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HomeMy WebLinkAbout4386DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -50 BOX 33 „- � .�., Ir �} a. ly,I ' .� �T :6 r `r ,'6 't }. PUTNAM COUNTY DEPARTMENT OF HEALTH OI�T'OFf►TIRO�TMETT�I;IA'I °SERVICE CERTIFICATE OF CONSTRUCTIO COMPLIANCE FOR ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 30 o foo Town or Village NA-P,% Owner /Applicant Name T,7(L/ b i"- C-kAZ K) iGk. Tax Map Block Z Lot Formerly Subdivision Name Subd. Lot # Mailing Address 7,0 I'P"3Sok 4W Ae?7V 4-M lt;/�- N Zip Date Construction Permit Issued by PCHD 11-1,3-o2-, P +*No h4eogr1*1nl AltlNr• ; 1V6. Separate Sewerage System built by p e1 W 169 Address ,�5� Ayw Consisting of Gallon Septic Tank and Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by Address �s9l2r% Building Type s f� Has erosion control been completed? -1%s Nurhber of Bedrooms ,Z Has garbage grinder been installed? Ala ., 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 Putnarounty Department of Health. Date: <111 W Certified by P.E. R.A. f (lles� n Yrotessionap Address �D ? ,l�zAe 1)1e. Wif n i . IM6oee e e' 06774 License # 0 7 053 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: J` Title: ��� Date: �6 White 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 Well Location Street ress: f Q -3Q c- � _wnN.illage d bMap, Tax Grid # • Block Lot(s) Well Owner: N e: AM P&$ f Use of Well: I- primary 2- secondary �� Residential blic Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling ]Equipment L-.,/ Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _>< Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter �in. Weight per foot alb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded / Threaded _ Other Seal: � d..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 jk 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 , �" vo L %' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ✓ Capacity Depth $6o Model 6'T1v �-'s- Voltage 2­3D HP Tank Type "O 3o Z- Volume t 7--6 Date Well ompleted e 3 Putnam County Certification No. D:eo f p ort i/ ell Driller (signature) s u7 rx�ct location of well with aistances to at least two permanent lanpmarxs to De proviaea on a separate sneevpian. Well Driller's Name lv �� Address;, �%. Signature: r Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH .S. O�: ':•6.�Nc _�.. O +. - ?�f�J:+.+�?3-A� .J..i!ndTH SER.7-.IC IES .,,. , GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM ,g4A-D C~wfck Owner or Purchaser of Building Building Cons cted by 30 os Location - Street Or- G y Z �_o Tax Map Block Lot ToZNillage Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan, or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the 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 the building utilizing the system. Dated: Month D Da Year General Contractor (Owner) - Signature corporation ivame (if corporation) pia% v��� 14A, Address: �� State Zip Signature: Title: �..� Corporation Name (if corporation) 3p�eAddress: State /, /1.11 Zip A" 7 Form GS -97 ~` YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Height Ya,1<)598, Albert H. Padovani, Director LAB #: 32.3 6558 CLIENT #: 56839 NON STAT PROC PAGE J. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CHADWICK, BRAD T. DATE/TIME TAKEN: 08/14/03 09:00 30 POSEY RD DATE/TIME REC'D: 08/14/03 10:00 PUTNAM VALLEY, RD 10579 REPORT DATE: 08/21/03 PHONE: (845)-526-8169 SAMPLING SITE: 30 POSEY RD ' SAMPLE TYPE..: POTABLE : PUTNAM VALLEY, NY 10579 PRESERVATIVES: NONE COL'D BY: BRAD CHADWICK TEMPERATURE..: < 4C NOTES...: KIT TAP COLTFDRM META: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 08/14/03 MF T. COLIFORM 08/14/03 LEAD (IMS) 08/14/03 NITRATE NITROG 08/14/03 NITRITE NITROG 08/14/03 IRON (Fe) 08/14/03 MANGANESE (Mn) 08/14/03 SODIUM (Na) 08/14/03 pH 08/14/03 HARDNESSrTOTAL 08/14/03 ALKALINITY (AS UNITS ' ABSENT 000 ML ABSENT <1 ppb 0-15 ppb 0.22MG/L 0 - 10 <0.01 MG A... N/A <0.060 MG/L 0-0.3 mg/l 0.015 MG/L 0-0.3 mg/l 4.41 M8/L N/A 6.9 UNITS 6.5-8.5 60.0 MG A... N/A 50.0 MG /L N/A 0r5 NTU. COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN7���=�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, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium thatfor people on a contain no more than moderately rpstricte' is suggested. are proscribed. Suggested guidelines state sodium restricted diet,the water should 20 mg/L of Sodium. For those on a � diet, a maximum of 270 mg/L of Sodium ` 1008 9104 9139 9146 2037 9O43 ,� ~ - `�. . YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 Albert H. Padovani, Director | LAB #: 32.306558 CLIENT #: 56839 NON STAT PROC PAGE 2 CHADWICK, BRAD T. DATE/TIME TAKEN: 08/14/03 09:00 30 POSEY RD DATE/TIME REC'D: 08/14/03 10:00 PUTNAM VALLEY, RD 10579 REPORT DATE: 08/21/03 PHONE: (845)-526-8169 SAMPLING SITE: 30 POSEY RD : PUTNAM VALLEY, NY 1O579 C'OL'D BY: BRAD CHADWICK NOTES...: KIT TAP SAMPLE TYPE..: POTA8LE PRESERVATIVES: NONE TEMPERATURE..: <4C COLlFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 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 METAL 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 WHlCH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD WATER: 70-140 MG/L- MG/L = MILLIGRAM PER LITER FA�D 'WATE /L'.-_--�.-L��-����n>b�l1d�' ' SUBMITTED BY: � . Albert k4. Padovani, M.T.(ASCP) . Director ELAP# 10323 | � .' �••e -.. �.+i .. !...' :� l: 'C�.l .. � ':.�y_ 4+.... 1. �. ;.