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Home My WebLink About4612DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.07 -2 -29 BOX 35 04612 t T is ., } 1 0 ;f ,��;Ir IN 6 1T , 1 IN Ass Is 04612 1 � AM COUNTY DEPARTMENT OF HEALTH N- _OF :- ENVIR0NM.EN -TALHE W.$ERYIC... S CERTIFICATE OF CONSTRUCTION COMPLIANCE FORSE, W MENT SYSTEM PCHD CONSTRUCTION PERMIT # %✓� 0- Located Located ag a2WX 4) elf fA� of V`tg Owner /Applicant Nam Tax Map Block Lo� Formerly " �7�rw��z Subdivision Name &ae Subd. Lot # Mailing Address S j ,6 ,� ��Cc� `7' !! (��1� %tom �' C Zip / 4fi' Date Construction Permit Issued by PCHD I If Separate Sewerage System built by r cX"647S7. Address Consisting of Gallon Septic Tank and Other Requirements: Water Supply: Public Supply From, Address or: Private Supply Drilled by 1,PCf &k Address & l 0 X 0111711404rIA "Bfflding Type % Ale '" / > Has erosion co i±rol been completed? Number of Bedrooms Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam epartment of Health. Date: OlId Certified by P.E. '< R.A. (Vesig ofess' nal) o r Address �, �' ., -�' : � ° -b �" , r�ti2. �l l"l.�� 'i? r. License # - —ter 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 revocatioW modi ati or c ge is necessary. By: - Title: Date: 1z" � White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL O"XffPLIETIIO1V RIEIPOuT Well Location reet Address: T e: r Tax G 'd # Map F�•%Block Lots) Cl Well Owner: Na Add ss: 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 _,14 Open hole in bedrock _ Other Casing Details Total length Ww/',/'in. Length below grade . Diameter Weight per foot V/ lb /ft. Materials: ZCSteel _Plastic _Other Joints: _ Welded Threaded _Other Seal: K_ Cement grout _ Bentonite Other Drive shoe: Yes _ No Liner:_ Yes '-.,No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours _ Yield �LO gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve "analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 7�7 ` ` or P `t - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity / d Depth ;Z F-,* Model L,'ar- y Voltage —2-:36 HP 9� Tank Type k)92C eo Volume 9"P Date Wel Compl ted 7) Putnam County Certification No. Date of Report 00 r1221 Well Driller (si nature) Nuri;:/�txact location oI wen wiui utstanGCS to UL Mdbt LWU Vciiiia►iciu iaiiauiiaina w w Yav•■.......,.... —1+... W ,....,.,..Y...... _ Address: Well Driller's Name � �.1.��„� Signature: Date: 10ht11 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner! Orange copy - Well driller Form WC -97 t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES o �1.:. s- ar.Cv�.7.:nrwm'r:::...►.r: •�s, .. � o'...R ' '6 ' _ •�;-. GUARANTEE OF SUBSURFACE SEWAGE T2yi ft'§YffItfN"'`�~ Aim Owner or Purchaser of Budd in Tax Map Block Lot, Building Constructed b ._itlage Location - Street Subdivision Name e, 4 A :!Z= Building pe Subdivision Lot M I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage ttaatment system serving the above- deacribed property, and thet is has been constructed as shown on the approved plan or approved amendment thereto, and in auurdance with the standards, rules and reguladws of dw Ptdnatn Canny Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good opastang condition any part of said system constructed by me which fails to operate for a period of two years immedi�"y"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 furt6er ngrces' to iiccePt' as conclusive the' .-deteiminatibn -1.6f . they 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 ti zing the system. Dated: Month D y YLar ignaturc: Z C �n1 Edys11 LGn 'title: General Contractor ( er) - Signature Corporation Name (if corporationj corporation D "� Corporation Name .(if corporation) / A �tiN � r �sl ( Address: Address: > C State Zip//�� State Zip// < q1 Form OS -97 'r ML ENVIRONMENTAL SERVICES 32:1 f::.f,.-"ar Street - .,a,,,,,__; • -.. -.b • y..