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HomeMy WebLinkAbout4594DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.07 -2 -3.1 BOX 35 04594 1, 11 ti LA i Ll oil 04594 ttp }5 1Q : ►912 n 10.9 448' O .&, ice I I Ion N 8 50 {f0 ". iY 16;.;,4,....: I ; I �pyrr 0 oK - ca++crete I . I curb a cmorets [FOOD Apff / . E poY�msnf DRIVE Fr BS AM DESKMIM ON THE TAX RAPS FM THE ).F -c. ARWEL TMs is ro: c�'nty t!u4r •nre �e WAS C.014Gr'laik—TVto No M4b. *cwt, , rK� sY, -%r,am w /Ivip�cr c. r� GVER.. 1�lE SYSTBM :ryl�i ,CDNSjiwi Htrtz.l�► nerrt 14.�ia..'r►f�s. ,ti+ysai E 'Nis gsgJ wr es. a oar ' q "X#2 C.gwn LOT .4 4 LOT .3 dip 4 .. a :r �04 ` 666NNN w ttp }5 1Q : ►912 n 10.9 448' O .&, ice I I Ion N 8 50 {f0 ". iY 16;.;,4,....: I ; I �pyrr 0 oK - ca++crete I . I curb a cmorets [FOOD Apff / . E poY�msnf DRIVE Fr BS AM DESKMIM ON THE TAX RAPS FM THE ).F -c. ARWEL TMs is ro: c�'nty t!u4r •nre �e WAS C.014Gr'laik—TVto No M4b. *cwt, , rK� sY, -%r,am w /Ivip�cr c. r� GVER.. 1�lE SYSTBM :ryl�i ,CDNSjiwi Htrtz.l�► nerrt 14.�ia..'r►f�s. ,ti+ysai E 'Nis gsgJ wr es. a oar ' q "X#2 C.gwn r•• �5.. � v ae...a a_ .ij,� .�. ..n' -.,., tit..'ac � 4v(rrn .. .�r,t � i�;r• �7•..rt* «O :.gut. •�-� q y : � ....r �w� •. -. �-. —� t.. q,s a • .. G'+:. v .1/i. f � r. w •�i- .+� ; ..tr- r.9�'�.; ; � .. .. .,�?' �RyJry�, ayi} (( 3 8Z X15' . aS; is}?osA 4GLom2Pi mex, M{ Fb p*moH c0i'mr, k T4! rva'jf J -4 .4j 4g iT Ulf PUTNAM COUNTTYY DEPARTMEN►TT OF { jHHEALTSHAC f0 TCONFORMANCE t� AIPPRO E AS NOTED WITH 1 APPLICABLE RULES AND REGULATIONS OF THE P TNAM COM TY HEALTH DEPARTMENT.` f . GN TUR DATE 'D'elsr�t Ptar1�� t'.Caos4nictron, 'K ,a PO:�aor430 la$tU�}Ti4.211i8 ' - .' i?!9(16itIL 1, , w •�G _ Phi ... v... r...- ,Ty..'.- ,,.... a.,. •..,e�•....t;.f.�s dri °•nn- ..... -.+�. w�-4tr.., .ow.t+ia�.. ;: ;,y,. -..., �,, ..►..., ,7G: :.::.d: ow. �. ...�ca. = .n;- f•i.71- )+•�,%�: w. ..'.i.ern ': v...s.. ��. ^.�ri.•r *• 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 Run -of -Bank Fill Quality Slope from Top to Toe Impervious Layer Installed trosion Control Installed Required Depth Date: Inspected by: Sieve Test Results (if applicable) - Additional -Commentz.: -r - , Reserved for Field Sketch if Apl2hcable DIAL SITS; Il\ SPr,CTrtOlV d % 1,'? � Date: V I �� (^✓ L- Alerted by: Street Location Owner Town vt Vo P ermit # Ifii1 ie4 scat # , Y. 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 ..... ............................... IL Sewaze Svstem 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 Bog - properly set ............... 6. 1 renc es 1. Length required Length installed 6 % 2. Distance to watercourse measured Ft.......... 3. Installed according to plan .... ............................... 4. Slope of trench acceptable 1116 - 1/32" /foot ............. 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 %...........I ............. 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends ca pped ....................... ....................:.......... g. Pump or Dose& Systems 1. Size of pump chamber .......... ............................... "tabk ........................... .... ............................ 3. Alarm, visual / audio ......... :.......... ............................... 4. -Pump easily accessible, manhole to grade ................. 5. First box baffled .....................:.. ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/BuildinLy a. House located per approved plans ................ ......... b. Number of bedrooms ............... I ............ ............ IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured /od ' ft ........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................. ............................... b. All pipes partially baclffilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercour g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .. ......:........................ i. Erosion control provided ............. ............................... Rev. 12/02 1,,44- 9X-L'S I de ?