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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -1 -38 BOX 33 I rm r r , 1. ' kc f E6 . ,6 ir IL E CT 04327 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director ofEmironmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 May 27, 2014 Phone # (845) 808 -1390 Fax # (845) 278 . -7921 Jorge Pereira 124 Allan Street Cortlaridt Manor, NY 10567 Re: Addition — A- 071 -14 No Increase in Number of Bedrooms 115 Peekskill Hollow Road (T) Putnam Valley, T.M. 84.4-38 Dear Mr. Pereira MARYELLEN ODELL County Executive This Department has received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated May 27, 2014. The addition is approved with the following conditions: 1. Please be advised that the above referenced lot was originally designed and approved with a four (4) bedroom septic system. -...m :.:. 2:=-The - :wu'.; bher��bccttaonis..n3utt=r aila.at four without. -A or.a�pro��:�xl?i�::_'::'':� Department. 3. The area of the existing sewage disposal system and its expansion area must be maintained. 4. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc . 5. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having jurisdiction. 6. This approval is valid. for two (2) years and expires on May 27, 2016. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43261. GDR:cml cc: BI (T) Putnam Valley Respectfully, Gene D. Reed Principal Engineering Aide AL EN ' BEALS, M.D., J.D. Commissioner of Health :...I2Ol�ERT MORRIS, P.E. - :. ,. Director of Environmental Health d MARYELLEN ODELIL County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 t Phone # (845) 808 -1390 - Fax # (845).278-7921 ADDITION APPLICATION RESIDENTIAL ONLY -T I - l Y STREET. I I�t�S���b�t,LTOV t��7cAx NYAP # �. -1 NAME ),D r- Let -ilc i eta PHONE qlq 13`V2W PCHD# FU I'S-q CA D � Dew FF—f 5�P_da ADDRESS i 2+¢ �� 6DfN-L1&W fl i O DESCRIPTION OF ADIDITIONc.��c�� LL *1VUM13ER OF EXISTING BEDROOMS NUMBER OF PROPOSED NEW BEDROOMS * "(FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) # °Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster; -t�I�C 10509,'Phone: X845):80= -13 -90: 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all Paving area including basement, to be shown and dimensioned and use of each room specified). (See Section 3.c of Bulletin HA -1) 3: Two sets of proposed floor plans (drawn to scale - with name, street and tax map #) * Non - professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations on the subject property to the best of your knowledge. Include date of installation known.. Contact this office with any questions. 5. Copy of Certificate of Occupancy from the Town or Certification from the Building Department with legal bedrdom count of dwelling. OFFICE USE COND ENTS 4. ALLEN BEALS, M.D., J.D. Commissioner of Health KMER'TgMORRIS, P:E::: r _:� a -,.• �. Director of Environmental Health MARYELLEN ODELL County Executive a .I�,..S.o•�+4u - �::�ar +r�. .7 �< ..,. - :y,'Csw ^:a � ..i • .. - DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Town Legal Bedroom Count & Proposed Addition Status Re: Q�z't % (Owner's Name) Tax Map # Address: Town: Year Built: According to r ords maintained by the Town, the above noted dwelling, is in compliance with Town Code. An-compliance with,TowtV.Code. . _.._ _ _ . ..a -b..ys M .- .v.-++ct�cm• ,- ,. -- .... -. .m ..- M.r._... <. _.�..- p'w.... •. ....,.. _.. w�.....� ...�. -r -e « .- ,a+-- aisw�.• ., v ....... .-• ........ -... .... _.•...•.e :..'....., � r The Legal Bedroom Count is: This information has been obtained from: Certificate of Occupancy: The plans for the proposed addition are considered: Addition to existing house only Teardown and/or re -build allowed under Town Regulations Building Inspector Date 5. CERTIFICATE OF OCCUPANCY ...VI AT9 N : PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - - - WELIJeG.OIVNLETICDN, REPOR'lC f Well Location et ddress: ill Tax druid # Mapg 1. Block I Lot(s)31 Well Owner: e: V A ss: 5 Use of Well: 1- primary 2- secondary sidential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing 2<_ Open hole in bedrock _ Other Casing Details Total length 161 ft. Length below grade [� Diameter in. Weight per foot 140 lb/ft. Materials: Steel _ Plastic _ Other. Joints: _ Welded X Threaded _ Other Seal: >�' Cement grout _ Bentonite Other Drive shoe: .< Yes No Liner: Yes ><No Screen Details . Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped XCompressed Air Hours Yield S gpm Depth Data Measure from land surface- static (specify ft) 36 During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve anal'ys`e "s `:°'- - are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface I .. .,r..__-- -.. -- - a .--[ " "' ._. -. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information , o Pump Type,e Capacity _ Depth iT g, Modl l /NIP Voltage 216 BP i Tank Typ 3o">,` Volume Date Well Completed 2h 03 Putnam County Certification No. 4� Date of Report Well Ddl er (signature )v I Z/ cxat;< LUUMIvn or wet, wiut atstances to at mast two permanr lanamarxs to oe providdea on a separate sh/eevplan. Well Drillees Nam�� 4 ac, Address Signature: �� Date: /u 6-1- White copy: HID File; .Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH CERT71CATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # N-11` Rpt �S 1. Locate at Re�%� s�i�<- i��L�w oc.cN Town or Villa Owner /Applicant Name mat U `� c a t� Tax Map 8--. Block 1 Lot -:s Formerly Formerly t A Subdivision Name F-O V ae, L ` G%;40.TV. S 1nlir,s v Subd. Lot # 4 Mailing Address 1:5S 0 y c- P-L obi �STRC- E: T �4 %Q N c Vr-e w o , QA . "'t. Zip to 5S % Date Construction Permit Issued by PCHD 01 Separate Sewerage Systems built by UoTE-0 54F-PT4c- 5ysTc. Address 3kk � ac-®FuP-1 Consisting of 1,"Z -5' Gallon Septic Tank and 400 L--F. ®F A 3sorzim oo Try cea 2-4"" Wa4r-- , 5Pkx--GV Ar Co" op. ccnore�-,- Other Requirements: "I" ®Ec-P f-TA t 0 i7 M At t3 meager S Apply: Public Supply From Address r or: X Private Supply Drilled by 0ocz-moaci {� or--r , .. lac.. Address 'Py rmo r, y ®L-& -Lv }_ - . �Bldg� ape �:` 6+T ii . a His `drQ'siotroritrol= be�ii pietd? Number of Bedrooms ` - Has garbage grinder been installed? �3 0 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: 9 Certified by _ Address !F� A.or -v (e')ArsQ^J. P.E.X R.A. (Design Professional) • I Co L-O 5P2_4 N SR W.Y. License # Q(o2- 5ro$ Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. By: _ Title: Date: 02 % o 3 e copy �-HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT __..... OTE• Exact location of well with distances to at least two perman t lan arks to be provided on a separate sheet/plan. Well Driller's Nam�B W,n- �ri �cC Address;/��- Signature: `�, �� Date. /� 3�� White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 rTa x Grid`# e ocaorip�y� Block � Lot(s) 3� Well Owner: e: A ss: Use of Well: sidential Public Supply Air cond/heat pump Irrigation 1- primary Business Farm Test/monitoring Other(specify) 2- secondary Industrial Institutional" Standby Drilling Equipment Rotary 'Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing � Open hole in bedrock _Other Total length /07 ft. Materials: � Steel _Plastic _Other Casing Details Length below grade Joints: _ Welded x Threaded_ Other Diameter 1�in. Seal: 7� Cement grout _ Bentonite _Other Weight per foot alb /ft. Drive shoe: � Yes No Liner Yes >cNo _.. Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Screen Details First _ Yes—No Second Hours Well Yield Test _Bailed _Pumped Compressed Air Hours Yield � gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 30, boa / Well Log Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface descriptions or sieye a�rta_Iys�s. are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Type?, .r;�,c. Capacity r during drilling, Depth i',�' o Mod list: Voltage 23 o HP /�S�icia Tank Typ Soy Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) J o3 4 __..... OTE• Exact location of well with distances to at least two perman t lan arks to be provided on a separate sheet/plan. Well Driller's Nam�B W,n- �ri �cC Address;/��- Signature: `�, �� Date. /� 3�� White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 rTa x Grid`# e ocaorip�y� Block � Lot(s) 3� Well Owner: e: A ss: Use of Well: sidential Public Supply Air cond/heat pump Irrigation 1- primary Business Farm Test/monitoring Other(specify) 2- secondary Industrial Institutional" Standby Drilling Equipment Rotary 'Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing � Open hole in bedrock _Other Total length /07 ft. Materials: � Steel _Plastic _Other Casing Details Length below grade Joints: _ Welded x Threaded_ Other Diameter 1�in. Seal: 7� Cement grout _ Bentonite _Other Weight per foot alb /ft. Drive shoe: � Yes No Liner Yes >cNo _.. Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Screen Details First _ Yes—No Second Hours Well Yield Test _Bailed _Pumped Compressed Air Hours Yield � gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 30, boa / Well Log Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface descriptions or sieye a�rta_Iys�s. are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Type?, .r;�,c. Capacity r during drilling, Depth i',�' o Mod list: Voltage 23 o HP /�S�icia Tank Typ Soy Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) J o3 4 PUTNAM COUNTY DEPARTMENT OF IiIIIEALTH DIVISION OF ENVRRONMENTAL HEALTH SERVICES -A _ _ P��IIC�'$'IOI�1 TO COI�TSTRUCT A WATIE WIE}LL.. �e /(e'�t +'pry _ L +f �. %;'Y•� �:ri- .(f -.. .. ...:.V„ <_..y. �C.-.. .. s..�Y.`S .. F MY -♦ .. r i Public Health Director -- LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH - 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (9.14) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 —6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278.6081 Fax (91 4)278-6648 OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OF (Signature) DATE: 9, The Putnam 'County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned -by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRM) PUTNAM COUNTY "Ek'ARTMENT OF HEALTH DMSI ®N OF ENVIRONMENTAL HEALTH SERVICES".,. GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM R� -� .min -�d- Owner or Purchaser of Building Tax Map Block Lot' 04,TArA 1 VALL Building C nstructed by Town/Village /_/ P k5 ff la u.ow Location - Street R E-5. (D ex) T /,ftZ Building Type F007 -# W S Subdivision Name M Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, °r 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 whore the failure to dpi e_,prtJpel a sGd tlr wtllful:©rrtne. t =acrol tie atl i;i iti wing tk - __ _ gltg oecu system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to- operate was caused by the willful or negligent act of the occupant of a building utilizing the