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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -40.1 BOX 33 1 ro I a li r r i i,yti 1 �� r + T �'6�} ; L r 04381 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location. Street Address:, q, &L Lh To Lj G rid Mapglt- Block"?', Lot(s) Well Owner: N�aipe: . Address: U, Use of Well: 1- primary 2-secondary Residential 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 >e' Open hole in bedrock Other Casing Details Total length ee; c ft. Length below grade 1� "� . A - Diameter 1 _,-_Fin. Weight per foot j� lb/ft. Materials: Steel Plastic Other Joints: Welded >< Threaded Other Seal: Z_ Cement grout Bentonite Other Drive shoe: _>e, Yes No ILiner: 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 Compressed Air Hours7 Yield 6 gpm Depth Data Measure from land surface-static (specify ft) -3o During yield test(ft) Depth of completed well in feet f e, 60 Well Log If more detailed information descriptions or sieve analyses are available,. please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface F M� U ) 2: If yield was tested at different depths during drilling, list: F Gallons P Per Minute Pump/Storage Tank Information Pump Type. Ca p atcl I 0 4 Depth 5V IV. del Voltage HP / Tank Type X Volume . Date Well Completed Z&4 i >�/pS .1 Putnam County Certification No. q ate of Report I 1/0 Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent 1a,fidm6yks to be provided on a separate sheet/plan. Well Drille Signature Address: Date: White copy: HD File; Yellow copy -Building Inspector; Pinkcopy - Owner; Orange copy- Well driller Form WC-97 .%Z Public Health Director r. ,,;,LQRETTA.. MOLINARI :.R.N..D &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)278-6558 WIC (914)278-6678 Fax (914) 278-6085 Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fax(914)278-6648 OWNERS NAME: V, S Co n' 9-T R U C- r t o C 61:z TAX NIA? NUMBER: S i c', R+ ELK-.2- L a 410, E911 ADDRESS: 15 -� LM y 0 (-i U e TOWN: flu T N VA_ L L 6 AUTHORIZED TOWN OFFICIAL: (Signature) DATE: Wail. 1 �N V LAV\ 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 4 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRIvi) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1�' ..1' ... _ .,„Y� `.�.... .., .-:.4' . -..,. ..s : .. ... ...i y.� _..... `, r::• .:J ." 'n . :� .�.. ..... ».'.'�. .. :_:.- s..,].'o-: ".,e .w .w `: »iti'•�,� � -:i GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM V. S. CeN S -rf2v T1 a h) CORD, Owner or Purchaser of Building VS• C C_ rJ s-r,2vc:-no,t-� Cc1zP. Building Constructed by I C OF_ 1, L116o D`ZIV6 M ► L L T— Location - Street SIaGLL-r Building Type Tax Map Block Lot ?QTi-JAP-,' TownNillaQe Say T K 'F fZK ES'TATC S Subdivision Name • l Subdivision Lot r I represent that I am wholly and completely responsible.for the location, workmanship, material. construction and drainage of the sewage treatment system sen-ing 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 revelations of the Putnam Counc-y Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition anv part of said system constructed by me which fails to operate for a period of two vear5 immediately follo«ving the date of approval of the `Certificate of Construction Compliance'' for the sewage treatment system; or any repairs made by me to such system. except where the failure to operate properly is caused by the ,villful or negligent act of thz,occupant.of the.buildin2 utilizing .th.e_....___.. .� .system. -.. -. -' • =- • .- •- r....... .. _- - r- _ r . ...._. The undersigned further agrees to accept as conclusive the determinatio Director of the Putnam County Department of Health as to whether or n t to operate �(�a) caused by- the willful or neQliQent act of the occupaj o th :'Moi}t _ , Day Year GeARk, ntraNtor (Owner) - Signature V, S . Co J.I ST'R u cT 10 PJ 0120- Corporation Name (if corporation) Address:37 CR( , dN Dnn, 20 A D State OSS I N I Zip 105-62 Sic-nature: Title: of Public Health e f rlu e of the s,, stem bulUding utilizing the III, 1k N Corporation Name (if corporation) Address: S? CROToN D19 n %ROAD State OSSW U-J6 tiv Zip lb E6'2 Form GS -97 YML. ENV I RON1 ,13ENTAL SERVICES 321 fr::ear• Street: Yorktown Heights,, N.Y. 10,391 -3 141 : 2`411 r,280 Q;m: -mac' Albert H. 1='adovani, Director LAB #. 1.508194 CL.. I ENT # .- 2173 NON STAT PROC PAGE 1 NNNNNNNN• VN aV NrVNNNNNNNNNNNN•V— NNNNNIV/VNNN NN NNNAINNIVNNaVNrvNNNNNMINNNN NNNN /V IVNNNaVNNneNNNN NORMAN ANDER SON' .INC. 152 BAC- GER ST" PUTNAM VALLEYa NY 10579 BATE /TIME. TAKE• N v 12/02/05 12:45 DATE:' /TIME: REC ' D e :12/02/03 01.25 REPORT DATE -. 