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HomeMy WebLinkAbout4596DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.07 -2 -3.3 BOX 35 04596 r. VI/ DIVISION .OF ENVIRONMENTAL HEALTH SERVICES ' . ) -" CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 0O � Q2 ��— Town or Village s T N% V�� y �� Owner /Applicant Name A1-4 4 4. %/J Tax Map &S�• 7 Block Z Lot 33 Formerly Mailing Address /0 [-0)( % /Z# J L _- Date Construction Permit Issued by PCHD _ Subdivision Name "r g— i C7 L' Subd. Lot # Zip Separate Sewerage System built by 141 1 L Sr' Co. Address !-:9'J ArZ &-t, Consisting of I ©' ®0 Gallon Septic Tank and 6 % 7C� 2 Potts" &)1d e '74ANci-,os Other Requirements: 7 <fL)1?C7 -/ N IN Water Supply: Public Supply From. Address or: Private Supply Drilled by 44o& z4 oJA Address EUT"nan l/ &&%l ,Building Type. Has erosion control A been completed? �a Number of Bedrooms Has garbage grinder been installed? 1110 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 o the Putn County Department of Health. Date: IV12-11i Certified by P.E. ✓ R.A. sign �;of, Tonal) �. Address LO ( �C' �f' S� 1 / /4e2j2;4C � IV' Z /C�q/ 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. Title: Date: r-Q_/,-2-7 e py - HD File; Yellow copy - ilding Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 F PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street ddress: Hof wa- C� 6 f e d To Q Pli -h G 44- Uc l d Tax Map# Map Block Lot(s) GPS�, Well Owner: Name: Address: I /`�/ lL TT�� i� /0 I r4),l ape, Use of Well: Residential _Public Supply I Air cond/ eat pump _Irrigation I - Primary Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Drilling Equipment _Rotary _Cable percussion Compressed air percussion Other(specify) Well Type _Screened ✓ Open end casing _ Open hole in bedrock _Other Yield gpm Total Length ft. Materials: ✓Steel Plastic Other Casing Details Length below grace "ft. Joints: Welded ✓ Threaded Other Seal: L, Cement grout Bentonite Other Water Bearing Diameter 1, in. Formation Description Weight per foot ( f, — lb/ft 1 Drive shoe: Yes t✓ No Liner: _Yes No Diameter (in) ISlot Size I Length (ft) IDepitto Screen (ft) Developed? Screen Details First I I—Yes No Hours Second Well Yield Test _Bailed _Pumped _ Compressed Air Hours f' Yield gpm Depth Date Measure from lana surface - static spec! y ft) During yield test ft) Depth o f completed well in ft. Well Log If more detailed information descri0tidns -or- sieve analyses are available, Dlease attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land surface r -h ,,. t°- (✓ If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Type, vh�J :yjr Capacity during drilling Depth t{- 2.5' Model list: Voltage _� HPi- Tank Tvue, ­v 304, , Volume NOTE: Exact Location of well with distances to at �.� €�la'u•N�wr'.�`'`.4a�� a�!�w"w,a ' �?;e�i:'. «��'t�!!�IA�ta.d'+'n� iFw��.4e landmarks to b6 pro ided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3106 BRUCE R . FOLEY .... -- _ - . _ .... .._ _ a• Pubfia- Realth— Dimetor,. .LORETTA . MOLINARI R.N., M.S.N. ._ .'lxtociate-Public ficalth Director. Dayaor of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Enviroameatal Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Servica (845) 278 - 6558 WIC (845) 278.6678 Fax (845) 278 - 6085 Early InterventionMreschool (845) 278 - 6014 Fax (845) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: ANaxTN TNC TAX MAP NUMBER: 85.7 -3 -3 E911 ADDRESS: 25 Wood Glen Rd. TOWN: Putnam Valley AUTHOPME.D TOWN OFFICIAL: 1/3/12. 40/_ -= I�AT1r The Putnam County Department of Health will not issue a Certificate of construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificatc of Construction Compliance. (E911 ver&m) V2111 W1 191, iii!d In M DIVISION OF ENVIRONMENTAL Gil A 9 SERVICES. art r . y� Y GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM A it/ /\j 7 Owner or Purchaser of Building Tax Map Block Lot AN)4 KIN RTA44M V�uey Building Constructed by TownNillage W ooD q Los:t4 D94 ye-.. erleI C4 L/'i Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. 