'), Well Owner: Name. Address: -36 y� Use of Well: 1- primary 2-secondary 74 sidential Public pply Air cond/hea ump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment i0-- . Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing -;,< Open hole in bedrock Other Casing Details Total- length �W;Ift. ft. Length below grade Diameter G " in. Weight per foot /lo lb /ft. Materials: ' Steel _ Plastic _ Other Joints: _ WeldedX Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: . Yes No Liner:_ Yes ?C No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped ZX, Compressed Air Hour Yield l'0 gpm Depth Data Measure from land surface- static (specify ft) 3o r During yield test(ft) Depth of completed well in feet moo 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 Jd So " If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump TypeEd� Capacity Depth an Model/-O S'o 5 - 9 Voltage :2- 30 BP Tank Typ44 l__�U Volume Date Well Co pleted q / / Putnam County Certification No. Date of Report 0 A Well Driller (signature) ��. ItIQD7C V xft location of well wttn atstances to at least two permaner ianamams to De proviaea on a separate sneevptan. Well Driller's Name7, azele s Address: Signature: /a.� Date: V , White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 II YML ENVIRONMENTAL SERVICES 321 Kear Street - (914) 245-2800 / Albert H. Padovani, Director LAB #: 32.906693 CLIENT #: 11297 BROOKFALLS DEVELOPMENT 330 WEST 45TH STREET NEW YORK, NY 10036 SAMPLING SITE: 4 BROOKFALLS RD. : PUTNAM VALLEY, NY COL'D BY: DAVID SCHWARTZ NOTES...: OUTSIDE HOSE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG'PROCEDURE PUTNAM CNTY PROFILE 10/14/99 MF T. COLIFORM 10/14/99 LEAD (IMS) 10/14/99 NITRATE NITROG 10/14/99 NITRITE NITROG 10/14/99 IRON (Fe) 10/14/99 MANGANESE (Mn) 10/14/99 SODIUM (Na) 10/14/99 pH - 10/14199 HARDNESS,TOTAL /q9 OLKAL NITY /AS ,10/1 10114/99 ` _ � �� -TURBWITYATUXY STAT PROC PAGE 1 ~~~~"~~~~~~~~~~~°~~~~~~~~~~~~~~~~~~~~~~ DATE/TIME TAKEN: 10/14/99 12:00P DATE/TIME REC'D: 10/14/99 01:30P REPORT DATE: 10/21/99 PHONE: (000)-000-0000 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM-METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT ABSENT /100 ML <1 ppb 0.70 MG/L <0.01 MG/L 0.19 MG/L 0.018 MG/L 55.3 MG/L 7.4 UNITS 210 MG/L 188 MG/L NORMAL - RANGE ABSENT 0-15 ppb 0 - 10 N/A 0-0.3 mg/l 0-0.3 mg/1 N/A 6.5-8"5 N/A N/A METHOD 1008 9101 9139 9146 2037 0-0:14(Lr ���^� ' _` -_'�V] COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE 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. \blic 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 that for people on a contain no more than moderately restricte is suggested. are proscribed. Suggested guidelines state sodium restricted diet,the water should 20 mg/L of Sodium. For those on a 1 diet, a maximum of 270 mg/L of Sodium _/ " YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heigh N.!/.-1{��98-- - | Albert H. Padovani, Director 32.906693 CLIENT #: 11297 STAT pROC PAGE 2 BROOKFALLS DEVELOPMENT 330 WEST 45TH STREET NEW YORK, NY 10036 SAMPLING SITE: 4 BROOKFALLS RD. : PUTNAM VALLEY, NY COL'D BY: DAVID SCHWARTZ QUTSIDE HOSE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE /TIME TAKEN: 10/14/99 12:00P DATE/TIME REC'D: 10/14/99 01:30P REPORT DATE: 10/21/99 PHQNE: (000)-000-0000 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANSE METHOD pI p pH SCALE IN WATER RANGES FROM 1 1-14. MEASUREMENT OF pH IS ONE OF THE IMP8RTA�T AND FREQUENTLY U USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE C CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF p pH IS 6.5 TO 8.5. Hd T TOTAL HARDNESS IS DEFINED AS T THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATI0N, BOTH EXPRESSED A AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO H HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH T THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L V VERY HARD WATER: ABOVE 300 MG /I ^ . .MODERATELy,�A W ER� 70�140 M MG/L� .�1G/L=MILLIGRAMJpEB�LITER_�,._=—' ._ ^ WATB�-~.140-300 MG/L BY Director ELAP# 10323 NOV -01 -1999 1209 FROM SADEY & WATSON, P.C. l u 'GO4JdJ r.Y�1 - PUTNAM COUNTY DEPARTMENT OF HEALTH GUARANTEE OF SUBSURFACE SEWAGE 'TREATMENT SYSTEM C� Owner or Purchaser of Building gIZC 1�JA e L4-10n --12 A t-t Building Constructed by Location - Street Building Type Tart MaD Block Lot f�cfiv(z*!y Town/Village 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 faihnre to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system.: The undersigned fiuther 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 building utilizing the system. Dated; Month Day / Year General Contractor (Owner) Signature Corporation Name (if corporation) Address: —29C-1> f- S re�- State w Zi p G r Corpor tion Name (if corporation) Address. ►` state zip 221�0 9 Form OS -97 a FJ P N i CL� 7 PUTNAM COUNTY DEPARTi1-IENT OF HEALTH DIVISION OF ENVIROIMMENTAL HEALTH, SERVICES FINAL SITE EMPECTION Date: 0 ecced -by- -- n - r... _ Street.Locatio _.:. To«n ' �%' Permit r T[M r Subdivision Lot r 7 Ito 1. Seivase Swstem Xrea . 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 ...... ............................... II. Sew ee Svstem a. optic tank size - 1,000 .... 1,20. other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation... .. ............................... d. Distribt ion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - properly set ............ ............................... ,�- 1. engtlP required_ �v Lengthinstalledv� 2. Distance to watercourse measured Ft.......... J. Installed according to plan ......... ............................... 4. Slope of trench acce table 1/16 -1/32" /foot ............. 5. 