12/13/05 PHONE: : (9:14)-528-1A91 SAI °IF'L I idG SITE: MILL. STREET SAMPLE 'C`!3= E:.. a F OT.AL RIGHT PRESERVAT IVES ° NONE COL' D . BY: SARAH ANDERSO1\1 TEMPERATURE:. „ - < 4C NOTES... e TANK: COLA FORM FORM METH -• MF" Nn /NNN /VN•VNry NNIVIVrvNrVN nINNrVNry NrV a- NNrv— IVNNN --1 NrVNIVNMIY IV•V ru eV--rvry aV lVnl rV /V•V N N rV N N:11 ry IV rV rv—nl rvrll nl aV n /ne DATE FLAG PROCEDURE RESULT PUT•NAM CNTY PROFILE 12/02/.05 MF T. COLIFORM PRESNT /100 ML 12/06/05 LEAD (I MS) <1 ppb 12/05/05 NITRATE N I TROG ':0.2 MG /L. 12/02/05 NITRITE N I TROG 0.01 MG /L 12/07/05 IRON (Fe) •:0.06() MU" /L 12/09/05 MANGANESE (Mn •'0.010 MG /L.. 12/09/05 SODIUM (Na) 9.15 MG /1_ 12/02/05 pH 7.5 UN I TS 12/0'7/05 HARDNESS, TOTAL 06.0 MG /L. .12/06/05 ALKALINITY (AS 96.0 MG /L. 12/05/05 TURBIDITY ("CUR <1 NTU 12/02/05 E. COL I ( CONE I ABSENT 100 /PiL.. NORMAL. •- RANGE ABSENT" 0 -•'15 ppb 0 - 10 N/A 0 -0.3 mg /I 0 -0.3 mg / I N/A 6.5-8.5 N/A IV /A 0••-5 NTU METHOD 1008 900:3 9052 9162 9002 '•x002 9002 9043 9001 . - .,..._... , G -._ - .—.- ABSENT COMMENTS DACT THESE RESULT'S . INDICATE THAT THE-- -WATE-R --( WAS) g sWAS= OF A SATISFACTORY SANITARY QUALITY AC I NG TO .T )RK: STATE AND EPA FEDERAL-DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE T:I:1 °IE OF COLLECTION. Pb /Cu LEAD limits for p EPA Lead & Capper than 10% of their than 15 ppb and a treatment must be potential. _tblic schools are set at 15 ppb. Rule for Public Systems require -s that no more distribution points have a LEAD value of more COPPER value of 1.3 mg /L, else water undertaken to reduce the waters corrosive Fe /Mn If both iron and manganese are present, their tota). value combined shall riot exceed 0.5 mg /L.. Na`': No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted di.et,the water should ,y . YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800� _' AIb,�rt'HL, Pad ovani�,-lDzre�= tbr'-`' LAB #: 1.508194 CLIENT Ng 2173 NON STAT PROC PAGE.- 2 NORMAN ANDERSON INC. DATE/TIME TAKEN: 12/02/05 12:45 152 BARGERST DATE/TIME REC'D: 12/02/05 01:25 PUTNAM VALLEY, NY 10579 REPORT DATE: 12/13/05 PHONE: (914)-528-1491 .^�� SAMPLING SITE: MILL STREET//^~������� ��L�� SAMPLE TYPE..: POTABLE : RIGHT PRESERVATIVES: NONE COL'D BY: SARAH ANDERSON TEMPERATURE..: < 4C NOTES...: TANK / COLIFORM METH: MF DATE FLAG RESULT NORMAL - RANGE METHOD 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. PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO META PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM ' CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE. IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L-, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN- SUBJECTED. '2»�'MG ��-~'-^~�^�~�-��VERY-HARD 'WTEF�4-ABOVE- 3l ME[A[--~---^~'`-'-- MODERATELY HARD WATER: 70-140 MG/L. MG/L. = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L - (1 grain/gallon = 17.2 MG/L) ;UBMITTED BY-. Albert H. pl'Adovani, M.T.(ASCP) Director ELAFI# 10323 ' YML ENVIRONMENTAL SERVICES 321 Kear Street - 'Ediqhoe p (914) 245-2800 Albert H. Padovani, Director | LAB #: 1.508574 CLIENT #: 2173 NON STAT PROC PAGE NORMAN ANDERSON INC. DATE/TIME TAKEN: 12/21/05 01:15 152 BARGER ST DATE/TIME REC'D: 12/21/05 02:25 PUTNAM VALLEY, NY 10579 REPORT DATE: 12/28/05 PHONE: (914)-528-1491 SAMPLING SITE: MILL STREET/ / ~ SAMPLE TYPE,.: POTABLE dL PRESERVATIVES: NONE ^ COL/D BY: SARAH ANDERSON «' TEMPERATURE.,: < 4C NOTES...: TANK-RIGHT SIDE COLIFORM METH: MF ~~.,~...~...............................��..w~.~...~~~~~~~~~~~~~~'`~~~~*~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 12/21/05'- MF T. COLIFORM ABSENT /100 ML ABSENT 1()O8 ' COMMENTS: . BACT THESE RESULTS INDICATE THAT THE WATER (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING-l7TTHE NEW YORK STATE AND EPA ADERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. � SUBMITTED BY: Director ELAP# 10323 RONIN ENGINEERING, P.E. , P.C. The Lindy Building, Suite 200, 2 John Walsh Blvd., Peekskill, New York 10566 'MI. (Z11,t) 736 aulit 0 Fax. (914) 736 -3693 ;L I . ' r I . 