system. t Day Year Si �'"�--- Dated: Month y Signature: Title: iryw-e A L �i Ge er Contractor(Owner)- Signature Foa woahmanAAtp & mateai.al - 2cya. Fon pump, �. oatA, aiaam - / ya. Corporation Name (if corporation) . UNrND SEPTIC _ 311 RRRAOA® "Vt. Address: yjl,�-lr Cu �� �f � � BEDFORD 141L S, RSV 90507 (?1 ,Q) 638 -30" State %• L7 Zip --- /7--0/ Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street ~ yorktqwn Heigh�s, N.Y. 10598 ' '� ' - Albert H. Padovani, Director A � LAB *: 32.304986 CLIENT #: 1818 NON STAT PROC PAGE 1 ANDERSON, NORMAN DATE/TIME TAKEN: 06/26/03 01:00P 152 BARGER ST DATE/TIME REC'D: 06/26/03 01:051::; PUTNAM VALLEY, NY 10579 REPORT DATE: 07/07/03 � PHONE: (914)-528-1491 � � SAMPLING SITE: PEEKSKILL HOLLOW RD : PUTNAM VALLEY, NY COL'D BY: PEREIRA NOTES...: TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE,.: < 4C COLIFORM METHm Ml-:' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/26/03 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 06/26/03 LEAD � (IMS) 1.2 ppb 0-15 ppb 9101 06/26/03 NITRATE NITROG 2.01 MG/L O - 10 9139 06/26/03 NITRITE NITROG <0.01 MG/L N/A 9146 06/26/03 IRON (Fe) <06060 MG/L 0-0.3 mg/l. 2037 06/16/03 MANGANESE (Mn) 0.017 MG/L 0-0.3 mg/l '-n , 2037 06/26/03 SODIUM (Na) 99.7 MG/L N/A 06/26/03 pH 7.2 UNITS 6.5-8.5 9 0 43 06/26/03 HARDNESS,TOTAL 350 MG A. 06/26/03 ALKALINITY (AS 268 MG/L � 06/26/03 =~_=TUR8IDIT1' /Tpy COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDl HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS | TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. - ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, e1se water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. YML ENVIRONMENTAL SERVICES 321Kear Street t wwam LqM.Q N � Albert H. Padovani, Director � LAB #: 32.304986 CLIENT #: 1818 NON STAT PROC PAGE E ANDERSON, NORMAN DATE/TIME TAKEN: 06/26/03 01:00P 152 BARGER ST BATE/TIME REC`D: 06/26/03 01:051':' PUTNAM VALLEY, NY 10579 REPORT DATE: 07/07/03 PHONE: (914)-528-1491 SAMPLING SITE: PEEKSKILL HOLLOW RD : PUTNAM VALLEY, NY COL'D BY: PEREIRA NOTES ... : TANK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: Ml-:' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~� RESULT NORMAL - RANGE METHOD pi--i pH E)CALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE THE IMPORTANT AND FREDUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. lici TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUi'l CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM () TO HUNDREDS OF MOIL, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBjECTED. SOFT WA','EF*,-. 0-70 1,iG/L VERY HARD WATERs ABOVE 300 MG/L "pVERQQQY ,~~ '-. -~_-^--. - ' ' _. SUBMITTED BY: Director ELAP# 10323 BADEY & WATSON LETTER of TRANSMITTAL ..Surveying . 4. 173n nanng, PX..,.... 3063 Route 9, Cold Spring, New York 10516 Date: 08 Oct 2003 TO: Mr. Joseph S. Paravati, Jr. Putnam County. Department of Health 1 Geneva Road Brewster. NY 10509 We are sending: copies F-11 0 F-31 F-11 0 El El 1 .1 date description of document File No. 86- 192.04 W. O. # 16032 RE: Pereira Peekskill Hollow Road Foothill Estates West Tax Map 84.-1-38 Pemutfritle/PO # Sent via: US MAIL MESSENGER PICK -UP FAX 03- Sep -03 7 lCertificate of Construction Compliance for Sewer Treatment System 03- Sep -03 I IE91 1 Address Verification Form 05 -Se -03 7 IGuarantee of Subsurface Sewage Treatment System Subd. Lot No. 4 PV -13 -99 ❑ UPS -NIGHT ❑ 0 UPS -2 DAY El F-1 UPS -3 DAY El El UPS -GRND El UPS -COD E] 07- Jul -03 Well Water Test Results 2 Pa es 26- Jul -03 Well Completion Report 18- Jul -03 SSTS "As- Built" 06- 0ct -03 A licatitin Fee 200.00 Dollars Copies to: . File Yours truly: John P. Delano P.E. Tel: (845) 265 -9217 ext 12 Fax: (845) 265 -4428 Email: jdelano @badey- watson.com 40 40-05 497800 630000 22514 J.';%. JUL -21 -2003 15:22 BADEY & WATSON, PC P.01/01 PUTNAM COUNTY DEPARTMENT OF HEALTH ]DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION JOSEPH GENE QUEST FQR FINAL - INSPECTION For: Fill' Date:.... Trenches PCID Construction Permit # _ Located: CTS _... 9v . .....- Owner /Applicant Nam.., paralm _ -.,.. TM . Block Lot . Formerly:,. NA .._ Subdivision Name: ' ® _ Bftw V" -- - ..... Subdivision Lot # Is system fill completed? _ . NA.— Date: WA . Is system complete? Yes Date: 7 _ Is system constructed as per plans? GdwrAy Is well drilled? Yes mate: ?� Is well located as per plans? GrOmW Are erosion control measures in place? __ . Yea I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Heats. late: ?1481 Certified by;:.. P. .h.� Design Professional Address: Ba*&VAbn PC 3Rxft%C IdS0n& W _ Lic. # _ Co wwnts: Form FIR-99 TOTAL P.01 P. 1 �M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. `�i� ;;i,.. 6:'c °'n •' mv.r ;��• i ^ice.. .r %_ ... .;�; ^.;: h. .6•.i• c. �r .'r, •- Q! " :v=•u CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # �- 9 Located at r 1rCSKtk- . 40 -k-0 W ( PAI Town or Village RnukNj 4UE P ooat'k < <-Ls Subdivision name E5cr --Y€ W zc ubd. Lot # Tax Map Block / 1 Lot 3 8 Date Subdivision Approved :TLJN)E. '2,00 Me) D Renewal 7( 9y Revision Owner /Applicant Name :'oe-(,15 peIZE 'LAS Date of Previous Approval[2Z Mailing Address � �� (1 VAR- 1.. ©er K. �'T �'"; P� t�ys�T �FR D�.9 , i�1,Y Zip l o c"c- Z Amount of Fee Enclosed 1,300, CO Building Type Lot Area o. of Bedrooms L- Design Flow GPD_e�W Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of i , S,57V gallon septic tank and 4 oD L. , — 'zi i ki c-" w i l s' A RV,0 Ti ©a1 TPO OCAH c 5PA C-E A KT- 4 FT 0, Other Requirements: Cu iZ i A,#Q XA-81P , G s -1 EM jcc r To be constructed by STc-V E I<A=<T U K Address Ptjr t& 1jA LLEY . 