_•E??1l:= fl!� F' A.Q.T.;ASSES.SMehx :(Tp he--r-&rn feted bv-Lead, Aaencv 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. Yes No B. WILL ACTION R CEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN'6 NYCRR, PART 617.6? . If No, a negative' declaration may b superseded by another involved agency. Fj Yes C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing'traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or comMunity or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: Ulm ' 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 resources? Explain briefly: Oil P- C5. Growth, subsequent development, or related activities likely to be induced by the proposed :act'iorr? Explain briefly: &)o �- C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: /V oce ?: C7. Other impacts (including changes in use of either quantity or type of energy? ,Explain•brid(y.- ' < D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL' REA (CEA)? (If yes, explairrbrief "'`" '° Yes E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain. E] Yes Q No PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explahations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impactof the proposed action on the environmental characteristics of the CEA.' Check this box if you have identified one or more potentially large or significant adverse impact's which MAY occur. Then proceed directly to the F EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and airy supporting documentation, that the proposed ai WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting determination. Name ofteid Agency v Date or T pe mrosponsible Officer Lead Agency Title of Responsible Officer L Signature of Responsible Officer i ead Agency Signature of Preparer (If different from responsible officer) PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM r _for UNL,15TED ACTIONS ,Ogly -� , K:,:. .:, c�;..s.> -:;4: ea .:.A. � 9..:iari:r::.•. ` `PART I - 'PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR 2. PROJECT NAME r 1711 ( 3.PROJECT LOCATION: % le VA Municipality , / County . 4.. PRECISE LOCATION: Street Add es and oad Intersections. Prominent landmarks etc -or provide map . : =.! ' •� 6 4S 5. IS PROPOSED ACTION: FQ-,Kew Expansion Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: © ���se � .�- SY57-. 7. AMOUNT OF LAND AFFECTED: ,o�� Initially oQ� acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICiWNS7. ` I describe briefly: Yes No f no, 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many'as apply.) esidential ❑ Industrial Commercial ❑Agriculture Park /Forest / Open`Space a Other (describe) .. 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY.OTHER .GOVERNMENTAL AGENC (Federal, State or Local) es a No If yes, list agency name and permit /. approval: O OL,0� we 11. DOES ANY ASP .T OF THE ACTION HAVE A CURRENTLY VALID :PERMIT OR.. APPROVAL ?....,... .Yes If yes, list agency name and permit / approval: 1r2. 'AS A R_E-SU�F PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? Des Lw,,No I CERTIFY THAT. THE`INFORMATION PROVIDED ABOVE IS TRUE TO THE 1315T OF MY KNOWLEDGE Applicant / Sponsor Name Date: A Signature--------- - - - - -- ' If A action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before'proceeding with this assessment 7- TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLV910. G.L. V 0.5' 1.0, 1.51 Pill 2.5' 3.0' 3.5' .5. 4.0' 4.5' 5.0' 5.5' 6.0' 6.51 7.0' 7.51 8.01 8.5' 9.01 10.0 Indicate level at which groundwater is encountered A/ 1A Indicate level at which mottling is observed -7 Indicate level to which water level rises after being encountered 01Z14 Deep hole observations made by:ApAt4 pc.