1. _- - .. I- .. .. _r .. :1. '1; 1. )L January 11, 2006 Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam. County Department of Health Division of Environmental Services I Geneva Road. Brewster, N.Y. 10509 Re: SSTS Construction Compliance V.S. Construction Corp. P. C.D.H Permit #PV-10-05 15 Bel Lago Drive Town. of Putnam Valley Dear Mr. Paravati Please nd - e ridos adIhe 76i ginal Well c6ip l6fibi� impOtand-witer atialyg for the dbov referenced project. The report has been completed to show the required PCDH profiles. Please review at your earliest convenience. If there are any questions or if additional information is required please do not hesitate contacting me at the above number. Thank you for your assistance in this matter. Respectfully submitted, Kenneth "'tl enneth M. Murphy Design Engineer LETTER OF TRANSMITTAL �..: C] ONIN ENGINEERING P.E., P.C. The Lindy Building; Suite 200 2 John Walsh Boulevard Peekskill, NY 10566 914- 736 -3664 Fax 914- 736 -3693 Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Department of Health I Geneva Road Brewster, N.Y. 10509 RE: V.S. CONSTRUCTION CORP. PC1DH PERtMI[ #PV -10-05 15 NEIL LAGO DRIVE (FORMERLY MILL ST.) TOWN OF PUTNAM VALLEY THESE ARE TRANSMITTED as checked below: December 28, 2005 ❑ FOR APPROVAL ❑ FOR YOUR USE ❑ AS REQUESTED ❑ FOR REVIEW AND COMMENT X PLEASE REPLY ARE SENDING YOU attached. ><.) Three copies of as -built subsurface sewage treatment system plan 2.) Three certificate of the construction compliance. 3.) Three guaranties of SSTS 4.) Copy of survey showing foundation location 5.) E911 address verification form 6.) $300 certified check for application fee. The information enclosed is for your review only. The well completion report and water analysis will be submitted when it is Obtained from the well driller (P.F. Deal & Sons). Thank you for your time and assistance in this matte. Respectfully submitted, e,.� 'PuA--r4. enneth M. Murphy Design Engineer 11/21/2005 CRONIN ENGINEERING 1 PAGE 01 4 'I; EA,LTH DIVISION OF ENVER.01NNIENTAL HEA Lr SERVIC ES - ATTENTION U AA W—W ❑ GENE MQL EST FOR EINAL MEECT10- For- All inf6rmatioo roust be ' fully completed prior to any inspections being made PCHD Construction Per-6t',epv-1 ;-, Located: 15"J%tL. LAGOI.Mve, Owner /Applicant Name. 0 tJ 7 TNT Formerly: Subdivision Name, 'Subdi-Osion Loc 11 system fill cunipleted'? Dare: Is system complete-, Date: Is system constn'lc,trd as per plans? Is well d60ed.' Date: s I _ - V Is well located h pz-r ? .-Ve ero5lO)a �11XY 11C,4 10 P16ce'.) VC. "r I zaAlqN 10 I_Ccy Block ;Lot ..4d I 00 '4V I certifii that as Listed, at the above premises has beta Co azd, I bavl- I.-.5pecte-4- and verified ch,:ir in accordance %vitaj me issued PC,-ED Consizric-clon Permit and approve' 1:1 ds. R -.j I e s a r J Re u 1,111 e.rii of tie P -,i al-n Co Dad rn n L Dare: Certified by C RWYJ 6A6 PE i Desire Profess orJ1 Address: comments. Form )-20-2005 It' 741 rFL:845-278-7921 NAME' PI COUNTY DEPARTMENT QE P. I lV 7l�i �1.n wT D A -D 1V11 Ce1� ll ®i imn���XV C`IYNS ll RUC Y IO V IEYOlYILY Jl iL' ` R V Y A9 MA JL 1Y1 E V T S Y S iL EN # � - ( - Located at M 1 LL STRi C d Town or Village to r" n VQ z���� Subdivision name SaU;1dFdRI,1 ES i , Subd. Lot # I Tax Map Block 2 Lot 4-0. 1 Date Subdivision Approved Renewal Revision Owner /Applicant Name VS CON S'T(Z U GTI 0l1j Date of Previous Approval Mailing Address 39 CRb'iOaU DAM Ro A D 0 5 S i N I N C r4 E 1/11 ��K Zip _10 56-29 Amount of Fee Enclosed -$4 8 , Building Type StiJGi6 r;Ml t -/Lot Area 26•S� No. of Bedrooms Design Flow GPD 1000 AC., Fill Section Only Depth Volume PCHID NOTIFICATION IS REQUIRED WHEN (FILL IS COMPLETED Separate Sewerage System to consist of I gallon septic tank and 500 L. �r6t) PVC, Zq-11 612AVCL !�I EnSC Other. Requirements: ��Y To be constructed by VS Co i► S -re U c-n OBI Address 39 CRa—iooQ DW m g O. d 'SSi 1,J l t-,) G6 A1>% Wateu• Sum_ Public Supply From Address or• i?rly tee. Supply DrillW_- by:,Q; ;;: A C:.. t.., �? -_ Address -` u TNi ��Zi✓ lnl STE12 , 1�v 10 •� U°I 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 reg _ the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction k 9V ctory to the Public Health Director will be submitted to the Department, and a written guarantee , dk sli8 o er, his successors, heirs or assigns by the builder, that said builder will place in good ating ' n ' ' n an a_ rt of id, wage treatment system during the period of two (2) years immediately follow i e e ofs ce prova of a Certificate of Construction Compliance of the original system or any re irs th eto. Xti ' Signed: z i r 29 2 0 . Date Address 2 -S-OHM KAe- Sk 8& ihii:S ` L L 110 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 w n nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pp r ve r disch a of domestic sanitary sewage prily�. By: Title: Date: 41V16 � White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 / PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL -please printertype— .. �: - , r•. - PCHD-Permit #. Well Location: Street Address: Town/Village Tax Grid # M I LL ST(ZL- CT fU ,1i,.)A M U(3 L L(. '\ Map 84- Block 2 Lot(s) Ifo , Well Owner: Name: Address: Sr) c 0-T-0 DI-1 ►'h V5 caNS -f2t)cT 0S511%3!