0,Y. Water Supply: Public Supply From Address ' �t or: Privafe'SupplyDrilledliy f�Sop. iJ A '( Q,s Address �i►i�n?J M •4'/ LUr=•`�? ` I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 071/11 License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary b the Public Health Director. Any revision or alteration of the approved plan requires a new penm' Approv d fo i ar of domestic sanitary sew ge only. By: Title: Date: 410 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr fessi nal Form CP -97 BADEY & °WATSON LETTER ®f TRANSMITTAL - Surveying & Engineering, - A C. _ _ ,.:: , .: : ,:..:....:.:..,.. _ . � -,:: •. ; ": - 3063 Route 9, Cold Spring, New York 10516 Date: 11 Jul 2001 (845) 265 -9217 (914) 628 -1800 (914) 739 -3577 File No. 86- 192.04 (845) 225 -3312 FAX (845) 265 -4428 W, 0. # 14228 RE: Permit Renewal Pereira TO: Peekskill Hollow Road Adam Stiebeling Foothill Estates West Subd. Lot No. 4 Putnam County Department of Health ap 84.4-38 Tax.IVfpermit 1 Geneva Road # 99 Brewster, NY 10509 Sent via: US MAIL E UPS -NIGHT F MESSENGER ❑ UPS -2 DAY PICK -UP FAX 11 UPS -3 DAY El ❑ UPS -GROUN El We are sending: UPS -COD El copies date description of document ❑1 1.1- Jul -01 Construction Permit for Sewage Treatment System. ❑ r Letter of Authorization ® I 11- Jul -01 ISeparate Sewage Treatment System Sheet 1 of 1 ❑1 11- Jul -01 A lication to Construct a Water Well ❑1 I FApplication Fee - $300.00 ❑ ❑ —� REMARKS: Signed: John P. Delano, P.E. r Copies to: File 5341 V. i BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N. Public Health Director Associate Public Health Director It I I I WW —'I- D -c brr 6f -'PpthW ,5crvi&s . ift t. DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509, Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278-6082 Fax (845) 278 - 6648 Date: L6 0 To: w+*.t 0 From: Adam B. Stiebeling A t. Public Health Engineer y,0 ...z nf6rmation. For your review — As discussed Notes/Messages SS�SI Fax #: 0 6 5 — I I LF7 No. Pages (Including cover sheet) .. .. ...... .�ase respond Attached as requested Please call In the event of transmission/reception difficulties, please contact this office at (845) 278-6130 ext. 2157. PUTNAM COUNTY DEPARTMENT OF HEAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES ��.: '�.. n _.a?iii r • . r " . uJ` i":5TK 'w's 1LG 7 P E'H$MI., .. -,F.i1 R;S• .EW.A.G-E, ?zT2.R A—H,.MFi1V 1. ,1� ►]1 1711 • . "7:: 7 -P _ '• r: :.:7. PERMIT # Located at F0EKS- %k--t- 4L _Q in/ Q0A1 Town or Village PVTUA M. 4U-Z �y Subdivision name � /� we<T-Subd. Lot # Tax Ma _ p Q Block// Lot 3 8 Date Subdivision Approved :TDOE7 Z.O, 116) 0 Renewal X 9! LRevision Owner /Applicant Name Zop-G e P�EIZs f 1r& Date of Previous Approval Mailing Address 5 191t�R- i..pe�,�S �-F- T; t�yN-T- �fER a') Ai,}� Zip 1 ocs- Amount of Fee Enclosed �30o, CO Building Type R Lot Area o. of Bedrooms L- Design Flow GPD J1�0^ Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1, S,5V gallon septic tank and . 4 Dl7 - �� wc-ii • wile AacO r,o&) -ate- #j(, -Hcs _cphce:,� &T- 6 FT 0, C/ Other Requirements: CVk 1 A Q )SLA,Nt _bj56P To be constructed by S7cV e' kA.CrOK Address In *& VALLC:Y Water Supply: Public Supply From Address ®r: _ Pnvate Sugply,.Drilled by... t�.Q A� )fi �n)c =, Address _ti? AM I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. s Signed: Address R.A. Date 07/ 11 A I License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 .1\ A VAN I ZED C,4R?'A FGE' .. 0 5TING CONDITION )N AT THE .51 TE N AND INSPECTION TREATED PINE I N DELIVEKED. BE GALVANIZED �LLED AT MIN. JG STUCTURE TO I JECT TO PLANS AND SITE %IE5,.JN WRITING, =MENT 0'F- -AM(. WORK. ,55uMeD 70 TONS � W cv oz LLj LLJ BE DRY t wW }- pZ FAX — g C)Z O �WZ O\U t'z' DRAWING N"ER 008' Lms REV 151 ON DATE DE%g I DE DY - .t,... DRAWING DATE 4 /Z Z� IDY cHc OR. - A� P /A�■ ,. �., A . LE N*T Al�GH • '.}•,• :,`..nom 1 24 ALLAN STREET GORTLANDT MANOR NY 1 0567 `b;y'• O.� �z O --A Q � Lli LLJ W _ O °� w,• is LL '1 PHONE (g14) 19 � µON Y. BE DRY t too 737 -2880 FAX — g .1 r k•" t'z' DRAWING N"ER 008' PHONE (g14) 19 � µON Y. NG5 PR 1,0R TO THE :OOTING TO .DEPTHS AND fo R I • EDUIRED- - - BE DRY t too 737 -2880 FAX — g .1 r k•" t'z' DRAWING N"ER 008' NG5 PR 1,0R TO THE :OOTING TO .DEPTHS AND fo R I • EDUIRED- - - BE DRY t too *.,,.., NG5 PR 1,0R TO THE :OOTING TO .DEPTHS AND fo R I • EDUIRED- - - ii 124 Allan Street Cortlandt Manor, NY 10567 (914) 737 -2890 Fax -1915 September 9, 2001 DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road Brewster, NY 10509 Attn: Mr. Adam Stiebeling Re: PV 13- 99_exp. date 7/21/2001, FOOTHILLS ESTATES, Sub -Dive Lot 4 Sec 84 Blk 1 Lot 38 , Filed Map 2477 -A date 6/20/90 Dear Mr. Stiebelinge With reference to the above subject application I hereby re- submit Plans for a 4 bed room house to conform the existing approval. Your review and approval is requested. Please note, I have increased the size of the arch opening, to the first floor study, and assure you the room is designed to be a home offices I have also re- designated the room over the garage [formerly Multi- Purpose] to unfinished at this time. I am not.certain what your concern was, however, the renewed permit PV 13 99 , signed by you on 7/26/01, is for a. _....._.. 