�n..r.O�.s �.w •pi.:.t f l• ���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 (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VEYIFYCATION FORM OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: rV 7 AUTHORIZED TOWN OFFICIAL: DATE: (Signature) 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 Certificatc of Construction Compliance. ;..� (E9I lverfrm) L 76-7191 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH S)ER.VICES a7-rErrrtnN � aosErs ❑ cnvF, MQUEST FOR FINAL INSP CTTON For: Fill All information must be fully completed prior to any Trenches insper-tiotts being made. PCI-ID Cons 'on Pem)}t # Located: v S 90 An (T) ('V) Owner /Appli t N- Whe: V X M ' Cakw etz- TM f5y _ Block 2- Lot —9:5�_ Formerly: -- Subdivision Name: Subdivision Lot # Is system fill completed? Date: _ Is system complete? VW 5' Date: Is systom constructed as per plans? 1Es Is well drilled? UAS Date: Is well located as per plans? Ya Are erosion control measures in place? 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 plants and the Standards, Rules and Regulations of the Putnam County Department of :H�alth. Date. - Certified by: PE RA. Design Pr fessional Address: Lic. # 074 Y-3 Comments: o i Form FIR -99 r� \� PU TNAM COUNTY DEPARTMENT DIF HEALTH .... _ . ._ CDR VRSRQN OIF .IEIqV gR O TI I T I'AL CONSTRUCTION / PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT X 2- 711- mjt-- 'M IR Located at 0��� to consist of Town or Village gallon septic tank and Subdivision name Subd. Lot # Tax Map RV Block Z Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name &A-D J • CGS,, VJ1 C;C Date of Previous Approval Mailing Address 13&6 S G Amount of Fee Enclosed #3COO, vO Building Type 5 -1^ - ®-- Lot Area of Bedrooms 3 /O:L Design Flow GPD_&60 Fill Section Only Depth Volume POI{RD NOTIFICATION IS REQUIRED WHEN FRILL RS COMPLETED Separate Sewerage -System to consist of gallon septic tank and Other Requirements: To be constructed by Address Water Sugnnly:: Public Supply FrQu1... _.... Address onr: _ Private Supply Drilled by #0441 MO /1s ad Address 91*e6 r" - 5/—. I repr`yent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the spa•° sewage treatmentsystem described above will be constructed as shown on the approved amendment thereto and in ar . , Lance 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. -�i� -�-- =- P. E. O fo 7 Signed: Address 14 3 P/� _ (�✓L. ® C7-6b 7 76 R.A. Date 3 1-7, 1 0 z,- License # a j q,73 APPROVED IFOR CORIgTRUCTRON: 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 p it. Approved or discharge of domestic sanitary sewage only. ��. By d-- Title: Date: 4,43 Z- White copy - HD /Ie; Y�ll�w copy - Building Inspector; Pink copy - QXner; O an a copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A.WAWR. WELL _ please print or type - ~'-� >�„ . �"PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # JR>S �efD Pvi ,j" � Map g Block Z- --Lot(s) VO Well Owner: Name: Address: g (,G _ e ZP—M T (4Y AO W cCk- ' _ ev Use of Well: Residential Public Supply Air /Cond/Heat P Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought S gpm # People Served Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X 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 No Name of subdivision Lot No. Water Well Contractor: Nog4 -t �-�J yl�c -,J Address: BA,2�y�cR- Sr�L- P�, r y� y Is Public Water Supply available to site? .................................. ............................... Yes No X Name of Public Water Supply: Town/Village Z—J& Distance to property from nearest water main: N Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: ,. , 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 (3.0) 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 3 - Permit Iss in Offici l: Date of Expiration 3 -D Title: , dl Permit is Non Transferrable . White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH MOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, --3 ____ BEDROOMS g / Q _ -I ".S_cl) ALL SUBSEQUENT REVISION f ALTERATIONS TO THESE HOUSE PLANS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL SIGNATURE & DATE PUTNAM COUNTY DEPARTMENT. OF HEALTH s DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS . •• • ;►:::. REV.IEW,SIIEET•FOR CONSTRUCTION.PERA NAME OF OWNER: ��'-�� STREET LOCATION: REVIEWED BY: RM, GR, A S ATE: l TAX MAP #: (CONFIRMED) al Y N DOCUMENTS Y N (REQUIRED DETAILS ON PLANS CONT'D) (/��PERMIT PLICATION L,6C )HOUSE SEWER -' /." FT. 4 "0'; TYPE PIPE CA ONf� WE ERMIT OR PWS LETTER (_)(_)NO BENDS; MAX.BEND: 5 451.- WICEEANQ.UT ( 0 RENEWALS (,/j(_) ETTER OF AUTHORIZATION CSC )SITE NOT] NGE) (�QL�DESIGN DATA SHEET (DDS) FILL SYSTEMS L )CORPORATE RESOLUTION (x(__)10' HORIZA NCH SLOPES 3:1 TO GRADE L1)L�SHORT EAF ((FILL SPEES 1 -5 (f�(_)PLANS -THREE SETS (�(�FH,L PRONSIONS L�jUHOUSE PLANS -TWO SETS ((_)FILL IN E EA _ LJ(f�VARIANCE REQUEST FILL GREATER THAN FEET SUBDIVISION U(_j CLAY B R CJC )LEGAL SUBDIVISION (_)(JFILL CERT ATI TE (_)(_)SUBD SION APP L CHECKED (�(�DEPTH GAUG UUPERC RA (�( JVOL. ON N FO .O.B., UNCLASSIFIED & IMPERVIOUS CSC JFIL QUIRE DEPTH (�L�SEPA ION DISTA E FROM TOE OF SLOPE L—) TAIN DRAIN REQUIRED TRENCH 1 C�L�LOCATED IN NYC WATERSHED ULF TRENCH PROVIDE _ 60FT S SUBMIT 8LJPARALLEL TO CONTOURS ( --)( —� 0(_)100 /o EXPANSION PROVIDED (U)UDE PCHD / ()DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL EP APPROVAL, IF 'D��"`(�GEOTEXTILE COVER DEEP TEST HOLES OBSERVED to km/6" -e SEPARATION DISTANCES ON PLAN - FROM SSTS LAC JPERCS TO BE WITNESSED (Z(_J10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL LAC % APPROVAL SSDS 'ADJ, LOTS (_ (�20' TO FOUNDATION WALLS C� ETLANDS (TOWN/DEC PERMIT REQ'D ?) ,�J(J100' TO WELL, 200' IN DLOD, 150' TO PITS L. )L_JDATA ON DDS PLANS &PERMIT SAME /� (/J(^}100' TO STREAM, WATERCOURSE, LAKE (inc. expan) L�PRE11► °NF'I�GURzNOTIFICA� TION`C➢�J� TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER .:.