^56' I-sy los-c'z Use of Well: —I Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 5' Est. of Daily Usage I goo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason NG bud W WrCfL SQCLC ' o i L` R o Po Sc D 9ES 1 O F-4-3 C 6 for Drilling Well Type . Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Jt--_ Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision S00::LJ 0 Z K ES 1 q TC S Lot No. I Water Well Contractor: f -F, 134Er1 L 5 SO,A S Address: 1411 �f2E.VJ -rT Is Public Water Supply available to site? ..... Yes No ............................. ............................... Name of Public Water Supply: !J I iq Town/Village N % Distance to property from nearest water main: ti 04 Proposed well location & sources of contamination to be prov' n separate sheet/plan. i Date: - ZO - OL? 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 el driller ified by Putnam County. » Date of Issue f �j ` Permit Iss 'n g Official: Date of Expiration Title: m�� Permit is Non- Transfe le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 - I PUTNAM (COUNTY DEPARTMENT 1l OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES a ,, r, ..'.Y ,�.. , � ,> -• -, a ... .`.. -..,, � ... ,, � .... .� � wvza7� .��,7 �xr �.ti, :v�..C!'. y.. -..w- � e - � �._ .., .. ,, .. �� .- .- ., LETTER OF AUTHORIZATION RE: Property of V. S. C oN S rg u c--r I o N C o1R P Located at M I L L &fQ (E C PvrN�lwt _ T/V i%(� �.L� "�/ Tax Map # Block 2 Lot � 0 . S Subdivision of 6 z -rq .-rc s Subdivision Lot 4, ( Filed Map T --r0D Date Filed Gentlemen: This letter is to authorize "Itrvio-r-MV L. C Qo/, J I N a duly licensed Professional Engineer _� o t to apple for the required wastewater treatment and/or water supply permit(s) to serve the above -noted propene in accordance with the standards; rules or revelations as promulgated by the Public Health Director of the Putnam County• Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and /or water supply systems inconformity «' e - oY `� e. le .45 a.nd/or- 147:ofth E ducat ion,La«..the.Pub.lic:Hzal.th�,� utnaP . a r1i f� Very tru 4,fPrke, �v LU Countersigned: Signed: P.E., i., rr �2C1 62980 ) "KO sE o� Mailing Address S -:5_0 f 13CUO Mailing Address: \I S COPS S-r1ZQ e.-t e t" � ,"FW6 LIrvDy 'aLn 6, Sui rC fop 3r) CRO i oN .t PN 12boJO State`fi 6KSVtLLf Ny'Zip lcL,�6C State 05 S i/'�,1(4 6, P3 Y Zip 10 5 6 2 Telephone: (q s '+) -726-26(4( Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH _ DIVISION :OFXNVIRONM AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERNIIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTiVIENT To: Public Health Director In the matter of application for: Cow sTfLu c Ti ytr SS -r E it WA TcYZ- Supp y I, VA L To C C , represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: VS CORP, Having offices at: S9 CfZy--ja >J O iqrll IZO, O S s 1 N i t`S C tQ V I o S6 2 Whose Officers Are: President.- Name: Vii L Address: (,_&A Mi✓ )qS 0190 /C Vice President -Name: SAME t4SiZ�s Address: neow Secretary -Name: C K C:. L (.L S Y3 1' u c c l Address: r - �SiA e nVoiJE�� Treasurer - Name: SOME 0 S SE C R E -r jog: �4 Address: C SiI MC A-C A196ilC and that I am and will be individually responsible for any a 1 a of the corporation with respect to the approval requested and all subsequent acts relatin - o. Sworn to befo e thi I _k_ day of ��2 t !✓ 2c o _5 wear NotarvNY L CRONiN blic, State of New York No. 4923313 Queffflwl in Westchester County Commission Expires March 14. 2,00 6 Form CA -97 Signed: Title:, . NONE: TL . c- .. -.c..d • .- . .�/-.�7.� NI-� -� p-.�o..E- RgNG ...�+ Try The Lindy Building; Suite 200 2 John Walsh Boulevard Peekskill, NY 10566 914- 736 -3664 Fix 914- 736 -3693 Joseph S. Paravati, Jr. Assistant Public Health Engineer Putnam County Department of Health I Geneva Road Brewster, N.Y. RE: WELL & SSTS CONSTRUCTION APPLICATIONS V.S. CONSTRUCTION CORP. TAX MAP L D. #84- 240.1 MILL STREET, LOT #1 TOWN OF PUTNAM VALLEY THESE ARE TRANSBUTTEHD as checked below: JUDY 11, 2005^ ❑ FOR APPROVAL ❑ FOR YOUR USE ❑ AS REQUESTED ❑ FOR REVIEW AND COMMENT X PLEASE REPLY WE ARE SENDING YOU attached 1.) Three copies of subsurface sewage treatment system plan Vie) Foqr SSTS construction permit applicatfi '3:)' Letter "6f aaathoriiatio -n 4.) Application for approval of plans 5.) Soil data sheet 6.) Short environmental assessment form 7.) .2 sets of house plans S.) $400 for application fee 9.) Application to construct a water well 10.) Corporate Resolution Please review at your earliest convenience. Thank you for your assistance nn, this matter. Res" nectfullly submitted, enaneth M. Murphy Design Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHREW FOR COPJST.RUCTIQN PERMIT., _ - ...... _ .... ..._ .. .r�•..r ... ...nX -,r. „f- .