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Home My WebLink About4589DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -27 BOX 34 r! ' i �, - so Ir IN-irli me ' mile MEN% oll r 44 6 �r 1.'� ' NN • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES NMI A k15 ..._; _.�.9: Well Location Street Ad ress: -7. Me.&O0 Cre4T � riv c Town/Village: M�1�4Q�.c, Tax Map # �, iMap8§- 10C�lock C Lot(s),�27 GPS � ; Well Owner: Name: Address: Chrmok ---&m GkL,9 ri MeAAOvj Crs l 7c. Mt�hopNe, Use of Well: 1 -Prima 2- Secondary Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion X Compressed air percussion Other(specify) Well Type Screened _Open end casing A Open hole in bedrock _Other Casing Details Total Length /,5-1 ft. Length below grade /-!A� Diameter (P in. Weight per foot ! -1 lb /ft Materials: '% Steel Plastic Other Joints: Welded %*"*- Threaded Other Seal: "% Cement grout Bentonite Other Drive shoe: '\ Yes ' No Liner: _Yes No Screen Details Diameter (in) Slot Size Length ft Dept to Screen ft Develo ed? First I _Yes No Hours Second I Well Yield Test _Bailed _Pumped \ Compressed Air Hours Yield / A gpm Depth Date Measure from land surface-static (specify ft) During yield test (ft) Depth o comp ete we m ft. 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 / 143 / ^4 fA#ViT-i If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type - Wnj c Capacity Depth M10 Model 7C�SI Voltage 0 HP / Tank Type g . felt Volume bate 5✓ Well'Compleked s 1NeI1 Dflller,PC Pumpkl_nstaller Certificate # IVY State # x . Y, PC Certificate. #Q(p ;, NY State# k Date of Report . J t Well Driller Name 8� Address `' kj k 3W y - <3 s�3 aF r t r xr e+'p 'per D filler (signature) 2�' a'� r Pump Installer Name "WAddress , 'k � 3s ;, ,µ J �t .... :. a4`F Y �T""hY )� /y' 'C .:L '..kr�FV j.. tix_if,e��3.<tYR`;1.�:;c P p l staller (signature S3'J`'i S NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 Harry W. Nichols Jr.. P.O. Box 252 Brewster, NY 10509 Tel: (845)279 -4727 2� iV �; 2 � 5 := �. ;:N- , � Fax (845)29 ' 728 Michael J. Budzinski, P.E. Director of Engineering Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: ' Individual SSTS Compliance .Hudson City Savings Bank (Formerly Boniello) 17 Meadowcrest Drive (T) Putnam Valley TM 85.06 -1 -27 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of Drawing S-6, "As -Built SSTS ", dated 06- 30 -15. 2. - "Certificate_ of Construction . Compliance for ,.Sewage Treatment System" dated 06- 22 -15. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 06- 30 -15. 4. Laboratory Report, dated 06- 23 -15. 5. "Well Completion Report", dated 6. Application Fee in the amount of $300.00 payable to Putnem; County �H .. : aIth Department >. s . 7. "E -911 Address Verification Form ", dated 02 -14 -08 If there are any questions concerning the enclosed, please call. Very truly yours, Harry . Nichols Jr.. HWN:jm 06 -039 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... KtN'F, O>1;TBTIFQ '_T, TAT wYS'�':El Hudson C,f 6aylk s &, Owner or Purch ser of Building Gdrrn %P& io n, eA o Building Constructed by Location - Street Building Type 8s, 0(Q z7 Tax Map Block Lot rurH AO U A L),6Y TownNillage Subdivision Name 4 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 system. The' undersigned- Tunher agrees to' accept' ds `cdnclusive" th6- determination of'ttie-WbTic' I-1ealth ' 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 J U� Day U Year 2-®i rl Signature: Title: General Contractor (Owner) - Signature Coen Name (if corporation) Co ion Name (if corporation) Address: hJ e.S f Fa Ce , y 1"e) Address: jA/4•.i- ;P'y State �,q „-, �� Zip State /�., k � Zip L Form GS -97 DIVISION OF ENVIRONMENTAL HEALTH SERVICES Il v�$dh `t� �IViH S �n Owner or Purchqser of Building Building Constructed by Q .M f, ,,, J aw cv-cst p vi v-e.,, Location - Street Building Type SUR. ss, aCs 2-7 Tax Map Block Lot ru i M AM U A 1_>, 6Y TownNillage Subdivision Name 4> 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 system. The undersigned `further- agree §16 46cepf "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 U P E Day U Year U i' o General Contractor (Owner) - Signature Coat on Name (if corporation) Signature: Title: gev t Co ion Name (if corporation) Address: G11 P.S f rO Ce-, by j" 6. Address: State P& Zip State )�Vf &..J S Zip u "L Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFA F, EYVAQg jjtE�A' 1 =S`, SL '-EN' � a._ H DJ Sd h C 1 54V1H S &n Owner or Purch ser of Building C,&rrn,r& 1�on1 e,110 Building Constructed by rl A4 r- G O-w GVtA 5 Nt v-e� Location - Street / � -e.5 ( of lr-"41 It Building Type 8S, oce Tax Map ru-rH All TownNillage ' z-7 Block Lot A,Ca.d o w S Subdivision Name rP Subdivision Lot # v A W,EY 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 system. The. :ndersi e-L. the drs to ucce t as concius�iV the'de�ermihation of the public Health g gr P 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 J VH� Day U Year I -e i l Signature: General Contractor (Owner) - Signature Co a ion Name (if corporation) Address: PJ e.S f JVa Ce , h,,y r 6 State , ',,., 4-j Zip Title: cart � Co ion Name (if corporation) Address: irtj & - � (�e-„ wit State /�',�,., u Zip �— Form GS -97 PO Box 733 Marlboro, NY 12542 Phone 845- 236 -7823 Fax 845- 236 -3911 ENVIRONMENTAL LABWORKS, INC. FLAP #10824' Mr. Lynn Morse 17 Meadow Crest Rd. Mahopac, NY 10541 Dear Mr. Morse, The following are results of the analyses performed on samples from 17 Meadow Crest Rd., Mahopac, NY received at the laboratory on 06/09/15. Sample Location: Kitchen Sink Date /Time Collected: 06/09/15 11:50am Lab Sample ID: 06091512 PARAMETER Total Coliforms /100ml E.coli /100ml pH @ 22.1 0C Alkalinity Hardness as CaCO3 Turbidity Nitrate as N Nitrite as N RESULTS ABSENT ABSENT 7.88 std units 165 mg /L 169 mg /L 0.184 NTU 0.333 mg /L <0.025 mg /L Collected By: Labworks - LON Secondary ID: LM15872 MAXIMUM CONTAMINANT LEVEL METHOD -- SM18 -22 9223B( -97) -- (Colilert) -- SM4500H -- SM18 -22 2320B ( -97) -- SM2340C- 97, -ll 5 NTU SM2130B- 01, -11 10 mg /L EPA 353.2, Rv2.0 1 mg /L EPA 353.2, Rv2.0 Lead <0.001 mg /L 0.015 mg /L EPA 200.8 Iron <0.051 mg /L 0.3 mg /L EPA 200.7 Manganese 0.012 mg /L 0.3 mg /L EPA 200.7 Sodium 16 mg /L -- EPA 200.7 _ Tire 'data cotrtaineari 'thi's °report •were obtained using EPA or other approved methodologies. This laboratory or any outside laboratory used are NYSDOH certified for these analyses. Vendor laboratories used were ELAP #11216 and #11549. The results in this report apply to the samples received by the laboratory, analyzed in accordance with the chain of custody document. This analytical report may only be reproduced in its entirety. If you have any questions, please do not hesitate to call us at 845- 236 - 7823. Thank you,e TrkdI,e LL tvd for Anthony J. Falco Laboratory Director Page 1 of 1 04 7P.$ 04 BRUCE R:. 