((.�(. �LFTTEKBI/ZBA ... ... _ _.. ... _ 1 : _Q WATERLINE ( .•, .; -.._ ._ . R _.. • . <........::.._ .. , 0' INTERNIITTENT DRAINAGE "CO URSE° 7 (_)(CjSOIL TESTING LOTS >10 YEARS OLD /Z__)200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS DETAILS ON PLANS _ (/�(_J10' MIN TO LEDGE OUTCROP (�REQUIRED L JS GISYSTE M.PLAN= (NORTH- :ARRUI' SEPTIC TANK L )(__)SSDS HYDRAULIC PROFILE (�(�10' FROM FOUNDATION; 50' TO WELL ( /)(_)GRAVITY FLOW WELL C-Z)UCONSTRUCTION NOTES 1 -15 (�UDiiGIENSIONSTO PROP�ERTYLINES DESIGN DATA: PERC & DEEP RESULTS �� �LJLOCATION OF SERVICE CONNECTION EXISTING &PROPOSED (�(�� 15' TO PROPERTY LINE 4L_)FOOTING/GUTTER/CURTAIN L�DRIVEWAY &SLOPES, CUT DRAINS SLOPE ( )(`)SLOPE IN SSTS AREA/ .� (520 %) (/_)(USDA SOIL TYPE BOUNDARIES (—)C4R' GRADED TO 15 %, IF REQUIRED C_..)(_)TITLE BLOCK; OWNERS NAME ADDRESS DOSE/PUMP SYSTEMS TM #, PE/RA; NAME, ADDRESS, PHONE# (�(�pUMP NOTfE (�L�DATE OF DRAWING/REVISION (�UDATUM REFERENCE UUDOSE 75% LUME/DOSE VOLUME NOT ED C�C�LOCATION OF WATERCOURSES, PONDS U)U)DETAIL FOMAIN, (PII'E TYPE, ETC.) LAKES,WETLANDS WITHIN 200' OF P.L. _;_)PIT AND D N & DETAILED UUPROPOSED FINISH FLOOR AND UUl DAY STO VE ALARM i'T-T 1 TAT -♦TAT BASEMENT ELEVATIONS "" C�WELLS & SSDS'S W/IN 200' OF SSTS C )C�STANDPIPES, 5' O IDES; DETAIL J���— PROPERTY METES &BOUNDS UU15' MIN to CDS => /o, '-4%,25'-3%,35'-l%, 100 % - <1% O(_)EROSIUNkCONTRUL�FURHO:USE W. ,,EIyL & (�U�20' MIN to CD D ARGE /100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE / UU10' MIN to NO -PER IPE COMNTS: O `S/hGC / ' 'Lien ME (REVSHEET)09 /01 /00 L BRUCE R. �FOLEY ~ Public Health Director DEPARTNMNT OF PIEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of . Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 1 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 2 085 Early Intervention (845) 278 - 6014 Fax(845)278- Date Preschool (845) 228 - 5912 Fax(845)228 13 �V __ To: J� For �E, �� b • �In Re: Proposed SSTS - C t 'G� R'6�9_ Dear Mr. �u ��f. -a -sue Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: . � , / 1(ft/!�""' �a S �'. �1Z�>� �.e,�.D Cr✓.ao �ar— `>�. t�t.DP7" cc�i ��. �' _3 111 r The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission revised to rei considered further. SR:cj �C4 sstsproposedrev lect the above comments, this application will be Zmcerely, +l "-.3d Shawn Rogan Public Health Technician BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services 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 Fax (845) 278 - 6648 April 18, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 SJF Engineering Services Stephen J. Ferreira, PE 103 Perry Drive New Milford, Ct. 06776 Dear Mr. Ferreira: i v Re: Application to Construct a Subsurface Sewage Treatment System on Posey Road (T) Putnam Valley, TM# 84. -2 -50 The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on April 16, 2002 is incomplete. Please be advised that the following information is required before the Department may commence its review. Fo1ma PC -97 (enclosed' ). • House plans submitted are considered to be a four (4) bedroom residence. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Should you have any questions or care to discuss this matter further, please contact me at (845)- 278 -6130 extension 2159. Sincerely, Shawn Rogan Public Health Technician SR:cj encl. r =77-1-72M, =77 xc-,= BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N. Public Health Director OIL Associate Public Health Director _ - Dir�c�a�' of- -Paiierrt Serviccs' 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 (Including cover sheet) From: Adam B. Stiebeling Asst. Public Health Engineer For-your information For your review As discussed Notes/iVIessages _L (, 0E: C�1&x,31.ev, I _.._.r ... _.... Please respond' 1:�>,-je, "Olt t Attached as requested Please call v� In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2157. noted that soil tests made during dry weather conditions are frequently misleading and therefore, from July 15th through September 15th, starting January 1, 2000; percolation testing for any new project will not be considered by the Department. The Department will witness percolation tests and/or entertain percolation test data during July 15th through September 15th only for those lots which have previous documented percolation test data (i.e. subdivision filed map or approved construction permit.) The Department reserves the right to require additional tests during a wet time of the year when it is deemed necessary. The Department may also require adjustments.to percolation test results performed in dry weather as experience may indicate to be necessary. Wet weather testing is strongly recommended. The Department will require the witnessing of soil percolation tests as follows: 1. Any lot less than 0.5 acres in size. 2. Any lot where all or most of the lot area is utilized for the primary and reserve SSTS areas. 3. Any lot where a two (2) bedroom dwelling is proposed. 