•.�, .. .y'�•�.•.+.: `.- •:"+v:: ;',.�.•�... yra••: -,p .�.:.:w•�:•,. .: y.'ai.m '-` . .. :�..A . NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: TAX MAP #: (CONFIRMED) Y N DOCUMENTS Y ( REOUIRED DETAILS ON PLANS CONT'D) UUPERMIT APPLICATION OUSE SEWER -'/<" FT. 4 "0'; TYPE PIPE CAST IRON L— J"WELL PERMIT OR PWS LETTER C__)NO BENDS; MAX BENDS 450 W /CLEANOUT UUUPC -97 � RENEWALS (�(�LETTER OF AUTHORIZATION l_!__ LSITE NOTE (NO CHANGE) C__)L_)DESIGN DATA SHEET (DDS) FILL SYSTEMS UUCORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (__)(__)SHORT RAF FILL SPECS/ FILL NOTES 1 -5 L_) _)PLANS -THREE SETS FILL PROFILE & DIMENSIONS UUHOUSE PLANS - TWO SETS C�FILL IN EXPANSION AREA C__)C_,VARIANCE REQUEST ,FAT GREATER THAN2 FEET SUBDIVISION CLAY BARRIER ( )(LEGAL SUBDIVISION � FILL CERTIFICATION NOTE U)USUBDIVISION APPROVAL CHECKED e IV DEPTH GAUGES UUPERC RATE VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS � CC_)FiLL REQUIRED DEPTH C )SEPARATION DISTANCE FROM TOE OF SLOPE C_)L _)CURTAIN DRAIN REQUIRED TRENC GENERAL LF TRENCH PROVIDED 60FT MAX. C� LOCATED IN NYC WATERSHED U )PARALLEL TO CONTOURS �) PLANS SUBMITTED TO DEP (__/)100% EXPANSION PROVIDED DELEGATED TO PCHD DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL (� DEP APPROVAL, IF REQ'D GEOTEXTILE COVER (_) ! DEEP TEST HOLES OBSERVED / " SFpATtpTTON DISTANCES ON PLAN - FROM SSTS C� PERC5 TO BE WITNESSED 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL CU J EX- APPROVAL SSDS ADJ, LOTS 1501 20' TO FOUNDATION WALLS (_) WETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 200' IN DLOD,150' TO PITS (__)DATA ON DDS PLANS & PERMIT SAME 100' TO STREAM, WATERCOURSE, LAKE (inc. eepan) (� P 'E 1969 NEIGHBOR NOTIFICATION TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER ETTER BUZBA 10' TO WATER LINE (pits - 20') -100 YR.- -FLOOD ELEVATION W/I 200' U - _ X50' INTERMITTENT., DRAINAGE COURSE,_ SOIL TESTING LOTS >10 YEARS OLD 200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS d O S 10' MIN TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK SSDS HYDRAULIC PROFILE 0(_)101 FROM FOUNDATION; 50' TO WELL (GRAVITY FLOW WELL C__)(___)CONSTRUCTION NOTES 1 -15 ( DIMENSIONS TO PROPERTY LINES C�DESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNECTION 2' CONTOURS EXISTING & PROPOSED (MIN 15' TO PROPERTY LINE (DRIVEWAY & SLOPES, CUT ( SLOPE FOOTING /GUTTER/CURTAIN DRAINS SLOPE IN SSTS AREA (520 %) _)U(SDA SOIL TYPE BOUNDARIES REGRADED TO 15 %, IF REQUIRED �) TITLE BLOCK; OWNERS NAME ADDRESS UU �T1VI #, PE/RA; NAME, ADDRESS, PHONE# DOSE/PUMP SYSTEMS DATE OF DRAWING/REVISION . U PUMP NOTES DATUM REFERENCE U DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (LOCATION OF WATERCOURSES, PONDS ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC:) LAKES,WETLANDS WITHIN 200' OF P.L. _PIT AND D -BOX SHOWN &DETAILED CZ(— PROPOSED FINISH FLOOR AND UUl DAY STORAGE ABOVE ALARM CURTAIN DRAIN BASEMENT ELEVATIONS ��pIPES; 5' BOTH SIDES, DETAIL k WELLS & SSDS'S W/IN 200' OF SSTS t to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % - <1% PROPERTY METES &BOUNDS U 20' MIN to CD DISCHARGE /100' with 182 cons day discharge . EROSION CONTROL FOR HOUSE, WELL & U(___)10' MIN to NON - PERFORATED PIPE SSTS, EROSION CONTROL _NOTE ' . COMMENTS: (REVSHEET)09 /01 /00 �• Will � ma 1. 11 ill CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHIlD CONSTRUCTION PERMIT # _VV -10 -- 0 S Located at 19' J& L L g 6 b Da do Town or Village PO -,JAM V14LLEV Owner /Applicant Name �Vi S. Car1_C t V y c.'`l 0iJ Tax Map S q. 00 Block Lot Formerly Subdivision Name SOV F H ro12 K CS TA T6 X Subd. Lot # i Mailing Address SO CRO 7-0 /IS AIN '__Q d XS I N i IJ 6. /-1, j, Zip 10S-6?