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 2. Year /2- General ractor (Owner) - Signature Corporation Name (if corporation) Address: / /:' y az Signature: Title: �//GL_ Caq s (� Corporation Name (if corporation) Address: �'_' I State Zip r - State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -28.00 - �:... : ,: ,' .... ' • ,. s. Alfiert�H...:.Padc -varl! r ** TEST REPORT ** LAB #: 9.200016 CLIENT #: 13399 . NON STAT PROC PAGE: 1 of 2 -------------------------------------------------------------------------- ----- ----------- - -- - -- ANAKIN INC. 10 FOX TRAIL MAHOPAC, NY 10541 DATE /TIME TAKEN: 02/01/12 09:30 DATE /TIME RECD: 02/01/12 10:06 REPORT DATE: 02/09/12 PHONE: (845) -621 -1824 SAMPLING SITE: LOT 3, WOOD GLEN DR, MAHOPAC, NY SAMPLE TYPE..: POTABLE WATER TANK PRESERVATIVES: NONE COL'D BY: ROY KING TEMPERATURE...: <20 >4.00 140TES ... : - COLIFORM METH: MF ------------------------------------------------------------------ ---- -- »_- _--- ~-- ~------ __ - - - -- START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE P ' 02/01/12 0400 02/04/12 0400 MF T. COLIFOR PRESNT /100 ML ABSENT SM 18 -20 9222B 02/06/12 LEAD (IMS) 14.0 ppb 0 -15 ppb SM 18 -19 3113B 02/03/12 0400 02/03/12 0430 NITRATE NITRO 1.97 MG /L 0 - 10 SM18- 20450ONO3 02/03/12 0400 02/03/12 0425 NITRITE NITRO 0.01 MG /L 1.0 MG /L SM18- 20450ONO2 02/03/12 IRON (Fe) 0.20 MG /L 0 -0.3 mg /l SM 18 -20 3111B 02/06/12 MANGANESE (Mn <0.01 MG /L 0 -0.3 mg /l SM 18 -20 3111B .02/06/12 SODIUM (Na) 8.00 MG /L N/A SM 18 -20 3111B 02/01/12 0423 02/01/12 0426 * pH 7.5 UNITS 6.5 -8.5 SM18 -20 4500HB 02/07/12 HARDNESS,TOTA 240 MG /L N/A SM 18 -20 2340C 02/07/12 ALKALINITY (A 118 MG /L N/A SM 18 -20 2320B 02/01/12 0400 02/01/12 0400 TURBIDITY (TU <1 NTU 0 -5 NTU SM 18 (2130B) �...,...":,_02/.03f•12t.-0406 D2 /0.4/ 2-CA00.... -E: ARSEATT'---- ,,:d... ....�. �._•= ':.:::I......:... COMMENTS: MFTC Total Co This result indicates that the water (was), (was Pnot of a s atisfactory sanitary quality according to the New or te and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. Pb /Cu LEAD limits for public schools are set at 15 ppb. EPA'Lead & Copper Rule for Public Systems requires that no more than 10t of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg /L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 .. (914) 245 -280.0 Albert H. Pado ani,`birector ** TEST REPORT ** LAB #: 9.200016 CLIENT #: 13399 NON STAT PROC PAGE: 2 of 2 ANAKIN INC. 10 FOX TRAIL MAHOPAC, NY 10541 DATE /TIME TAKEN: 02/01/12 09:30 DATE /TIME RECD: 02/01/12 10:06 REPORT DATE: 02/09/12 PHONE: (845)- 621 -1824 SAMPLING SITE: LOT 3, WOOD GLEN DR, MAHOPAC, NY SAMPLE TYPE..: POTABLE : WATER TANK PRESERVATIVES: NONE COLD BY: ROY KING TEMPERATURE..: <20 >4.00 NOTES....: COL•IFOPM METH: MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER RUNNING FOR 10 -15 MINUTES MINIMUM) 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 is suggested. * pH pH SCALE IN HATER 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..,., -I£ - A'- FIRLD•-ME- ASb'REeMtNT 'AND IS, TESTED'C3U`1'SID� '1 "HE -T OL151I1G` I'II�IE: " - pH REPORTED FOR REFERENCE ONLY. 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 .O 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 WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) ALK (ALKALINITY REPORTED AT pH 4.5) IMS IMS = IMMEDIATE METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINUMUM OF 6 HOURS OR OVERNIGHT) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE 0 Y TO T SE SAMPLES RECEIVED BY THE LAB SUBMITTED BY: Albert H. Padovani, M.T.()%SCP) Director FLAP##. 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 �_p :- ** TEST REPORT ** LAB #: 9.200067 CLIENT #: 13399 NON STAT PROC PAGE: 1 of 1 ANAKIN INC. DATE /TIME TAKEN: 02/17/12 08:00 10 FOX TRAIL DATE /TIME RECD: 02/17/12 08:35 ROY KING REPORT DATE: 02/20/12 MAHOPAC, NY 10541 PHONE: (845)- 621 -1824 SAMPLING SITE: LOT 3, WOOD GLEN DR, MAHOPAC, NY SAMPLE TYPE..: POTABLE WATER TANK PRESERVATIVES: NONE COLD BY: ROY KING TEMPERATURE..:' <20 >4.00 NOTES...: COLIFORM METH: MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL RANGE METHOD 02/17/12 0430 02/18/12 0430 MF T. COLIFOR ABSENT /100 ML ABSENT SM 18 -20 9222B COMMENTS: MFTC al oliform = This result indicates that the water (was) (was not) of a satisfactory sanitary quality according to ew York State and EPA federal drinking water standard for this parameter. This comment.applies to the Total Coliform test only. THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE ONLY TO THESE SAMPLES RECEIVED BY THE LAB SUBMITTED BY: ' Alber vani, M.T.