10 ft. from pr lm - Ift .......... 6. Depth of tren <30 inc s face .................. 7. Room allow r oxp i ....................... 8. Size of grave 3/4 -1' /' diean ............... ..... p 9. Depth of grav ' rich 12" minimum ................... ( � 10. Pipz.ends. capped.. ............. .................. Pum 'or Dosed Sti,stems Size o hamber .... .. 2. 0 ,v tank ................ .. ..................... 3. Alarm, sua u io............ 4. Pump ea� a cessible, ma ole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle......... III. House/Buildin a. House locatEd per approved plans .. ..........................:..." I b Number of bedrooms ................... ............................... . I IV. Well a: well located as b. Dist _ ea measure FS" above"grade ....... ............................... drainage around well acceptable L/ L Boxes properly uted........ ..... b. , A1LDioe&oartially filed ........................ ..... All es V de�f b = - Back 1 onta s sto s <4" diar Curtain ' .&-stars cording to plan.. ain drain outfall protected & dir.to exist wa rse - om STS area ..... .r ... at. 'Vi.+'' LVYV�79i•\/i.l'tWF�. -. ................. i. Erosion control provided............ .......................... Rev. 1/97 —T-b f, M ol^ ul-11 Or Ul l -1G -1yJJ Wb; dy F-NUM bHULY & WH 15UN. V.U. 'I U .... ... _ ..,. .,,naw V,. cne AJrA1.ln rxA t4U. lyt4L'Itflyll PUTNAM COUNTY DEPARTMENT OF HEALTH _ .. DIVISION Off' ENVIR0NMZNTAJ. HEALTH 2787921 P,01 P. 2 $QUEST Ft7R FINAL] PBC�"�ON For. FiII_ Trenches,___, PCHD Construction Permit # P�(~ Zq —16 Located MQ0 WftEr>_ ¢oA IP Owner /Applicant Name $RDWWS MaxPmum TM —Block,_„_Lot l Formedy____w, Subdivision.Name�J�61 Ott 05, PASW Subdivision Lot # Is system fill completed? A Date Is systoai complete ?_,,.,` _ � „�_ Date Is system constructed as per plans? G6r,Itt,� Is well drilled? Date Is well located as per plans? Are erosion control measures "in place? I Mdfy that the system(s), as listed, at the above premises has been constricted and I have Wpected- 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. r .. ' Date: ic? °ice Certified by:.. :PE rj Design Professional Comments: e"*111 4 i' xc 7 o ob- o� ► r� .- c al -vuT"; .fooyt pgL . J AcDDMo116JA'L 2." t i F- f:tAdbS 'MIN tMOM . &YAe A-v- its-is-- FOR: 0 ADAM D OM Form FIR -99 TOTAL P.01 zu- ";p r run ISHLCT 6 WHIbUN. P.C. TO P. C. D. H. 1G•iv in rVAAM X11 Lily AL'ALIA MA RV. 19142787921 PUTNAM COUNTY DEPARTMENT OF HEALTH P.01 P. 2 Dili ®1� r Owner /Applicant Name LWMW 0 I.N.ILBlock Lot 9 Formerly Subdivision Name -� Subdivision Lot # 2- Date Date - - - - Date- I comfy that the s), as lisp at the above premises has been c=t motod and I bave ialspected od verified their completion in ac=ftce with the issued PCHD Co stmctiou Perusal and approved plus and the Stoftds, Rides and Regulations of the Powsm County Department of Health. iiddby: ;` Desigga Professional g= f g'; !M W 0,# - - - - - - - - - E�jQr= At Is10 FOR. ® ADAM 0 MM TOTAL P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 5906VF -A � Delyl t DPMP-0�1 C. O PP 33o Wss-r d54-ti 5 -mr-� 2. Name of project: KFPeWS 0,:�VEt.WM4JT-3, Location TN: (t twArm yis 4. Design Professional: J0 4W P. 'Det.Dr.tc�, (? 5. Address: 63P�3�`� ��TSc�►J P.G . 1ZT-- 6. Type of Project: Private/Residential Food Service Commercial 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 >< 8. Is a Draft Environmental Impact Statement (DEIS) required? ......................... NQ 9. Has DEIS been completed and found acceptable by Lead Agency? ............... p� 10. Name of Lead Agency . P C Da+ 11. If this project is an area under the control of local planning, zoning, or other officials, ordinances? ....................................................... ............................... \(ss 12. If so, have plans been submitted to such authorities? ........ ............................... rl 0 13. Has preliminary approval been granted by such authorities? NO Date granted: LJ Q 14. Type of Sewage Treatment System Discharge ................. surface water >e groundwater 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? ....... ............................... NO 18. If yes, name of water supply X44- Distance to water supply 19. Is project site near a public sewage collection or treatment system? ................ NO 20. Name of sewage system �1A Distance to sewage system OL 21. Date test holes observed K56 22. Name of Health Inspector H. RUWZ wSIC,I Form PC -97 23. Project design flow (gallons per day) ........:........................ ............................... 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... v' 2 NO 25. Has SPDES Application been submitted to local DEC office? ......................... A 26. Is any portion of this project located within a designated Town or State wetland? Nn 27. Wetlands ID Number ........................................................... ............................... t4 A� 28. Is Wetlands Permit required? .............................................. .............:................. 00 Has application been made to Town of Local DEC office? ............................... N LA 29. Does project require a DEC Stream Disturbance Permit? .. ............................... No 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 NQ 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 t-1® DESCRIBE: 32. Is there a local .master plan on file with the Town or Village? ......................... YG6 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................. ............................... ia0 - �. .�. .. a,x ... . -., . -. .. •o, .. -« �. . - .' .__ -s ..j .. - z*-7• s .... - - .e .. .aa ... v . -. .. . ...oa -. ._ ...