_ Date Construction Permit Issued by PCHD 1 14 - 2 0 0!5- 37 CR rf0fQ DA rti '2 0 Separate Sewerage System built by q, S. Cr�,o S I-2 y c ri t o /.l Address O s s C. /Q y t o Sb 2 Consisting of 15-06 Gallon Septic Tank and �c)O L - � i(�i F-gr a Rt 1 1 L D PO P1PE� ,,� A S4 6VP \1CL--JRei,1C" Other Requirements: dater SuP P -11: Public Supply From Address re Private Supply Drilled by , f . fkn L Sod -I, iAJ C Address Eu T rJ fl r%, AV Building Type: "� ` ? ' rvir �� Has erosion control been completed? `1 f S Number of Bedrooms 6ye Has gar > FQPu installed? / n I certify that the system(s), as listed, serving the built plans (copies of which are attached), in ac plans and the standards, rules and regulation Date: J '� _ 2 `� -�' Certified by Address 2 'T0 hPJ QALX11 IRLL)1:7 G .pn*ucted essentially as shown on the as- PC Construction Permit and approved Dement of Health. P.E. ,� R.A. 1 oS6` License # b 6 2 S Pi 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 q9• - Title: APAtC Date: I o2 40 6 White copy - HD File; Yellow,copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional a Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address:.. :. ,...._ _ 15 &L LR &a TownNillage:,; ;,J ; TA TAX Map qL - Block 2 Lots) 6, Well Owner: N e: Address: Use of Well: 1- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing }! Open hole in bedrock Other Casing Details Total length eft. Length below grade .5 Hot Diameter in. Weight per foot [�_lb/ft. Materials: Steel _ Plastic _ Other Joints: — Welded >� 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 )� Compressed Air Hours L Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are •available; please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface G f ` _.... _ ... _ If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capaci :_ Depth 3B Model fi Voltage �3,o HP Tank Type 3Ct Y Volume, Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) iNm'h: Lrxact location of well with distances to at least two permanent lanamayks to be provided on a separate sheevplan Well Driller's Name 11r i P Signature: 4 yZZ �� ?�Address: .S Y. Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 pUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address 37 CRoIDN DA v Rost D, ,vy lose. Located at (Street) M iLG st Tax Map 934 Block 2 'Lot 1-6 _ (indicate nearest cross street) '* Municipality Drainage Basin PEIc594Le- /fyuacv gee Td_ f' ?: C':C,u Rl Vej Date of Pre - soaking SOIL PERCOLATION TEST DATA Date of Percolation Test O S - 17 -01 Hole No. Run.No.. Time Start - Stop Ela se Time (p1 lin.) De th to Water From Ground Surface (Inches) Start Stop Water Level Dro In Inc�ies Percola; c l: R1te Min Ins ::: 1.4 I 1Z ZI --&4 7,t8 7_ _ I4 I Z 7 3S 7 15 1 l2q_ �3G I:_ tZ J., 12 3b_ S, 1 I Lo,�3 1 3 1 3 0 eG I I S I�Lo 1 4 i 5 3 Nn-r,t;-ic - T - =•- •- �- - -- • •� ��Y�u«u a, DGi1IvG ucpuI ULILU dUPLUAIMdLCiy- equal percolation rates are obtained percolation test hole. (i.e. $ 1 min for 1 -30 min/inch, <_ 2 min for 31 -60 min/inch) All data t,� .submitted for ?- Depth'measurements to;be made from top of hole. TEST PIT DATA ;. .. �: g; RC-R1P,T-I.ON:.0F:SOIIJS EI- COUNTERED II ;TE'5T1 -f0 9 ��.., 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' 9.0' 9.5' 10.0' HOLE NO.--rW HOLE NO.- -1-H G HOLE N0. =r� Ps o t_ -T-0 Ps o 1 A� sRaw/N siuf S�j q,,SPV IMM 90-OWM SiL-rV SANny Loar -, I I , I ? Indicate level at which groundwater is encountered tJ o Nef 6: /-3co vn► i 02Lf .D Indicate level at which mottling is observed pl ar,)4� CR SCRVE0 Indicate level to which water level rises after being encountered f Deep hole observations made by: CRoN trJ 4 �i WEC'9Zi^3 6 ' ., Date (11(4 V go 20o d Design Professional Name. M oT Address: Coo ,aJ 2 So Signature: L:. ,ceot's i �C F'C. G Design Professional's Seal Uj G 62960 �V Nk0FESS%O�A�� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FORAPPROVAI;-OPPLANS FOR- - -- .;:.: -... A .WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: V, S. Ca .0 S 'T72.v `-r CC) 2 3 Ct � v 1 -0 0 5�t� 2. Name of project: S S TS 'W9Lk. R PaNtr3. Location TN: ,To-; N►4n1 U -A LL!t \Z 4. Design Professional:02omi iJ Address: ^,-, lbk ►-i W I L Sk Cjz_�'� 6. Drainage Basin: 66K5KlLL, koLt.uW. 'J?R00k_' K 7. Tyne of Project: X Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial' Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ....................... 10. Has DEIS been completed and found acceptable by Lead Agency? .............. Exempt Unlisted_ N� 11. 'Name of Lead Agency " I °o);.s VA LUE Y P�►iN "j iJ G lSa (A 12 12 .Is this project-in an area under the -control of;loe-al planning; zoning, officials, ordinances? .........................:.............................:. ............................... 13. If so, have plans been submitted to such authorities? c. S' 14. Has preliminary approval been granted by such authorities? Y Date granted: '� ? 