(ASCP) Director FLAP# 10323 REBECCA WENBERG, RN, BSN Public Health Director PAUL ELDRIDGE County Executive ROBERT MORIIS,FE �'�. a -•- DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 845 -808 -1390 November 2, 2011 Roy Fredriksen, PE PO Box 950 Mahopac, NY 10541 Re: Field Inspection — Anakin Builders Inc. Wood Glen Drive (T) Putnam Valley, TM 85.7 -2 -3.3 Dear Mr. Fredriksen: A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed at this time in reference to this Department's open work inspection. 4 1f you have i ny� f ; er- �q­ uestions, please confacf me at (845) 808 -1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw PUTNAM COUNTY DEPARTMENT_ OF HEALTH .I Dr- VISION OF ENVIRONNiENT� HEAL -Tlt 2V'IiCES ATTENTION JOSEPH 'GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construe •on Permit # PV-0�--OG Lit, �v Located: W bob (T) Pir, V � Owner /Applicant Name: 4t,4L4- -Kin TM L6, Block Lot Formerly: Subdivision Name: /' / Subdivision Lot # Is system fill completed? Is system complete? Q� Is system constructed as per plans? Is well drilled? ieS Is well located as per plans? Are erosion control measures in place? Date:,_ Date: Date: :! �b� ,0 I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. ,.. .. "Date"' ....._ � � � �.. Certified by Desi Professional Address: / SAO ,A °,p 1 Lic. # Comments: F, Form FIR -99 -�-O-�-a6 (Kh 11. 04011231 12 LI 1 _i I 11.11 Jg ff I T OF IENWRONMEN �y� A L 1HIIEAILT HI SERVICES .-' - 1F "C� � .c.. .- . ... . � r. / �, � Y. �L's•a �. w.-T .. ... YwY- ~:.1,. r ..t � r ;i i,.. v .. i .� •. .. ..- .. 7TRUCTffON PIE ffT FOR SEWi P]E�T # Located at LJ®Up PrI y2� Subdivision name ' P—/ • L14 ;`, Subd. Lot # Date Subdivision Approved 51'W03 Owner /Applicant Name Ti-K� � GIE TREATMENT SYSTEM ST1EM Town or Village emLl Tax Map Block Z, Lot 3 Renewal Revision Date of Previous Approval Mailing Address O I L G Amount of Fee Enclosed Zip /04-f Building Type ktl? Lot Area No. of Bedrooms -3 Design Flow GPD6o MIR Section Only Depth Volume PCHiIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Se>ma>ratte Sewerage System to consist of /000 gallon septic tank and 4100 F®�- 2 11- w t oc. T;51—:Zoc,�e-s_ Other Requirements: 2 Fr- 9,-f,'Z F 111 ( (o d ® C - To be constructed by I—ap Address _Wa>teur Sun DpRy: Public Supply From _ _ Address or: -n Private Supply Drilled by 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 sy 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. Signed: Address (I C f"L' P. E. t-� R.A. Date (0 11 e6) �O)4 r44M,, ', t4- `� i DS 4- License # 6 -QS-Q� APPROVED YOR 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 Mit. Approved for discharge of domestic sanitary sewage only. Title: >9 Date: !�9 Vitopy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL or t -pd:' ..z-' � _ _ . -. :: � � _ • _ a • a?CfID.'Perm3t �# � • :, : � � �. � � Well Location: Street Address. Town/Village Tax Grid # U4�o 61 EV1 Droe -u Map Block 2- Lot(s)3,3 Well Owner: Name: Address: `l Ai4,+k1li, t o il�X izf t j±� G, Use of Well: L I esidential Public Supply Air /Cond/Heat 13ump Irrigati n 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 ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling h- " 5E. Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No ✓' Is well located in a realty subdivision? ...................... ............................. ....... Yes t,�No Name of subdivision A/C , LI S I , Lot No. 5,3 Water Well Contractor: 75-D Address: Is Public Water Supply available to site? .................................. ............................... Yes No t./ Name of Public Water Supply: "'—' Town/Village �-- Distance to property from nearest water main: Proposed well location & sources of contamination to be larovided separat sheet/plan. 40J Date: d Applicant. Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. / Date of Issue !q A> Permit Issuing Offic' Date of Expiration Title: - Permit is Non- Transferrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health PROJECT (Owners Name): DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 COVER SHEET l ) ON C - ROBERT J. BONDI County Executive STREET: Lo4 3 PHONE #: lu MUNICIPALITY: ovv�- V il e. TAX" NUMBER _�� ,°7 3. 3 DESIGN PROFES SIONAL:: _ _ ..,r r DATE:- ❑ REVISION REQUESTED ADDITIONAL INFORMATION Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 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 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health t.C?RLTT MOLENA �;�RN- rvISN:. :..: ,..1� - Associate Commissioner of Health November 15, 2007 Roy Fredriksen, P.E. 