4. Any lot where Department engineering review indicates a concern relative to - ._ soli 5. Any lot within the NYC Watershed delegated to Putnam County Health Department per Delegation Agreement. (Appendix J) The Departmental representative will observe a minimum of three (3) runs or until the percolation rates have stabilized in each percolation test hole. This will be performed after the holes have been presoaked. C. Deep 'Kest Holes The design of a SSTS is predicated upon site conditions, percolation test results, observation of soil strata in deep test holes and the location of adjacent wells and SSTS. One segment of the Department's review of a proposed SSTS is the inspection of deep test holes. Generally, the Department will require a complete submission of plans prior to our inspection of the deep test holes. The Department will inspect deep test holes prior to receipt of a formal submission; however, a plan showin at least the outline of the lot to scale must b rovid the Depar representative either or at the time of the site inspection. Property corners staked by a Licensed Lan d Surveyor, where warrante , must a visible to the Department Inspector at the time of the initial inspection. T 'd d0 1N3Wi6Ud30 A1Nnoo WUNind :3WUN T26L- 8L2-Sb8: 131 LT:OT 3ni 2002-8 -NUf '9 _ m _ %if— 'if,:a <-^ Stephen J, Ferreira, P1. 103 Perry Drive New Milford, Connecticut 06776 (860) 350 -2499 Gene Reed Putnam County Dept. of Hea1Ch 1 Geneva Road Brewster, NY 10509 Re: Chadwick Site Dear Mr. Reed: January 8, 2001 Y have attached the Request for Field Testing and a map for the Chadwick site. Two deep holes have been inspected back in May by Adam Stiebling An additional hole was requested at the time and is ready for you to inspect. If possible, I would like a copy of the results from the other holes that Adam has in his files. I will also have a site plan for you at the time of the inspection. .._ _.....� .. Thanks, Steve.. 10 30Vd ANV11800 d0 NMOl 6ZOTPEZ016 60 :01 Z00Z/80/10 01/08/2002 10:09 9147341029 TOWN OF CORTLANDT PAGE 03 Ta/UOSW 5346P IIV 'Oul wc3-jsanbd-vw z0oz @ 19 %5fjWd'A)IFA'fjd yens w(mj Builinsai Aepp m ssol Aug joj /%j!jpS0od%o.A ou a%unsse sibildons sal pue asan'Odew -*Sn )a XSP He sawnsse as() qualm sll oi se tMM6 AJURARm -so aPew 5! ucigeluasWal ON 'AjU0 JOU011gmuolul 51 dew 51 .4,L ,19401711 480 O -%04 100U*:'0uI'WOW;t0nt>dAN t0030 r . ko' IS *i:3 P7 ir pid Cn 4k IV E S%. cp mlm—mmzm� . I jo I 02-ed. JAN-8-2002 TUE 10:18 TEL:845-278-7921 sduW :IsajabdvW NAME:PUTNAM COUNTY DEPARTMENT OF P. 3 job 04 Awq '.18"44 100U*:'0uI'WOW;t0nt>dAN t0030 r . ko' IS *i:3 P7 ir pid Cn 4k IV E S%. cp mlm—mmzm� . I jo I 02-ed. JAN-8-2002 TUE 10:18 TEL:845-278-7921 sduW :IsajabdvW NAME:PUTNAM COUNTY DEPARTMENT OF P. 3 BTOOk P II .5 10579 F `:-''�' . -- StIllw 1 e usellm dams < semnPerk Cem TN RD -awso Cam # krson I n, A COU 4TY ley ou 7- h oub ca 0 ik - N 7 Copyrigh No part c (3 orbyany recordIn( 132 1 without r M The Infon authorli• contain s ca attention FOR ADIOINI G AREA SEE HAGSTROM'S WESTCHESTER COUNTY ATLAS r 2 'd 30 1N3W1ZItid30 .11Nf100 WtiNlfld:3WaN T26L- Ba- Sb8:131 ZT:OT 3n1 2002- 8 -Nti!' SAN-4-eM 11:47 F' 0M:PUTWM C"TY DEPPRT 645 -278 -7921 BRUCE P. FOLEY Pt+ O Health Dtraebr DEPARTUENT OF BEALTH 1 0eneva Road Brewster, New York 10509 70:919147341029 LDUTTA- MOLMAW RX. M.Q.N. dsaacum PuM.- Hgalrb Director proctor of palfau ,wrvtorn AD information below must bed eoerepleted psior to arty sche4utlin& l�; � O le � REASON: Pl iW TEST. � YES NO o 0( Propow4 S.STS within tom' drainage basin of Wut BrArXh or 10e05 Comer o "oirs. 19 Proposed S3'IM whbin 500 feet of reservoir, anaewoir SUM er trOUVOl latM P ...._ Proposed SSTS Within X00 feet of a watercourse or a ®EC weed. Aq : _ Peiapt3 SST `. e n sar_ ea¢ 81ron lan Sallostslday err 5? DFA hem* requimtl- rn Noposed 5ST3 for m comical project. �■. it< is the responsibility a the design profes_gaftt to provide & above information prior to soil tasting. Ibis Departmeaut will determine the NYCDER project status (Joint op Velept4 based on the response, U you Answered ja to ar+.y- of the queWom, NYMP must witms the see! testing. ;l'liiq Pepumc i will coordinwte a mmftally soltable time for field temirng wlek the PMH, the mist Profession and NYCDEP• 9T a projm!ctt hag beets detemiped to be Delegated based an the above nspome and then subsegnent infor lion ittdiieates NyCDEP is ragidred to witatm the soil testir g k wiQ the eels rm risibility of the deoimn yrofessiaal to sebedule re- witneming of the sell emting With NYCDEP. 1QNd-1H00 30 NMO1 6ZOTPELP16 60 :01 Z00Z/80/10 SJIF ENGINEERING SERVICES 103 Perry Drive New Milford, Connecticut 06776 (860) 350-2499 (860) 662-2618 Sean Rogan Putnam County Health Department Devision of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: SSDS Construction Permit Sect: 84 Blk: 2 Lot: 50 0=1 e Road Putnam Valley, New York Dear Mr. Rogan: Please find enclosed: April. 1, 2002 1. Plot plan and separate sewage disposal system. 2. Two sets of house plans. 3. Construction permit application. 4. Letter of Authorization. 5 * ---t-A—ppli&dtioti;forapp.-6Niad*-(Yt-piap.s!,--.:..:,—�.'-.,,.....- 6. Application to construct a water well. 7. Soil Data Sheet. 8. Short environmental assessment form. 9. Updated survey. 10. $300.00 Certified Check. 