� � � —. .. ...� -r ��. -a -.Y, 34. Are any sewage treatment areas in excess of 15% slope? . ............................... 1�1U 35. Tax Map ID Number .......................... ............................... Map_ Block 1 Lot I �. 36. Approved plans are to be returned to ..... Applicant X Design 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 penalty of perjurly, 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 T'IT'LES. - A%W-K ULZ6-fq . P. f�- Mailing Address: ................................... 30&1-2> rzocJTTT- C4i.D PUTNAM COUNTY DEPARTMENT OF HEALTH' DIVISION OF ENVIRONMENTAL HEALTH SERVICES -;;A- DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 521cov-F ,:> CEQ�oPcr ett—z Address -3i c W. 45-J- -jT P-JI, NW, Located at (Street) bZ0DVF*tA,5 CpAcip Tax Map � . Block Lot lf,.Z (indicate nearest cross street) Municipality f2QT,y-JAj,4 Watershed MEY-Sy6u, V�� e(z,&jZ SOIL PERCOLATION TEST DATA Date of Pre-soaking f ZZt Z�):3 Date of Percolation Test I !LLzA-Lb-7 ... ..... . ....... D: iff f Va er,:::: Water From Ground Level Percoiatit�� . . .......... TtmeIa 3 IMC Surface Stop ' :o" e- R Run ...... S.. 41:10 1-5 , k-A A 2 11•40- 10 :310 b z Yz Vz. -I A 3 11ti2 - 12;4t W zf, 30'yz- 4 5 10 2 • 25 2-1 YZ, I L 3 20 '717 4 ,5 2 .3 5., NOTES: -J. Te's&,,t6-b6,rep eated at same depth until approximately equal percolation rates are obtained at each percolation :5 test hole. (i.e. 1 min for 1-30 min/inch, ,s 2 min for 31-60 min/inch) All data to be subm 60d for r . review. 2 .1 Dep, t .�,' th measurements to be made from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH :.;..: = IMLE NO: G.L. wr�soo L- 0.51 1.0' 2.0' s t--r- LO A" 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' r• , 2 HOLE NO. 2 - - HOLE NO:=., ..... L star- LO M-4 Indicate level at which groundwater is encountered — e�1oT. Pj.5ccxjof ; D Indicate level at which mottling is observed — N-ta c)5s.Go,,,►v-A> Indicate level to which water level rises after being encountered — LA Deep hole observations made by: i3�,.� w p-�x, , p c— Date sir 15-7 Design Professional Name: DELAN30 Address: 4, WA-r-;6,J , P.G Signature: �• Design Piroffessional's Seal Nil. tat. �. d . , . 14.16.4 (2/87)—Text 12 PROJECT I.D. NUMBER 617.21 SEAR _ _Appendix C__.. State Environmental Quality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I PROJECT INFORMATION (To be completed by Applicanf.or. Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME. �i2cx0kF�rt.IS� VJVPlYIE'N� ` CD MVP0I��rp.� Cc)tzP 3. PROJECT LOCATION: Municipality T-J VAU,9,Y County 1 UT11Jh'" 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) �� Ma(� �rc,v�decl� .. • 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modificalionlalleratlon 6. DESCRIBE PROJECT BRIEFLY: 1 CO+�`3'i'�Ci�ivrJ t°5�r ��t.� F��1�. IZ�S���.r cj�•r1CiS`C5��1"'r rrk 1/�� 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately I ' Q acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? %Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? RResldentlal ❑ Industrial ❑ Commercial: ❑ Agriculture.-: , = ❑ Park/Forest/Open_space -:: = O-Other bescribe: ' Sk GtI;� " rv�ccV- iS (Zk- SLOet -J 7A1- 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? FSl Yes ❑ No If yes, list agency(s) and permlVapprovals ibWK3 cat; �• V �-�� Q-x t tc.�l�JC PE�L1�tlT 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ >No list Yes , It yes, agency name and permIL /approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERM ITIAPPROVAL REQUIRE MODIFICATION? ❑ Yeso I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE. Zb MLAtJd P ,S. Date: V o qb Applicant/sponsor name: r �' Signature: a 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 i . PART il— ENVIRONMENTAL ASSESSMENT (To be completed by t�gency) rA.DOES1, ACTION EXCEED ANY TYPE 1 T HRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. Yes ❑ No CTiON-RECEIVE�000RDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6NYCRR, PART 617:6 ?` If No, a negative declaration o superseded by another Involved agency. Yes ❑ No LD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE'FOLLOWING: (Answers may be handwritten, If legible) Existing air quality, surface or groundwater quality or quantity, noise lovels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly. C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent developmenl, 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. D. IS THERE, OR IS THERE LIKELY TO BE, 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 Identitled 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 (0 magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box If you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a' positive declaration. ❑ Check this box If you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL *NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Oilicer in Lead Agency Name of Lead Agency Date Title of Responsible Officer t. Signature of Preparer (if dilletent from responsible officer) L PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Mc- oy_F-ftl.S COP-P• Located at fZC>AV r T/V ?u7Tf ~ 9A� Tax Map # tA Block 1 Lot 1 fo .2 Subdivision ofcsi"E+t Subdivision Lot # 2 Filed Map # Z _ Date Filed co o el o Gentlemen: This letter is to authorize MW,) P. DE -A N-0 , P. E, a duly licensed Professional Engineer k_ 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 - Lawandtkie'Pitnam County Sanitary Code. - - - Very truly yours, Countersigned: . Signed: �� J �L P.E., . # (o Z 0� (Owner of Property) Mailing Address BADE-J State +If,: W V0241— Zip I OEJL�, Telephone: C114- Mailing Address: 33Q W . $54b State tai.' Zip I T o _ Telephone: 2-(2-- 2-G5 -- 6189 Form LA -97 a ' h DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: P6- iZM(15 FbIZ 5Si5 4- WeLA, represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: '82oc)"Pt, , D&VF_LWM e_ CexzP4 Having offices. at: vJOa-r 4c-5;,4'In -:5–teg —. N SV4 Whose Officers Are: President - Name: Address: Vice President - Name: Address: Secretary -Name: Addres's: LL ._... 