�4,0 � /MAC'( 6momA6p IL Date Design Professional Name: KQj K6,EA4 Address: P., 0 s � X S O Y is s4/ Signature. Design Professional's Seal 2 ijftk lull VAR11 Owner -AblAkJ.4 IWC. Address IQ FOX -.112A I L lo MA 4W Located at (Street) Ca LE L) ST: Tax Mat)gb.l Block 2 Lot I (indicate nearest cross street) Municipality n3:tjpM V p, 1 -1 -p, Y Watershed --�dp-sohj I L07- SOIL PERCOLATION TEST DATA Date of Pre-soaking J 0 ) I Date of Percolation Test 16 2,00 Z-- percolation test hole. (i.e. s I min for 1-30 min/inch, --q 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 2 27. Is any portion of this project located within a designated Town or State wetland? 1-40 -W.etLand ID .Nu ber,. _ _ . - .._... _ :.:... 29. Is Wetlands Permit required? .............................................. ............................... t�y Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. .... .I .......................... 1.C�. 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No 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? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number .......................... ............................... Map Block �- r 37. Approved plans are to be returned to ..... Applicant ,,/ Design Professional -- :I`inTE:: 11_za plica ons for - Pv w and app o of anew SSTS to b�`located vv u'giri `dig l`dYC; Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES. Fa Mailing Address • .... ............................... 4c" IG64 PUT'NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR. APPROVAL OF PLANS FOIE ��• ., ..: o =�iL:' .c�s%�+s= e; -.._� _ ,n.� �4. E y �' G'oa.-- .:.se- . -sa•r. m.��♦a .:..5. a; ....... -,' • A �S1AST"���T' + �'Il�'A�'l�IIE1��''`� ��i �:- •���r �:4 . >.�•.::.�., ._ 1. Name and address of applicant: 10 izAIL 2. Name of project: JZ14LJ4 6,, 3. 4. Design Professional: Ro .D ah1 5. 6. Drainage Basin: 9Q / 1Z i\16L 7. Type of Prro,ject: v" Private/Residential Apartments Office Building Location TN: Address: 0 -F�a X V's-0 Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... t4,o 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other off cials..ordinances? :. :: _ , ............. ..... ......:......�....:_. s - ; ._._ _ /QC 13. If so, have plans been submitted to such authorities? ........ ............................... y �' 14. Has preliminary approval been granted by such authorities? *—s Date granted: Z.0c� 3 15. Type 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? ....... ............................... _-1v 19. If yes, name of water supply Distance to water supply 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 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ............................... v° 00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... ma 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 8/99 TEST PIT DATA DESCRIPTION OF SOILS. ENCOUNTERED IN TEST HOLES D E It1�LE_I TtJ._ G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' _ 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' :1-I'DLE NTO., ...HOLE NO. 9.0 ; 10.0' �! ` j Indicate level at which groundwater is'encountered Indicate level at which mottling is observed,,,, Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: 2.rKS Address: d as `J :Z �_ ' 4 r� Signature: Design Professional's Seal 2 . , "DE 1G. DATA SHEET - YSIUB531RF C9` Owner 4144k ,FC.. Address Zo /vx %/ G UV Located at (Street) 'll 00Q> &Jg4 Qr1 Ue-1 TaxMaP90 Block 2 Lot 3m (indicate nearest cross street) Municipality eta • V4 11 e Watershed ✓C/- SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 1 2 3 4 5 3 4 5 1 2 3 4 1 5 1 1 1 I I NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 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 lIDUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of 111-4 Located at LV Oc N T/V fie Tax Map # �s Block 7- Lot B. Subdivision of Subdivision Lot # , Filed Map # Date Filed /Z Gentlemen: This letter is to authorize 20y — G3��,tK,S "-4 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 tretment and/or water supply systems in conformity with the provisions of Article 1.45 and/or 147 of the Education Law, the Public Health Law,.an.d.the.Putnam County Sanitary:Cpde: . ;I C. Countersigned: P.E., R.A., #rte Very truly yours, Signed: (Owner of ) Mailing Address Pb �0?C 9.S�y Mailing Address: /0 �X j(Z4tL_ State Zip c641 Telephone: / L 1�� ��W ol4i'loac- State - Zip Telephone:— Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . ,_ .