2 0,0 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If.surface water discharge, what is the stream class designation? .................... N .A 17. Waters index number (surface) ........................................... ............................... N (� 18. Is project located near a public water supply system? ....... ............................... rJ 19. If yes, name of water supply N (k) Distance to water supply 20. - Is project site near a public sewage collection or treatment system? ................ tj 21. Name of sewage system Distance to sewage system J t � 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ............................... to,) C 6,'� e- /Q-3 K 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... E Has SPDES Application been submitted to local DEC office? ......................... .N JJ C 2 27. Is any portion of this project located within a designated_ Town or State wetland? C i��i" . .L{:;T. 28. _ :.`� �_ ,r.r:�." `z. a ++fr.': .. .. . .. i ..� :a?P • '.- l-:;f� _ :�V • - -r•'u ;.�Q,r;aY 4. .,. ..... ... o.i Wetlands ID Number ........................... ............................. ............................�.� _ 29. r Is Wetlands Permit required? ;* Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .......... '`' 0 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, - landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any Qv C other potentially known source of contamination? ............................... Yes/No ,. DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... .s 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... N 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number .......................................................... Map Block Z Lot 46. d -.31-Approved-plans-are to be'returned to .., ..pplicant X -Design-.Professional. . r ...• .; NOTE: All applications for review and approval of a new 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 review and approval of other aspects of a project, such as stormwater,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. 1 hereby affirm, un der penalty of perjury, that information provided oil this form is true to Ilie best of my knowledge and belief. ,False statements fade herein are punishable as a Class A misdemeanor pursuant to Section 210'-'45';'0 -1i1ie Penal Lary. SIGNAT'U.RES & OFFICIAL TITTLES: i L. cR o ice! i Mailing Address: CRotiriki C- NG•tNC'_Q l 1\16' W A L- S 1-( ez-Ub f r( K S lC l t✓L, lam( `% /0 Z-6 6- .A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? if yes, coordinate the review process use the FULL EAF ❑Yes ❑No - B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration maybe superseded by,another involved agency.. Yes • .. ONo _ _ _ ..... . , . � �; :. ^ .. 4 ':: � . _ - - n; ,.<R n P. • ; 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: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A communiWs 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 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. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? ❑Yes ❑No If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑Yes . ❑No If Yes, explain briefly: Part !11- DETERMINATION OF SIGNIFICANCE (To be completed byAgency) ° - i• .' " - INSTRUCTIONS: For`each' adverse'effect identified above, determine whether it is substantial, large, important or otherwise significant. ; Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency ? Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) date 617.20 SEAR Appendix C State Environmental Quality Review SMOKY. ENVIRONMENTAL. For UNLISTED ACTIONS Oniy Fart I e PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR: 2. PROJECT NAME: V.S. Constnuction Corp. SSTS Construction for Southfork Estates, Lot #1 3. PROJECT LOCATION: Municipality Town of Putnam Valley County Putnam County 4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map) North side of Sprout Brook Road, approximately 125 ft. west of the intersection with Gallows Hill Road 5. PROPOSED ACTION IS: lNew ❑Expansion OModification /alteration 6. DESCRIBE PROJECT BRIEFLY: construction of subsurface sewage treatment system and a water service connection for the construction of a single family house 7. AMOUNT OF LAND AFFECTED: Initially 26.5635 acres Ultimately 26,5635 acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? NYes ONo If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential Olndustrial OCommercial OAgricultural OPark/Forest/Open space OOther Describe: Surrounding lands