'POLB1i• LOR>BTl'A M0L1NAPWXM;' M.S.N., i�Qltc Hdol�h 'Dln'Olpr ,� - �; - vivaorwe- 14q..l[4altA Las1,96, «= . _'s. • ; — ... - DEP4TMEN'T OF HEALTH 1 clonova Road Prowster, New York 10509 Ear{rooucaW Veelti (911)371•/170 Pu(914) 371.7921 ' Nonlo/ 3ervkw (914)371.6111 .WIC (914)271.6679 .FuP14) 271.6013 , LeAy'Tikrrie lit. 014 Pruelool (914)3714on Pu(914)771r•6611 E911 ADDRESS VERIFICATION FORM OWNERS NAME: ccut,_w+ 1 y :f Blg t4 i f, + 10 TAX MAP K"ER: S 2 IrL E911 ADDR ss.., M ecl jgwQ 0441 bpi TOWN: AUTHORIZED TOWN OFMCIAL: LIZ DATE: ' 'Z The "Putnam- County Department of Health will not fssue a Certificate: of. Constroctiou Compliance unless the above form is completed; i.e.; a addresg fi;a3sigueri -by an atithosted. 4o?tmoUld&L Th6 fomi 4.1 iv. bi subls>ltted ftb:`11he appllcatiou `tor a Certiteate of Copstructioli Compliance.. (E9I I VfRFR[ ijiL v _t6 iuiv ur' EN VIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location I / /l1- Town "- / ' Date: lel.7 l 19 6 Inspected by: c.(_S 2 Owner Subdivision Lot # 1. Sewage System 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 ...... ............................... 11L Sewage System a. Septic tank size - 1,000 .......... 1, 250 :.......other ................ b. * Septic*tank. installed level ..............:. ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost ...................................................... 3... Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......:.. ............................... 6. Length � h 1. required (�o Length installed 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 - 11h" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends ca pped ........................ ............................... g. Pump or Dosed hystems 1. Size of PAP. chamber .... : ................ ... 2: 'Overflow twik:. -. :. s : - ..'. "-. _ . :.`.`". ... '.... :...:.:.:...... . r- 3. Alarm, visual/ audio ........:............ .........:..................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle.....:..... M. House/Building a. house located er approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured . . 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 protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided .................. ............................. — Rev. 12/02 Um R WW wo - VIA, NNUM WANG /11111 lj�zc. SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner o Health - October 24, 2006 Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive — ROBERT MORRIS,.P.E.- ..... - .,.... e"ct&r e-�nviroriinerila��fealth ' Re: Field Inspection Meadowcrest Drive, (T) Putnam Valley TM# 85.06 -1 -27, Lot 6 The above referenced separate sewage treatment system can be backfilled. The following comments is must be corrected m the field. _ Fifth Junction Box top is broken and must be repaired. j o6 ✓2. Silt fence must be erected and maintained as per approved plan (front of house and around well). If you have any further questions, please contact me at (845) 278 -6130 ext. 2155. JD:kly Sincerel seph Digit Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 +ab ( P.01 1 PUTNAM COUNTY DEPAx$'Y'11+1ENT OF EEAiLTH DY'V'iSYON QF EN�?I+ '- �.,�::� ��►''��IE�t• •� "' .. � . � ..� &M FST POIR FIN I - MISUCTIAN For: Fill Date: to -- +� 0 Trenches PCHD ConsMiction Permit # ;-PV A-03 / Located: mw�wc.a " joe&k&= (T) (t ` r Owner /Applicant Name: Block __ G Lot Formerl t�P c y. ___.__ , _ ...... _ w .w,• ..___........_ _� Subiavisien ?dame: 5�,6� iivision Lot # __ Is system fill completed? _ Is system complete? Is. Mtem cotastruottCd as per plans? _ Is well drilled? Is well located as per plans? Are erosion control measures in' place? Date, Date: Id - -dC� Date: -O 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 Constriction Permit acid approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: .1 Certified b Professional de .. Address: V.t H Commute; FOR: 0 ADAM GE]Vir d (NAMB) form KPI-99 OCT -23 -2006, MUA 1.7: l TEL: 845 -278- 792:1 `!A11E: °t!TNRM COUNT'`i' DEPARTMENT OF P. 1 VV D L D PUTNAM COUNTY DEPARTMENT OF HE 3 DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'I1U—N.C�� ;TOW SEWAGE: 1rI�E1AT1 N.T-'SYS T'EPvi - PCHD CONSTRUCTION PERMIT #m: _r __ Located at 17 clove cve s r I v e, Town or Village Owner /Applicant Name A v 460 h tl Sa v i h s &►+ � Tax Map S!3.0 Block 1 Lot 2-7 FormerlyC, c I Subdivision Name / 41A4o w5- Subd. Lot # Mailing Address X11 -5-f' 00 Cfet4 tv-1 Roa c� Pa Jr6k"4 , Date Construction Permit Issued by PCHD - I -06P Al, T, Zip 47CD6- Separate Sewerage System built by C • Qer i -e- l l 6 Address Consisting of 17s6 Gallon Septic Tank and le47 /,10, 64so r-p tioh 7ratic -� e5 Other Requirements: Water Supply: Public Supply From Address- or: X Private Supply Drilled by Address Building Type 40 nt g Has erosion control been completed? S - - ` Number of , eliiooms �} Has garbage grinder been inst41ed ?' a ' - I certify that the system(s), as listed, serving t% built plans (copies of which are attached), in ac plans and the standards, rules and regulation�S Date: Certified by Address were constructed essentially as shown on the as- issued PCHD Construction Permit and approved 7� `o ty Department of Health. 1�;7 P. E. Any person occupying premises served by the abaves��einF License # 00 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 approval0are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. Byecy A°R< Date: 3 k Wh HD F ile; Yellow copy - Build' g Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 M COUNTY R P R r M n T OF HEALTH PERMIT # P V l Located at A <-4 rje 4; c v e- & I a 4., Subdivision namee �Q.5 J � Subd. Lot # Date Subdivision Approved C' Owner /Applicant Name C r , a, Mailing Address Town ok V4 fte Pryf Tax Map &�,0(Q Block I Lot 2--7 Renewal j/ Revision Date of Previous Approval 03 Zip oC E � Amount of Fee Enclosed 5-00 �1 Building Type Lot Area 10,91'1 No. of Bedrooms --I Design Flow GPD OX Fill Section Only Depth Volume Separate Sewerage System to consist of 12 5 X gallon septic tank and nI s Other Requirements: To be constructed by T A 1 � Address Water Supply: Public Supply From Address or: t/" Private Supply Drilled by -]/ 13 D Address ._�.. -. ., w Ra,: ._ .o . � .e- �.•n..., .. y,,. zx�. -�., _..�: •t••c, . � _ >y �- -- .�... -_ m .:.�... .-o- - .. . e ...'M. ,_ :.�,y .i ..+a .y.• ..�a. •�� - <.. ... . -''o d I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date '7 - 22-8 ° d 6 License # 12-4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new ermit. Approv for discharge of domestic sanitary s wage only. By: f.._ Title: Date: White copy - HD r; ; Ye to copy - Building Inspector; Pink copy - O er, Or ge copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL p ' V / 1 please print or type PCHD Permit # ! / CJ —t✓ 3 - VridH a:4;s- 'j.',- :. >r -..: *! r :..,,, �,.