11. List of adjacent property owners notified in accordance with the required neighbor notification. The information enclosed is provided based on our recent conversations and our field inspections. Please feel free to contact me if there are any further questions or information required. Sincerely Your /St'-->he J. Ferreira of 84 00 V --, FUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION ATION RE: Property of 1,32.,09b f c y,4 o w i c k Located at T/V ,,,*^ V ,4L, j Tax Map # Subdivision of Block Lot Sn Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the .standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law,.the Public Health v;. and. the utn.azn Catitity' Sanitary. Cocie..:: Countersigned: P.E., R.A., # Mailing Address 1p State CT Zip C6776, Telephone: % - 3 So - Z Very truly yours, Signed: (Owner of Property) Mailing Address: ��b r�r ea— S� rti Q 4- Ally' /GS 9S State /V l ` Zip /,�J w Telephone: .g�L1s' s'z -6 — z � 6 Form LA -97 A a SJF ENGINEERING SERVICES S,tepftn J.,,Ferreira; RE.. - 103 Perry Drive . _ .... _ New Milford, Connecticut 06776 (860) 350 -2499 Sean Rogan / Gene Reed Putnam County Health Department Division of Environmental Services 4 Geneva Road Brewster, New York 10509 Re: Neighbor Notification April 1, 2002 The following is a list of neighboring properties and the corresponding tax identification numbers that have been notified of the proposed application: The return receipts will be forwarded to you as soon as they come to me. Please contact me if there are any fiuther questions. Sinc ely Yours, r Stephen J. Ferreira Name: Address: Tax I.D.: 1. Barbara Somerville 22 Posey Road 84 -2 -51 2. Jack Nathan Cooperstation, Box 500 84 -2 -52 3. Judy Veglia 18 Posey Road 85.13 -1 -2 4. Louis Molinaro 25 Barger Street 85.13 -1 -6 5. George Sommer 31 Barger Street 85.13 -1 -8 6. Christopher Sarro 33 Barger Street 85.13 -1 -9 7. David Labate 35 Barger Street 85.13 -1 -10 8. Guy Hoffman 39 Barger Street 85.13 -1 -12 9.. ,.. John GuJla .. 43 Barger Street 85.13 -1 -13 lb. - Carlos Correia - "'" 262 Sptotrt'B'ruoic Rd_ °-g4 =Z -48 11. Bradley Chadwick 24 Posey Road 84 -2 -47 The return receipts will be forwarded to you as soon as they come to me. Please contact me if there are any fiuther questions. Sinc ely Yours, r Stephen J. Ferreira PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 5'14 3 Inspected by: P Strut Z ocation. o :.. '•Owner lad CCiG:A.; M .. ,. . Town Permit # 17 d 2-_ TM # qq - �_o Subdivision Lot 1. Sewage Svstem Area 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 .. ......................I........ H. Sewage System a. Septic tank size - 1,000 .... ..... 1,250 .........other ................ b. • S eptic tank installed level ................ ............................... c. 10' minimum from foundation ........................ . d. Distribution Box 1. All outlets at s ation -water tested.: :............... 2. Protpaae ow frost .................. ............................... um 2 ft. Original soil between box & trenches Junction Box - properly set .......... ............................... V, yl�.11\.IlVV � -� l/ 1. Length required Length installed Z 2. Distance to watercourse measured Ft.......... 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 in trench 12" minimum .......:........... 10 :...Pipe ends capped ............................:: g: -Puina'or Dosed S•vstems' 1. Size of pump chambe ........................... .... .. 2. Overflow t .......... ............................... 3. Alarm, ' a audio ........:........... ............................... 4. easily accessible, manhole to grade ................. < <. irst box baffled .......................... ............................... 6� Cycle witnessed by H.D.estimated flow /cycle........... a. house located per approved plans ... ....................:.......... b. Number of bedrooms ....................... ............................... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured 1 (,9 W- * • ft........... c. Casing 18" above grade ............................. :................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . 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 p rotected & dinto exist watercourse�� P . g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 �K 1�w � l , � i 1 ME �J �K 1�w � l , � SITE INSPECTION FOR FILL PAD Fill pad located per the approved plan Fill Pad Length Required Length Fill Pad Width Required Width Fill Pad Depth Required 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 Applicable Date: Inspected by: s- as , ;:� t)L /ba @It71 —Test 12 � • .. :Qu.,. =1FRWECT I:D.NUM6EA••— . _ _ _ ._ .. �...;; =.. - . _.,:.aa<.. , . ;517..1;;.:._ .: .. ....:....T ... _ _ ._ ..,5"�...Q•R .. Appendix C 1 State Environmental Cuetity Review 1 SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only _ PART i— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) . I. AICANT PONSQ��Q� /C� � .. �. 9RQ.IECT NAME 3. 'PROJECT LOCATION: �j fGG MunicipaUty �G� County 6. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, Ott, W provide map) 7 "oc S.' IS P 0 OSED ACTION: ZNew ❑ E c snsibn ❑_ModiOCstlonlalleratloll / 6. DESCRIBE PROJECT BRIEFLY: �•_ al fi�✓ 3 �.IJ11GO.e -r �YNGG� /cj¢!At /Gy � /'Q.�� -w/ /poi v iOvytL S-t- 7' 7C .S�.S ✓" �5. 7. AMOUNT OF LAND AFFECTED: Initially ZV acres' uIllmattly acres' 6. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTMER EXISTING LAND USE RESTRICTIONS? Yea ❑ No If No, describe briefly 9. W T IS PRESENT LAND USE IN VICINITY OF PROJECT? Resldenl'al O Industrial ❑ Commercial C,Ap pItulp C.Park/FwasUOpin space ❑ Other . 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTIMATEL Y TROM ANY OTHER GOVERNMENTAL AGENCY. (FEDERAL. STAT�R LOCAL)? Yes ❑ No 11 yes, list agency(s) and permiWpprovals 7-P GVAI 13(/! 4.0.,^4- 00ejg�.j y�a 11.