4 $ed..:. toom ,Approval... -The exis ing,_conf;igurati.on 1s- •for - >3 bed -rooms- - We wish to obtain building permit and commence work ASAP, and will re- file for any future expansion. I have enclosed 3 copies of drawings A -3 (first floor plan) and A -4 (second floor plan) for your review and approval. Your attention is appreciated. Yours truly, INI ARCHITECT TJn4�AC. entini , RA CC: Mr. Jorge Pereira, Owner 155 Overlook Street Mt. Vernon, NY 10552 kI�I:�Tt� R�Ej PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES I:':..�'. ��. if'::.ti.i.�..., - -. � . .," . x. r . :. • - YE "A �dYR ^*.II IM-- +T��'•.i. �V- ��� +'��:Lix/N. ' .. .. v. . � � x... .. � • - .� _ .A .��. .. ^-. xl RE: Property of Located at T/V Putnam Valley Tax Map # Jorie Pereira Peekskill Hollow Road 84 Block 1 Lot 38 Subdivision of Foothill Estates West Subdivision Lot # 4 Filed Map # 2477-A Date Filed Gentlemen: 06/20/90 t . Tliis. letter is to authorize John P. Delano, P.E. a, duly licensed Professional Engineer X or Registered Architect _ to apply for the required wastewater treatment andlor water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public H ealth Director of the Putnam County H ealth 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 m conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public H ealth Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: yox hezl P.E,, A_J� 062505 _ (04r of perry) Mailing Address Badey & Watson, P.C. Mailing Address: 155 Overlook Street 3063 Route 9, Cold Spring Mount Vernon State New York Zip 10516 State New York Zip 10552. Telephone: (845) 265 -9217 _ Telephone: 914 - 668 -5680 — Form LA -97 ti ,- d PUTNAM COUNTY DEPARTMENT OF HEALTH DI VEHON OF E V V J RONMENTAL HEALTH SER_C7 JlC j... , (CONST]1 U CUON P EflSMI IE TREATMENT SYSTEM P ERrzoT # -, 13 - Located at e 5V-iw Vo"W PDM--,) Town or Village PLkTW M \/ F�, Subdivision name fCOT4(L(.1E �\A) Subd. Lot # - Tax Map _8 Block Lot *�p b Date Subdivision Approved J WJP— 20 s ( Ono Renewal Revision Owner /Applicant Name 1 11f ,S Dgxjp. -i Lys -Date of Previous Approval Mailing Address X30 �t> T 4 S??� � - e.D1 �c�174, Zip 1 � Amount of Fee Enclosed %�� Building Type rW-5f DaJT7P4.,-, Lot Area 1.4 No. of Bedrooms 4 Design Flow GPD WO IFiII Seetnon Only Depth I VoRume Separate Sewerage SIstem to consist of i 250 gallon septic tank and 400 t. - t-JU4 W (2PriWv ` �( 5 -PACW A- Cc r—. v C—. Other Requirements: CQtZMcJ rgmtJ , °l lei- 1 - ' To be constructed by W61-'U14— Address _ RkTt J hly� Water Sulg0 v: Public Supply From Address oir: � Private Supply Drilled by ¢4QtZt�A� _ . � . 1 Nk, -~ _ Address PIT�lfnM VA. -y/ I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 0 oq Al License # �r250� APPROVIEIID 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 approve plan equires a new permit. Approved for discharge of domestic sanitary sewage only. By: Title: l Date: Whit - HD Fill Yel p Bit ing Inspector; Pink copy - Own r; Orange copy - Design Professional ����,���� Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A_WATER.WELL - -- - d%:::. .. - s•....i:�:p`:. - _'s- r V '... .,,-, .. -� c. ... .... i ,..�. .��:� r �,.^a.e•':.Lt•S ,a .' - .d. :i•.► "a�n:� �'..[�, �%'j i. �r . ... pie`ese print or typ �'HD Permit #ro Well Location: Street Address: TownNillage Tax Grid # Fl✓&--5Pu-'4+) { W0 iZP. M ap 16-A Block l Lot(s)3e Well Owner: Name: rpoo-pct„i� Address: t i, Pm soap 13?)0 WI.45JA4 ST. 0" %621 IW3� 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 5 gpm # People Served _� Est. of Daily Usage aCXD gal. Reason for, Replace Existing Supply Test/Observation Additional Supply Drilling >/, New Supply (new dwelling) Deepen Existing Well Detailed Reason l Qe- L& WAT- EE:IZ 5LXPO ,-i tD for Drilling Well Type �C Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes C No Name of subdivision iU.- �Js;S�' Lot No. Water Well Contractor: OW -MA4J AN'��t3t ( (JAG. Address: NLTtJ A4k Is Public Water Supply available to site? .................................. ......... ....................... Yes No X Name of Public Water Supply: t& Town/Village � A Distance to property from nearest water main: ? i M i L .— Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: o Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED.FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue )7,7,1 Permit Issuing Official: Date of Expiration Z ol Title: Permit is Non- Transferra le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 1' . I - - i o�. { I r I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES v _ APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM Name and address of applicant:IGort1S� �F�.lFJt �C�e�st Calf'. 2. Name of projcct: �j2s X;F�rt,t., Darn -3. Location T/V: .?Lo -t lW �1— 4. Design Professional: TowJ P,Q1 ,¢? 5. Address: DDE4 tuaT%Ks.f'z'� 6. Drainage Basin: l 4654- (, i-bt,t rJ, Nzz04 fz�-q COLD 5Y��1C� Nf IF 7. Type of Project: je Piivate/Resi dent ial Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted >( 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... �p 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N 11. Name of Lead Agency an :f6aAunder the coiitrol of Toca1 pTanning,'zotiirig; or other " officials, ordinances? ......................................................... ............................... 