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HomeMy WebLinkAbout4379DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.-2-39' BOX 33 04379 F PU�+�TNAM COUNTY DEPARTMENT OF HEALTH v . 1 � p SrO OF -1:J1 \ ♦ .1LRO1 ,,M-EN-- TAL . �, Rm f:3!.R:JR 'P :Y, CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at/fA� uc -%ale" ' �' '� Town or Village /0,' Owner /Applicant Name/?eA�✓, �✓' 1, /a Tax Map Sy Block Lot Formerly Subdivision Name 4�A Subd..Lot # 4 Mailing Address 'Ve le /cs'klrA �u Ile VZip ,�t�5"r7 Date Construction Permit Issued by PCHD %Ja f Separate Sewerage System built by 2L,� 6'" y J L"-Sr �:= n Address 5 / J ✓��.f�� ./ Consisting of / ,2 -& Gallon Septic Tank and s® r Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by Address Building Type / Gri ' ' ' Has'erosioit control been cofpleted? Number of Bedrooms .4 Has garbage grinder been installed? ,10 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: / el , Certified by IF Address 40W hL Any persofl occupying premises2rved by o0 to secure the correction of an unsani Y treatment system shall become null and voi of the private water supply shall become n approvals are subject to modifi ti on or change P.E. 1/' R.A. License #-� '() hall promptly take such action as may be necessary i om such usage. Approval of the separate sewage c sanitary sewer becomes available and the approval en a public water supply becomes available. Such in the judgment of the Public Health Director, such revocati modifi atio r an s necessary. By: ° Title: Date: !� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Profes Tonal Form CC -97 L 4 PUTNAM COUNTY )(DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REPORT Well Location Street Address: Muller Mountain Road Town/Village: Putnam Valley Tax Grid # MapV" j Block 2 Lot(s)r:.�j Well Owner: Name: Brian Cook, Address: 14 Muller Mountain Rd, Putnam Valley, NY 10579 Use of Well: I- primary 2-secondary X Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing )[Details Total length 52 ft. Length below grade 51 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: Welded X Threaded Other Seal: X Cement grout _ Bentonite Other Drive shoe:. X Yes No Liner: Yes X No Screen ](Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air =Hours Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 540' Depth of completed well in feet 625' Well Log If more detailed information descriptions or e .. ....._ ... _ . sieve analyses are available, please attach. )(Depth Fro Yn Surface Water Bearing Well Diameter(in) ]Formation Description ft. ft. Land surface , -. hwiders 15. Hit roc at 15' 15 52 a Diiilin in roc] "set casing routed 52 625 in rock granite __Dri-l-linc If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5cfpm Depth 560! Model 5Gs10412 Voltage 230 HP 1 Tank Typ6 WX302 Vol u e 8b aal , Date Well Completed 10/27/00 Putnam County Certification No. 002 Date of Report 12/4/00 W iIle si re) lco,m al, J . NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sneevplan. Well Driller's Na P. F. 'eal & o - s, Inc. Address: 4 Rtna¢n Ave., Rnister, W 10509 Signature: Date: 12/4/00 lcolm T. Be , Jr. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 NR rwORTRE Z-LA, B-ORA7 39 MILL PLAIN ROAD - DANBURY, C' IA$$ (203) 748 -7903 - FAX (203) 748 -0652 . r.. SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: LABORATORY REPORT ZY..•QF.,DA 06811 . 11 DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED. @ LAB: TESTED BY: LAB ID-0 REPORT DATE: COOK, MUELLER MOUNTAN RD., PUTNAM VALLEY, N.Y. HOSE BIB WELL NONE 'RY . .;�T�eS'E:�`P13= 0iii3u�:d�;.a_. .,-s..a;•;- -p'� NY Cert: 11471 1/16/2001 2:30 P.M. ED SCHAEFFLER 1/16/2001 LAB #11471 PFB007 1/23/2001 REPORT TO: TEST PERFORMED P.F. BEAL & SONS METHOD # 4 PUTNAM AVENUE BACTERIAL: BREWSTER, N.Y. 10509 ��" :: , . r.. SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: LABORATORY REPORT ZY..•QF.,DA 06811 . 