•� ��, �Lot(s) G''ve 5J ! "Ul�hQhl Map ✓�,ffz Block f Z Well Owner: ame: ]Address: 0eJ Pv�,4" rswthG Ghl�l/0 ntr- i c2' ! Use of Well: _Residential Public Supply Air /Cond/Heat Pump Irrigati 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm #People Served 'C�- Est. of Daily Usage a _ gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling /New Supply (new dwelling) Deepen Existing Well Detailed Reason ,ta - for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ........:...................... Yes No i,-` Is well located in a realty subdivision? ..................... .............. ............................... Yes �/ No Name of subdivision 7-71 e- e il4 -u_S Lot No. ce� Water Well Contractor: 7—,8 D Address: Is Public Water Supply available to site? ........ . ............................... . ............... Yes No c% Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination be provided on separate shee plan Date: '2.29 —0 Applicant Signature: _ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the .Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a w�ter well driller certified by Putnam County. Date of Issue —0 Permit Date of Expiration Title: _ Permit is Non -Trap fer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - OwNer; Orange copy - Well driller Form WP -97 SHERLITA AMLER, M®, MS, FAAP Commissioner of Health ,LORETTA.MOLINA_RI, RN,,MSN x' Associate C omMisstonir`of fi(ealtff Harry Nichols, PE DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 i September 6, 2006 ROBERT J. BON ®I County Executive ROBERT MORRIS, PIE_ -_ DireLior of Environmental Health Patterson Park; Suite 106 2050 Route 22 Brewster, New York 10509 Re: Proposed SSTS for Boniello Lot # 6 — Meadows Subdivision (T) Putnam Valley, TM# 85.06 -1 -27 Dear Mr. Nichols: This Department has received and reviewed the revised plans for the above referenced project and the following comments are offered for your consideration. 1. The NYSDEC wetland boundary validation block is to be shown on the septic site plan. 2. It appears the proposed footing drain will require a DEC freshwater wetlands permit since it is shown within the 100 foot wetland buffer. J.-.A. note should be.olaced. on -the= la.n requiring the installation of an�orange cor <st;uctzon < -� - fence along the 100 foot wetland buffer to prohibit unauthorized access and/or _ .. �_ disturbance within the wetland buffer. Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. MJB:cj Respectfully, Michael J. u Director o Er Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing - Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of Located at ,LETTF{R..,.�. OF AUYQRI7AT . - - a I- ON ov TY Py Tax Map# Block �. Lot Subdivision of Subdivision Lot # 6 Filed Map # 2-06-3 Date Filed Gentlemen: This letter is to authorize , r r �, I ; �t�r�l s' 'Jr•j a duly licensed Professional Engineer 'Ji,-*'Zr Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions. of.-Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putn nary Code. . Very truly yours, Countersign Signed: rt, AAAM P.E., R.A., (Owner of rroperty) L �:`- `"vjrSS1 Mailing Address � C. OLD State Zip. Telephone: cj fE_ 27 9 - -Iyo Mailing Address: O DJ , 1k State Zip Telephone: _ Form LA -97 Sept. 8, 2006 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Michael J. Budzinski, P.E. Director of Engineering RE: Proposed SSTS for Boniello Meadows Subdivision - Lot # 6 Putnam Valley, NY T.M. # 85.06 -1 -27 Dear Mr. Budzinski: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 2794567 Email' hnengineer @aol.com In response to your September 6, 2006 review letter, we note the following: 1. .....NYSDEC Wetland. Validation. Block is now.shown,on the Plan. 2: Fool `C1rairi location has been` revised so 4 not to encroach on ` the 100' wetland buffer. 3. Note regarding installation of construction fence has been added to the Plan. We trust the enclosed has addressed your concerns and, request your continued review of this application. Very truly yours, Harry W. Nic Is Jr., P.E. HWN:gav 06- 039.00 September 5, 2006 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 - ATT: Michael J. Budzinski, P.E: Director of Engineering RE: Proposed SSTS - Boniello Meadows Subdivision — Lot # 6 Meadowcrest Drive Putnam Valley, NY T.M. # 85.06 -1 -27 Dear Mr. Budzinski: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 279 -4567 _Rail: liuengineer@aol.com. In response to your August 14, 2006 review letter, we note the following: 1. The site wetlands were flagged by the NYSDEC, and survey located by Joseph. , L--ink;: 2. Enclosed is copy of Link survey with NYSDEC certification block and signature. 3. Well detail now specifies 20' minimum length of casing. 4. Additional Erosion Control features added to Plan. Reflecting the above, enclosed are five (5) copies of SS -6 `Proposed SSTS ", rev. 09/01/06. Kindly continue with your review and issuance of the Construction Permit. Very truly yours, # 6" - Harry W. chols Jr., P.E. HWN:gav 06- 038.00 i SHERLITA AMLER, MD, MS, FAAP Commissioner of Health ,91$�Rt ;cP Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 August 14, 2006 ROBERT J. BONDI County Executive Director of Environmental Health Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 f� Re: Proposed SSTS for Boniello Lot # 6 — Meadows Subdivision (T) Putnam Valley, TM# 85.06 -1 -27 Dear Mr. Nichols: This Department has received and reviewed the submitted application and plans for the above referenced project and the following comments are offered for your consideration. ;✓ 1. The NYSDEC wetland maps have recently been revised and consequently you are required to contact the NYSDEC to determine if the wetland boundary shown on the submitted plan is still valid. V2. The DEC wetland validation block is to be provided on the plan. ✓ 3. The well detail is to specify a minimum of 20 feet of casing. V 4. Erosion control measures are to be shown for all of the proposed site construction (i.e. house,,drive etc.). Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. MJB:cj Respectfully, G Michael J. / dzin ', P Director o nginee Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 July 31, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 2794567; ATT: Mr. Joseph Paravati, . Assistant Public Health Engineer RE: Individual SSTS - Revision - Boniello Meadowcrest Drive Town of Putnam Valley T.M. # 85.06 -1 -27 Dear Mr. Paravatii: Enclosed are the following: 1 -. Five (5) prints of SS -6, "Proposed SSTS ", dated .07128/06. 2 "Short EAF ", dated 07/28/06. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 07/28/06. 5. "Application to Construct a Water Well ", dated 07/28/06. 6. "Design Data Sheet ". 7. Revision & Renewal Fee in the amount of $500.00. Kindly review the enclosed at your earliest convenience and, if acceptable, issue the revised permit. Very truly yours, Harry W. A)holsJr., P.E. HWN:gav 06- 039.06 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 2794567 July 31, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Mr. Joseph Paravati, . Assistant Public Health Engineer RE: Individual SSTS - Revision - Boniello Meadowcrest Drive Town of Putnam Valley T.M. # 85.06 -1 -27 Dear Mr. Paravatii: Enclosed are the following: 1. ' Five'(5) prints of SS -6, "Proposed_SSTS ", dated 07/28/06. ;. "`Short EAF" dated - 07/28/06:= 3. "Application for Approval of Plans for a Wastewater. Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 07/28/06. 