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:,, 'G Director of Environmental Health Re: Proposed SSTS — Anakin, Inc. Wood Glen Drive, (T) Putnam Valley TM # 85.07 -2 -3.3 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. Please clearly distinguish between the house and the driveway. 2. The cast iron pipe should not be shown leaving the house corner. 3. The proposed side slopes are greater than 3:1 on the northwest side of the system. 4. The regrading at the end of the system is not complete (no proposed 716 contour). This office wiii contiftue'its review upon consideration of the above mentioned comments: Please feel free to 'contact me at ext. 2157 if any questions arise. JSP:ens Very truly yours jose�ph S. Paravati, Jr. 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 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845).278 -6014 Fax (845) 278 -6648 SHEIRLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Roy Fredriksen, P.E. P.O. Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 (ROBERT J. BOND➢ _Count y.E.xecutive ROBERT MORRIS, PE Director of Environmental Health April 25, 2006 Re: Proposed SSTS — Anakin Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -3.3 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. Fill pad side slope regrading is within 100 feet of a NYSDEC wetland. This requires a permit from the NYSDEC to be submitted prior to approval from this Department. 2. There appears to be some proposed fill. contours .missing.: - This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. JSP/kly Very truly yours, Joseph S. Paravati, Jr. 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 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early InterventioniPreschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health Ct ilk i TA`1110LINAkI, RN, MS1V ~ Associate Commissioner of Health DEPARTMENT OF HEALTH . 1 Geneva Road, Brewster,"New .York 10509 So�,� "'VkTj . Roy Fre sen, P.E. P.O. Bo 950 Mahon c. NY 10541 Dear Mr. Fredriksen: ROBERT J. BONDI County -Executive. April 11, 2006 Re:. Proposed SSTS — Anakin Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -3.3 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. Fill pad side slopes need to be at 3:1. O �!/ The discharge pipe to the curtain drain needs to be 10 feet from the trenches. Please provide a second set of curtain monitoring stand pipes (after the ctrl -de -sac). This office will continue its review upon consideration of the above - mentioned comments. Please feel_ free to contact me at est. 2157 if any questions arise. JSP/kly Very truly yours, Joseph S. Paravati, Jr. 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 (843) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERB.,ITA AMLERt, MD, MS, FAAP Commissioner of Health IIJ ®lliiJ��A'1�'VLYNAB41l, I.BN, SVIL�N �. Associate Commissioner of Health Roy Fredriksen, P.E. P.O. Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: B8®B$ERT .I. B ON ®B County Executive - .... - � - - - -' .::+din T •`. Q,. ... � .. "F_ ::;< �+.� - '.:+� - +.: �; .. .,. .. DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 April 11, 2006 Re: Proposed SSTS — Anakin Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -3.3 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. Fill pad side slopes need to be at 3:1. 2. The discharge pipe to the curtain drain needs to be 10 feet from the trenches. 3. Please provide a second set of curtain monitorizig stand .pipes. (4fter.the cul >de- sac)...., - -- This office'will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. JSP/kly Very truly yours, ell( Joseph S. Paravati, Jr. 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 (843) 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 MOUNARI, RN, MSN Associate Commissioner_of Health Roy FredrXsen, P.E. P.O. Bo 95,0 Mahopfic, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH. = = 1 Geneva Road, Brewster, New York 10509 vP�Tl ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health March 30, 2006 Re: Proposed SSTS — Anakin, Inc. Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -33 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. Please increase the SSTS plan view at 30 scale to include the wetland flagging. It doesn't appear the 2 foot solid pipe is being provided. Please clarify the plan-to clearly show the 2 foot solid pipe before the trenches begin. Please show the expansion area as if it were to be installed (boxes, 2 foot solid, etc.). Side slopes of fill pad need to be at 3:1. Please show •the-Water line and the service connection. " ✓�! Please show the location of the stand pipes in the plan view. Please show the dimensions of the septic tank in the detail. .Please provide a note stating that the SSTS, well, and house are to be staked by a licensed land surveyor prior to construction. lease provide basement floor plans for review. Please be advised that although only 2 bedrooms are being proposed, house layout is for a minimum of 3 potential bedrooms. This office will continue its review upon consideration of the above - mentioned comments. f ( to C °b Please feel free to contact me at est. 2157 if any questions arise. o -A 'a% u- 044.'. i -a-A - Very truly yo,,urrss, 6o7seph S. Paravati, Jr. Assistant Public Health Engineer JSP/ky 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 SHERLII'TA AMLER, MID, MS, FAAF Commissioner of Health LORETTA MOLINARI, RN, MSN . Associate Commissioner of Health Roy Fredriksen, P.E. P.O. Box 950 . Mahopac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. B ®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health March 30, 2006 Re: Proposed SSTS — Anakin, Inc. Wood Glen Drive, (T) Putnam Valley TM# 85.07 -2 -33 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. Please increase the SSTS plan view at 30 scale to include the wetland flagging. 2. It doesn't appear the 2 foot solid pipe is being provided. Please clarify the plan to clearly show the 2 foot solid pipe before the trenches begin. 3. 'Please show the expansion area as if it were to be installed (boxes, 2 foot solid, etc.). -4. Side slopes of fill pad need to be at 3:1.. 5. Please'0iow the waterline and the'service'connectiori; 6. Please show the location of the stand pipes in the plan view. 7. Please show the dimensions of the septic tank in the detail. 8. Please provide a note stating that the SSTS, well, and house are to be staked by a licensed land surveyor prior to construction. 9. Please provide basement floor plans for review. 10. Please be advised that although only 2 bedrooms are being proposed, house layout is for a minimum of 3 potential bedrooms. This office will continue its review upon consideration of the above- mentioned comments. Please feel free to contact me at est. 2157 if any questions arise. Very truly yours, oseph S. Paravati, Jr. Assistant Public Health Engineer JSP/ky 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 • w +. �z -o4, PUTNAM COUNTY DEPARTMENT OF HEALTH DTVI5ION OF ENVIRONMENTAL HEALTH :...i ° �.,; •.. . INDTVTDUAL WATER SUPPLY &.SURSTJRFACE.SEWAy &.?'13 wtl ENT.aYSTEIiA& ; ° E 4iTfi1-SR",*T FOXC0NSTi'UCTiON PERMIT NAME OF OWNER: STREET LOCATION: Wc>47d & leo 4DWkt -' REVMWED.BY: 'RM, GR j6? SRDATE: '3 °Z� l �" b TkLX MAP #: (CONEMMED -7 ) 3 Y /N DOCUMENTS Y N (REQUIRED DETAILS ON PLANS CONT'Dj PERMIT APPLICATION HOUSE SEWER -'/" FT. 4 "0'; TYPE PIPE. CAST IRON WELL PERMIT OR PWS LETTER (_ ,(ENO BENDS; MAX BENDS 45' W /CLEANOUT RENEWALS (LETTEROFAUTHORIZATION LJL_) ATE (NO CHANGE) j/tv f 3 DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION EAF PLAINS -THREE SETS dLSHORT �HOUSE PLANS - TWO SETS ( _j( JVARIANCE REQUEST SUBDIVISION LEGAL SUBDrMION ' ( lY )SUBDIVISION APPROV*L CHECKED _ RATE ,•n; v. ,'n .^ �PERC FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED GENERAL (�( GCATED.W NYC WATERSHED ' S SUBMITTED TO DEP EGATED TO PCHD < P APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED �(� E S TO BE WITNESSED - APPROVAL SSDS AD3, LOTS WETLANDS (TOWN/DEC PERWr REQ'D ?) (� ATA ONDDS•PLANS & PERMIT SAME - 1969 NEWHBOR NOTIFICATION FLO0i"v"li.'IrEVATIONVf 200' SOIL TESTING LOTS >10 YEARS OLD •DETAILS ON PLANS XREQUIRED ( )SEWAGE SYSTEM PLAN-(NORTH ARROW) SSDS HYDRAULIC PROFILE �ZHGRAVrrYFLOW )NSTRUCTION NOTES 1 -15 SIGN DATA: PERC & DEEP RESULTS CONTOURS EXISTING & PROPOSED .UVEWAY & SLOPES, CUT �FOQTING/GUTTER/CURTAJN DRAINS USDA SOIL TYPE BOUNDARIES JC_ffrrLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# ATE OF DRAWING/REVISION DATUM REFERENCE . ,(LOCATION OF WATERCOURSES, PONDS J LAICES,WETLANDS WIT1MI 200' OF Y.L. ,(PROPOSED FINISH FLOOR. AND BASXMNT ELEVATIONS j WELLS & SSDS'S WAN 200' OF SSTS PROPERTY METES & .BOUNDS . )(}EROSION CONTROL FORZOUSE, WELL & SSTS, EROSION CONTROL NOTE _...,..._...____ ..,„..__.