are zoned single family residential 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? WYes ONo If yes, list agency(s) name and permitlapprovals Town of Putnam Valley— Building Permit, Putnam Co. Health dept — SSTS & Well Permits 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ®e Yes ONo If yes, list agency(s) name and permit/approval Subdivision Plat Approval — Southfork Estates Subdivision" 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Oyes Mlo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/Sponsor name: Cronin Engineering P.E.: P.C. /Kenneth Murphy date. 7 -20-05 Signature: 1 If the action is in a Coastal Area, and you are a state agency, complete a Coastal Assessment Form before proceeding with this assessment OVER 1 PART &ENVIRONMENTAL ASSESSMENT (To be completed by Aoencv). , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: -.Inspected by: Street Location Owner Town Permit # o —.495-- TM # Subdivision Lot. # S / 1. Sewage System Area YES LNG COMMENTS i a. STS area located as per approved plans ..........:................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................ d. Stone, brush, etc., greater than 15' from STS area.......... ✓' e. 100'. from water course / wetlands ...... ............................... IL Sewage System N", a. Septic tank size - 1,000 ......... 1, 250 ......... other .............. b. ' Septic'tank installed level ...:............ ....................:.......... c. 10' minimum from foundation .................... .... d. Distribution Box fC 1. All outlets at s ation -water t4 4 :............... 2. Protect ow frost .................. ............................... 3 um 2 ft.Original soil between box & trenches e. J nction Bog - properly set .......... ............................... 6. renc es 1. Length required Length installed eCbO 2. Distance to watercourse measured Ft..fxp7 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. • �. 7. Room allowed for expansion, 100 % ......................... . 8. Size of gravel 3/4 - 11/2" diameter clean ...................: _ - 9.. _Depth .of gravel imtr -12'- _ .,.. . 7. .. .... a .... 10. pipe ends ca pped ......................... .....: ........................ . g. Puma or DoseAv6stems 1. Size of pump chamber.......... ... . j).y... 2. Overflow tank .........:..... ........./ 3. Alarm, visual/au ................ 4. Pump. eas' cessible, manhole to grade ................. 5. Firs x ba$ led :....:.................... ............................... 6 � ycle witnessed by Ii.D.estimated flow /cycle........... IIL House/Buildhi a. House locatedper approved plans .................. ... . b. Number of bearrooms ....... ............................... ... IV. Well Well located as per approved plans....... < ........................ b. Distance from STS area measured La >-) _ ft ........... c. Casing. 18" above grade ................ ..:.......... ................... d. Surface drainage around well acceptable ....................... V. Overall Worlonanshin . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled.......................................... c. All pipes flush with inside of box ... .....:......................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan . f. Curtain drain outfall protected & dinto exist water r u g. Footing drains discharge away from STS area ............... h. Surface water protection adequate.... ..- :.......................... i. Erosion control provided ................. ............................... Rev. 2/02 . Form - '. � ., :�'i;�L.. .�' �r� i� .a !a -y . .: '�" « .' .�o. +%`.'.. '.. .. tee: ±y _ -_ .,'y" :"�_i��.:_J ....;_�_..r. ". �_ n,'a.�I. p-jv''��:'..i ;v s j�•Ly' SITE INSPECTION FOR FILL PAD Fill pad located per the approved plan Date: Inspected by: Fill Pad Length Required Length Fill Pad Width Required Width Fill Pad Depth Run -of -Bank Fill Quality Slope from Top to Toe Impervious Layer Installed. Erosion Control Installed Sieve Test Results (if applicable) Additional `Comments Reserved for Field Sketch if Anal Rennired l)Pnth .l; • +k it If �r Ii SMWJr -' P PATOACUOU7 JUMW e "Located In "SOUTXFORK E'STATE'S" A. sn..RR :;Aft p /pM [n w ge.um C-F a. *" olr AMR ?f& 8DD6 v +raP ra r986 Situate in the MYAF OP MrN" vAU" COMM7 or AMAUX A7 Scale: > '=60' Nov. 28, 2000 -0• w Ofoi+w s� sY D—" J Y f-W st—n : P.0 AMR It dM6 -[4f. of N4 me➢ Al� OM. dY AM6 -Boos. IH! AM .9bb A61e! '.I O Bas w ➢lrrusty ST /IAC ! IOCBIIJJ DLRNLR t lbn+srtY JAYr9 /. ! 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