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. Sworn to before me this / L day of (month) (ye 4r) Notary is ►S�'i'a's , ..�.�,C355o Oil ltes Jan, Form CA -97 Corporate Seal ....� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNIENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATKIENT SYSTEMS REV �VSHEETFORCOKSTRUCTIONPERYIIT LV STREET LOCATION x_ tiqu, S NAME 0 OWNE REVIEWED Bl R-NI; GR, AS, MB, BH Y DOCUMENTS Y PERMIT APPLICATION. C -1 WELL PERMIT PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS -TWO E `3CJ,40 '_ SUBDIVISION GAL SUBDIVISION ' BDIVISION APPROVAL CHECKED RC RATE 12 „L REQUIRED DEPTH WTAIN DRAIN REQUIRED ANDPIPES GENERAL )CATED IN NYC WATERSHED ANS SUBMITTED TO DEP ;LEGATED TO PCHD T APPROVAL, IF REQ'D .EP TEST HOLES OBSERVED SP fZCS TO BE WITNESSED t APPROVAL SSDS ADJ. LOTS ;ION CONTROL:HOUSE,WELL, SSDS ' & DEEP HOLES LOCATED :ESENTATIVE OF PRIMARY & EXPANSION \TION MAP AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE & DETAILED 'OF PROPOSED SYS. )PERTY METES & BOUNDS SSE SETBACK NECESSARY (TIGHT LOT) JSE SEWER - 1/4" FT. 4 "0; TYPE PIPE BENDS; MAX.BENDS 45° W /CLEANOUT GII " \Y BARRIER FT. HORIZONTAL;S J 3:1 TO GRADE LSRECS FILL NOTES FILL CER ON NOTE DEPTH G GES FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. kRALLEL TO CONTOURS 100% EXPANSION PROVIDED �O Sid Z� f Z ETLANDS (TOWN/DEC PERMIT REQ'D ?) ON PLAN - FROM SSTS D A ON DDS PLANS & PERMIT SAME 0' TO P.L., DRIVEWAY,.LARGE TREES, TOP, OF FILL �- -1'969 NEIGHBOR NOT QATIOX -�:_� _:,:- - 20'�TG'PFOUNDATtON WALLS' 15 "WELLTOPL ` ER BI/ZBA 00' TO WELL, 200' IN DLOD, 150' PITS 10 FLOOD ELEVATION 00' TO STREAM WATERCOURSE LAKE (inc. expan) THER REQ'D PERMIT(S) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER IRED DETAILS ON 10' TO WATER LINE (pits -20) WAGE SYSTEM PLAN - (NORTH ARROW) 50' INTERMITTENT DRAINAGE COURSE DS HYDRAULIC PROFILE 00'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS RAVITY FLOW ONSTRUCTION NOTES 15'MIN to CDS= >5 %,10'- 4 %,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <I% ESIGN DATA: PERC & DEEP RESULTS 20'MIN to CD discharge /100'with 182 cons day discharge CONTOURS EXISTING & PROPOSED SEPTIC TANK VEWAY & SLOPES, CUT 10' FROM FOUNDATION; 50' TO WELL 0 TING /GUTTER/CURTAIN DRAINS WELL OIL TYPE BOUNDARIES Fl DIMENSIONS TO PROPERTY LINE Tl_TLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION M',PE/RA; NAME,ADDRESS,PHONE# OF DRAWING/REVISION M REFERENCE OCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: B OLLOVLOW )L r 0 -0' 7 ii ---19 0. q 3 35 Ot 4 D We# 0 250 GAL. �PRECAST CONC. SEPTIC TANK -4'C.I.P Dc .V N D O 01- well ' 54Tie y 1 4 .. ' 4 pole 0 AS -BUILT RELOCATION- DIMENSIONS 1A 9;2' SEPTIC TANK IN 1C 115' SEPTIC TANK IN 2A 8.0' SEPTIC TANK OUT 2C 16.7' SEPTIC TANK OUT 3A 35.0' END LATERAL 3B 96.2' END LATERAL 4A 47.3' END LATERAL 48 102.4' END LATERAL 5A 51.0' BEGIN LATERAL 58 60.0' BEGIN LATERAL 6A 88.7' END LATERAL 68 53.3' END LATERAL 7A 96.0' END LATERAL 76 53.7' END LATERAL 8A 91.0' END LATERAL 86 39.6' END LATERAL 9A 36.3' BEGIN LATERAL 96 39.0' BEGIN LATERAL 10A 39.5' BEGIN LATERAL 106 43.9' BEGIN LATERAL 11A 43.5' BEGIN LATERAL 116 49.2' BEGIN LATERAL 12A 48.5' BEGIN LATERAL 126 54.5' BEGIN LATERAL 13A 290 BEGIN LATERAL 13B. 44.6' BEGIN LATERAL 14A 34.4' BEGIN LATERAL 14B 48.3' BEGIN LATERAL. ;15A 40.8' :. BEGIN LATERAL'• .. 158 51.5' BEGIN LATERAL 16A 45.2' BEGIN LATERAL 168 57.5' BEGIN LATERAL 17A 38.1' END LATERAL 17B 1 97.8' END LATERAL 18A 42.3' END LATERAL 188 99.8' END LATERAL 19A 92.3' END LATERAL 19B 44.0' END LATERAL 20A 94.0' END LATERAL 20B 48.7' END LATERAL 216 36.9' CLEAN -OUT 21C 38.2' CLEAN -OUT DW 56.8' WELL EW 78.2' WELL E OCT 2 91999 OADEY & WATSON SURVEYING & EidGiNHRMG P.C. LOCATION PROPERTY OWNER BROOKFALLS ROAD BROOKFALLS DEV CORP Tr%WM fK P HTMA►A VAI I cv 2tm %.ccT wmvu VT f� � '- rs�^a* , '—ter �, --�-. ,. ,;. 1..'¢ -.,;-•��S rte" r.�:e•¢c- P-c. ¢ =Yu' °. ^- �t';',".?� --* e � t'^ � �C�- -' -, . . �. P01riA11[ t70UBTiY DIPAYTMENr OF l8lBALT 141 H i�su rero.ia.re.�i� mil. , ilk FOR 86WAfE DislOBAL SZSiW ...,®•. a� � "' • ., _ _....�. -- � _ ..�. Ttu`�Y/ap'Bloe`i fr � , ,�•• Q^, = 1...... ...,,.. t�..a�iApMe.•t 1 eV';O Rewwal_ ❑ ❑ xa Daft'of Pttwims Approval ZIP ° ` - - - n 30�6g Tme 3 . (S A • 19\ etM Cl� Lot. Aran 1,'5, 3 Ac cis Nober of Bfalral�sa 3 Dealgt Flow G P D *c© Saearata Seiiaase 8yat= to oaidat a[ �Galha Sapda Task and_- 1�1J�Li To 6a;aaeahstetad by ' ` KJU`(J I t�l �t't I Ut trua r- r: r - Adihen Watts, Stn.. X S 4 b r�� .ate.. 1?4M M A\re: �JR'uJ� �,M 1Gj W SvAYb.. . Y Ober 1 >represent2that.l am, wholly and eoMplotely risponsible;fbr the design and location-of, the_:proposed system(s)i l) that the separate =a dl eel s Qem above tlistribeA will be.calstructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns o ream County bepastmen't of inliii , anq that on Completion thereon a'.'Certificate, of Construction Compliance'• satisfactory, to the Commissioner of Mwlthwill be subinitted to the oepaftmant. ,and a' written guarantee wilt be furnished the owner. his successors, hales or assigns try the builder, that said WNW will place in good.