___FII,L•SYSTEi1i5 -- _ _ . HORIZ0NTAL;3,AST TRENCH LOPES 3:1 0 GRA E PROFILE & DIMENSIONS IN EXPANSION AREA ()U CLAY BARRIER - - - - - -- - -- VUFILL*CER ON NOTE PLAN FOR R.O.B., UNC ON LASSIFIED & IMPERVIOUS SEPARATION DISTANCE FROM•TOE OF SLOPE TRENCH LIZ TRENCH PROVIDED 601T MAX. &00 lqt 4.A 9 PARALLEL TO CONTOURS }GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN : FROM*SSTS L)10' TO F.L. DRIVEWAY, LARGE TREES, TOP OF FILL . _);O' TO FOUNDATION WALLS ��J1115Q00Q0','�' T 14 0 C WAETCH — .$2 _0:� 0S' iINN DL' Oti D t �1u 50M ' DTRQ . 1 P.T.M• 1 TS P 'IT'ffi1S�aAn 6- TO S T,AM ,W TV, RCOURSE LAI E(inc. 10 TO WATER TINE (pts - 20 ) �,,. y�, c� ,5,• -�� X50'• INTERMITTENT DRAINAGE COURSE LJ2001500' RESERVO mi ETC. 150' GALLEY SYSTEMS _)10' MIN TO LEDGE QUTCROP SEPTIC TANK _J10' FROM FOUNDATION; 50' TO WELL WELL ==;M TENSIONS TO PROPERTY LINES -_,-3LOCATI0 Olaf F sERvIcE CONNECTXO SLOPE (IN SSTS AREAS20 %) _j(REGRADED TO 15 %, W REQUIRED - DOSEmum S 5TE ,/ UUP.UMP NOTES . 10 LJC_JDOSK 75% OF PIPE V OSE VOLUME NOTED UUDETAIL FO .MAIN, (PIPE TYPE, ETC.) U( )PTT -BOX SHOWN & DETAILED 'L--) Y STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, T BOTH SIDES, DETAIL IT AM to CDS=,--S%, 20' -'t %, 25' -3 %, 35'-1 "!0,100 % - <1% 0' MIN to CD DISCHARGE/100' with 182 cons dap discharge (__(___)10' MIN to NON - PERFORATED PIPE 5r,rMsLt lrfv7/S PUTNAM COUNTY DEPARTMENT Ofd' HEALTH DffV S ION OF ENVIRONMENTAL HEALTH .SERVICES ..�.._ ;`.< .n' .. ' ..w, .e- ..�,e. -+c:� ... f: s. - -' �r -•.:X. a .. . 1�.' .:is. Ci.i:.. d .. ....�� w: ..... .. AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: I, K �. represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: H f-j'4 k /,-j 7�4 C, Having offices at: a F0 Whose Officers Are: President - Name: 10yo 1 rem„ Address: _ l 0 R T941 Vice President - Name: Address: Secretary -Name: Address: - r 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. S orn to before me this day of y -� 0,woqy," — (mon w (yea') Notary blic JOAN ROBBINS NOTARY PNUo IC, State Now York Qualified in Westchester County Commission Expires November 30,21_ _ Form CA -97 Signed: Title: Corporate Seal tv Seal . Vn (-�, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION T Located at LO QO D & Le�4 r)4 \1,e . T/V VA Tax Map # Block - Lot 33 Subdivision of Subdivision Lot # Filed Map # Z Date Filed 12'5'®3 Gentlemen: This letter is to authorize a duly licensed Professional Engineer A.,f:�'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- H..ealth apd -tih� Futnait, &fiiy- anitary'Coue. Countersigned: P.E., R.A., # Very truly yours, Signed: (Owner of P Mailing Address �O e a < Mailing Address: t LWL. dq�km C." State Zip 254 1. Telephone: ZIVA yd a , V . State Zip_ 65 Telephone:Lj Form LA -97 . •- Q';I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date. -Y If a 5,11 Inspected by: G Street Location W,.d QlaK Dtg Permit # V - TM # _100 5-1 7 —.2- 313 Sub&ision. Lot # 3 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...................................... IL Sewage System a. * Septic tank size. ,000 ........ 1,250 ......... other ................ b. 'Septic t3l&i eVel............ ............................... c. 10' minimum -from foundation ........................................... d. Distribution Box 1. A outlets at same elevation-water.tested ................... 2. Protected below frost .................................................. 3. .. NEnimurn. 2 ft. Original soil between box & trenches e. Junction Box properly set ......................................... 6. 1'renches 1. Lengthrequired oa Length installed 6ePe) 2. Distance to watercourse measured 4-1e:, .0 Ft.......... 3. Installed according to plan ..... * ............................ I ....... 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 surfice ................... 7. - Room allowed for expansion, 100% ......... s ............... S.. Size of gravel 3/4 -1'/z" diameter clean ..................... 9. Depth of gravel in trench 12" minimum ........ I ............. 10. Pipe ends .ca p ed ............ .................................... e -1-9 Fieofpump .2. Overflow tank ............................ 3. Alarm, visual/ audio ... .... : ........................................... 4. Puinp easily accessible, manhole to grade .................. 5. Tirk box baffled ............................................................ 6. Cycle witnessed by, H.D.estirmted flow/cycle ............ DIL House/BuUdin`9 a. House located per approved plans. . b. Number of bedrooms ..............3 . ..... Ic IV. Well (��4 Well located as per approved plans ................................. b, Distance from STS area measured /t9ep . , ft........... c. Casing. 