�. .. �� �r+6 :,•4 _ ! - u.r....J� .� � �7l- ` .r ,. _., � tl� .. .. .. ' .r t:, ! -iv�GT �"I� :A �T�r� AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: 19 / 6 b I 1 represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: 4C• Having offices at: /o Fo )C i 2 L 4 L))AIJ62 4 C, d-, �Z Whose Officers Are: President - Name: 120 Address: /0 Vice President - Name: Address: Secretary -Name: 0 Treasurer - Name: Address: and that,I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. worn to before me this day of _(mont o (year) Notary PGOlic V JOHN ROBBINS NOTARY PUBLIC, State of Now York No. 60. 4725810 Qualified In Westchester Co�r�y Commission Expires November 30, 20 Form CA -97 Signed: Title: Corporate Seal I V o- \ Ca` --o, % jaQB Npw y PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRTJCT.ION`PE`�,NI`,: , NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, OR, AS, SRDATE: TAX MAP #: (CONFIRMED) Y N DOCUME NTS Y X (REQUIRED DETAILS ON PLANS CONT'D) (_)(_)PERMIT APPLICATION ( USE SEWER -Y" FT. 4 "0'; TYPE PIPE CAST IRON L)(__)WELL PERMIT OR PWS LETTER U NO BENDS; MAX BENDS 451 W /CLEANOUT UUPC-97 RENEWALS (_JULETTER OF AUTHORIZATION (SITE NOTE (NO CHANGE) UUDESIGN DATA SHEET (DDS) FILL SYSTEMS UL_)CORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE C_)C__)SHORT RAF FILL SPECS/ FILL NOTES 1 -5 UUPLANS -THREE SETS (� FILL PROFILE & DIMENSIONS ((__)HOUSE PLANS - TWO SETS (FILL IN EXPANSION AREA UUVARIANCE REQUEST ,FILL GREATER THAN2 FEET / SUBDIVISION LEGAL SUBDIVISION CLAY BARRIER ILL CERTIFICATION NOTE SUBDIVISION APP VAL CHECKED &_��,PERC U DEPTH GAUGES RATE FILL REQUIRED DEPT U VOL. ON PLAN FOR ROX., UNCLASSIFIED & IMPERVIOUS (__) SEPARATION DISTANCE FROM TOE OF SLOPE ( CURTAIN DRAIN REQUIRED TRENCH GENERAL ( LOCATED IN NYC WATERSHED F TRENCH PROVIDED 60FT MAX. ARALLEL TO CONTOURS PLANS SUBMITTED TO DEP 00% EXPANSION PROVIDED fD ELEGATED TO PCHD ETAIUDUST FREE CRUSHED STONE OR WASHED GRAVEL EP APPROVAL, IF REQD EOTEXTILE COVER (_) EEP TEST HOLES OBSERVED ",!n CS TO BE WITNESSED X- APPROVAL SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME -)PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA " ti0 ��'R FT�QOI} .LEXAIMN" W111 2901 L_ _)( )SOIL TESTING LOTS >10 YEARS OLD SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT YL OTING /GUTTER/CURTAIN DRAINS DA SOIL TYPE B OUNDARIES LE BLOCK; OWNERS NAME ADDRESS #, PE/RA; NAME, ADDRESS, PHONE# TE OF DRAWING/REVISION . TUM REFERENCE (_) LOCATION OF WATERCOURSES, PONDS A'KES,WETLANDS WITHIN 200' OF P.L. V�2AKSRMENT OPOSED FINISH FLOOR AND ELEVATIONS (_) LLS & SSDS'S W/IN 200' OF SSTS (__)(_z)PROPERTY METES & BOUNDS (—) EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE :OMMENTS: REVSHEET)09/01/00 U 'TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (� 0' TO FOUNDATION WALLS (� 0' TO WELL, 200' IN DLOD,150' TO PITS 00' TO STREAM, WATERCOURSE, LAKE (inc. espan) (� 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' O yyATER�,INE. (pits 120%,-.1- Sa° iIVTERMITTE�t -T DRAIrTAGE'CO "ARSE° 200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS x)(__)10' MIN TO LEDGE OUTCROP � � SEPTIC TANK l �1u10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION L )M 15' TO PROPERTY LINE SLOPE LOPE IN SSTS AREA 520 %) (_JUREGRADED TO 15 %, IF REQUIRED DOSERUMP SYSTEMS UMP NOTES OSE 75% OF PIPE VOLUME OSE VOLUME NOTED (� DETAIL FOR FORCE IPE TYPE, ETC.) U PIT AND D -BOX SHO & DETAILED �) 1 DAY STORAGE VE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL (� 15' MIN to CDS = >5 %, 20'4 %, 25' -3 %, 35' -1 %7 100 % - <1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge 10' MIN to NON - PERFORATED PIPE SIIE_RLIT�► AMiER, MD,.MS, FAA_ E_ �Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Roy Fredriksen, P.E. P.O. Box 950 Mahopac, NY 10541 Dear Mi. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 :ROBERT_ J• BONDI , FJ C6unty Executive September 20, 2005 RE: Application to Construct .a Subsurface Sewage Treatment System Anakin, Inc Wood Glen Drive, Lot 1 (T) Putnam Valley, TM # 85.7 -2 -3.1 The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on July 11, 2005 is incomplete. Please be advised that the following information is required before the Department may commence its review. • House plans have not been submitted. -. �_ :a ::�DP igr: data shut is:,to..raote:sQ?I�tPstingjr lilts. �Z£..the rt;stilfis are cc?�i ed Ate -� design professional.. The professional stamp is to be affixed to the data sheet. • Proposed well is to be dimensioned from two property lines. • Provide standpipe detail on the plan. 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. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext.2166. lVey yo orris, P. E. Senior Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health - LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Roy Fredriksen, PE PO Box 950 Mahopac, New York 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 January 30, 2006 ROBERT .I. BON ®I County Executive _ 1,/ Re: Proposed SSTS — Anakin, Inc. Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -3.1 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. There are 2 different sets of floor plans on file. Please advise this Department which set of . floor plans to review. `/ Z. Please show the curtain drain location on Lot # 2 and note the 50' minimum separation distance. —3� All proposed grading from the subdivision plat needs to be shown (driveway, house, right-of- way, etc.). " 4. f Please layout the expansion area in the same way as the primary, showing boxes, 2 -foot solid pipe, etc. Please provide the basement floor elevation in the plan view. r a ..6, Please;label-the cast iron pipe in the.plan -view and..change_thet} � e - f pipe shown, in the profile from SDR -35 to cast iron. c 7. Please label the SDR -35 pipe (between tank and first box) in both views and provide size, I type and minimum pitch. Please provide a separate standpipe detail. - .What is the purpose of the dry well detail? Please show its location on the plan, if one is being proposed. 'r0 Please provide a design data sheet signed and stamped with the subdivision data. 11 House foot print shown on the plan doesn't appear to match either floor plan submitted. l� Please provide a note stating that the house, well, and SSTS are to be staked by a licensed land surveyor prior to construction. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. C Uk �0 �A-j JSP:cj 9 Sincerely, t S�,.el . Paravati, Jr. 11Z Assistant Public Health Engineer /�, Environmental health (845) 278 -6130 Fax (845) 278 -7921 �� 3' �� / (a 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 T_ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL, please print or type PCHD PelTllit # Well Location: Street Address: Town/Village Tax Grid # WOc)D G I iorl ."-. P.A r. \/A lle Map&6-7 Block Z Lot(s) 3, Well Owner: Name: Address: 4rl Kir7 efC_ I /o FoX j ral j , Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ✓New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling - j S -s , Well Type . Drilled Driven Gravel Other Is well site subject to flooding? .....................:........................... ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes i./ No Name of subdivision /fit L1� Co4sr Lot No. Water Well Contractor: '7"Q4D Address: Is Public Water Supply available to site? .................................. ............................... Yes No (-,- Name of Public Water Supply: —' Town/Village �--- Distance to property from nearest water main: Proposed well location & sources of contamination to be rovided on separate sheet/plan. Date: w/ 1 q 1 A phcant Signature: _ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 3 16 toc Permit Issuing Official: .