-opaiatir g con Oitbn any part of said »wage disposal system during the period of two (2) years (mmWiately following thedate of the Issu- ance of, the epp►aiof of -tho Certlfkate of Constructiop Compliance of the Original system or a y repairs.thereto• 2 t the drilled well described above WHO be located as ahown -on the approved plan and that said well will W Installed in rdanoe with, the., stand ul ZrPA—Z s. Lof the Putnam County. Degrtinant :of lfeaK RA. — o.t. LG .= iU signed Address iyC�11 v► a r, /V' +cent. No .CrXoF YG�� 'APPROVED FOR CONSTRUCTION This approval expires two :y s ro t a data issued s construction of the building .Ms undertaken and is revocable for cause o may be amended or modified when considered Y by the C ssioner of Health. Any change o► n of construction requires a na per Approved for disposal of domerik,'anits e, and /or. w ter supply only. R2V . 10/88 gab By Title W DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 . 'APPLICATION `'TO 'CONSTRUCT" A ` WA YER LL PCHD PERMIT # WELL LOCATION S r`e`st Address i"ie \` t5kii6 Town Village City Tax Grid Number T I Q 04Ln WMeV -aK WELL OWNER Name Mailing Address comer s �, C &Private O Public USE OF WELL Q - primary 2 - secondary 0 RESIDENTIAL . ® BUSINESS ® INDUSTRIAL ® PUBLIC SUPPLY O FARM O INSTITUTIONAL O AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY ® ABANDONED O OTHER (specify 13 AMOUNT OF USE YIELD SOUGHT 6' gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�al ® REPLACE EXISTING SUPPLY 13 TEST /OBSERVATION ®: ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL ^1 W CSi 17 �niC REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE MDRILLED ®DRIVEN ODUG OGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Im -r'n . � 41W, Lot No. }, WATER WELL CONTRACTOR: Name 9 A"r, Address : A ? k rNaNl Ave fv �Y Tcl` IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY .. DIST�,NCE TO PROPERTY ,FROM: NEAREST WATER �M1IN LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt;* (30) days of the completion of water well construction, the applicant 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 attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and-all water or waste products from such well dr ing operations be contained on this property and in suc a manner as not to degrade or he w'se co irate surface or groundwater. Date of Issue: l 19 G'0p Date of Expiration `� 19qi�r Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PC -1 PUTNAM COUNTY DEPARTMENT OF HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: cominP. ')DC'v'to . N'. i ►a 2. Name of Project: 4. Project Engineer: S ek I License Number:*- 060&'J &'J Phone: '21) 6. Type of Project: Private /Residential Food Service Apartments Institutional Office Building .Realty Subdivision 3. Location T /V /C: "00 ?Chr arn' Mey 5. Address: Commercial Mobile Home Park Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Status ('Ch'eck O.ne) - Type - I... ..,_:Exempt-` Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. /yo 9. Has DEIS been completed and found acceptable by Lead Agency? IV IA 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .......... ............................... N'C> 12. If so, have plans been submitted to such authorities? .................. 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water Ground Waters 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? .................. NO 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... ,n/0 20. Name of sewage system Distance to sewage system 21. Date test holes observed: 22. Name of Health Inspector: 23. Project design flow (gallons per day) ....... ............................... S- co 11/93 4 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. /V0 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... ,/0 27. Wetland ID Number ..... ................. ............................... 1y 1�C 28. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? .................. I-vA 29. Does project require a DEC Stream Disturbance Permit? ................... 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 or NO /V y 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ 35. Tax Hap ID Number ......................... ............................... -5g 36. Approved Plans are to be returned to: ........ ......... _ Applicant Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. % 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 Lau. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: (p C 2 ►l\i SGG A4 Y IGSqg I Stop Payment Request and Indemnity CITIBANCO The undersigned is the remitter or payee of the instrument described below and requests Citibank N.A. (hereinafter referred to as Citibank) to stop payment on the instrument and to take the additional actions indicated. STOP PAYMENT NUMBER Instrument ❑ Official Check 2 Certified Check ❑ Personal Money Order ❑ Other (specify) Person Issuing Instructions Remitter (Purchaser of check or account signer on certified check) ❑ Payee named on instrument Name Telephone Number 51,rino, I 1(qJq) 'gA LAa --7u4 a Address Description of Instrument Instrument /Certification No. Date Issued /Certified Amount Payable To j Branch of Purchase Branch Number (.12— umber or Certification . 6 Customer Account Number Customer Check Number Check Date For Certified Check I I I / - / Reason for Stop Payment ❑ Lost ❑ Stolen ❑ Destroyed For Personal Money Orders Only Purchaser Indemnity Agreement Additional Action Requested 21s-sue Refund ❑ Issue Replacement .