� F.. •. _.wv r.�c:r...si.G n..n n3 '!i� j � -= `. t=i... >4: i {. �� _ '' _ . ... - P 1 4) 245-2800 Aloe -t. H. Padovani . Director LAD #2 32.005262 05262 CLIENT #k: 4603 NON STAT PROC PAGE 1 DUDYSITYN . RICHARD DATE /TIME TAKEN: 08/18/00 07: i iO A O �� -,i � DATE /TIME REC D : 08/18/00 1000A � 0A F BOX 5�:�._ MiAHOPAC, NY 10541 REPORT DATE! 08/25r`00 PHONE: (914)-621-5845 SAMPLING E T TL• g LOT 4, MEADOW CREST PUT. VALLEY COs � D 84'' . R. DUDYSITYN NOTES... 2 WATER FAUCET SAMPLE YPE .. a POTABLE PRESERVATIVES: NONE TEMPERATURE,.: < 4C COL I FORM METH: Mf° DATE. FLAG PROCEDURE RESQLT NORMAL - RANGE ;=`UTNAM CN'T•' ` PROFILE c_ 9 18 /00 MF T. COL I ORM ABSENT /100 ML ABSENT 08/18 /00 LEAD { IMS) :::1 ppb 0 -15 ppb 08 /18;.••00 NITRATE NITROS 0.20 Mai /L 0 -- 1CD 08/19/00 NITRITE NITROt3 - :'-'0.01 MtG /L f'f /i= 08/18/00 IRON (Fe) <0.060 MG /L 0-0.3 mg / 1 08/is/00 MANGANESE (Mn j <0.010 M &L 0 -0.3 mg/1 0803/00 SODIUM (Na) 4.22 MG / L N/A 08/18/00 pH 6vO UNITS 6.5-8.5 08/12/00 HARDNE SS .TOTAL 30.0 MG /L N/A t,8 /le,+06 ALKALINITY (AS 12.0 tdG/L N/A I.0 t .Y... t t JR _y "`;U y �� i- ,5.,NTU..... ,.. COMMENTSt ?FACT, THESE RESULTS INDICATE THAT THE MATER :zj;)WAS NOT ; OF A SAT I SFACTO :Y SAN I'TARY DUAL I TY sACC ORB I t�1 HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% cif their than 15 ppb and a treatment must be potential,, ib 7 is .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 that for people on a contain no more than moderately re_;tricte is suggested. are proscribed. Suggested guidelines state' sodium restricted diet,t•he water .should 20 mg /f_. of Sodium. For those on a diet, a maximum of 270 me /L of Sodium METHOD 1008 9101 9139 9.146 2 •3 7 c. ,_x o 2037 9043 YML ENVIRONMENTAL SERVICES 321 Kear Street (914) 245-2800 ' - | - Albert H. Padovani, Director LAB #: 32.005262 CLIENT #: 4603 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DUDYSHYN, RICHARD PO BOX 830 MAHOPAC, NY 10541 SAMPLING SITE: LOT 4, MEADOW CREST : PUT. VALLEY COL'D BY: R. DUDYSHYN NOTES".": WATER FAUCET ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE ' FLAG PROCEDURE NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~�~~~~ DATE/TIME TAKEN: 08/18/00 07:00A DATE/TIME REC'D: 08/18/00 10:00A. REPORT DATE: 08/25/00 PHONE: (914)-621-5845 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TFMPERATURE..: < 4C COLI`ORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. iMEASUREMENT 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 645 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 ON 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 360 MG/L ,..�.-~'MODERATELy'HARD TER;-70-140��'M�/L� ' MG/L�= MILLIGRAM--PER, LITER' HAKD WATER: 1.0��00� MG/L � --- ' -''r- JA-"`'017A MGIUY ~� °------~`--~ SUBMITTED BY: Director . .� � ~' � { � � � ELAP# 10323 r� o Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road i Brewster, New York 10509 L4REi A -41 . YG` 1L ;4:'4[iW41".,S'Q:y+$dd.&iV{ . .�. ;.� .' ci•.1', Associate Public Health Director Director of Patient Services _Environmental Health (914) 278-6.1.30 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 OWNERS NAME TAX MAP NUMBER: E911 ADDRESS: TOWN: rJ OA�'�rn /�t M tq K) VA AUTHORIZED TOWN OFFICIAL: (Signature) f SATE: 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 Constructidn Compinancea (E911 VERFRM) W tXA ViRO \lLE\TAL HEALTIJ SERVICES FINAL SITE INSPECTION S:re2t Lo n ��. Owner _ J, To��y /rn Permits Subdivision L 1. Sewage System Area a. STS area located as per approved plans .......................... b. Fill section - date of placement 3:1 barrier Loth. Width Avg.Dpt1n C. \_w-al soil not stripped ................. :..I............................-- d. Szone, brush,. etc., greater than 15' from STS arm....... e. 100' from water course / wetlands .... ............................... I1. Sewas; Svstem :ptic taZ< size -1,000 .: 1 o) - ........other ............. D. Septic tan'.