13. If so, have plans been submitted to such authorities? ........ ............................... NO 14. Has preliminary approval been granted by such authorities? t-J/A-Date granted: WI 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... P! 17. Waters index number (surface) ............................... ................ .................... 18. Is project located near a public water supply system? ....... ............................... n3O. 19. If yes, name of water supply 01A Distance to water supply A 20. Is project site near a public sewage collection or treatment system? ................. rl� 21. Name of sewage system iJ Distance to sewage system —tom 22. Date test holes observed 901Qe3 23. Name of Health Inspector 24. Project design flow (gallons per day) .............................. S)OO 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... tyD 26. Has SPDES Application been submitted to local DEC office? ......................... KJ 4- 2 27. Is any portion of this project located within a designated Town or State wetland? (-0 20. Wetlands ID` Nu ni' be r .................................................................... ............. .................. 29. Is Wetlands Permit required? ................... nip Has application been made to Town or Local DEC office? :.............................. tJ A 30. Does project require a DEC Stream Disturbance Permit? ........ I...................... KJO 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 applietion-or industrial activity? ............................ Yes/No N►o 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous, waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Arc community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... NO 35. Are any's`cwage treatment areas in excess of 15% slope? . ............................... NO 36. Tax Map ID Numbcr .......................... ............................... Map F,,4 Block_ Lot 35 37. Approve plans are to be returned to ..... Applicant,.,.. Design P.lr. fe,fi iogal.. "NuTE: A11' applications -for. review and approval of anew SSTS to be located within the NYC Watershed shall 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 re,.view and approval of other aspects of a-project, such as stormwatcr plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 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 perjury, that information provided on this form is true to the.best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES &, OFFICIAL TITLES: Mailing Address: ...................... ?� f� cATI�___ 9 COLD SpetiG l� IOSl� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRQNMENTAt, HEALTH SERVICES ..... ..... 7 DESIGN DATA SHEET - SU.B.SURF-ACE.-SEWAGE TREATMENT. SYSTEM Owner 5ocxpkot• c, .�7 MstJ r Address -530VJ. 4544A ' ;;rr-,,k Located at (Street) POEA/_ 'Block .1 Lot 3�3 stz.i Lk_ 4A� Ly W [WAC> Tax Map. (indicate nearest cross, street) Municipality P41-t-iAo1 YA-L,Lt Drainage Basin UWj (34� LIL- t4o SOIL PERCOLATION. TEST DATA Date of Pre-soaking Date of Percolation Test Hole No. Run No. Time Start - Stop Ela Time Min.) Dvth to'Water rom 'Ground Surface Start Stop Water Level ro D In. Inctes Percolation Rate Min/inch. A 4 0 2 1-'42-- 11'(50 S Zq 3 3 4 5 4.0 E3 2 2-A 2-71 3 4 5 2 3 4 NOTES: 1. -Tests ,-tp':b;` "at - .�egga '*..at same depth until approximately equal percolation rates'are obtained at each pqrcol'ation te'st'.", 4o e-6, "I _� (i.e. s min for 1-30 min/inch, .5 2 min for 31-60 min/inch) All data to be submitted'f6• review:: 2. Depth measurements '.'to be made from top of hole. Form DD-97 I DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9:0' " 9.5' 10.0' TEST PIT DATA PESCRIPTION. 0E SOILS—ENCOUNTERED IN TEST HOLES HOLE NO. _ i 4 HOLE NO.',..� 60 S t LT- IAA,(yl 5% LT- LOAM HOLE NO. 2 ' Indicate. level at which groundwater is encountered }- t,3o-y Ei�k0Uw Indicate level at which mottling is observed -- k3c 1 0 Indicate level to which water level rises after being encountered — tj /A Deep hole observations made by: A wATso•,,J ip.C, I Date Design Professional Name: 20H,-Ij p DELA Address: �f` ` WM50T j Q =G 4�ti4t7ltitirirlrl ++j '' -LC.1_ �-Y �� 1'V IU�7 le q fit �y�f Wit' �JF :°� •tai' �r�� to � :1�1'.• wr^� y�� 'L'1 Signature: rt ��Y.v!i3u�iN � a' �Y Q Design Professionals Seal Imo:. 14.184 (2/87) —Tex1 12 PROJECT I.D. NUMBER 617.21 ;l Appendix C Stat,e'Envirdhmgrt•al 0061111y Review. SHORT .ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only • PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEQR - 1. APPLICANT /SPONSOR 2. PROJECT NAME. Mk&,LoP,,)1N i Cc oa1C �,¢,S P °✓v1 Ti- Ce�2f'. J. PROJECT LOCATION: Munlclpallty FIXT-tj ' �>I �t \%� County PU 1 1IJ v 1 4. PRECISE LOCATION (Sheol address road Intorsocllons, prominonl landmarks, alc., or provlda map) Moe S. IS PROPOSED ACTION: XNew Expanslon ❑ Modllication /ailoratIon 6. DESCRIBE PROJECT BRIEFLY: ���15'T vhl ©� StO�iCal- ri�t�lti� G' 7l DAN 1 S��iX- SqS -jT 7. AMOUNT OF LAND AFFECTED: Initially < 1� �- • acres Ultimately 'L -� acres 8, WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? NrYes 0 No It No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? lCtRosidenllal 0Industrial 0 Commorclal ❑ Agriculture ❑ Park/For031JOpon space 0 Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? I�Yes 0 No If Ilst yos, agency(s) and permlVapprovals PLAT -JAM CJ. 'TrJuvr�l �- • P�ITN•�NI VAclt� `-i— 8t.tt 1. -f.