5:. "Application to Construct a Water Well ", dated 07/28/06. 6. "Design Data Sheet ". 7. Revision & Renewal Fee in the amount of $500.00. Kindly review the enclosed at your earliest convenience and, if acceptable, issue the revised permit. Very truly yours, Harry W. hots Jr., P.E. HWN:gav 06- 039.06 SHERLITA AMLER, MD, MS, FAAP ROBERT J. BONDI Commissioner of Health County Executive LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 k( 510 it REQUEST FOR FIELD TESTING All info%mation below must be fully completed prior to any scheduling. DATE: ENGINEERING FIRM: L MCL JS PHONE #: ? 7'1 -IGO PERSON TO CONTACT: #—NEW CONSTRUCTION ❑ REPAIR PROGRAM El ADDITION PROGRAM REASON: DEEPS: prl/,PERCS: ❑ PUMP TEST: ❑ ROAD /STREET: L., -e-- ( 6i'- Lazo s1' TOWN: �� ( TAX MAP #:�� SUBDIVISION: -r-4 cia Z LOT . #:�� OWNER: a &!n 1 -P1110 NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING S N Q v T OF Zvt} ! L k S Jf L (� .Proposed SSTS within the drainage basin of West Branch or Boyds Corner & Croton Falls Reservoirs. _ .. n. Proposed, SSTS. within 500 feet. of a. reservoir, reservoir stem or. cpntrol lake.,..._ . L 'Proposed SSTS within 200 feet o ' "a wateri oUrse'or a "DEC wetland. ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered Yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYCCEP. If a project has been.determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the esig "n professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY JE ONLY X4114 L AJJ( ITE: /Z -g / P� TIME: REQ. FOR FIELD TESTING:KLY Environmental Health (845) 278 -6130 Fax (845) 278 -7421 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (843) 278 -6026 WIC (845) 278 -6678 - Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL k 5 e A i i4 i a I`"6 # � C ✓O°N.l � ST iiR.0 � CTIO- N . _ PERMIT F OR S EWAGE_ T_ REAT PETIT SYSTEM PERMIT Located at /�yl FAQ ad ART P Id own r Village Subdivision name&OOT6 41J Subd. Lot # Tax Map Block/ Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name C, U d Al Q gy x e) Date of Previous Approval Mailing Address 13 49® d%,? 0- *j ® Q Zip /Q " Pow Amount of Fee Enclosed (eX66 Building Type -) — Lot Are4 No. of Bedrooms V Design Flow GPD_Sgd Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of MUM gallon septic tank and AA � Other Requirements: G® o B ?e ® ®DO P,51- P . �� O Pot 4441 To be constructed by f=k P Address L Water Supply: Public Supply From Address or: Private Supply Drilled by /`� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments sv tem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. 4- Signed: P.E. R.A. Date Address /A1d':,Aj ® ®� �ed9 License #/� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title:./ Date: copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # 10V-49�-6� Well Location: Street Address: To illage Tax Grid 0, AW " 4BI L;6t(s),'a Well Owner: Name: Address: 64)yf / 00'v / /- 40 OW 0 U f Well: –.../�esidential Public Supply Air/Cond/Heat Pump _ Irrigation r im ary Business Farm Test/Monitoring Other (specify) 2-secondary Industrial Institutional. ;;p--- Standby Amount of Use Yield Sought gpm. 444pw �iervea ' Est. of Daily Usage 221gal. Reason for — Replace Existing Supply Test/Observation Additional Supply Drilling 4'Rew Supply (new dwelling) _ Deepen Existing Well Detailed Reason for Drilling Well Type A-fMlled Driven Gravel Other Is well site subject to flooding? ................................................................................. Yes No Is well located in a realty subdivision? ..................................................................... Yes No Al No. Name of subdivision j9,#y;p d -r Lot Water Well Contractor: T7? Address: Is Public Water Supply available to site? ................................................................. Yes NoZ--- Name of Public Water Supply: Town/Village Distance to property from nearest water main: &A� Proposed well location & sources of contamination to be pro ed on separate sheet/plan. Date: Applicant Signature: L This permit to construct one water well as set forth above, is granted under provisions of Article 10 -of the Putnam County Sanitary Code and Subpart 5-2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED ' FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 0 /cl Permit Issuing Official: A/ Date of Expiration Title: Ass-i-5-&:Ea A f14— Permit is Non - Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Fonn WP-97 CONSULTING ENGINEERS ❑ Daniel J. Donahue, P.E. 200 Breckenridge Road.._ .__. -- -- .,..� 914 -628- 7376 TO WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via , f Y/ r+ the following items: • Shop drawings. ❑ Prints ❑ Plans ❑ Samples ❑ Specifications • Copy of letter ❑ Change order ❑ THESE ARE.. TP NSIMITTED• as- checked below:-- _ - For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment Cl ❑ Resubmit copies for approval • Submit copies for distribution • Return corrected prints . ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: It onolosurso aro not os noted, kindly notify us of 0 Ppiimr. X, A CONSULTING ENGINEERS 9 Daniel J. Donahue, F.E. 200 Breckenridge Road tv*opac..N.Y, 1.0541 TO A7 I DArg f/ 11Z F VMS i Z-0 j . "a It N I Ql Je , ng . WE ARE SENDING YOU 0 Attached ❑ Under separate cover via —the following Items: 0 Shop drawings 0 Prints 0 Plans E) Samples 0 Specifications C. Copy of letter 0 Change order 0 THESE ARE TRANSMITTED as chocked below: Approy ad as submittod - ❑. � fr., Resub d�_,,cap* for approval-.. 0 For your use ❑ Approved as noted 0 Submit —copies for distribution 0 As roquested 0 Returned for corrections 0 Return —cor P! prints 0 For review and comment C1 — 0 FOR BIDS 70E 19 0 PRINTS RETURNED AFTER LOAN TO US 4 r "r If -is. eqO-joiC or o f Xeo/ `.410'_* e COPY TO— of W nup" on 1W 04 fwft4 Way "ft us at on". j1. LORETI'A MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services •rte ROBERT J. BONDI County Executive - � �.. ,e,.r F"� •'_^^t %..'�*... lMEN.y:r %.-• •'.'k: '.; e.'�. - .. eo:0 <.n _ :r-:'°` :'.t.m. - 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 July 28, 2003 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 Re; Proposed SETS - Boniello Meadowcrest Drive (T) Putnam Valley TM# 85.0' -1 -27, R. S. Lot # 6 Dear Mr. Donahue: This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. �. Tax map number provided is in error. Please provide correct tax map number for subdivision lot # 6. 4K -� It is recommended that equal distribution be provided. (� ft I- �'. D) _ A distribution box detail needs to be provided. - 6f X-r J. 49 ®� �µ The approved subdivision plat calls for two (2) feet of fills/. North arrow is not pointing in the same direction: as the subdivision_ plat: - A nUW ai-�u�rtu ue- pruvii ed c'once'rning he 5epalratibn alstai�ce tietvveen the Z�+.: drainage pipe and the 2" force main (plan view and profile). i Please show driveway location. - do6^... l+w� The wetland buffer shown on the septic plan does not correspond with the location shown on the approved subdivision plat. ��' P &1e a4 rte® ��9 Silt fence is running through the proposed system. a/^... Pump chamber detail needs to show min imum/maximur� cover and bedding material. c � Forcemain requires 42" of cover (profile and detail), A6 �` d Gwi�7 L - 1 Head loss and friction calculations need to be provided J Curtain drain needs to be a minimum of 15' from the SETS. d`r— Curtain drain discharge needs to be outside the wetland buffer. doo G If wetland buffer-.has been relocated by DEC, please provide documentation and sign - off on the relocation. 