18" above grade ................................................. d. Surface drainage around well acceptable ........................ Y.' Overall Worlananship a. Boxes properly grouted .................................................. b. All pipes partially backfilled .......................................... c, All pipes * flush with inside of box ....... * ........................... d. BackE material contains stories <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain draiii outfO 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 _- • SITE INSPECTION FOR FILL PAD Date: Inspected by: Fill pad located per the approved plan Fill Pad Length Required Length Fill Pad Width Required Width Fill Pad Depth Required Depth Run -of -Bank Fill Quality Slope from Top to Toe Impervious Layer Installed Erosion Control Installed - Sieve Test Results (if applicable) ..gym._ ._. ,,,:,�_..�;.,, b ._.a.. _. ,.__�,;:. .•:q;:.q._.�..::.��:. �. Additional Comments. ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ­i • Z.; -::SURSURF-ACZE-SEWA-G'-E-,-TiREATNlEiN'�T S`Y,9MM­- Owner 4L(i41zw X�-C, Address 0 �X 7; h Z-, Located at (Street) QQ Q C /�-r f)rl Q C-, —Tax Map Block_ Z Lot 3,3 I (indicate nearest cross street) Municipality 9 -. .1449- n /a() C/-**, gAg Watershed_. SOIL PERCOLATION TEST DATA NOTES: P. 1�fi- tqlkkepe ed same depth until approximately equal percolation rates are obtained at each (i.e. :5 .1 min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be u [n'tt ��bmitte ,d -fso e. I... Di! is to be made from top of hole. X, Form DD-97 Depth towaier".:'. Water From Ground "Level Percdlatiop Elag Time 'Surface (Inches) `-,Stop. Drop in lute Run No.. :.,,-.:Start'!, Stop.:, Start IngHoIeNo.. es Nlimhkh.'. 1 2!4'1 -317 _3* Zt 2Z 2 ,.,0 2- 1 314 3 3.41 4:1? 3Z 2 Z44 31� 10. 4 5 le- zz 1 .3A z> 2 3 3 3:Sb Zz Imp 4 5 2 -1 fie X NOTES: P. 1�fi- tqlkkepe ed same depth until approximately equal percolation rates are obtained at each (i.e. :5 .1 min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be u [n'tt ��bmitte ,d -fso e. I... Di! is to be made from top of hole. X, Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES -:..DEPJ HOLE :,NQ.. HOLE NO. 12 H, HOLE IVO G.L. 0.5' - G. b rim fv,) - 8 pm .5 �Sot 1.01 IS 2.0' 2.51 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.01 10.0 Indicate level at which groundwater is encountered _ a -h e-- Indicate level at which mottling is observed —7fT Indicate level to which water level rises after being encountered Deep hole observations made by: 6 A Date i c) /6 Design Professional Name: gov Fnegot&gseN Address: PC-, k�� !�2dAur, V Signature. Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION y�(ytFOR�j APPROVAL �O�F' PLANS j�FOR _ /♦� '." 1� "^ t' -EP, 1vBd. TDV'13Ji "1 °Y��1:7 1 ��iJ•111. .' .. oa i� - .. : ��+'�.:�,.: :. ..'r+. .i. '...vA' ..'r �:r... .. ... A 1. Name and address of applicant: T2�r4- t�6dbt)A<, 14. J/ lasS 4-1 2. Name of project:1R140.4 Gnz •-err' 3. Location TN: 4. Design Professional: 1264 5. Address: p/y^Bd�c �J`;O 6. Drainage Basin: yt>S.e,•, j2�ViCr�._. I/ / /,� ,, Gf - 7. Type of PrWect: rivate/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 Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ........................ 10. Has DEIS been completed and found acceptable by Lead Agency? ..........:.:.. 11. Name of Lead Agency Exempt Unlisted t/ .t*-> 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ... .. . .. ...................... .. ... 13. If so, have plans been submitted to such authorities? ........ ............................... e 14. Has preliminary approval been granted by such authorities? Date granted: 2, oo3 15. Type of Sewage Treatment System Discharge ................. surface water LXgroundwater 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? ....... ............................... o 19. If yes, name of water supply Distance to water supply — 20. Is project site near a public sewage collection or treatment system? ................ oil 22 24 Name of sewage system Date test holes observed /0 ProJ 'ec pt design flow (gallons er day) Distance to sewage system 23. Name of Health Inspector a ................................. ............................... �O, 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ..................... Form PC -97 8/99 2 27. Is any portion of this project located within a designated Town or State wetland? 