11 DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED. @ LAB: TESTED BY: LAB ID-0 REPORT DATE: COOK, MUELLER MOUNTAN RD., PUTNAM VALLEY, N.Y. HOSE BIB WELL NONE 'RY . .;�T�eS'E:�`P13= 0iii3u�:d�;.a_. .,-s..a;•;- -p'� NY Cert: 11471 1/16/2001 2:30 P.M. ED SCHAEFFLER 1/16/2001 LAB #11471 PFB007 1/23/2001 1.0 mg/L 10 mg/L No defined limits ...._ _.._ .- ,.I�7o 21�fii�ed lnx►it� ,�, ,. . ,.:�.,: � . o-.... 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50mg/L 20.0 mg/L ** 0.015 mg/L * ** ml= milliliter mg/I--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count "Notification Level ** *Action Level COMMENTS: ire -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OTABLE or FOT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 1 /16/2001 4.. Laboratory Director +; -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800-826-0105 OUTSIDE CT: 800 - 654 -1230 MAXDH M CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR STANDARD BACTERIAL: ��" :: , • Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml PHYSICALS: r'''=° °' " ` • Nitrate Nitrogen' • Color (Apparent) 0 - EPA 110.2 15 • . Odor ND - - 3 Units . • pH 7.23 - EPA 150.1 No designated limits • Turbidity 0.91 NTUs EPA 180.1 5 NTUs 1.0 mg/L 10 mg/L No defined limits ...._ _.._ .- ,.I�7o 21�fii�ed lnx►it� ,�, ,. . ,.:�.,: � . o-.... 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50mg/L 20.0 mg/L ** 0.015 mg/L * ** ml= milliliter mg/I--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count "Notification Level ** *Action Level COMMENTS: ire -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OTABLE or FOT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 1 /16/2001 4.. Laboratory Director +; -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800-826-0105 OUTSIDE CT: 800 - 654 -1230 ' CHEMISTRY: ��" :: , • Nitrite Nitrogen g <0.005 mg/L as N EPA 354.1 r'''=° °' " ` • Nitrate Nitrogen' <0.20 mg/L as N SM 4500D -`m/I .' • Hardness 46.0 mg/L EPA 130.2 - ' y ` " "" Y ,�r}:' • • Iron Manganese <0.03 0.033 mg/L mg/L EPA 236.1 EPA 243.1 �° "' • Sodium 3.8 mg/L EPA 273.1 `~'' t> .. • Lead 0.002 mg/L EPA 239.2 1.0 mg/L 10 mg/L No defined limits ...._ _.._ .- ,.I�7o 21�fii�ed lnx►it� ,�, ,. . ,.:�.,: � . o-.... 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50mg/L 20.0 mg/L ** 0.015 mg/L * ** ml= milliliter mg/I--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count "Notification Level ** *Action Level COMMENTS: ire -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OTABLE or FOT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 1 /16/2001 4.. Laboratory Director +; -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800-826-0105 OUTSIDE CT: 800 - 654 -1230 a BRUCE R. FOLEY 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 (914) 278-7921 Nursing Services (914)27,8-6558 WIC (914)278-6678 Fax (914) 278-6M Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fox(914)279-6648 14 b 1 1 it ijl Ij1 ®wl4ms NArym TAX MAP NUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OF (Signature) SN- L�4C 61 L�4. X'0 Ei c 'y- DACE: ........ _ _ . _ 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 VERFR1v0 ,C V TNAM_ Cto V N d".J[ DEPAR TMEN J OF HEALTH GUARANTEE OF SIMSUR FACE SE181AGt TREATMENT SYSTEM 6 er or Purchaser of Building Tax Map Block Building Constructed by Loca:zon - Street Building Type TownNillage Subdivision Name Subdivision Lot a - vs. I represent that 1 arts wholly and completely responsible for the location, workmanship, material, constructiGn and drainage of the sewage treatment system.. serving the above - described property, and that is has been constructed as sh6wn on the approved plan or, approved -amendmen.t thereto, and in accordance «vith the standards, ru.yes and regulations of the Putnam County Depanwnr of Health, and tteceby guarantee to the owner, his successors, halts of assigns, to place `tn good operating condition arty part of said system Constructed by me, which faits to operate for a period of two years inuriediately folim-ying the date of'approva.I of the "Certificate of Construction Compliance" for the titewyge reatment.system, pr any repairs made. by trte to such system, except where the failure to operate pr is ca��sed'ay't}ie wlllttcI or ziegl'Cgetit °aCt o1`the UGCUpant of`the build g u it Lir!g theM $Vstenl , I he undersigned further agrees to accept as conclusive the detannin6f) i 61' the pub) c PrAM Director of the Putnam County Npa3rtment of 14e8lIh as to whether or not ffic failure of the system to operate was caused by the willful or negligent act of the occupant of the building at 11VA11g the Dat n Day IZ Year 'of , .. _ 7)A. _ `�---- (Owner) - Sign.atilre Corporation Name (if corporation) r Address:�...(tU4;1�t�..5±�_. State ._ zip _2 SCE Signature: Corporation Nance (if corporation) State .— _ -.. -.Zip _.- ...__.� G,..,- (:,.?,T PUTNAM COUNTY DEPARTMENT GIF HEALTH N- ENTAL_HEA_ ILTH SERWCES PeN + S rc '� CONSTRUCTION PERMIT F® ATMIENT SYSTEM a PIERMIIT # r -3,/, F f Located at /K; if %%i ,% A/ Town or Village J i ryt in V Subdivision name r � �i ,� � 4Subd. 'Lot # -it, Tax Map o:� } Block 2. Lot Date Subdivision Approved Renewal Revision Owner /Applicant Namef, .,, e / /,-" Date of Previous Approval Mailing Address Amount of Fee Enclosed Zip /e. 7f Building Type i � = �, Lot Area Z ��; ' No. of Bedrooms Design Flow GPD Y s O Fill Section Onnlg Depth Volume PCH D NOTIFICATION IS RIE UIRE D WHEN FILL IS COMPLETED Separate Sewerage System to consist of ✓�. � r✓ gallon septic tank and de Other Requirements: To be constructed by Address ?� c: >�'✓, %�1- ,' %`�`� ' Sit bla';•.. _ -ublic'.Supply -From : Address or: _+� Private Supply Drilled by �%i7'�y & � n Addre "s 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: ;e i , / .!�'i�%P --� �r �� of N P.E. Address, y' .77 ?- f" � f "� -° i ter ?," ✓ �' i s �G� r M. APP]R ®V, IE FOR- CONSTIRUCTION This apVkal expires two years from t is��8e� u onstruction of the sewage treatment system has been completed and inspected by the PCHD and is rev o ay be amended or modified when considered necessary by the Public Health Director. Any revision or alt e s pproved plan requires a new pe 't. A roved isc a of domestic_ sanitary se age only. `g 0 Sri By. Title: t z ' Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Profe sion 1 Form CP -97 _ :_ • BRUCE R .. FOLEY_. __. T Public Wealth' Director' -, LORETTA MOUNARI R.N., M.S.N. _Associate_Public •ffealth Director - Director of Pdtterit Servicis�•• DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing services (845).278 - 6558 WIC (845)278-6678 Fax(845)278-6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 July 20, 2000 Frank Sullivan, P. E. 2972 Ferncrest Drive Yorktown Heights, NY 10598 Re: Schlageter, Mueller Mt.. Realty Subdivision TM #84 -2 -39 (T) Putnam Valley Dear Mr. Sullivan: This Office has conducted the inspection, of the above referenced project, as requested.. Site as constructed has not followed plans.as approved February 25, 2000, by this Office. Due to this, the area of proposed SSTS must be relocated. Relocation requires a revised plan approval. Co�ltact this Office to witness deep and perc test in "New" area. �ZD© ' •limit- plans-with new topography feilecting cui`rent.cpnditions on,site. - , - *, Survey topography to be certified by L. S. Submit "Revised" SSTS /site plan for review and approval, as outlined in Putnam County Health Department Bulletin ST -19, with $150.00 revision fee. Provide "sleeved" driveway crossing for effluent line. This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, aL 4--iw Adam B. Stiebeling Assistant Public Health Engineer ABS /jp cc: Schlageter, 7 Hidden Meadow Lane, Putnam Valley, NY 10579 PUTNAM COUNTY DEPARTMENT OF HEALTH -IDIVISION QF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address e 171 / / 1 r7l .t1W �� W 99e Located at (Street) /2;? AJ Tax Map ?,//-Block (indi ale nearest cross s1reet) Municipality G Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking e) Date of Percolation Test 0 a 5 -- .1. Tests to be reneated at same denth until annroximatelv eaual percolation rates are at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be subrr, itted for review. 