{ installed level ............. ................ ................ c. 10' minimu:-n from foundation...... ...... .. ........................ d: Distribtuion Box -1. A-11 outlets at same elevation -water tested ............. 2. Protected below frost .............. ............................... 3. Minimu-n 2 k0ri;inal soil between box & tead Junction Box - properly set ......:........... !—T Lezgt_n required Lent h installed 2. Distance to watercourse measured Ft..... 3. Installed according to plan ................. :................. S!ope of trench acceptable 1 /16 - 1 /32 " /foo:........ 5. 10 ft. from property line - 20 A.- foundations...., 6. Depth of trench <30 inches from surface ........... . 7. Room allowed for expansion; 100% ................... 8. Size of gavel 314 - It /z" diameter. clean .............. 9. Dep`ui of gravel in trench 12" minimum ............. 10. Pipe ends capped .................. ............................... g. Pum p or Dosed Systems 'ize.o pump c ham. er ............. ............. 2. Overflow tank ...................... ......... ....................... 3. Alarm, visual / audio ............. ............................... 4. Pump easily accessible, manhole to grade........: 5. First box baffled ........................ :............................ 6. Cycle Y itnessed by H.D.estimated flovi /cycle.. III. HouseBuildinQ a. House located per approved plans ......................... b. Number of bedrooms .............. ............................... IV. Well i 'ell located as per approved plans ....................... b. Distance from STS area measured fl.. c. Casing 18" above grade ......... ............................... d. Surface drainage around well acceptable ............. V. Overall Workmanship a. Boxes properly grouted ......... ............................... b. All pipes partially backfilled . ............................... c. All pipes flush with inside of box ........................ d. Baekfill material contains stones <4" diameter... e. Curtain drain & standpipes installed according t f. Curtain drain outfall protected & dir.to exist wa g. Footing drains discharge away from STS. area... h. Surface water protection adequate ...................... L Erosion control provided ..... ............................... M.Y. 1197 Date: Inspected by: �P�/ Siff (1Z 0, r �e.�.,. — _�-- -� F •��^w ��: k, -` .'s' , •s1,". � f �.. � d�'�. -- y � ®iV L� �tl.�H �1V ;�3� !Vj_��;gL�7.��i�� < � � , ..... _ .. DANIEL J. DONAHUE, P.E. �..'.,J, r .;� -..: <. :.a ^^�`.. °`s.NSc.•. .�s�z:uTi� r.}_...w -:G... ....:j -, -sy •5�:��`>. r.�i %.�:a't: -%�-; :'':5+: -: ,�::- ��:, .s ;c_•�.:".;'�. '��.,: .,�,. 120 Breckenridge Road Mahopac, NX 10541 914- 628 -7576 September 1, 2000 Putnam County Department of Health Geneva Road Brewster, N.Y. 10509 Att: A. Steibling. RE- As Built SSTS Lot #4 Meadowcrest. Drive Putnam Valley (T) TM# 85.67 -2 -29 Dear Mr. Steibling: Enclosed please find: 1. Certification of Construction Compliance 2. Well Log and Bacti Results 3. Guarantee and two copies 4. Four copies ofthe.asbuilt. plan . .•._ 5. Filing -fee of $200.66 W..., By:,� � Daniel I Donahue, P.E. Site a Sanitary o Environmental PUTNAM CO.""TYWr MTMENTOF HZAkT.H__., . WMION OF NMENTA kkAtftl' SiMiCES REOTI ,ST FOR FINAL Ri-SPECTIM Date: 'A f) PCHD Construction Permit 0 For- Fill Trenches Located: .—OT V) Owner/Applicant Name: f TM f Block L04E or Formerly: Subdivision Name: &ff!U aug Subdivision Lot 0 Is system fill completed? Mitf — Is system Complete? Is system constructed as per plansf Is well drilled?