�•-� Date of Expiration 21t6l o Title: d �L Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 " IlUITNAM COUNTY DEPARTMENT OF HEALTH � rs t:� �_:..:a:'Lr <�t�. �5`,> ., ..._.. _ _., .a- :h ^_-.w ..x,.. �.. -., rtti -�`'S r.n .._ •�... _ {7w CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM �= st IPIEIMIT # Located at QAjp Q 6 Ihi✓� Vii/'! ✓� Town or �/illage C t`J i /le " Subdivision name1 -/� Subd. Lot # Tax Map Block L. Lot 30 Date Subdivision Approved � i i ®r Renewal Revision, Owner /Applicant Name t4 ,q K1 ri , .d rf G Date of Previous Approval Mailing Address l c . Fg- x -r/Li/ L Zip /c5S4 Amount of Fee Enclosed ?400 Building Type Lot Area No. of Bedrooms 4 Design Flow GPD P-300 Fill Section Only Depth VoRu ae PCH D NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Sepairate Sewerage System to consist of /Z 6 0 gallon septic tank and Other Requirements: F1— C M:u n To be constructed by Address Watea- ly:_ ._... Public.Supply From Address or: VPrivate 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 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 (� I License # 5'_CkS_d6_ 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 pe it. Approved fo discharge of domestic sanitary sewage only. By: Title: �" Date: //6 ®6 Whi copy - HD File; Yellow copy - Bui ding Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 03/07/2008 00:59 7588766 SHOOTERS PAGE 01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION U1 SEPH GENE, REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed p'or to any 'Trenches inspections being made. PCHD Construction Permit # _ ?,.,/ „ d Located: Lint-%n Q fcLh O r Vc- (T) (V) Owner /Applicant Name: TM -St.5 Block _ '� Lot :7. Formerly: _ _ f Su division Name:fZ�C� _ - -- Subdivision Lot # Is system fill completed? Date: Is system complete? _ 1-4 Date: Is system constructed as per Tans? Is well tlzilled? yr�e T� Date; _____2-j'7'/6-,2 Is well located as per plazas? Are erosion control ;measures in place?— I certify that the system(s), as listed, at the above p remises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of c.. .. Health. N_. - ..4. _ 4. .._.. -_... ...._ .... Date: Certified by: PE ✓ ' I2A ,1y� D sign Professional Address: oz4 9 � ''Il4 IL12dC, 1_%I Ln.S'4,lc. # y C6 Comments: Form FIR -99 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health _.... LORE'ITTA MOLINARI, RN, MSN Associate Commissioner of Health March 10, 2008 Roy Fredriksen, P.E. P.O. BOX 950 Mahopac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 R®BERT J. B ®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Field Inspection – King Wood Glenn Drive (T) Putnam Valley, T.M. # 85.7 -2 -3.1 The above referenced separate sewage treatment system can be backfilled. The. following comments must be corrected in the field. _�..,,..,...•_—1 ._Call v7hmfea- dyIbTwet inspt6tion,-bedro6n-rcozmt-arI iritair-drain inspeetion.-- If you have any further questions, please contact me at (845) 278 -6130. JD:kly Sincerely, J oh 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 J� G� SHERLITA AMLER, MD, MS, EAAP q, ROBERT 1 BOND[ Commissioner of Health County Executive LORETTA MOLINARI, RN, MSN F� YO ROBERT MORRIS,. PE Associate Commissioner of Health Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 July 28, 2009 . Roy Fredriksen, PE. P.O. Box 950 Mahopac, NY 10541 N Re: Field Inspection — King Wood 'Glerin Drive (T) Putnam Valley, TM # 85.7 -2 -3.1 'Dear Mr. Fredriksen: open. 7/01 redboeref�renced IbtT muitit iispeet o: tr� vpr �. comments to be addressed in reference to this Departments open work inspections. If you have any further questio.ris, please contact me at (845) 278 -6130, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:kly 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 YML ENVIRONMENTAL SERVICES 321 Kear.Street Yorktown Heights, N.Y. 10598 .