2. Depth measurements to be made from top of hole. Form DD-97 Depth to Water'**:,., Water From Ground -Level U9 aj)$e Time urface (Inche, rop In. e Nn.... N S, Start stop es 2 3 4 5 L 2 3 4 5 77 2 3 4 5 -- .1. Tests to be reneated at same denth until annroximatelv eaual percolation rates are at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be subrr, itted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. G.L. 0.5' 1.01 1.51 2.01 2.5' .3.0' 3.5' 4.0' 4.5' 5.0' 5.51 6.01 65 7.0' 7.5' 8.01 8.51 9.01 9.51 10.0 HOLE NO. HOLE N0'. -7"- 2 Indicate level at which groundwater is encountered Indicate level at which mottling is observed e? Indicate level to which water level rises after bein; encountered Deep hole observations made by: "k -a Date ell 0 Design Professional Name: Address: C( 7 -2- C- Y- �S 167 Signature: Design Professional's Seal - asp w d PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION.QF ENWRONMENTAL HEALTH SERVICES `X \ �b CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PIE T # j V zx 9 Located at 1*10 &,11e� Town or Village �� •� / /cgs Subdivision name Subd. Lot # _ Tax Map 7'? Block _, Lot Date Subdivision Approved �f 9d Owner /Applicant Name . /fa � �I' .jCv/41a,4 ,f e,— Mailing Address V4.,, lyeCzA e 4 "l Amount of Fee Enclosed 361V Renewal Revision Date of Previous Approval f! Zip Building Type %�e , .ew Ce Lot Area 1, ' No. of Bedrooms �° Design Flow GPD ��'r a ]Fill Section. Only Depth Volume PCH D NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of % Z,�r✓ gallon septic tank and Other Requirements: r� Q.� � %.� i^� %� �� —10 i cy To be constructed by Address C„ --- -'""-� d -Water sumly .,j.,Pubtic Supply.From. Address off: Private Supply Drilled by�� lv ds� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and thai 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 : �� �--� P. E. � Date %/ � Address %7 r e e # ijwl, APPROVEW FOR CONSTRUCTION —This approfal expires issued unless construction of the sewage treatment system has been completed and inspected by the PC le for cause or may be amended or modified when considered necessary by the Public Health Director. Any r alteration of the approved plan requires a new it. Ap rov f di 14 of domestic sanitary sewag only. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Profession I Fonn CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION.TO CONSTRUCT A- WATER-WELL' ;�:; please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # Map 1Y Block J.,, Lot(s)-3 Well Owner: Name: Address: Use of Well: _ZResidenfial 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 O al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ;-New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type _drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ................. ............................... Yes Y' No / jam .............. Lot No. � Name of subdivision /%� � �� z �"��` Well Contractor: r� !�>r���cr.� Address: /, der'' t / . !r'�� Water /I✓' Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village --- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separateshheeet/plan. _ .. -.. :� -.licariYSignature:�� Date: pp % 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 Z- u3 I qq, Permit Issuing Official: &L. Date of Expiration 411i'101 Title: Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PIJTNAM COUNTY DEPARTMENT OF HEALTH DIWSION ®IF ENVIRONMENTAL HEALTH SERVICES � � - -. F .. w. a •� �4 � -.i c s+C G Ky� �,'tn a .q >...v- �:i�.' =- . �.'ir !...f,. . ° ,. �.. a .;�. - w .. .` - RE: Property of LETTER OF AUTHORIZATION a ���� Vic' '� l�a�e ��✓ Located at T/V Tax Map # Block 2, Lot 3 Subdivision of f%e--,/le4— ,�i- �Sd�As�.4 Subdivision Lot # Filed Map # Date Filed IW4 Gentlemen: This letter is to authorize W h � '�'/ l/ VG a a duly licensed Professional Engineer A' or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in :..w.:.:conformi_ty.with thc.provisions of Article 145 and/or 147 of the Education Law, the Public Health _,. .