- Is well located as per plans? Are erosion control measures in place? Dane: Date: Date: I cortif has been constructed , y that the WAem(s), as listed, at the above premises co and I have inspected an& verified their completion in accordance with the issued PCHD Construction Permit and appioved plans and the Standards, Rules and Regulations of the Putnam County Department of HeaW Date: Certified by: I —PE—RA- De* Profesdonal . - Address: Zi ddE Lic. # Comments; FOIL: ADAM 0 GENE 0' (NAME) te Form FIR-99 BRUCE- `lt:-- Pb- LtYA._ Public Health Director April 11, 2000 ' LCRE ITA ' MOLII3ARi A. -K Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 -.7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (9!4)278-6082 Fax (914) 278 - 6648 _ CERTIFIED RETURN RECEIPT REQUESTED R. Dudyshyn Construction 30 Strawberry Fields Lane Mahopac, New York 10541 Re: Meadows Realty Subdivision Lot #4 Meadow Crest Lane TM# 85.07 -2 -29 Dear Mr. Dudyshyn: F1,( IC It has been brought to my attention that construction on the above referenced lot has begun. This notice is -to advise you that the required erosion control measures have not�been in or are installed incorrectly, as shown on an approved plan dated November 30, 1999. 4 . Effective immediately, a notice of non - compliance will be issued for a violation of the Putnam County Sanitary Code, Article III, Section 2, Paragraph C, and a stop -work order shall be requested from the Town Building Department as required by Article III, Section 2, Paragraph D. This matter is to be corrected by Monday, April 17, 2000. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj cc: (T) PV Building Inspector . Dan Donahue, PE OV'. V. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT i2-::5 TREA M NT SYSTEM PERMIT #� Located at k jP-4 -p0lu+ e-X PS7- Don v i Town or Village Subdivision name )q Ph 0(0,%,j Subd. Lot # Tax Map f: l �) Block X Lot Date Subdivision Approved/ Renewal Revision Owner /Applicant Name �•_ �� J �4 ��, min ;J`f Date of Previous Approval JI Mailing Address ?lj �5 %'i,�i�,�' i /�� s G•�'.c/� i�- 7�<'ii'° Zip Amount of Fee Enclosed Building Type !`/ �' , Lot Area /jA- No- of Bedrooms 4 Design Flow GPD ilk Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and [r L- �i �,24- j.i • rf j- e� L Other Requirements: To be constructed by Address Water Sunup Public Supply From Address or: Private Supply Drilled by ~Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage 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: Ile Address P.E. R.A. Date V . -,Oft�Aeet License #� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew pe it. A rove fo dis ar of domestic sanitary sew ge only. By. "- Title: Date: White copy - HD File; Yellow copy - lding Inspector; Pink copy - Owner; Orange copy - Design Pr fessi nal Form CP -97 I ^ PU Y NA M COUNTY DEPARTMENT ®IF HEALTH DIVISION OF ENVIRONMENTAL IH[IEAIL'll'IH[ SERVICES Jd, >I 'i{ ®I,1:'I',Qv ' I TSTR�;1�T. �?�A,'T I� �El please print or type PCHD Permit # Well Location: Street Address: TownNillage Tax Grid # Fret Olt ra --teIy ' _ AV -641t? Map;j , '% Block Zl. Lot(s) Well Owner: a e*- 7 ddress:,�o s Use of Well: esidential Public Supply Air /Cond/Heat Pump Irrigation Il rimary Business Farm Test/Monitoring Other (specify) !-secondary Industrial Institution Standby Amount of Use Yield Sought gpm effided Est. of Daily Usage3 2 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling AIew Supply (new dwelling) Deepen Existing Well Detailed Reason q � -49 c�. r / 11 t X for Drilling Well Type 4--15rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes ''" No . Name of subdivision Lot No. Water Well Contractor: Z %L Address: Is Public Water Supply available to site? .............................. ............................... Yes No Name of Public Water Supply: T� Town/Village Distance to property from nearest water main: '- Proposed well location & sources of contamination to be pro ' ed on sep to plan. Date: / % Applicant, Signatz"r-e :.. 