• DOES ANY ASPECT OF THE ACTIOU HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes NO 11 yes, list agenq name and ptirmlUapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REOUIRE MODIFICATION? ❑ Yes No I CERTIFY TMAT , HE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE $or a Dat. AppllcanUSpon y Z D v Signature: i 9 T 1' 1 1 If the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 - . ...... ...... ___.. PART BI®ENvIRONMENTAL ASSESSMENT (To be completed by Agency) A DOES ACTION ED ANY TYPE I THALSMOLD lid S NYCRR, PART 617.187 If yes. agardrncts flits rovrow procoas and use the FULL EAF, 0 Yoe no p. WILL ACTION RECEIVE COORDINATED REVIEW As PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.57 01 Rio, a hells §% ooclaratron - .I r"►oY be augers ded by another 0nv0irOd agency. °" 9cp��� DYes N0a .c. r— COULD ACTIO4 RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten. If kg1blo) C1. Existing on d Y quality, surface or groundwater ualit or ou y emit . "*ISO levals, axlating traffic pottems, mid waste production or disposal potential for oroslon, drainage or flooding problems? Expla9in briefly., Cl Aesthetic. agricultural, a]rchaoological, historic, or other natural V cultural f0sdums., Of go@1muhlty or mighborhood "Actor? Explain, bristly. /Ij� C3, Vegetation or fauna, flilh, 1014tltioh of t flldlilo epocioa, algnificarrl Aabttota, or throotohorf W. padangared apetios7 Explain briefly: lit. A community's existing plans or Ocala as officially adoplod, or a thongs In ueo or Intonoity of ON of Lrind Of other natural resoureaV Eaploin briolly Cs. Growth, subseovent development, or rolaled activities Ilholy to be Induced by tho prop000d action? Explain briefly. C6. Long term, snort term, cumulative, or other effects not Identified In Cl -CS? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of onargy)? Explain briefly.. D. IS THERE. OR 15 THERE LIKELY TO SE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ® Yes o If Yes, oxplam briefly ° PART III— DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRl1CTIONS: 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 (La. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility., (el geograpiiic scope; and (f) magnitude. If necessary, odd ottschments or reference supposing materials. Ensure that allplanations contain sufficient detail to shove that all relevant adverse ImpaC.ts havo been Identifled and adeduately addressed. ® Check this box It 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 eny supporting Documentation, that the proposed action WILL NOT result In any significant edverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: o IAsk r nnI a pe hamt o ►ponslble 011icer on LOU Ager LIN ,Qnaluie o sedan ,bI Ilrcer•,n h Agency rjjnDlure 010106101 (1 dr erenl earn retpan►,ble orlrter) -Z -- xIe , PUTNAM COUNTY DEPARTMENT OF.-HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET.- SUBSURFACE SEWAGE.TREATMENT SYSTEM Owner /Zh(D Address �cs� 4_'*96 Located at (Street) /,3st/LG mod s. Tax Map 9V Block Z Lot S s (indicate nearest c oss street) Municipality .P AL&". Watershed 640wI&e -00 - Date of Pre - soaking SOIL PERCOLATION TEST DATA'. : same depth until approximately equal percolation rates are obtained at each (i.e. s 1 min f6r 1 -30 min/inch, -,5'2 min for 31 -60 min/inch) All data to be to be made from top of hole. Form DD -97 G.L. . . 0.5' .. 1.5' ;... 2.5' 3.0' 3:5' 4.0' 4.50 . 5.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN.7EST HOLES oil - HOLE NO. ` / ..... Ho VO. .z. HOLE NO. 5.5'...... 6 :0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' Indicate.level.at which groundwater is. encountered Indicate level at which. mottling is observed Indicate level to which water level rises after being encountered �--- beep, hole observations made by: S7 «�A41�� Date o/ Design Professional Name:. TWA.*/ Ar?i/1.� Address: Signature: Design Professional's *Seal a e PUTNAM COUNTY DEPARTMENT OF. HEALTH. _ - DMSI0 loI O F tN_ IR_* `ON i1ENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COM1 MERC1AL SITE INSPECTION FORM SECTION A. ,GENERAL INFORMATION Name of Project ft]12J i Site Location Building construction begun _ County Extent Is proVerty within NYC Watershed ? ................. ❑ Yes ❑ No SECTION B. TOPOGRAPHY (Please check all appropriate bones) I. F-1 Hilly ❑ Rolling__a Steep.slope. -- . __ = Gentle "s o Flat — 2. ❑ Evidence of wetlands ❑ Low area subject to flooding ❑ - Bodies of water scsn Drainage -ditches Rock outcrops 3. Property lines or comers evident ............ ............................... ......... ❑ :. Yes o oin the properly. ❑ . Yes ❑ No ­"Do watercourses exist on odj4. .5. Will these affect the design of the sewage system facilities ?................ - Yes No ❑ ❑ .6.. Do watershed regulations apply_in this development ? :.! :............. Yes o Will extensive benecess .............. - Yeses N 8. Will extensive fill be necessary for SSTS? ... ...............:............... .. ❑ Yes ❑ No 9. Do filled areas exist within the SSTS area ? .............................. Yes . ❑ No �� f Wit✓ x, a If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS'` - -10.: Appearance of soil: and_ � avel oam ' :: a`Clay. = ❑ Hardpan �Mixtu e �� 11. Observed from: ❑ Borings ❑ Bank cut ackhoe excavations ti 12. Soil borings /excavations observed by on 13. Depth to groundwater f h ''`! on - 14. Depth to mottling Ic on � 15. Are test holes representative of primary & re ...... ............................... Yes No 7 16. Soil percolation tests made by on - 17. Soil percolation tests witnessed by on SECTION D (on back) Form ST -1 o. 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? � Yes � No 19. Will groundwater or surface drainage require special consideration? ..................... ❑ Yes F_� No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... 0 Yes F_� No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... 