- Law, and the PutnamCounty. Sanitary Code. Countersigned: P.E., R.A., # Mailing Address m /j "111* State iZ p- % d �� Telephone: :,G .7_ 41 �S Very truly yours, Signed: (Owner of Property) P-, Mailing AddressZh�4_t.04_j 1-7411001d State N ` Zip Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH . J DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1 Name and address of applicant: a le- fc'�' V 2. Name of project: 3.F Location T4. _ I�AZve � G� 4. Design Professional: 5. Address: 6. . Jne of Project. J--Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty, Subidvision Other (specify) 7. Is&this project subject to State Environmental.Q.uality. Review (SEAR)? �' :Type Status ( check one) ..................................... ::................ Type I Exempt Type II Unlisted 8. Is a Draft Environmental Impact Statement.(DEIS) required? ......................... a .. . 9. Has DEIS been completed and found acceptable by Lead Agency? :,_.1.0 Name -of Lead- Agency 11. If this project is an area under the control of local-.planning, zoning, or other officials, ordinances? ............................................. ............................................ ,. 12. Ifso, have plans been submitted to such authorities? ........................ ... �/� 13'.* Has preliminary approval been granted by such authorities ?ye-J Date. granted: 14. Type .of Sewage Treatment System Discharge ................. surface water groundwater 1,51. 'If surface water discharge, what is the.stream class designation? .................... 16. `.Waters index number (surface) .............:............................ ............................... 1:7.. Is-project located near a. public water supply system? .... 18. If yes, name of water. supply Distance to water supply , I_eo 1;9. Is project site near a public sewage collection or treatment system? ................� 20. Name of sewage system Distance to sewage system // /" 21'.. Date test holes observed /� 6rG 22. Name of Health Inspector Form PC -97 23 Project des flaw (gallons per day) ...........:. ........... ...'........................... 24: Is State Pollutant Discharge Elimination System (SpDEg) Perm' ermit required ?:.: 25. Has SPDES Application been submitted to local-DEC off ice? 26. Is,any portion of this project located within a designated Town or State wetland? Ald 27 "Vrytlands ID Number...................................... �. 28.'.-- Is "Wetlands Permit required? A�D application 1'ias been made to Tow n office? of Local "DEC. oce? ............................... ----- 29 Does project require a DEC ' Stream Disturbance. Permit? .. ............................... Al: / 30: ° Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, ` landf lling, sludge application or industrial activity? ............................ Yes/No 31 Is- project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any _. other potential known source of contamination? ... ............................... Yes/No - DESCRIBE: 32:. Is.,there a local master plan on file with the Town or Tillage? ......................... /1/'® 33; Are community water and/or, sewer facilities planned to be developed within :.. `15 years in or adjacent to project site ? ................:.: ......................................... 34. Are any sewage. treatment' areas in;excess of15 /o.slope? .....�� .........:..../ - - -- -� 15.' 'Tax Map ID Number .... ............................... ....................... Mapes dock g- Lot's .. 3.6. ` Approved plans are to be returned to ..... Applicant ��i 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. Il hereby affirm, under penalty of perjury, that information provided on this form is true t® the best of wry knowledge and belief. False statements wade herein are punishable as a .Mass A misdemeanor pursuant to Section 210.45 of the penal Law. SIUMIURESA OF'F'ICdAL,.TITLESo Rdailini Address: .................................... 