131 POE 16 In order to maintain property line separation requirement, it is highly recommended that the proposed system be staked prior to construction- f %f eat V &1d -% ee > LORETTA MOLINARI R.N., M.S.N. Acting Public-Health Director "''L irdctor= of '1"ahehi -oer'vice July 28, 2003 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 Dan Donahue, PE 120 Breckenridge Road Mahopac, New York 10541 M3 Dear Mr. Donahue: ROBERT J. BONDI County; Executive Proposed SSTS — Boniello Meadowcrest Drive (T) Putnam Valley TM# 85.07 -1 -27, R.S. Lot # 6 This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. 1. Tax map number provided is in error. Please provide correct tax map number for subdivision lot # 6. 2. It is recommended that equal distribution be provided. 3. A distribution box detail needs to be provided....... ^'4. The approved subdivision plat cabs for two' (�� feetroffiii. 5. North arrow is not pointing in the same direction as the subdivision plat. 6. A note should be provided concerning the separation distance between the 24" drainage pipe and the 2" force main (plan view and profile). •7. Please show driveway location. 8. The wetland buffer shown on the septic plan does not correspond with the location shown bn the approved subdivision plat. 9. Silt fence is running through the proposed system. 10. Pump chamber detail needs to show minimum/maximum cover and bedding material. 11. Forcemain requires 42" of cover (profile and detail). 12. Head loss and friction calculations need to be provided.: 13. Curtain drain needs to be a minimum of 15' from the SSTS. 14. Curtain drain discharge needs to be outside the wetland buffer. 15. If wetland buffer has been relocated by DEC, please provide documentation and sign- off on the relocation. 16. In order to maintain property line separation requirement, it is highly recommended that the proposed system be staked prior to construction. 17. Floor plans submitted contain 8 bedrooms. ..._. __ cam:_ :-� � .r:.i; :- ;; :�c�.., :: ;;c ; -.;,; • . �- 'fhis ot°tice W-If r contiriueits review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP:cj .�.s.. � ra-• . .e . - .+c+ ._ fir. � .k 'S�. .. y.+.; ....r.. ...., .tee v0..y _. �« . N �� rs!r .. ..... �... ..1w . 'frl � �a O'� .. +�. . r ..- .�� .� �. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT ' j J t cam s:- •..: =2. -.. .. ,y -" c ..,. .:��'+: n�: ., NAME OF QWNER: iOCALTION: J. REVIEWED.BY: RM, GR, AS, SRDATE: 7/,29/03 TAX MAN: (CONF D) -7 ` ,� - L 7 Y N DOCUMENTS Y N (REQUIRED DETAILS ON P C)PERMIT APPLICATION (�ti)'U OUSE SEWER - 1 /a" FT. 4 "0'; TYPE PIPE, CAST IRON WELL PERMIT OR PWS LETTER -I- )NO BENDS; MAX BENDS 45' W /CLEANOUT J (� PC =97 RENEE S % v-. (��,�-- �LETTER OF AUTHORIZATION (SUS , DXAT ANGE)C . ULJ SIGN DATA SHEET (DDS) ?""' FILL SYST (� CORPORATE RESOLUTION (__)U10' HORIZONTAL; PAST CH SLOPES 3:1 TO GRADE SHORT EAF (-)(UFML SPECS/ TES 1 -5 � � �PLANS -THREE SETS C--)C &DIMENSIONS Ulm OUSE PLANS - TWO SETS ( L IN EXPANSION AREA C 6VARIANCE REQUEST FIZZ GREATER FEET SUBDIVISION (J CLAY BARRIER w (�LEGAL SUBDIVISION (___ C )FILL'CERTIFIICA OTE SUBDIVISIONePROV CHECKED UUDEPTg GAU jj� C RATE F L (�C_)VOL.Q*PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS FILL RE UIREp ! DEPT$ U [g TION DISTANCE FROM•TOE OF SLOPE TAIN DRAIN REQ �� TRENCH GENERAL (t/ )LF TRENCH PROVIDED, 60FT MAX ?w'/ (__)�LOCATED.IN NYC WATERSHED iU/ PARALLEL •TO CONTOURS �( LLEGATED TO CHD DEP 100% EXPANSION PROVIDED (��)DETA&IIADUST FREE CRUSHED'STONE OR WASHED GRAVEL EP APPROVAL, IF REQ'D (,_•�GEOTEXTILE COVER (�(�PEEP TEST HOLES OBSERVED / SEPARATION DISTANCES ON PLAN - FItOM SSTS (ee )(, - SPERCS TO BE WITNESSED ✓ - APPROVAL SSDS ADJ, LOTS (U-) 10 TO P.L. DRIVEWAY, LARGE TREES, TOP OFF �Tl S (T OWN/DEC PERMIT REQ'D ?) 20' TO FOUNDATION WALLS 0100' TO WELL, 200' IN DLOD,150' TO PITS TA ON DDS PLANS & PERMIT SAME �50'TO 100' TO STREAM, WATERCOURSE, LAKE (ina expaca, (!)C PRE 1969 NEIGHBOR NOTIFICATION CATCH BASIN, 35' STORMDRAIN, PIPED WATER U TTER BIIZBA ( 10' TO WATER LINE (pits - 20') ' UU�W YR, FLOOD ELEVATION W1I 200' off% • )50': AV7'ER1YII'iTENT DRAINAGE -. _,. <, ... „v ... -. v .-.3T .. .r. UUSOII, TESTING LOTS >10 YEARS.OLD�� /5i38'SIZ'VOfR, ETC. 150' GALLEY SYSTEMS AGE SYSTEM PLAN- (NORTH ( J)UGRAVTTY FLOW N. (_ CONSTRUCTION NOTES 1 -15 a • :tai ( -IC ESIGN DATA: PERC &DEEP RESULTS %k w ' - MT- M & PROPOSfED 1 �ya DRIVEWAY & SLOPES, CUTS G/GUTTER/CURTAIN DRAINS ( )USDA SOIL TYPE BOUNDARIES (-!}(TITLE BLOCK; OWNERS NAME ADDRESS TM# PURA - NAME ADDRESS PHONE# 'MIN TO LEDGE OUTCROP SEPTIC TANK 'FROM FOUNDATION; 50' TO WELL ATION OF SERVICE CONNECTION 15' TO PROPERTY LINE SLOPE 'E IN SSTS AREA ��(_-00 %) [LADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS ' ' (-�} PUMP NOT_ES_,_._ ......._ .__�___ DATE OFDRAWING /REVISION DOSE• 75%o OF PIPE VOLUNM60SV VOL-UM E NOTED DATUM REFERENCE . LOCATION OF WATERCOURSES, PONDS T� F RCE-.MAIN, (PIPE TYPE, ET�'G:� 3' '..' LANES,WETLANDS WITHIN 200' OF P.L. �(JPROPOSED FINISH FLOOR AND U(_)I DAY S - GE ABOVE ALARM BASEMENT ELEVATIONS CURTAIFi DRAIN �`� ' _ _ _ WEIS,S & SSDS'S W/IN 200' OF SSTS �ANDPTPES. T BOTH SIDES, DETAILS f fJ�"i ✓�lr� `i5T L � L- (( ��yy✓, 15' MIN to CDS=>5 %, 20'-4 %, 25' -3 %, 35' -1 %,100 % - <1 %y PROPERTY METES & BOUNDS UU20' MIN to CD DISCHARGE/100' with 182 cons day discharge eLft S' (_,,,_,}EROSION CONTROL FO1�.HOUSE, WELL & - SSTS, EROSION CONTROL NOTE U�C__)10' MIN to NON - PERFORATED PIPE ►MMENTS: 00 5 L C lquv► 1�� S,r SU r t'✓j fi• �*., VSMT)09101/00 June 13, 2003 DANIEL J. BDONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road cA"f,ahl1i`•1 845 -628 -7576 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Joseph Paravati RE: SSTS Permit & Well Permit Property of Carmine Boniello Meadows R.S. Lot #6 Putnam Malley Dear Mr. Paravati: Enclosed herewith please find the following: 1. Form PC -1 I SSTS application 3. Well permit application 4. Design data sheet 5. Letter of authorization 6. Fee in the amount of $300.00 7. Short EAF 8. Two sets of house plans • . 9 Fump curye Do Site o Sanitary o Environmental PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - OF RE: Property of Located at /I P*00 0 GiQO 7 10/?/ yfi 0V L % �'�1'�`1 y,�la� ax Map # - „r, d Block ! Lot c2--V Subdivision of TWO Ai Subdivision Lot # LP Filed Map # Date Filed Gentlemen: This letter is to authorize Z ?eM ! &L J , j)D a duly licensed Professional Engineer 14, or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: C4 }b , fs-MiS A_ P.E., R.A., # (Owner of Property) Mailing Address /{Jf�rvy�e.