0 Yes F_� No Inspection data 22. Do_ adj ace wells wells and/or sewage..systems exist ?..:.: ........:...... : -- "`� Yes No 23. Additional comments 24. Site observer /inspector and title 25� - .- .Date(s) of observation(s)inspection(s) TEST PIT ROFILES Hole# Lot# -- :- -,--Hole # - - - -- - - - - _Lot #.__... - -- Hole #.::...,_... ..... ..._ lot Depth to water, Depth to water De th to water - - -- - - '- - -Depth to mottling ` '_: Depth to mottling _ rt -� Depth to mottling Depth to rock/unp 7.r 7 Depth to rock/imj t Depth to rock/imp. Je., 1 l G. -.0 ';5. 3.0 4.0 5.0 a N, a - -- - - - - 03 A4 _ 6.0 `" ✓ " 7.0_" 8.0 9.0 10 1.0 _ - -- - - 2.0 - .. -2._0 -- t 3.0 A .10 - 4.0 .. 4.0 5.0 6.0 Pr 7.0 8.0 0 10.0 10.0 5.0 6.0 7.0 8.0 9.0 10.0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES " APPLICATION FOIE APPROVAL, OF !'CANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: A '... 44Z 7. 01144 I ck 3&68'- 5 J?j4J-6 . S7 - 2. Name of project: efll'ow ick 3. Location TM W,*(4 V4U,6y 4. Design Professional:. 67m _ &fA4 5. Address: las �. laeivr� 6. Drainage Basin: � �C' 14104 !c ,,� �� ?,� N04 A f, qA0 Cr Z 7 76 7. Tne of Project: Private/Residential Food Service . Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEAR)? Type Status check one Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... A� 10. Has DEIS been completed and found acceptable by Lead Agency? ............... = 11. Name of Lead Agency aA :12� Is.1his pr e.ain an area'urideflhe coritrol'af l�cal�ila �iing; zobiiig; or uiher officials, ordinances? .. ....:.......................... .................... ............................... .... 13. If so, have plans been submitted to. such authorities? : ......... :............................... 14. Has preliminary approval been granted by such authorities? Date granted: iw 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........ ........................: ..... 'a ...... ... .......................... 18. Is project located near a public water supply system? ....... ............................... 19. If yes, name of water supply Distance to water supply 4A 20. Is project site near a public sewage collection or treatment system? ................ 21. Name of sewage system Distance to sewage system 22. Date test holes observed � I a I J-23. Name of Health Inspector .&_cyv&„ s-rnxg . 24. Project design flow (gallons per day) ..:.............................. ............................... &00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.:. 26. Has SPDES Application been submitted to local DEC office? ......................... A10 Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? A10 . .. ..... 2S. Wetlands ID Number .................... ............................... .., 29. - Is Wetlands Perini' required? Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ...................... .I........ Nv 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 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 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................:.. -� 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ........................... ..... NU 35. Are any sewage treatment areas in excess of TS% slope? /Va . 36. Tax Map ID Number .......................... ............................... Map 8q Block y Lot 5'0 37. Approved plans are to be returned to ..... Applicant_ Design Professional NOTE:.All applications for review and approval _of anew SST to bP to ;atedmithiri-thoNYC-V�'atershed shall '" y J sent�to theDeartrrient; 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. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of nay knowledge and belief. false statements made herein are punishable as a. Class A misdemeanor pursuant to Section 210.45 of the Penal IL w. 01 : I I WV Z Z M Zr sOA6 Hi.:1V3JHA "N3 Mailing Address: .........:::'fi.,'t� i.lCl- Mjc1cr,-1Z4 C7 06776 PUTNAM COUNTY DEPARTMENT OF.-HEALTH pIVyLS� IQN- OF U-NV..I. RONM_ NTA�. HEALw._T.. H .SERVICES: .. r: DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Located at (Street) Tax Map Block Lot (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA. Date of.Pre- soaking Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s l min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. ± 2. Depth measurements to be made from top of hole. Form DD -97 ! d W ryAr +M i FAMILY ROOM m SUN ROOM 1 1 /2 -x9 1/4- AOGRG -LAM �• t :t I 0- i. . W CEILING ( 1-WF 1 I ! CIL I I 1-7' R.O. 4' -0" R.O. 1 (2) 2x10 SPF /2 (2) 2.10 SPF 2 KITCHEN j 836 — 4 jyp( L ( O" R.O. ;(2) 2x10 � DowN G ! e I! 26 ! J TO THE SST OF MY 1010WUDCC, MIFF AM PROFESSIONAL "B' _HALF AMEANT• WJS;FACTORY MAN XlURFD NOME (R°7) PUN HAS BEFl! App�y� FROM A . SET OF FUN PLANS ! ! RAILING INSTAL(£p FREVI(AISI.Y APPRl11ID 81 7}� NEW Y1pM OEPARD M OF STATE IN PLANT BY GREST i FPROTION NO. MOTT5- 96 -Ot6, WSfACTW IM NO. MDT05, UP i DWAT04 Dkn 06/03/02, MTRCN HAS NOT BEEN MOOIREO IN ANY MANNER. '!jE EJtERGY PORTION OF THIS FMN PUN 1U5 BEEN LIVING ROOM ',• S PREPARED UA1't'. IHE ENERGY CONSFINATION (b1J5lRI1CRTX7 G0� OF NEW YORK MO S IN FULL COMFIIWCE WITH THE ENOW ODOE. 1'- ' 9' -10 1 4' 3 -17 3 a' LANDING . WAPLIANCE 61%PPORRO USING INE PROPOSED NEW YORK STATE ENERGY (2) 1 1 /2'x9 1/4' MICRO -LAM DINING ROOM BIB CUS�C WD R; MECCHECR SOFTWARE Vi'RSIW 3.3 RELEASE IB — — IN CEILING — — — SITE LOCA1pNiWWR VALLEY, N.Y. — — — — -- — — -- 3I I :-0.3(-STEEL ' DEGREE DAYS. -IOW .. NEN YORK STALE SNOW WP ZONE: 35 TRUSS SPAONG: 24.0/C _ pf n T -6 t/2* 3' -0 1/2" ( 12• -0' '"'—_ {F: At- V-3 L 11' -31/4' I 2T- 51/4 "I' I BUILDING DEPT. FRONT 'F DATE r,.,. Lr L PERMIT NQ. Y D1A. FUTURE V. BATH 3 "A" -HALF 2.1 R -30 CEILING INSULATION 4F NE VISE LWOLOCAnoNs �PrE SE TV A PHONE LOC. R_ PANEL Box LOC. ci s m w c- w m •G9 jr F RZWAL Ru PORTION JUL 3 A 2002 w..x++ru+w cwc l.res4 110mes. now Atnnu+accurma•4r. All 1`7911V reserved. ClASSIG WOODWORKING. F'U INAM VAf_L_tY. N.Y. ((:A Homes. 