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 � g Permit Issuing Official R. Date of Expiration 1 01 Title: Permit is Non- Transfer al>i White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of P. oK c��j f�1L Located at Tax Map # JS-, l/ Block Lot Subdivision of. reW 14 �F �) 6uJ' Subdivision Lot # _-�V- Filed Map # .� f �-s� Date Filed Gentlemen: This letter is to authorize J "u —L J • fl l w?r! fr`- 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 145.a_nd/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: P.E., R.A., # (Owner of Pr petty) Mailing Address /o) G Rree,4r i l -e 9a/' State Al ip 16 f� / Telephone: Mailing Address: 15".� State Zip z2 Telephone: Form LA -97 P U VT COUNTY DEPARTMENT OF HEALTH DIVISION OF EP_ VIRONMENTAL HEALTH . SERVICES s'^ -.. _ � .. . . -..... _a', .� �o t.�..a:: ... - <p - ,. - $ _ .•� -< ' b.a-• .. ; a-a - '�` o' =�c.. . � <e.-• r; �'b`..Qa'. .. �i��.,�s AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In th matter of application for: far- •j %it � �°E''� �� 4t 4 represent that I am an officer or employee of the corporation and am authorized to act for: Narne of Corporation; Having offices at:� c- Whose Officers Axe: President - Name: • <<5'�/�/ �� %i Address: 6 7if /20 5o,1A '�RLrzm . /ice President - Name: <7/- Address: �� 'ax d,-.30 D o��;� XX Secretary -Name: �_ _..... Address:. Treasurer - Name: Address: and that I an and will be individually responsible for any and all Acts of the to the approval requested and all subsequent acts relating thereto. 1.2 S orn to before me this r (Mo ) . Notary TE ii. F "IN KELS' E I N Notary Public, State of New York No. 4774786 Qualified in Put• u 060 Commission Expires Form CA -97 ay of (year) Signed: Title: (Corporate Seal ;prporation wi #`respect f'r-.cs;d P.:r)� I ✓ November 9, 1999 DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road Mahopac, N.Y. 10541 914 - 628 -7576 Putnam County Department of Health Geneva Road Brewster N.Y. 10509 Att: Mr. Adam Steibling Dear Mr. Steibling RE: SSTS Permit & Well Permit Property of R&D Construction The Meadows R.S. Lot #4 Putnam Valley Enclosed herewith please find the following: 1. Form PC -1 2. SSTS application 3. Well permit application 4. Design data sheet 5. Letter of authorization 6. Fee in the amount of $300.00 7. Short EAF .. _ 8. Corporate Affidavit 9. Three copies of construction plans for fill section and trench layout 10. Two sets of house plans. By: ZA *-:Z—. Daniel J. Donahue, P.E. Site - Sanitary - Environmental V _ AKRNST AAA. t DIN, RM. , KITCHEN . - 99Aaf26 WAM iJ1a1L�9 1 � I '. 2 B i 61 DBPf FO ffQgl$81 1,<t •loor WHITEHALL 27'x 36'- -wl20' GARAGE C-+ i Oft °2 ;f$�t7pi82: !�� ;" cctos IN bn tr HALL AIM i-y V ,r c"� !t1}alYi tA+ U� ww a am, 3' ra f �� 4La104 t08a0t1 t7 C7 pq and Floor a ps "M LYON !wtOmin INC. W' Old Trail Road, Seiinsgrove Pa. 17870 Telep.1jone (717) 743.0111 —:1. PUTN•AM. COUNTY DEPARTMENT OF HEALTH 1Dl . ISION OF ENVIRONMENTAL HEALTH SERVICES v� :. .. AP. PLICATION FOR APPROVAL -NF iP1,AN5 FUR A WASTEWATER.TREATMENT SYSTEM 1. Name and address of applicant: 6" i '9 S''! J-4e i• -1 2. Name of project: "�S' 3. Locatior6v: �rr� �•, ,l /� %%t� 4. Design ProfesAofml:U/v po,vgHu E a 5. Address: /..v r�,v,e.oae► /Pa 6. Drainage Basin: ff��yIijw � 1h r9Hc, "01--e4 zy, yr 7.Tyt r' t: _ Privat6kesidential .Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) _ 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ................:........ A/0 10, Has DEIS been completed and found acceptable by Lead Agency? ............... /Y M 11. Name of Lead Agency dzA i 12. Is this project in an area under the control of local planning,. zoning,. or.other- ._ . :_�ft"uria ', erdi�iaY�cES? ....... .................. ....:.:.....::...:::.:.......:.... .................. - 13. If so, have plans been submitted to such authorities? ....................................... Nd 14. Has preliminary approval been granted by such authorities? Date granted: 15. Type of Sewage Treatment System Discharge .....:.1 .......... surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... Nlrf• 17. Waters index number (surface) ........................................... ............................... /rhy 18. Is project located near a public water supply system? :.... ..............................