�ir� State Zip 6i Telephone: R y,(�`� Mailing Address: d yQy� State jj . 4. Zip I [ W-A t . Telephone: (914) 3.%j s - Qg 6o. Form LA -97 30r- -20 z V- 10 U.S. GPM SERIES: 3885 120 SIZE: 3/4d SOLIDS 35- ..... . RPM: 3450 110 5 -G L IS 100 5 F 30- . ....... S.. 0- ... ....... 25- 80 70 . ........ ..... 20- 0 J 15 50 .. ........ . ... . . .... ........ 40 T. 10- 30 ....... ....... . ... .... . .......... ------ ----- 20 .... . ...... -T 0 O Op 10 20 30 40 50 60 70 80 90 100 110 120 0 10 20 30 rn3/h CAPACITY Effective July, 1993 C 1993 Goulds Pumps. Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRINTED IN U.S.A. C315853450 W. S, IP Du al ).Donahue. P.E. 200 flTeckavidSe Road Mahop=, N.Y. 10541 914- 28 -7516 . ........... r *•Y9 fig . WE ARE SENDfNG YOU 0 Attached 0 Under separate cover via —.—the following Items: C2 Shop drawings ❑ Prints ❑ Mans ❑ Samples ❑ Specifications C3 Copy of letter 0 Change order 0 THESE ARE (T tANSMiTTEV as chocked below. &Afor approval 0 Approved as submitted C3 Resubmit copies for approval stlokour use 71 Approved as noted 0 Submit copies for distribution _0 Returned for corrections ❑ Roturn—corrected prints ❑ For r*vWr* and comment C ❑ FOR BIOS DUE 19- 5 PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO 3310NED: A*t As not" kht0j, ""ify us at once. DIN, LrV. RM. 182XI210 1st Floor oil �I 71 13ATH 3: - LAUN. FAM. RM. 1611120 2nd Floor N 1-15 LPlum LYON HOMES INC. Old Trail Road, Selinsgrove Pa. 17870 Telephone (717) 743-0111 r. L", DIN- -Rif cfziv C. LFV. RM. 1841029 7sl Floor _j CHEN mmw RK �II'I II BATH FAM. RM. 16631tv 54x108• 2nd Floor N 1-6 r PENN LVON; Admas, INC. Old Trail, Road, Selinsgrove Pa. 17870 Telephone (717) 743-011 t OFF 14-16 -4 (9/95) —Text 12 I.D. NUMBER .617.20 SEAR Appendix C [PROJECT - .�-�np- .- ....,„,. ,�.;�_�_ o___�:�. °:.�:: ��.....:3iater° Env( roiir�i��ieY�f�a� "Rei�`i'b•1+►'-�•; .. .. -;�-,. a.;� - :- i:�::�.:.._........., SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (robe completed by Applicant or Project sponsor) 1..APPUCANT /SPONSOR // 2 2. PR ECT NAME 3. PROJECT LOCATION: _Le Municipality f fn tr/kt (' ILGI County 4. PRECISE LOCATION (Street address and road Intersect) ns, prominent landmarks, etc., or provide map) M.t.�UCUW7i'Y�5� i•l i �i 5. IS P,R�,O�8ED ACTION: L"J New ❑ Expansion ❑ Modlticatlontalteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially O 8. WILL P�POSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? GNa9 ❑ No If No. describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ PaddFcre3t10pen apace ❑ Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OJI LOCAL)? Yea ❑C�No�- It yes, list agency(s) and (jpormlUapprovals A 44 / 11. 00A ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? • Urysa ❑ No If yes; list agency name and permit/approval S �S c /`C D 12. AS A ULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? es ❑ No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor na a C2 r t^'-1L-t h �L LI t �e_)G G Date: 7-26-06 f f • Signature: 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 II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Dyes o B. WILL ACTION kE EIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? if No, a negative declaration may be superse d by another Involved agency. ❑ Yes o C. COULD ACTION AESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise. levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: Ido C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood cf av cteerEx_p(ain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species; significant habitats, or threatened or endangered species? Explain i? fly-.4' C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resou' ? riefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PRO ECT AVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes :. _ o , "t' iS. fi'iERE,'0R ERE L)KEEf Y0'BE, -CONT uVERSY_AELATED TO *POTENTIAL AOVEkSE E� VIRONMENTAL IMPACTS? ❑ Yes No If Yes, explain briefly PART ill— DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it Is-substantial, large, important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural);'(b) probability of occurri(g) duration; (d) irreversibility; (e) geographic scope; and (0 ritagnitude: If necessary, add attachments or reference supporting mn�';�aterials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. If question D of Part 11 was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. U Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Le-a-d Agency Title of Responsible Officer Signature of Responsible Officer. in Lead Agency Signature of. Preparer (If'different from responsible officer) Date 2 PUTNAM, COUNTY DEPARTMENT OF HEALTH DIVISION. OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM 'Address .13 41:� 0 -7 t 6 od D),) ✓Lle_,,, Owner C4wr,14 ti e- B , Located at (Street ) .6JoIJ C*, jre, Tax Map 05�t4_� Block Lot 27 (indicate nearest cro s street) Municipality Watershed o )say t Ll ew, SOIL PERCOLATION TEST DATA Date of Pre-soaking -7 2, f 0 Ce Date of Percolation Test -7 '3 .. ....... ............................... ......... ........................... . . .......... ..... ....... De 4", ..... ........ ...... .. ..... .......... ......... ........................ .... .. .......... ...... .. ... . . .............. ::Ime ... .... .. . .. ............ . .. e. E d :. Y 01i$:�i� .. ....... . . .... p I ........ 6k: ................ .. ..... to Cl 11-9.0 _1 ..2 9 2_= 1o,12- bO 2,7-11- Z3 i. 3 10*11(9 ;3G 2 1 �-22Z '0 1 '/,9 2-7 5 4'. tOL — L 2 elmi- - 10 S f I - l 3G :2- 1 22-S IX z .3 -2-6 4 5. 2 NOTES: 1. Tes6 t6.:-be re pe ated at same depth until approximately equal percolation rates are obtained at each : .jp6rcol ' ation test hole. '(i.e. :g I min for 1-30 min/inch, 2 min for 31-60 min/inch) All data to be submitted for review. 2'. De th'measu . reinents to be made from top, of hole. -T Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 2 Indicate level at which groundwater is encountered A c),t e- Indicate level at which mottling 'is observed ,�� 9 Indicate level to which water level rises after be'ng encountered e, Deep hole observations made by: D i Date aic6z Design Professional Name: Address: 1-0 (�-o 1, Signature: Design Professional's Seal 4. G.L. g 0 .51 !Z 'iv SO i (� Iq h �'i !'Sat L -T� � ri TvpSO j i- 1.0' /W Py LO 6-A SAQp Y LaAA 1.5' 2.0' 2.5' S iLT y SA-AU D 3.0' 3.5' N /t-Uz io r?0101 XF_L4,0W 6RvIU4 4.0' $" i �? i 5�4A� 0 51 LT)! =.'. S .D 4.5' 5.0' 5.5' 6.0' 6.5' C-0 - 7.0' 8.0' - . . 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered A c),t e- Indicate level at which mottling 'is observed ,�� 9 Indicate level to which water level rises after be'ng encountered e, Deep hole observations made by: D i Date aic6z Design Professional Name: Address: 1-0 (�-o 1, Signature: Design Professional's Seal 4. g r^ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION. OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR 4. 