-:.Indemnity Agreements.. -- I All Other Instruments (Less Than 90 Days Old) I (the "Purchaser" of the personal money order described above), request the designated Citicorp. entity on which the money order was drawn (the "Drawee ") to stop payment on this money order and agree: (a) to indemnify the Drawee and Citibank, against all loss, liability, costs, claims, damages or expenses they may suffer resulting from complying with this re- quest; (b) to notifythe Drawee promptly, in writing if the money order is found, recovered or destroyed, or if this request maybe cancelled for any other reason; (c) if the money order is paid because I gave the incorrect information, I will pay the Drawee or Citibank any amount paid by the Drawee or Citibank in respect of such money order; and (d) this agreement and the rights of the parties shall be governed in all respects by the laws of the State of New York. Signature Date If the date of this stop payment request is 90 days or less from the date of is- suance or certification, the following section applies and is part of the request. To persuade you to comply with my stop payment request, I agree to the following terms and conditions: 1.1 will repay you (Citibank) forany losses, liabilities or expenses you may have as a result of complying with this stop payment request. If any legal action istaken against you concerning theinstrument, I will payall yourcosts, attorney's fees and judgment. 2.1 will notify you promptly in writing if the instrument is found, recovered or destroyed, or if I wish to cancel this Stop Payment Request for any other reason. I will deliverthe instrument toCitibank if it comes into my possession. 3. 1 understand that you may, before complying with my request to issue a refund or a replacement instrument, assure yourself that the instrument has not been paid. ' 4. This Agreement may be modified only if Citibank consents in writing. It will be governed by the laws of the State of New York. Signature Date Please complete the affidavit on the reverse side of this form Citibank Use Only Date Stop Placed Form Completed By / / Branch Number Refund/ Date of Adjustment Agent Number Adiustment Date of Replacement Agent Number Replacement Amount in Numbers i Amount in Numbers Amount in Words Amount in Words Currency /Country (e.g., ,Francs /Swiss) Currency /Country (e.g., Francs /Swiss) (NOT FOR USE BY: NBS BRANCHES) Payable To Replacement Serial_Number TEM 173500 (SF 2080(L)Rev. 12.94) PAD 50 Instructions: Check was issued or certified less than 90 days ago: TO BE G Both the Remitter and the Payee must complete the Affidavits below. COMPLETED G For checks of $10,000 or more, the Remitter must obtain an indemnity bond. FOR ALL Check was issued or certified more than 90 days ago:. _ INSTRUMENTS EXCEPT o Either the Remitter or the Payee completes the Affidavit below. MONEY ORDERS o No indemnity bond is required. Affidavit of Remitter State of SS: County of A. I am the remitter of the instrument described on the reverse side and I reside at: OR Al. I am the (Title of Officer or General Partner) of having its principal place of business at: I which is the remitter offthe described instrument. B. While in the remitter's possesion, the instrument was lost, stolen or destroyed under the following circumstances: OR B1. The remitter delivered the instrument as follows: C. To the best of my knowledge the instrument was lost, stolen or destroyed. (Signature) Subscribed and Sworn to me this day of: 19 Notary Public J Affidavit of Payee �l/ State of " ol-{- SS: County of N A. I am the person to whom the instrument was made payable and l. reside at: 7'- m OR Al. I am the (Title of Officer or General Partner) (l�iiilW M LO 4XId � of having its principa� ace of business at: Alt� to which'the instrument was-payable: B. The payee received the instrument and while in the payee's possession, the instrument was stolen or destroyed under the following circumstances:. OR B1. The payee did not receive the instrument. C. 7,o the best of my knowledge the instrument was lost, stolen or destroyed. ELIZABETH H. REGENSBURG Notary Public, State of New York .yo. 4630940 Qualified in Putnam County mission Expires February 28. 19� - Subscribed aridgworn to me this . C, C L day of / Notary Publ' Approval for refund or issuance of replacement instrument _ date V. .1231A DESIGN DATA SHEET- SUBSUFACE S&gAGE DISPOSAL SYSTEM FILE NO. owner ' `�DeV,+C . Address CC) 60(-Viet' SAC J L04.frTi.lei ,N,V IG,yc Located at (Street) Sec. ISLA, Block a Lot (indicate nearest cross street) Municipality -Vh2 X67 nanl yclklev Watershed'►�eC�S►/���� yo\mo creev -i SOIL, PE RCOI ATION TEST DATA REQUIRED TO BE SUBKITrED WITH APPLICATIONS Date of Pre - Soaking "7 /4-7 Date of Percolation Test 7 ho /3-7 HOLE NUMBER ClaM TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches !g- 1 t,00 - ..2 3a: CJD a i - -So as 013 k 3 0 4 5 2 Q ;aa - a;'S7 1tr 3 ja;40 -- Q, 5-7 .1 a a a�, tr �f 5 1 2 3 4 i 5 - NOTES:'..... I,' .- Tests• :to . be - repeated. + at.� - depth Lmtil.,apprcxamately 'eeua.l. -sail. ,rates • -.. • a....:L t• ..'Y are obtained at each percolation test hole. All data to' be sukmittod for review. 2. Depth measurements to be made from top of hole. rev. 9/85 179 :i G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 11' 12' 13' 14' TEST PIT DATA REQUIRED TO BE SUBMITTED. WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES. HOLE NO. HOLE NO. 10 HOLE NO. INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED 7 -0 INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER ING ENCOUNTERED -G �, fn Cr4Nj T, ree rna n DEEP HOLE OBSERVATIONS MADE BY: 6 A D VY .�, C AAW/V DATE: 5-/5 fsl DESIGN - Soil Rate Used Min /1" Drop: S.D. Usable Area Provided &000 Zr�L No. of Bedrooms Septic Tank Capacity /� dC9 gals. Type Absorption Area ed By & L.F. x 24" width trench Other Name ca - m r n e 7 e VAO 2. F Address (,)^Qr, Sa - b d 7 THIS SPACE FOR USE BY HEALTH DEPARTMENP ONLY: tiZz� Soil Rate Approved sq.ft /gal. Checked by Date APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS :.._ EVIEW SHEET for CONSTRUCTION PEA41T • ;F:.. n "• .