— /Vo 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? .........6...... ZV4 21. Name of sewage system Ai /,q Distance to sewage system A6&y 22. Date test holes observed —L —� 23. Name of Health Inspector R, P* e6 et f, - 24. Project design flow (gallons per day) ............ :................................................. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit.required ? ... /n 26. Has SPDES Application been submitted to local DEC office? ......................... /V /N r 2 27. Is any portion of this project located within a designated Town.or State wetland? 28. Wetlands ID Number .......................................... . ............ ................................... ......:. .................... ....... 29. Is Wetlands Permit required? ................................. I................................................ Has application been made to Totivn or Local DEC office? ............................... .._._ w 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, - landf lling,.sludge application or industrial activity? 32. Is project located within 1,000 feet of existing or abandoned landfill, s 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 Tillage? ......................... i;r . ��. r^a`re co, MU w % x and/or sewer facilities planned to bed evelo�ied'cvltl2in ' 15 years in or adjacent to project site? ................................ ............................... No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... jND 36. Tax Map ID Number ......................................................... Map T,,o% Block_ Lot-) f 37. Approved plans are to be returned to..... Applicant - Design Professional NOTE: All applications for review and approval of a new SETS to be located within the NYC 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 stormwateraplans 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. 1 hereby affirm.- under Penalty of perIury, that information provided on this form is true to the best of my knowledge and belief. False st atemchts wade herein are punishable as a Class A misdemeanor pursuant to Section 210. o Law. SIGNATURES & ®F7FIIC14L TITLES. Mailing Address: .................... ........... .4 p1 �� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .F. � (- _ .4: i =t: .?; '- . w.> rr•V'i:fcJ•.-_:y ,.'.(.'ei..a:". a;.• «.;_�:�.• a b..-- ... . - r. :r.. .. _ R -- a r. ... •..- sr:ijirwr.r:r � •••.1�i+• DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner _ & l . Address '21 6 ldf Located at (Street) � Wa Tax Map '9,1 O Block � Lot. (indicate nearest cross street) ,p Municipality y 47;y. 4411,e 5 Watershed l SOIL PERCOLATION TEST DATA Date of Pre-soaking s Date of Percolation Test A /1/11�) 3 i s— 3 Z> 2 _ iz . 3 . s� d- 3 y 30 4 5 2- 0 3 - ° 4 5 - 1 2 3 4 5 NOTES:. 1. Tests to be repeated at same deptl 36 C�_3 C. 26 LI f ?6 k' 'V _1L2 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 • is TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED ED IN TEST HOLES 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: �Vr Date /-V,09 • L PROJECT 1.0 NUMBER 617.21 SEOR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM ...;.:.. ,,,..;...�;,.�• - *' - ''P�&�4074'LISTED "ACTI6NS- O`ni•y� �- -�"• PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) I A LICANT /SPONSOR a 2 PROJECT NAME "1 PRISJECT LVC TI, r Munrcrpalrly joL•� �(ili /" % County ------ • - - - -- -ham_ �1 -- - - - - -- --- - - - - -- - - - - -_. --=- - - - - -- ..