1C WASH: I,WAri rA RF TML+ NT,.S:V5" + M. 1. Name and address of applicant: 2. Name of project: ag• • S (J— 3. Location' 4. Design Professional: , f Address: 6. Drainage Basin: 7. Type of Project: !/"-- Private/Residential Apartments Office Building. Food Service Institutional Realty Subdivision v I / Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review •(SEQR)? . Type Status (check one) ....................... ............................... Type I Exempt Type.II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS). required? ... N� 10. Has'DEIS been completed and found acceptable by Lead'Agency? ............... ,�- j 11. Name of Lead Agency 12. Is this project in. an area under the control of local planning, zoning; or other. oflicials,,.ordinaaces? ................. - 1.3. If so, have plans been submitted -to such authorities? ... .............. ........ ................... /yo 14. Has preliminary approval been granted by such authorities ?,UU Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water "groundwater 16. If surface water discharge, what. is the stream class designation? ..................... JA 17. Waters index' number ( surface) :......................... :..... ............................................ 18.. Is project located near .a public water supply system? ....... ...................:.. .......... . AY0. 19. If yes, name of water.-supply ,{-- Distance to water supply �. 20. Is project•sit&riear a public sewage collection or treatment system? .......::::..:.: 21. Name of sewage-system -- Distance to sewage system 22. Date test holes observed Tu ltt- a-0,0(,i 23.. Name of Health Inspector 24. Project design flow (gallons per day) .................................. ..............................: —goo.. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?:.. _ Ud 26. Has SPDES Application been submitted to local DEC office? ......................... 14- F rm PC -97 2 -27. Is any portion of this project located Within a desighated, Town or State wetland? y6s 28. Wetlands ID Number.. .:...: .. ............... ...... 29. Is Wetlands Permit required? ............................................................................. Has application been made to Town _or Local DEC office? ................................. 30. Does -project require a DEC Stream Disturbance Permit? ............................... 31. Is or -was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, la.ndfillingi sludge application or industrial activity? ............................. Yes/No - A/d 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? ................................. YesfNo /Uto 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? ................................................. k.) . . ............. .35. Are any sewage treatment areas m.excess.6f 15% slope? ......... ....... . ................ 36. Tax Map ID Number ...................... * ......................... ........... Map �� Block Lot 37. Approved plans are to be.returntd to ..... Applicant k--`_D_esigri'Prdfession'Al for -6 appli, ittio%s- rovLfof -ne?;v-S bT',':'Lo bc116itted-wid-&i the .NYC VdtefsFed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the prpj ect may require DEP approval of lhc,SSTS prior to final approval-by the Department. Project A within the watershed may also require DEP review and approval of other.aspects of a proje6t, such as stormwater plans or. the creation of impervious surfaces; and the project applicant should obtain the appropriate forms for such acAvities from DEP and submit those forms to DEP for review and approval. IS If the application is signed by a perso'n -other than the' applicant shown in item I.,the appl�ti on th Pt be -accompanied by a better of Authorization (Form LA-97). Failure to Omp'ly.With t1ft prow if , on may be grounds for the rejection of any submission. C/) C-_ ea .4- I hereby affirn, under penalty ofperjury, th at information provided on thi PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES, e:,: -.•c -a- -N ,�,r„S.t.. t'.�:.; "..li�. ;. r; •'4; _:. c'^.- -', ..� e.n ..C:.L , "per.. ,d, a.: -,._ =s' -•vim: 'a] -.. :a-.�n.•w.�e �... .c .:.f:. i -.., n, .,+. .,Gj,- '41,�.T. ..- �::� =►:�•. DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ,d6NN1, U-0 Address %�''i'fl '00Cw(:wiST Located at (Street) �Db% C�S%�C� �� S�Tax Map Block Lot v icate nearest cross st eet) Municipality U /iI� �� Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 3 4 5 1 2 3 4 1 1 5 NOTES: 1. Tests to be at same depth until approximately equal percolation rates are obtained at percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -bu mmimcn) An data to oe submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 1 2 _.. 3 4 3 4 5 1 2 3 4 1 1 5 NOTES: 1. Tests to be at same depth until approximately equal percolation rates are obtained at percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -bu mmimcn) An data to oe submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 z 3 4 5 1 2 3 4 1 1 5 NOTES: 1. Tests to be at same depth until approximately equal percolation rates are obtained at percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -bu mmimcn) An data to oe submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 T'ES'L' PIT DATA 2 —"DESCRIEPTION OF SOILS ENCOUNTERED IN TEST DOLES �� G`�/��o✓'L 7 G.L. S' ��, �r s °-7 `I Y 0.5' A�0 1.0' � aGJ 1.5' �U► 2.0' 11.1- sib- �� 2.5' 3.0' 7 d 6 ll �d SA �® 3.5' 4.0' 4.51 e� 0 /VO k- 5.0' 5.5' 6.0' 6.5' 7.0' 7.511, 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed A 0A aA519')8D Indicate level to which water level ris eing encountered awA I ) . Deep hole observations made by: Date Design Professional Name: Address: Signature: Design Professional's Seal 11.161(2167)—Text 12 PROJECT I.O. NUMBER e4�s9 SEOR Appsndix C Stets, EnArpnn Alit! QU2HIy- lR.6mjat .-. SH60 ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— •PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT (SPONSOR t. PR ECT�IAJ�IE RW 9. PROJECT LOCATION: d Munleipality 1/f � County 4. PRECISE LOCATION {Street address'end road Intersections, prominent landmarks, etc., or provide map) G,eArJ r vx /dam S. IS PROPOSED ACTION: a Ne•x ❑ Expsnsion ❑ Modificationtalterstion 6. DESCRIBE PROJECT BRIEFLY: C(J q V C771 6,V 7. AMOUNT OF LAND AFFECTED: d 1� Ultimately v f a' initially acres acres 8. Veil PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No If No, describe briefly 9. V49AT IS PRESENT LAND USE IN VICINITY OF PROJECT? QrResidentle! C3 Industrial ® Commercial E) Agriculture ❑ ParkffamsstlOpsn space Other Describe: 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY GOVERNMENTAL AGENCY (FEDERAL (OTHER STATE QYe� LOCAL)? No N yes, list a9eney(s) and permlVapprevals / °v !✓�,o � 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes L1 No It yes, list agency name and pirmitlapprovol 12. AS A RESULT PROPOSED ACTION WALL EXISTING PERMMIAPPROVAL REQUIRE MODIFICATION? IOdF� ❑ Yes IeJ No . I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE `'' / J, Appticentlsponser name: Date: Signature: 17 It the action Is In the 6o:a1 *sal Aim and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessmew OVER 1 PART II-- ENVIRONMENTAL ASSESSMENT (To be completed by kgency) A ^OES ACT ?ON EXGfeIQ ,4P1Y TYPE 1 Tiff {gSHCLQ ltd E iLY: R o4ERT 617j - :; ", ,yam C !ON E $. w - . v..a... �a. ... .. »w t - ass . 