111103 Af"uf° I e �O LP�� �'41l riPhts reserved. D - - _ xaa, O W z o. iZ O U - n Opp � :ti_r O F W O • GrUM i T. z wE F n ! d W ryAr +M i FAMILY ROOM m SUN ROOM 1 1 /2 -x9 1/4- AOGRG -LAM �• t :t I 0- i. . W CEILING ( 1-WF 1 I ! CIL I I 1-7' R.O. 4' -0" R.O. 1 (2) 2x10 SPF /2 (2) 2.10 SPF 2 KITCHEN j 836 — 4 jyp( L ( O" R.O. ;(2) 2x10 � DowN G ! e I! 26 ! J TO THE SST OF MY 1010WUDCC, MIFF AM PROFESSIONAL "B' _HALF AMEANT• WJS;FACTORY MAN XlURFD NOME (R°7) PUN HAS BEFl! App�y� FROM A . SET OF FUN PLANS ! ! RAILING INSTAL(£p FREVI(AISI.Y APPRl11ID 81 7}� NEW Y1pM OEPARD M OF STATE IN PLANT BY GREST i FPROTION NO. MOTT5- 96 -Ot6, WSfACTW IM NO. MDT05, UP i DWAT04 Dkn 06/03/02, MTRCN HAS NOT BEEN MOOIREO IN ANY MANNER. '!jE EJtERGY PORTION OF THIS FMN PUN 1U5 BEEN LIVING ROOM ',• S PREPARED UA1't'. IHE ENERGY CONSFINATION (b1J5lRI1CRTX7 G0� OF NEW YORK MO S IN FULL COMFIIWCE WITH THE ENOW ODOE. 1'- ' 9' -10 1 4' 3 -17 3 a' LANDING . WAPLIANCE 61%PPORRO USING INE PROPOSED NEW YORK STATE ENERGY (2) 1 1 /2'x9 1/4' MICRO -LAM DINING ROOM BIB CUS�C WD R; MECCHECR SOFTWARE Vi'RSIW 3.3 RELEASE IB — — IN CEILING — — — SITE LOCA1pNiWWR VALLEY, N.Y. — — — — -- — — -- 3I I :-0.3(-STEEL ' DEGREE DAYS. -IOW .. NEN YORK STALE SNOW WP ZONE: 35 TRUSS SPAONG: 24.0/C _ pf n T -6 t/2* 3' -0 1/2" ( 12• -0' '"'—_ {F: At- V-3 L 11' -31/4' I 2T- 51/4 "I' I BUILDING DEPT. FRONT 'F DATE r,.,. Lr L PERMIT NQ. Y D1A. FUTURE V. BATH 3 "A" -HALF 2.1 R -30 CEILING INSULATION 4F NE VISE LWOLOCAnoNs �PrE SE TV A PHONE LOC. R_ PANEL Box LOC. ci s m w c- w m •G9 jr F RZWAL Ru PORTION JUL 3 A 2002 w..x++ru+w cwc l.res4 110mes. now Atnnu+accurma•4r. All 1`7911V reserved. ClASSIG WOODWORKING. F'U INAM VAf_L_tY. N.Y. ((:A Homes. 111103 Af"uf° I e �O LP�� �'41l riPhts reserved. D - - _ :3. } : 12' -4" t (2) 1 1/2'x9 1/4• MICRO –LAM , i :.. IN FLOOR T, rr (' i I .iy 1, 40 -0'. _ 9' -8 1/2- 8' -7 1/4- 7' -4 3 4- s 12' -0" A' V. F UR iN A? (D BEDROOM 3 !I o BATH 2, !r BATH 1 :* . 26 $ Q ;i.`. YI 26 126. V 2' -0' (4) LAYERS 3/8" (3) PLY 2 6 ° 24/O PLYWOOD 2jp 1 DEEP — — — — 26 .26 39' HIGH 26 4 SHELVES DOVM WLL — — — — T.: " 0 i.2� 2 F— Tl I .,•• L`J �I X14 8 'Po II 1= rpp 9' -10 1/4- .t (2) 1 1/2"x9 1/4" MICRO -LAM J' IN CEILING (DROPPED HEADER)t� (2) 1 1/2 "x9'1/4" MICRO -LAM IN FLOOR BEDROOM 7 i. BEDROOM 2 ® 1 1 1 i.; . 0 GI TO THE BEST OF MY NNO%UDCE. BEUFF AND PROFESSIONAL JUDGEMENT, THIS FACTORY MPNUFACIURED HOME (FMH) PUN ROOF FOR WALK OUT DAY HAS BEEN APPROVED FROM'A SYSTEM SET OF MN PUMAS °D ® ON SITE 13Y BUILDER PREVIMY APPROVED BY,THE NEW YORK DEYARiYENT OF STATE APPUGATION NO. M0705 -W -Olk NHNFACIURERS NO. M0705, E)MnON DATE 08/03/02. WHICH HAS NOT BEEN AIOpFiEO IN C ANY MANNER THE ENERGY PORTION OF THIS FUN PLAN HAS BEEN PREPARED USING THE FiTERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK AND IS W. FILL COMRIANCE WITH THE ENERGY CODE . COMP114AE IS U�FG THE PROPOSED NEW YORK STALE ENERGY 23' -2 1 2' 3' -0 1 2' : 12' -0' CONSERVATION CON CODE YECLHECK SOFTWARE VERSION 3.3 RELEASE IB BUILDER: DASSIC WOODWOWK SITE LOCATION: PUINW WM, N.Y. V -3 1/2� I 11' - 1/4" I -5 1/4' DECREE DAYS: 7000 NEW YM STATE SNOW MAP ZONE: 35 TRUa SPA7NG: 24*o /c FRONT 1 02 -333 Coavria6t(c) 2002 Crest Homes. BBOS dtenufscturine L.P. _;All ri bts reserved. 1 i J i 6 e 0 0 1 r I t2 1 "C -HALF D"-HALF 5 �AD 4 R -30 CEILING INSULATION VISE LINO LOCATIONS TV 8 PHONE (- PANEL BOX LOG. 6 w W Z L AAPROY - U PJJREO 1O ACTOAY _ !LT POR1 N JUL, 10 2002 'REST HOMES UAL ABE R EN02 -333 ABE ENSIONED FLOOR PLAN DEL 4028 -2601 4I5 7 -IO 3. NO. EN02 -333 SCALE: well as ai r.�.�A:�_ a. ./<`•w1S, r. 'R. :. .�: :� '`GRAPHIC SCALE ty 70 is 30 o in ,7 IN 18E7 ) '4 1 Inch - 80 R X63 �S 83' 'E _21W.� �• t N 0705'081W N UP 0 �F Septic T Sanita GRAVEL 0� PGA R Q-0e` / 8 o; 010 L_'— 7. TRAVELED WAY TEa KA • -pv \Or - o z- 0 AS —BUILT SURVEY BY: FILED MAP DESIGNATION THOMAS C. MERRITTS, LS. g 10 ,� SHEET 122, BLOCK 1, LOT 23 AND 24.1.1 189 BRADEY AVENUE 'UC u AS NEW TM #: 84 -2 -50 HAWTHORNE, NY 10532 AE BEFORE WATER SUPPLY: (914) 769 -8003 ICE WITH ALL KENT OF HEALTH PRIVATE WELL BY: STEPHEN J. FERREIRA, P.E. NORMAN ANDERSON, INC. 103 PERRY DRIVE 152 BARGER STREET NEW MILFORD, CT 06776 PUTNAM VALLEY, NY 10579 (860) 350 -2499 LA p. C V1 N L�. C 8 Q Q, ENTIRE SITE /fop by i i tlONC, Q, d *1 Ce�•m� �l 163.06. mom, mo LOCATION DIMENSION (FT.) LOCATION DIMENSION (FT.) Al 176 B1 176 A2 180 B2 179 A3 185 B3 184 A4 18B B4 187 A5 193 65 191 A6 137 136 132 A7 142 B7 137 A8 146 138 141 A9 152 B9 146 A10 157 B10 149 All 107 611 95 Al2 113 B12 100 A13 119 B13 105 A14 124 B14 110 A15 27 1315 27 N PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION pF ENVIRONMENTP HEALTH SERVICES. Irl APPROVED AS NOTED FOR CONFORMANCE WITH APPLICABLE RULES AND REGULATIONS OF THE P NAM COUNTY HEALTH DEPARTMENT. dusW'� � (• D NA URE &TITLE ATE FILED SSDS LAYOUT "AS-BUILT" PREPARED FOR BRAD CHAD WICK 30 POSEY ROAD THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYS'. INDICATED ON THE PLAN AND THAT THE SYSTEM WAS SITUATE IN THE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCT .. r� r r S A1�?DARL.; RULE, ANJ? .RF�(AIATIONS. OF, THE PUTNA�i - T TG WN Or P UTNAI'�i- VALL ; i' : } - -. AND THE NEW' YORK STATE ' DEPARTMEW OF HEALTH. P UTNAM COUNTY NEW YORK "NO GARBAGE GRINDER WAS