1d -14 (4187)- Text 12 [PROJECT I.D. NUMBER 817.21 SEGR • k Appendix C State Environmental Quality Review a , SHORT -ENVIRONMEKTAL.ASSESSMEN.T: FQAV:,. For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICA T ISPON� ,R 1. PROJECT NAME. 3. PROJECT LOCATION: Municipality /i✓ County , d. PRECISE LOCATION (Street address and road inters lone, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: New ❑ Expansion (] Modilicatlonfalteratlon 8. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: % Initially acres Ultimately acres 8. WILL PROOOSElf ACTION COMPLY WITH EXISTING ZONING Oh OTHER EXISTING LAND USE RESTRICTIONS? ' zes ❑ No If No, describe briefly 8. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? esldential C3 Industrial ❑ Commercial ❑ Agriculture C3 ParklForesUOpen space C3 Other Deacrlbe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Yes ❑ No It yea, list agency(e) and pem iVapprovals > �C�� ✓ � � � � ° ` //� 11. DOES ANY ASPECT OF THE ACTION HAVE .A CURRENTLY VALID PERMIT OR APPROVAL? > ❑ No It Ilat agency nertte and ���� �/�fGl `r �� ��% S �G' ✓% ,Yea yes, permlUepproval 12. AS A RESULT OF ROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ApplicanU Date: sponsor ,name: / _ 1 � ' Signature: f If the action is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 BART 11— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) i A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. _ ._,. . ❑.Yes:- _ Clslo: _ B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: e 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 Muse or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced -by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. 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 Identified above, determine whether It Is substantial, large, Important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (P) 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 EA►F 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: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Title of Responsible Off icer Signature of Preparer (if different from responsible officer) I ate A .. r. -4j+. •I PUTNAM COUNTY. DEPARTMENT OF HEALTH N ME­ .0 NIAL_ H SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner /I' Address .0 ze 'Tax 'Lot Located at (street)' (I daic te nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking �:&al Date of Percolation Test A .......... ........ . ... .... ... -W De th t ter p Water "T rom: roun i;`i` Hole R to Trine S t s ADrI': Inches .... .:.:::.:............:.:: ;.:::::..:::F..:.:......:..:::. 0 1 11C Kf2 12, A?, 3 zz, 4 2 f. 3 14 Ax lie) > 4 5- 2 3 NOTES:. :' 1 :! Tefts1to'be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. P.eoffi measurements to be made from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION GE SOILS ENC ®UNTEREID IN TEST HOLES 2 -gym V*c' . V -. �... D)✓PTH� � e. E ..._... ._ ^ �., a A. ; a, .�QY_ 9 � •.p,�... �•T: :� HOLE IV0. HOLE NO. ^t �4r '` r _...� ' � .. �a , HOLE N0. 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' ;4q Indicate level at which groundwater is encountered .w e7 e Indicate level at which mottling is observed ,�d/� e Indicate level to which water level rises after being encountered �- Deep hole observations made by: rj���'v'a NI Date Design Professional Name: j±'Z ,5 C/ / I Address: Signature: Design Professional's Seal C'4 `;', � I - nwPv - - - - - - - - - - 4V, CA - UO P: 717, 7 if iv Y,.. . . . . . . . . . . . . . . . 7. the evatom 77 . . . . ......... 40 rticl aL6 I.UWJLyj Leyfil L1Ltl11L V1 api, 171i3lon of Env h ��qkmentali A noted xor., conr ' moo With 1DP able bid. a done is Co j Z, :aa,t^• �. n-ro mil. . %a �� NG -.,..( .i` .. ✓:.i -'r: .L r—. ^� .��: .r+- tc 7sr�_'�. '�..�'.. ot�•' - -. +.A., c::�A 3i.. 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