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BOX 33
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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.
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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.
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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
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NAME:PUTNAM COUNTY DEPARTMENT OF P. 3
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NAME:PUTNAM COUNTY DEPARTMENT OF P. 3
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FOR ADIOINI G AREA SEE HAGSTROM'S WESTCHESTER COUNTY ATLAS
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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
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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
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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)
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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
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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 — — —
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PREPARED UA1't'. IHE ENERGY CONSFINATION (b1J5lRI1CRTX7 G0�
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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
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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
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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