(914) 245 -2800 . Albe`rt`--H': Padovani; 'Director ., LAB #: 9.900544 CLIENT #: 13399 NON STAT PROC PAGE: :2 of 2 ANAKIN INC. DATE /TIME TAKEN: 06/02/09 09:00 10 FOX TRAIL DATE /TIME RECD: 06/02/09 09:25 MAHOPAC, NY 10541 REPORT DATE: 06/09/09 PHONE: (845)- 621 -1824 SAMPLING SITE: LOT 3.1 SAMPLE TYPE..: POTABLE WOOD GLEN DR, PUTNAM VALLEY, NY PRESERVATIVES: NONE COL' D BY: ROY KING TEMPEPATURE - :.: < 4Z:......._ . NOTES ... :.WATER TANK COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO 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 WHICH 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 HARD KATEFc:- -140 -3 0.0 MG./ L:. _.. (,1 ' gz dih/yallbri"= ' ] 7 : 2 'NiG /L) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE ONLY TO THESE SAMPLES RECEIVED BY THE LAB SUBMITTED BY: (� m, 40 '(0 Albert H.) Padovani, M. .(ASCP) Director ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (,914.)_..24.5 -2800 _....... _ . _- _ .. _... . -.... _ ''Aibert H.- Paclovan"" Director LAB #: 9.900544 CLIENT #: 13399 NON STAT PROC PAGE: 1 of 2 ANAKIN INC. DATE, /TIME TAKEN: 06/02/09 09:00 10 FOX TRAIL DATE /TIME REC'D: 06/02/09 09:25 MAHOPAC, NY 10541 REPORT DATE: 06/09/09 PHONE: (845)- 621 -1824 SAMPLING SITE: LOT 3.1 SAMPLE TYPE..: POTABLE : WOOD GLEN DR, PUTNAM VALLEY, NY PRESERVATIVES: NONE COLD BY: ROY KING TEMPEF?fTURE, -,:. <- 4C NOTES...: WATER TANK COLIFORM METH: MF --------------------------------- - - - - -- --------- ------------------------------ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/02/09 MF T. COLIFORM ABSENT /100 ML ABSENT SM 18 -20 9222B 06/08/09 LEAD (IMS) 3.8 ppb 0 -15 ppb SM 18 -19 3113B 06/03/09 NITRATE NITROG 0.65 MG /L 0 - 10 SM18- 20450ONO3 06/03/09 NITRITE NITROG <0.01 MG /L 1.0 MG /L SM18- 20450ONO2 06/04/09 IRON (Fe) 0.096 MG /L 0 -0.3 mg /1 SM 18 -20 3111B 06/04/09 MANGANESE (Mn) <0.010 MG /L 0 -0.3 mg /l SM 18 -20 3111B 06/03/09 SODIUM (Na) 9.89 MG /L N/A SM 18 -20 3111B 06/02/09 pH 7.0 UNITS 6.5 -8.5 SM18 -20 4500HB 06/03/09 HARDNESS,TOTAL 226 MG /L N/A SM 18 -20 2340C 06/03/09 ALKALINITY (AS 132 MG /L N/A SM 18 -20 2320B 06/03/09 TURBIDITY (TUR 1.4 NTU 0 -5 NTU SM 18 (2130B) COMMENTS: MFTC THESE RESULTS INDICATE THAT THE WATE (WAS),(WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD THE 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 10i of their than 15 ppb and a treatment must be potential. iblic 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 are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium SHERLITA AMLER, MD, MS, FAAP Commissioner of Health . 1C,Q)R�E'I.A 1VIi LINV ARi, `R1V; iVgSN Associate Commissioner of Health September 4, 2009 Roy Fredriksen, PE P.O. Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Construction Compliance — Anakin 18 Wood Glen Drive (T) Putnam Valley, TM# 85.07 -2 -3:1 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. The pump /storage tank information has not been completed on the well completion report. 2. The pump installer needs to sign the well completion report. ...�, .b., .._..��,...... �_ >_ :..... , n >.._. _•__.....- _ ._ .... -. �.. ..._ » . -., .• . ....._..- ......��....... 1 his office will continue its review upon consideration of the above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. JSP:kly Very truly yours, OJoseph S. 5ra Jr., PE Assistant Public Health Engineer 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 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 PUTNAM COUNTY DEPARTMENT OF HEALTH _ DIVISION OF ENVIRONMENTAL HEALTH SERVICES ill .... t...._.u.N..., WELL COMPLETION REPORT Well Location Street Address: we m d II E4 iOr Town/Village: ° /041hua, a11e V Tax Map # Map Block Lot(s) ;G PS „h; Well Owner: Name: Address: gi lr !b l=ox %r&d j%ca`iotd,* � Ny Use of Well: 1- Primary 2- Secondary Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _ rotary _Cable percussion _Compressed air percussion _Other(specify) Well Type Screened Open end casing _ Open hole in bedrock Other '" Casing Details Total Length jjEWt. Length below grad" Diameter k in. Weight per foot 16T lb/ft Materials: Steel Plastic Other Joints: Welded V Threaded Other Seal: ement grout Bentonite Other Drive shoe: Yes ✓ o Liner: _Yeg-L-.,, No Screen Details Diameter in Slot Size Length ft Dept to Screen ft Developed? First _Yes No Hours Second Well Yield Test _Bailed _Pumped _ Compressed Air Hours 'T�- Yield s' gpm Depth Date Measure from land surface-static (specify ft) 30 During yield test k) Depth of completed well In ft. b �v 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. Lan Serface d _ _ tee; .6lwY. Gar w G[' JS If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ms, a &Capacity Depth to 2 Models s so —I Voltage a 36 HP I Tank Type lA.)X 30A, Volume u Date Well Completed WeII Driller PC Certlflcate #(ToQ °'g ,' NY State # '1 v �Yb i Purnp.lnstaller -PC Certlficatp #� cry'. "NY State #' .� Oabl h '; .�`� Date'o 'Rep rt is „ 'h• Well D I er Name Atldress tf1�Vl YJ�� Driller (s)griature) 7, , , l P11 :Installer ame 8r Address n r t kf . hS t i 'i ..+ ✓"" `• f _ S`' 1 Z5 � '� .n�/ �.�( 5'A ���^ t .I �1 t �4 df^�%._�° (�•'..�.�.YS �C , �`t ? {� '_ -^' l.ix ,x. x.::...«. .: ...x 4 •.+_..s •, , n�\ .�' :�� .. . S.. ..A'. t ... '�: a Pumpinstaller(slgnature) i;,� �; 1 4 'I.k N ' {u gI X.: C C S Yi'r y L e.. i V u 4 t .�y,,y t LO /I/��I,G 35 V v !�. f141i NOTE: Exact Location of well with distances to at least twn nermanpnt lanrimarkc to , nrnvirlari nn a cannrata chaat /nlan White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 E911 ADDRESS VERIFICATION FORM[ OWNER'S NAME: A qn gal • TAX MAP DUMBER: ��• � � .'3� D E91.1 ADDRESS: TOWN: \/,9/l ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health AUTHORIZED TOWN OFFICIAL.,: Mc..0c. G �- (Signature) ,:.. -. DATE: The Putnam County -Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. E911 addressverification 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 InterventioniPreschool (845) 278 -6014 Fax (845) 278 -6648 r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES V.�s -- � .. :'u� �..:•; ''rr :e. -., ;:. .. � - :. ,..�... �::c -�.,° ...: ..� .c >,,�°:�,:.:�w�•� =r :,:. =.:,ai ciis +::•; "r. t: ;�,ewye.. �.: a• "��.,. ..o�wc -i ��+� �... GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM A14M�'� Owner of Building At-op-jP1, Building Constructed by . 7 z -2. l Tax Map Block Lot TownNillage i,t�o� � C��,�.r� err t� 'T�� �=, u� � %�.� •; -f-� �. . Location - Street Subdivision Name )cl in / 4, —_ I 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 system... a . 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 Day Year Signature: General Contractor (Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: /,,> �,� ��/,1i� Address: State /� '� Zip O. State Zip zoo�,�V/ - � P Form GS -97 lilt .F'� x /, O `e+ ¢' �, # ��� i ii :,\ i it CERTIFICATE OF CONSTRUCTION C LIIANCE FOR SEWAGE TREATMENT SYSTEM[ PCHD CO TRUCTIION PERMIT # Located at c3vr-) 6 L /4 Town or Village tq'r /4 41 Owner /Applicant Name t4 14 k j , Tax Map Block Lot _ Formerly. Mailing Address /0 Date Construction Permit Issued by PCHD Subdivision Name yzl &u69 (;Of-L3 p c,, Subd. Lot # i tq Zip /WW Separate Sewerage System built by 6 �. �i f Address Consisting of a �� Gallon Septic Tank and (� � ` �4 Z "2"rU-)4`CL5- '��&A-C-I¢ -S Other Requirements: �� r� C Ut -r4 c i4 Water SuDDIv: Public Supply From ore Private Supply Drilled by An o o.1 d l Address d��ZCy�£IL l ,, P�; �1r�J�% ✓i Address luildir*�n Type��dVilr; �.� _.� Has erosion control been completed? Number of Bedrooms 4 Has garbage grinder been installed? 6q 'v 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 Date: 57& L c, Certified by Address the Putnam County Department of Health. / a l (� . eoe��'I- P. E. � R.A. License # 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. y: Title: Date: e copy - HD File; Yellow copy - uilding Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97