�► t:.1 C, . �f'�m t •� . 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMrr OR APPROVAL? ❑ Yes ,IZg No It yes, Ilst agency name and permIUapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes &No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AppiicanUsponsor name: 1104t1 _PrDFAA,VC), ?_ F41 1& F/PRPUCA-tjr Dale: 409 /Q.,7 Signature: i IN If the action Is In the Coastal Area, and you are a state agency, compiete'the Coastal Assessment Form before proceeding with this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 611.121 If yes, coordinate the review process and use the FULL EAR ❑ Yes ❑ No 0. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617,61 If No, a negalivo_declaratlon . may be superseded by another tnvoived.'agency.- ❑ Yes ❑ No ` C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Cl. Existing air quality, surface or groundwater quality or quantity, nolso lovels, exlsling traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaoologica1, historic, or other natural or cultural resources; or community or nolghborhood{ character? E- xpialn briefly: C9. Vegetation or fauna, fish, shellfish or wildlife species, significant habltats, or throalenod or endangered spocies? Explain briefly: Cd. 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 development, or related activities likely to bo Inducod.by the proposed actlonl Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-057 Explain briefly. C1. Other Impacts (Including changes In use of either quantity or typo of energy)? Explain briefly. D.. ISr- -?��i✓E?E --OR IS THERE tIK[t�Y l(i pE ;ir:ONTRCTVERSY RE6117E' O POTENfFAL At?VERSE, EN,WRONMENTAL"'W PACT ST- N o If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE.(fo be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, largo, 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 boon Identified and adequately addressed. ❑ Check this box If you have identified one or more potentially large or significant adverse Impacts which MAY occur. Than proceed directly to the FULL EAF and /or prepare a'poslt(vo 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: Name of Lea Agency Print or Type Name ol Response le Officer in L.ead Agency 71t le of Responsible 011icer Signature of Responsible OHicer in Lead Agency Signature of Pieparer(I i -rent from responsible officer) to 2 r PU TNAM C ®tTNT(Y DEPAR�T�!IENT ®F 'TIE �I,'TTI D�VJ[SI ®lit OF E1�TVI1� ®1VNdENTAL :EALTII SER ;�ICJ:SR T AFFIDAVIT CORPORATE OWNERAPPLICATION ,.. e , FOR PERMIT APPLICATION SUBMITTED TOPUTNAM'COUNTY'HEALTH DEPARTMENT, . Yj i r Ir'. To: Public Health Director In the matter of application for: ON&7 ;tCT[c i Pte ► i t 5 2 SSA , w��1 1. ;, represent that I am an officer or employee of the corporation and am authorized to act for:: Name of Corporation: �E (AP.� :r Having offices at: 530 w'�'' t3Co y ; Whose Officers Are: r. President -Name: Address: , ! i , Vice President - Name: Address: Secretary -Name: { Address: r Treasurer - Name: '� r S• Address: ` {, and that I am and will be individuallyresponsible:for;any and "all acts of the corporation with:respect U to the approval requested and all subsequent acts;relating thereto. . i 9f tla ` f;• ";Title-' P , l! Sworn to before me this i •day of ' /17 fl C q (month ) ' (year) C, G 1�Ot1� ublic JEA N p York,. NotaN Public �tat�5046eW' No. 03-464 nt$ Qualified in Broax Cou orporate Seal t. commission E*ic Q`i 9 Form CA -97 DIVISION , C N , ,/. 2e 1 A i HEALTH i i E LETTER OF AUTHORIZATION RE: Property of 13C-c0V_FA w1;, MyELVPM W4_rj� CorZP. Located at PF_F1P51,_11 W_ 46LLo&_%J 2oAD T/V ?c t- NAm s/PUEYrax Map # Block 1 Lot 7M3 Subdivision of F00-11 l Lk, E�s i wT!F_ vet i Subdivision Lot # 4 Filed Map # 2,411 -A Date Filed O 2-p 90 Gentlemen: This letter is to authorize JOtw P. D -r=,LAt-jo , P F' . 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 tretment and/or water supply systems in c f ity with the proyision�s o icle.14S.and(Qr.:1.47 of the Education Law, the;Publ c He�alih:- .. _ . utnam'Coun Countersigned- Mailing Address , i�A� t� ,� •C• -3m,6 rz7-_'1 . COU? .5 pe.t.tJC-a State Yag4L . Zip 10 Si �. Telephone: Very truly yours, !W (Owner of Property) Mailing Address: 330 W . 45+tA S t slew qozjz State 1J�e Zip I 00 c _ Telephone: 212 - 2C5-- E t Bcj Form LA -97 p� F..:- _ i. LETTER OF TRANSMITTAL BADEY_ & WATSON " Surveying an Engineering, P C 3063 Route 9 Cold Spring, NY 10516 (914) 265 -9217 739 -3577 628 -1800 FAX (914) 265 -4428 To: Adam Stiebeling Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 Copies Date . No. Description 1 03/09/99 1 1 1 03/18/99 1 03/09/99 1 01/22/88 3 03/09/99 1 of 1 1 03/09/99 1 03/18/99 . Signed: John P. Delano, P.E. Copy to: File Date: March 16,1999 File+Noc'�86- 192.04 Re: Proposed SSTS BROOKFALLS DEVELOPMENT Peekskill Hollow Road Foothill Estates West Subd. Lot #4 Putnam Valley TM 84.4-38 Sent By: ❑ US Mail ❑ UPS El UPS Overnight ❑ Fed Ex ❑ Messenger ❑ Pick -Up Construction Permit for Sewage Treatment System Letter of Authorization Application for Approval of Plans for a Wastewater Treatment System Affidavit - Corporate Owner Application Short Environmental Assessment Form Design Data Sheet SSTS Plan floor plans; Application to Construct a Water Well Money Order - $300.00 I v . BRUCE R. FOLEY LORETTA MOLINARI R.N. M .