`.r,:yi•=. - -.••e .r •... , � _ _ .. .,.- ». „. .•.: _;r?.: p. -. ..:: .Cita.r =� -i. .'x -' -.c� - 'o., ... , STREET LOCATION VVV111 NAME OF OWNER BY B. HEDGES R.MORRIS OTHER DATE TAX MAP # DOCUMENTS. Y M PERMIT APPLICATION m PC -1 m WELL PERMIT L11 PWS LETTER M ENGINEERS AUTHORIZATION - M DESIGN DATA SHEET(DDS) m CORPORATE RESOLUTION CD PLANS THREE SETS m HOUSE PLANS - TWO SETS m VARIANCE REQUEST SUBDIVISION LEGAL SUBDIVISION L77 SUBDIVISION APPI O7 CHECKED m PERC RATE )A m FILL REQUIRED �+ •DH m CURTAIN DRAIN RE + UIRED STANDPIPES - Y 'EXP. AREA; SH ; GRAVITY FLOW, S SIZE d 3 CIF PUMPED PIT & AILED- - NO. OF BEDROOMS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM LXA,PROPERTY METES & BOUNDS OUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE m NO BENDS; MAX. BENDS 45° W /CLEANOUT FILL SYSTEMS LAYBARRIER �0 FT HORIZONTAL: SLOPE 3:1 TO GRADE FILL SPECS m FILL NOTES j ILL CERTIFICATION NOTE EPTH GAUGES ILL PROFILE & DIMENSIONS VOLUME GENERAL FILL IN EXPANSION AREA X- APPROVAL SSDS ADJ. LOTS 'WETLAND ( TOWN/DEC PERMIT REQ? ) M' DATA ON DDS PLANS & PERMIT SAME LF I m PRE- 1969 - NEIGHBOR NOTIFIFICATION m PAR m' LETTER BI/ZBA _ m 100°, 1 °00 YR. FLOL?I? ELEVATION. L TO CONTOURS ANSION PROVIDED_ m60 FT MAX / REQUIRED DETAILS ON PLANS F iLDS VAGE SYSTEM PLAN - (NORTH ARROW) 10' TO P.L., DRIVEWAY, LARGE TREES TOP OF FILL M.20'TO )S HYDRAULIC PROFILE m GRAVITY FLOW FOUNDATION WALLS 15' WELL TO P.L vSi, b'e`ITOIVTOME ER NOTE) -100 TO WELL, 20V IN D.L.O.D., 150' PITS SIGN DATA: PERC AND EP RESULTS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) o FOOT c'�T STING & PROPOSED e °50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (PITS [VEWAY & SLOPES CUT AA) " � -20') I 50' )TING /GUTTER/CURTAIN DRAWS V INTERMITTENT DRAINAGE COURSE 3SION CONTROL; HOU SE WELL , SSDS 200 FT. RESERVOIR, ETCH 150 FT. GALLEY SYSTEMS )SION CONTROL NOTE 15' MW TO C.D. S= >5 %,20'- 4%,25' - 3%,30'- 2 %,35'- 1%,100' <1% PERC & DEEP HOLES LOCATED 20' MIN TO C.D. DISHARGE /100' WITH 182 CONS DAY DIS. mm REPRESENTATIVE OF PRIMARY AND EXPANSION SEPTIC TANK m LOCATION MAP m 10' FROM FOUNDATION; 50' TO WELL '�d4XCZO r:q � =: .rd [C � ........ ,:. ",ti d. - -- -.... `F�:a � N `.. , -. �•t'+ r -: -nom .:� '� a.. .R: _. 0LEY, .S.S: • Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 October 24. 1996 Carmine Devito 60 Barker Street Mt. Kisco. NY 10549 Re: Proposed SSDS: Devito Foot Hill Street (T) Putnam Valley Dear Mr. Devito: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: "The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard." 1. Proposed contours are not shown returning to the original grade. _ If possible, it is requested the scale be converted to a standard.enneering_scale. i.e.. 1 " = 20' or 1" = 30' for the -plan and profile view. 3. It is advised that the footingigutter drains be tied into the curtain drain. 4. Current codes requires that 100 96 expansion area be available. 5. In the profile view, the junction boxes are to be shown following the proposed contours. i.e., a foot below the proposed grade. 6. The house is labeled as 3 bedroom, the SSDS is designed for four bedrooms, revised as warranted. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yours, & f Robert Morris, P. E. Public Health Engineer R., L jp r� Carmine DeVito, PE - 60 Barker Street; Apt. #624 Mount Kisco, NY 10549 29 October, 1996 Mr. Robert Morris, PE Putnam County Department of Health Division of Environmental Health Services 4 Geneva Road Brewster, NY 10509 Re: Proposed SSDS: DeVito Foot Hill Street (T) Putnam Valley Mr. Morris: Enclosed are the revised drawings for the proposed septic disposal system for the above captioned project. The drawings have been modified as follows: 1. The scale has been converted to standard engineering scale; 2. Proposed contours are shown returning to original grade; 3. The system design has been reduced to a 3 Bedroom design; 4. 100% expansion is available as shown; 5: The junction boxes are shown following the proposed grade; 6. The footing/gutter drains have been tied into the curtain drain. Please note that all permit applications and supporting documentation submitted that may state the septic design as 4 Bedroom should now be revised for the 3 Bedroom design as shown on the drawing. The revised septic design has 511.0 linear feet (1022 square feet) of absorption trench. Thank you for your assistance and attention in this matter. I look forward to hearing from you soon. 4a7rmine DeVito, PE / / PUTNAM COUNTY DEPARTMENT'DIF HEALTH DHVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TR EATMENT SYST EM l/ tl PERrwT # IA f/ �, d! I,A Located at S Subdivision name 15TWys FAi' Subd. Lot # Town or Village PUTC .1AM Wrt, � Tax Map Block i Lot W.,Z Date Subdivision Approved zTUN F,_ zo . jq Lo \J Renewal Revision Owner /Applicant Name 4FAA e> DEA46toPME-R-�J—i Date of Previous Approval Mailing Address '3'-6g) \ F--S -k 4C,'$tq S Pf" , Wast'i e,,J�e Zip CC oU, Amount of Fee Enclosed 4 , o0 Building Type Lot Area I $r. No. of Bedrooms __A__ Design Flow GPD Fnll Section Only Depth VoRume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED 0- Separate Sewerage System to consist of 11 Z,SC, gallon septic tank and Sao tr- — Z Sa l' %A yg t Ol< iZm or-J % S SPACE4` /t=i G F:t" Other Requirements: To be constructed by (Agl Address. Pu71,JA+4 VA- L&,4E!