28 :- :Wetlands-ID Njzmbe _ 29. Is Wetlands Permit required? .................................... 1 .;:i:t'� ........................... l' ' r Has application been made to Town or Loc r13hC 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, landfilling, sludge application or industrial activity? ............................ Yes/No t fl 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 C 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 .......................... ......... .I..................... Mapg 1 Block ;0- ' Lot 3 37. Approved plans are to be returned to ..... Applicant ✓Design Professional .- • - ��1C3�' E,- A1?- applieatidn�foY� •e���v`•appro�lof a nr�rSSTS to be loeated v�itru-�`;he �1Y+C'�Iate�sl�sliail:� 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. ll hereby affirm, under penalty of perjury, that information provided on this fora is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to SICNAT URES & OFFICIAL TITLES.- Mailing Address: ................................... V4 j4 A�-L' ['(' V la�'/ - PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM FsRC�'JE�CT'INFORMATION� ( To be completed by Applicant or Project Sponsor) t ^ 1.. APPLICANT /SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: Municipality ' V4 1 tel County Ott 4: PRECISE LOCATION: Street Addest and Road Intersections, Prominent landmarks etc -or provide ma, a 1 00D Cj (e�i fir- /vex `�"-':•:- 23.3':,:_ . 5. IS PROPOSED ACTION: ew Expansion Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: U` - Off! 7. AMOUNT OF LAND AFFECTED: Initially • 2,3acres Ultimately ��,li� acres .`i'i•': { -' ' 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRI6ZION5 ?., , : fq-Yes • F No If no, describe briefly: - c � �.. .. -. ... '. �. . .. ., ... - 1. _.. �� .. .. .. _ ._ ,- .. _. .. .y' • c 9. WHA IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) esidential Industrial Commercial Agriculture Park / Forest / Open'Space F.-I 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 p rmit / approval: d 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY, VALID ,PERMIT OR_ APPROVAL ?..., ., ❑Yes IF yes, list agency name and permit /approval; 12. AS A RESUerOF PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? QYes No I CERTIFY THAT THE; INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: r Signature__ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before'proceeding with this assessment f. FAi�T I? = 'FNS'AC - ASSES�i` EN -T FT-&U ; bMijliat d-bv Ud id-- fY yj �` ��. -:„q /$`' :.� �. �. •n; w Yoe,, A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review pr o> and A't`,the FUtetAF. Yes No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN'6 NYCRR, PART 617.6? .- fdo, a negative declaration may be superseded by another involved agency. Yes [] No 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 comrriunfty or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A 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: C5. Growth, subsequent development, or related activities likely to be induced by the proposed'actioo? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy? .Explain briefly D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL . �.., ENVIROtVCutE.., ALAR- E- A.(_ CEr)�. :.if`vrns,ezpia�n.b,r!efl � •, :` -- -. �.� F` - Yes F No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex lain: El Yes F] 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 explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked ves. the determination of si4nificance 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 signi)cant adverse impacts 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 ' a hi'supporting documentation, that the proposed a, WILL NOT result in any significant adverse environmental impacts AND provide, an attachments as necessary, the reasons supporting determination. Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Date Title of Responsible Officer i Signature of Preparer (If different from responsible officer) mmwmmw-=� 60 fn PU F khl COUNTY 0EPA," `'MEN; OF HEALTH MVI-'IIi!I\I U!-- i A(J, 1 APP VE'.�' S N'iY1 ELF APPLIGiVISLE 1-;-ULE'SAND PUTN !V', GOU u1:)' HEALTH DEPAR"I'MIENT. ROY FREDRIK,SENq PE Consulting Engineer Design Planning Construction P.O. BM 930 Phooe S 11-928-0265 Mabo pa. 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