-S.N. Public Health Director �� �� Associate Public Health Director , W. ,, __r: r » . ,.. , .. Director ' oJ = Patierif ;Services DEPARTWIENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date; ! a To: -�At4 �Ea rte No. Pages (Including cover sheet) ]From: Adam B. Stiebeling Asst. Public Health Engineer flCase resliond' :;Asdi,s,cussed For our review Attached as requested ]Please call Notes/Messages —yo e t2 �C1� , � � - 1 3 "� a% Zi 7 Zl Of � P In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2157. 9• ° . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. .. L.,•7 „c-• -... ..rte.. ~... _ .. _ _as' ,r a I v'.• ... �... .. CONSTRUCTION PERMI E TREATMENT SYSTEM PERMIT # - 1.3-99 Located at ,1LSK tt�: Nal.l�u3 �/� Town or Village pUT1-1 M \/AU1= . Subdivision name fbDTWL , (\14 Subd. Lot # Tax Map $4 Block Lot 3 8 Date Subdivision Approved JWX-10 , 10( °10 Renewal Revision Owner /Applicant Name &WOV_FiAU.5 DF,,N � Date of Previous Approval Mailing Address 3-.30 \6[55T 4c i` SSTLg4a;, 0 p uJ -`c)P,—' . ty Zip (00 Amount of Fee Enclosed Building Type 1ZE (- DCt47Pti Lot Are No. of Bedrooms 4 DesigoFlow GPD WO Fill Section Only - 'Depth . Volume Separate Sewerage S ys tem to consist of 1 250 gallon septic tank and 400 LX - 2A 0 U W i1- Ae6o2PnotJ TP? Nc.4 SPAMP f �r 0.G. Other Requirements: Cc teMt3 D[zMI J . '-1 Fr D .-P To be constructed by MT Address Rky- -J 911yK Water Subply: Public Supply From Address a �ori jZ� Private Supply Drilled' by�tJpftiy�A i�l" , I iJG Address R,1TNfhM Vp I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed Address R.A. Date O 0 License # 6,2S0 �- APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewn a treatment ted and ins a PCHD and is revocable for cause or may a amended mo ified when considered necessary by the Pu is Health Director. y revision or alteration of the approve plan equires a new permit. Approved for discharge of domestic sanitary sewage only. By: Title: ti Date: Whit - HD Fil Yel p B it ing Inspector; Pink copy - Own r; Orange copy - Design Professional Form CP -97 A- fL. (E N T I Gv1 -T[ . � . - �tr°•cc:0� � $ � � $ 124 Allan Street Cortlandt Manor, NY 10567 AIRBORZE EXPRESS 6550740840 (914) 737 -2890 Fax -1915 June 7, 2001 DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road Brewster, NY 10509 Attn: Mr. Adam Stiebeling Re: PV 13 -99 expo date 7/21/2001, FOOTHILLS ESTATES, Sub -Div. Lot 4 Sec 84 Blk 1 Lot 38 , Filed Map 2477 -A date 6/20/90 Dear Hr. Stiebelinga With reference to the above subject application I hereby re- submit `\ plans for a 4 bed room house to conform the exisitng approval. Your review and approval is requested. The owner of the property , whose name appears (Cc:) below, wishes to commencement construction prior to the expiration of the Healt Department Approval. I have enclosed two full sets of plans and a partial copy of the SSDS approval provided to the owner at closing. Yours truly,,. z..,. JOHN,-A. LENTINI ARCHIT , �oCnA4 _ini , ( s. CG`) Mr. Jorge Pereira 155 Overlook Stre Mt. Vernon, NY 10 1 4 4 ,4 � PUTN AMC QtJIdTY' HOUSE PLANS APPROVED #0 f ioEDROOS OM CO UN 2 2 ONLYs ; y . .. .. .. : . SignatllX'�E & Title --- - - - -�� • .. •• •' -i.': •..}' • • ' . j.. OONSTRUOTION NOTE: A COPY OF 'THr= HOUSE P`LAN5 5Uf3M I TTE-V TO THE SU I I.. D (NG I NSFIE TOR j , INHEN I =ICING I=OR .3UIL.DING 1=?RMIT �, MUST E3E SU�3MITTED TO THE f�UTNM COUNTY HEALTH PEPARTMENT TO' VERIFY THE 5EDROOM COU NT. ' 56' -0' OWNER /APPLICANT TIRST FLOOR PLAN. 330 WEST`45 °H STREET NT CORP. SCALE: 1 /.4" = 1'-0 NEW YORK, NY 10036 i PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR LOCATION TEDR001S. OM COUNT ONLY; 0/6 '`� BADEY & WATSON, sure r PEEKSKILL HOLLOW ROAD noe"`�lOe ac FOO THILL ESTATES WEST - LOT 4 PUTNAM VALLEY TM 84. -1 -38 3081 Route 9 (914) 285 -9217 Cold Spring, Ne. York 10518 828 -1800 -7)ca,111 ® 739 -3577 FILE NO. 86- 192.04 (914) 265 -428 (Fax) (M 314 -1595 Signature & Title '-- -1, j?at0 587'08'477- 1RR 9.9' N_ - N_ I Q •Q S� eF �E Z 1� (311 W N W W W s O N C 11 8 G 7 _R °°° Z °�p> 5 O,P 3 C3� W_ 4' PVC I O GAL SEPTIC TANK N 4" GF � N V • v I Z O N N 0 N44 20'20 "W 9.40' Q) N W Q \ 0 o 0 1 �2'g9 V , NOTE 1. HOUSE LOCATION AND SURVEY INFORMATION IS AS SHOWN ON THAT CERTAIN MAP TITLED "SURVEY OF PROPERTY PRFPARFD FOR JORGE FERREIRA PEREIRA & VIRTUDE R. w, I 0 0 0 0 M c0 0 0' 00 .00 _ d X w 0 z v_ x a a w 0 co OD M I I .r N I <O ro 0 z J N Q z } m Q O U } m 0 W AS -BUILT RELOCATI ON- DIMENSION S 1A 42.6' . SEPTIC TANK 18 29.2' _ SEPTIC TANK 2A 50.0' SEPTIC TANK 2B 39.2' SEPTIC TANK 3A 89.2' DROP BOX 3B 87.0' DROP BOX 4A 95.0' DROP BOX 4B 92.7' DROP BOX 5A 101.0' DROP BOX 56 99.2' DROP BOX 6A 107.0' DROP BOX 6B 104.6' DROP BOX 7A 113.0' DROP BOX 7B 110.4' DROP BOX 8A 120.2' DROP BOX 8B 116.5' DROP BOX 9A 128.9' DROP BOX 9B 123.2' DROP BOX 10A 73.0' CURTAIN DRAIN 10B 74.5' CURTAIN DRAIN 11A 138.0' CURTAIN DRAIN 11B 143.0' CURTAIN DRAIN 12A 117.0' CURTAIN DRAIN 12B 94.3' CURTAIN DRAIN 13A 164.0' CURTAIN DRAIN 138 148.0' CURTAIN DRAIN 14A 116.7' END LATERAL 14B 99.3' END LATERAL 15x _U.6= END LATERAL 15B 105.2' END LATERAL 16A 129.8' END LATERAL 16B 112.7' END LATERAL 17A 135.8' END LATERAL 17B 120.0' END LATERAL 18A 141.0' END LATERAL 18B 125.8' END LATERAL 19A 147.0' END LATERAL 196 132.2' END LATERAL 20A 150.0' END LATERAL 20B 136.0' END LATERAL WC 64.3' WELL WD 81.5' WELL / �0/ F \V r O ' r f; � Y Y 587 08'47', t ��Z D O W Z • � W N C,•1 Z O N C Q c Q �T T Q v O Z W O 6 N C3� W t� Z V 1 O. Z �L lz