-r' W e Water Snanniva Public Supply From Address ic' Pnvate Supply'I)nlled by+a�ltk2,6�1 'did e Address'°�-i'� 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 sys m 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 R.A. Date IC) 1 q! License # fv2� 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 neq permit. Appro for discharge of domestic sanitary sewage only. do By: Title:7o,Q, or-, ew(-. Date:-12jZ1jjR White copy - HD le; copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professio al Form CP -97 PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL 1; please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # 14F $ f2of4> RkZy`lAt1,4 VALLF—ke Map IM Block t Lot(s)16•2- Well Owner: Name: t,ers - F-AeUS Address: obv n +'i'c�a s3o W. 45+k S� t�0✓ti� tom( toa3� Use of Well: _�! Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business. Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _� gpm # People Served Est. of Daily Usage 00 gal . Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason POTAOLZ VJ -5L4ppa im for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes_ G� No Name of subdivision fboll- -t d t, Frs t "ST Lot No. 2 _ Water Well Contractor: NfllZmAt`1 AN aa,� l KY, Address: (at&TNA4✓l y Is Public'Water Supply available to site? ......................:........... ............................... Yes No _ Name of Public Water Supply: bL /A Town/Village i P� Distance to property from nearest water main: 7 i ,Mt Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: ,q%" Applicant Signature: Qdzf . &-• 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 w ter well driller certified by Putnam County. A Date of Issue I-JZ11179 I Permit Issuing Official: Date of Expiration I 114Z01,00 Title: ]PM&f�Dr� o Permit is Non-TransferrAbld White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Fonn WP -97 ss :i rp L -i ds; 4 ',P 1...�1 1 Y vw �J 5 If Sent By: TOWN HOUSE MANAGEMENT; 2125814334; Dec-4-98 5:01PM; Page 3/4 00- CONTINENTAL V [lot 2424 ROOM arcm Ar .. U 66U `Auld akkfar mffuft in j*e AprdaNr S,,i, PUTNAM COUNTY DEPARTMENT OF HEA T1, TH CLO U Iwo% WOTJSE PLANS APPROVED FOR BEDROOM COUNT ONLY; BEDROOMS Con tintenul V 1st Floor 576 Sq. Ft. nrw— I Signature & TitlfONTINENTAL'Ili Date 27640 nw,"..75, tz Hvrfl 1-1"1000 1 tvrtt contifttental III Ist Fluor 1,100 Sq. Fv- CW Ux as Continental M 2nd Floor .1.100 Sq. rn. Contintental V 2nd Floor $76 Sq. Ft. CONTINENTAL VI xr-1 C—t- 27642 rT Continental V1 I st Floor 1.155 Sq. Ft. Continental VI 2nd floor 1,155 sit h goo "We're Building Our Re-butatwx EXCEf With Your Home." and reoin 4w an dppmximase. RR. #2, Box 683 • Lhwpwd, PA 17045 •&fpgn&& to Am&nm high perfemmwit windowfiw a nsiniowl invw1mmL I-800-345-6767 (Sre par lmd&• for ektisib.) tvw; WALA-86 allow 0=0 "m to ciam Uft I.- au Ao Continental VI 2nd floor 1,155 sit h goo "We're Building Our Re-butatwx EXCEf With Your Home." and reoin 4w an dppmximase. RR. #2, Box 683 • Lhwpwd, PA 17045 •&fpgn&& to Am&nm high perfemmwit windowfiw a nsiniowl invw1mmL I-800-345-6767 (Sre par lmd&• for ektisib.) tvw; 1 "'Were Buildhig Our Deputation With Your Home." IEXCW Photographs may sbow exterior elalwtions and options wbirb Tara stow pest of the Series Sperafuatiotts. °N°' ° w v waa NOTE: Glade to Andersen W-lindows. (See your builder.) A •I 1� Iy1 1 1 ,x - 4 A •a . I'3 1 "'Were Buildhig Our Deputation With Your Home." IEXCW Photographs may sbow exterior elalwtions and options wbirb Tara stow pest of the Series Sperafuatiotts. °N°' ° w v waa NOTE: Glade to Andersen W-lindows. (See your builder.) A •I 1� Iy1 1 1 ,x - 00- DINM ROOM xrfcumq -,jv4,&bkfvr upgrade in the *nWk &-jo 17 T A* r PUTNAM COUNTY DEPARTMENT OF ALTH u cw ,mv wx HOUSE PLANS APPROVED FOR BE ROOM COUNT ONLY; 11T or •.w I . -.1. —1 - CONTINENTAL V 2424 ftD1100Y /; wagon 0 to. EDROOM Continental V I st Floor Contintental V 2nd Floor f�Q 576 Sq. Ft. 576 Sq. SL &AM fir CANITT ENTAT V1 27642 continfentsl III 1st Floor 1,100 Sq. Ft. Ys Mua 1H F.W&v 00" hh MIX Continental VI I st Floor 1.155 4 rt. Y)L: VAL OWN= 63 NM#M N too" 0 r-alf.13* cw Ao ;zm Continental III 2nd Floor Contintentsd VI 2nd Floor 1.100 Sq. ft. 1,155 EL 0 Our Retut4tion "We're Building . W With Your Home. EXC MANUfUCTUREO AI AR BTRUCTV1tES " Axvrp/axs ard, rom d= am 4tpr=.flw$r. R.R.42, Box 683 • Liverpook PA 17045 wnmjr to Andema high p4rmxre windmfiW4minima! inwomra. 1-800-345-6767 (rwror hander for sktaib) ,s 4, ) NO EXISTING SSDS WITHIN 100' OF PROPOSED WELL " NO EXISTING WELL WITHIN 200' OF PROPOSED SSDS ' ^380• SLEEVE DRAIN PIPE 380' INSIDE CORROGATED DALY. / / //// --- 370' / — — — — . _ PIPE UNDER DRIVEWAY — EWAY / _ MONUMENT Q �_ / I:I I' �Jf• GRAVEL SWALE 291 i ' j I / 1 / T yL • ° / niched cy6d. d 1 !;5 If 1/ 1 ROPOSED WELL /I l I ' l 71 I �I I , l l I I I /• 0 % T/ n ,y \�� --` / �� j / %_ _ ,�. _. - _ _ . -.. ;. �`1 nNC °a / /PROPOSOEQI�M /P N / 3 ¢ ! I l I l' : ' / n / % RESIDENCE j�'B / I l : Ili i 20' m n. (/ B.F. . er 378 // / / o - �B / / / / /-' F.F. Ele, 387 iIOOR �/% / / ' l / / / I/ 1 EXPANSION /.. /. F"--)0' min. I 1 l! I f i / G /AREA mmum PALL . uy 1 { / � / . / � mum. pdch ON 0 C qEaL SEpTic. fl JK q0/ l l I / ��' T Yi JUNCTION BOX / (TYP.) . / (ABSORPTIONS }R �NCH�. 1�' [. 1 NCH � � - -/ -71 STANDPIPE .. CURTAIN DRAIN AREA =1 .83 acres F NO �7(ISTING SSDS WITHIN 100' OF PROPOSED WELL 9 , ! GRAVEL SWALE NO EXISTING WELL WITHIN 200'IOF PROPOSED SSDS A PLAN VIEW a,:= Scale: 1" = 30' E ROB FILL TO SETTLE NATURALLY FOR DE AT LEAST ONE FREEZE –THAW CYCLE OR HANICAL COMPACTION IN APPROXIMATELY . OF THE INDISTURBED UNDERLYING irrY TESTS ARE PERFORMED IN THE UNDISTURBED TO BE SUBMITTED TO THE PUTNAM COUNTY , ACTION IS TO BE UTILIZED. •. ENT OF FILL ARE TO BE CONDUCTED 390 �; { SOIL SMEARING AND EXCESSIVE SOIL ' 3 �room� , Residence EINAGE ABSORPTION, BE FREE OF FINES OR - IN =PLACE PERCOLATION RATE AT I ..