'o .✓:. t<� ..' �ci�.'�_,.D: 'Y',�. w-' ,l dt�ptFb e,aa:. G.�.YI. ii:...t�.. - tJYas ONO B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED., CTIONS IN 6 NYCRR, PART 817.6? It No, a negative declaration may be superseded by another Involved agency. U Yes 191 Nb C. COULD ACTION, RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) Cs. Existing _alr quality, surface _or- groundwater quality or• quantity, noise levels, existing traffic patterns, solid, waste production ttir disposal, potential for erosion; °dratnaq ®or floa4Ing imblema? Expfaln btlefly. / if Ale r , C?. Aesthetic, agricultural, archaeotoglcal, historic, Or other natural or cultural resourees;"or community orfielghborhood chirscler? Exptain,brlefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened' or endangered species? Explain briefly: /V a NZ- C4. A community's existing plans or peals 89 officially adopted, or a change In use or intensity of use of land or other natural resources? 94min brV /VaM� c - C3. Growth, subsequent development, or related activities 10iely to be Induced .by the proposed action? Explain briefly. C+J f7 /taw CO3 C8. Long term, short term, cumulative, or other effects not Identified In CI-07 Explain briefly. < CD c'> W E C7. Other Impacts (including changes in use of either quantity or type of energy)! Explain briefly. D. IS THERE, OR 15 THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? C3 yes O No If Yes, explain briefly PART III --- DETERMINATION OF SIGNIFICANCE (To be completed by Agency) iNSTRUCTtONS: For each adverse effect identified above. determine whether it Is substantial, large, important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and M magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. D Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a• positive. declaration. Check this box If you have determined, based on the information and analysis above and any supporting ocumentation, .that the proposed action WILL NOT result In any significant adverse environmental Impacts 4 "provide"on attachments as necessary, the reasons supporting this determination: nt or Type flame o esponsr a icer in Lead Agency rgnature of esponsi a Officer m ea gency Name of lead Agency "Title oT��sponsi a Officer rtr. sgnature of reparer fit diff event from responsible of icer) FUTNAM ONMENTALAL ]DIViSiON ,OF �' NVH OF PLANS FOR � A ppLICATION FOR APPROVE yST04 1. Name and address of applicant: V r A�,�� y, i�6 r 3. Locati� 2. Name of project: �!N d c.�rs�v� e'de'e!a® 4. Design Professional: adN rtG . J• aoryAHul� 5. Address: -- 6. Drainage Basin: 7. Jy,R,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 (SEQR)? Type Status (check one) ........................ ............................... Type I Exempt Type II Unlisted y 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 1414- 10. Has DEIS been completed and found acceptable by Lead Agency? ............. Al 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .............................................. ............................... ....... 1' _.... 1.3 = If fio; a+e piat °been submitted to such authorities? ........................ TM �' ..... :......... iV o 14. Has preliminary approval been granted by such authorities? Date gt cited: � Ayut - 15. T :. .. ype of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? ..........:......... 17. 'Waters index number (surface) 18. . Is project located near a public water supply system? ........................... 19. If yes, name of water supply Distance � water supply. 0. Is project site new a public sewage collection or treatment system? ............... � 21. Name of sewage system 4.,1— Distance tQ sewage system 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gall ons per day) ...........:......... .... �o 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? .......................... FOYM PC -97 2 gl 27. Is any portion of this project located within aAesignated Town or State wetlandT A/� .. 29. Is Wetlands Permit required? ......, Has apPlicati.on been made to Town of -Local DEG office? ............................... 30. Does project require a DEC Stream JDisturbance,Permit? ....,. ,. .. . Ala 3 l ; Is six was project site used for ag aculWW activity involvirig application. of pesticides to orchards or other crops, solid or hazardous waste disposal, landfill�ng, sludge application or andustnal activity'? Yes d 32. Is ro ect .locat ed �nthin 1,000 _feet of existing' or abandoned land fill hazardous waste site.salt, stockpile; la�ndfill,;sIudge disposal site or Any, 35. .Are any sew ige treatment areas in excess of 15% slope? ................... ....36. Tax =Nap ID Vnnber .......... ... ma,�2 Block Lot 37. Approved plans are to. be returned to Applicant, �_ Design Pxofessonal NOTE;. All 4 pplicaizons for -rer iew and approval of a`rtew SSIM to tw. located *W" the PdY� 'at�rsl d�, 1 i' be "sent to the DeWtirAent, and need not be sent in duplicate, to the DEP, although the project rmay 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 laps or the creation of impery ous-surfaces, and the project applicant should obtain the appropriate forms or such activities from DES' and submit:those forms to DEPT 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 QViay be grounds for the rejection of any submission. under penalty :of perjury., that information, provided on this form is,true . ��,�O'M best o, f my knowledge and belief: False statements made herein are punishable as A misdemeanor pursuant to Section 210..45 of the Feral Low. t ® o i?19 F41 A-07 Cn Mailing�d dress: .......................... ...... rrts e� �i PU i NAM COUNTY D DMSION OF E EPARTMENT OF', HEALTH, �E t �TTAL AJC,�' SERV- =Dltr'al Sl'EE�:_ DA T.- SUBSURFACE SE 6�t' GE, TREATMENT SYSTEM Owner ®►�f O,G.G ICJ Address, Located at (Street) Oro (indicate nearest cross street) P �-1B1ock Lot Municipality , Watershed SOIL, PERCOLATION TES's DATA `. Date, of Pre-is oaking . Date o .Percolate a Test, -� -- -- - -•- - rr•�......o.�y 6Y..ai �tivtauvn cai6� are OOtatned 8t SaC Percolation test bole. 0`.e. s l min for-1.30 min/inch, s 2 thin for 31.60 min�iach) All data to be submitted foe review. c . Dep* measurements. to be made i'ront top of hole. Form DD -97 TEST PTT DATA 2 '.ce�J►P'.5��511'Il� DEPTH - HOLE NO. l HOLE NO. ' HOLt 140. 0.5' �. 1.0' 2.0' ' 2.5" 3.0' ..:�. r=. o 4.0. CL 4. Indicde.level,at which groundwater is. encountered . indicate level at which. mottling is observed Al A/ AN Indicte level to which water level rises after being encountered IDeephole observations taade by: Date 2 10 Desip Professional, N=e: ,41v i `/ _;Y �SssioIy�r 0 oS.D°�gy�� r; S i gnture: Design Professional'iSeal LdAl) r'e 'ZI 7gr r E wo iii 1 Of LdAl) r'e 'ZI 7gr r E wo