- - ---4- a PRECISE LOCATION (Slr(:et address and road intersections, prominent landmarks, etc., of provide map) 5. IS PROPOSED ACTION XNew O Expansion ❑ Modificationlalteration s. DESCRIBE PROJECT BRIEFLY C D N S 7 i� C i /< �v 1 AJ.A, F,9^1 c y 4 rx" '0 c ,v 0 fe 7. AMOUNT OF LAND AFFECTED initially [ � xt'_4.1r__ acres Ultimately _,S_ �i M acres 8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? I4 Yes O No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential lr _1 Intluslrial ❑Commercial ❑Agriculture Park/Forest/Open space O Oiner Describe- DES•AC 410 - 4NVt3EVC•�A.OGRt q,.APPROVAc; OR- FUN OtT JG;' NOVVOR-ULTiMAFL-L-Y- FROM 'ANY-OT•h E•RGOVEP..,*E.N- TA+••,IA STATE OR LOCAU ?? arYes O No If yes, list agency(s) and permitlapprovals 11 DOES ANY ASfECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? O Yes No If yes, list,agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? 0 Yes O No If 1 i CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponsor name• " -._ —_ -._ Date: ll f/l,001 Signature: _ —_.. ""T IC — If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART li— ENVIRONMENTAL ASSESSMENT (To t)e culTlplr,tc!D t;y +cio;I.:y A. DOES ACTION EXCEED ANY TYPE' I THREiSHOLO IN 6 NYCRR, PART 617 12? It yc r oonl,n.ur ;'ort •:' r ^•v r?r %cess ano use the FUL,L E`41..' I Yes UeNO - 6 W;1.1. ACTION RECEIVE. COORDINATLD REVIEW AS PROVIDED FOR UNLISTED Ac lloris IN G NY(-,I-,P, Pr 11.41 0176? It No a negative decia(atn:)n may be superseded by anolhrllnvolved 2qi nuy C COULD ACTION RESUE.1 IN rA VEl" SE EFf`Ecr.1; ASSOC IA7ED WITH 1 Hti f Ui... )d °!hrC, fA "• `l 'lvlpTt�rs ;:ifitEg (� - ; CI Existing au quality, surface or groundwater quality or quantity, noise levels, ex;sung uaii,c : ;a,l)rns, sold waste production or disposal. potential_ for erosion; drainage or hooding problems? Explain brie Ely: C2 Aesll,el,c, agricultural, arcnaeoiogP.:at n•sinw.. pi other natural of cultural n %gpUrr ;, ; ;, or comrriult.7', Jr 1-1r,.1r10010ld Lhararlerl Explain brier;,, C3. Vegetation or fauna, fisn, shellhSh o, - If;iile spec: es, significant haoilats, or threatened or endargdreeJ spec es? Explain briefly r A/ ® r C4 A community's existing plans or goals as officia;ly adopted, or a change in use or intensity of use of land or other natural resourceS*7 Explain wielly N,r rV c C5. Growth, subsequent development, or related activities likely to be induced by the proposed action'? Explain briefly. Al C6. Long term, short term, cumulative, or other effects not identified in Cl-05? Explain briefly. ty C7. Other impacts (including changes in use of either quantity or type of energy), Explain brietly. D. IS THERE, OR IS ❑ Yes 4ERE LIKELY TO 6E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? No If Yes, explain briefly 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. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Coec this box if you have determined, based on the information and analysis above and any supporting - docurMntation, that the proposed action WILL NOT result in any significant adverse environmental impacts F--AND provide on attachments as necessary, the reasons supporting this determination: -'-- -_ "- -- Name of Leaf; Agency C" - CY•1 } U' I. or- pe Name o Responsi le O icer in Lea -Agency title o. Responsible Officer Si�n }lure o —Responsible Officer in lead Agency Signature of Preparer (if different from responsi Ie olfrcrr) - ------------ -- Date - -.. 2 SSTS TIE - INS (MEASURED BY TAPE) UNIT A B I SEPTIC TANK 50 32 J. B.1 84 92 r - _.. ...... .... 2 83 95 3 82 99 ' 4 82 103 If 5 n' 83: /' 1 <::'n . n F aX^ :t 7; . 4a 4 1 :• a4i n /a .r F - r . r > - END OPTRErIiZ 140.p SUBDIVISION MAP PREPARED FOR HENRY WIR7'7," l ry ko $ 140 151 PAINT MARK filed April 24, 1987 as map nL3O 2226 I o� ,9 141 149' ON WALL O 10. 143 147 „ ,43: 145. _55005254W 11'_. Z 12 146 144 l424 660 i OLD STONE WALL GENERALLY ON.PRea0l Y LINE 15 24 72 (D } "1 16 q 1 �! 16 25 78 w � V' �• 17 49 94 vl, F 18 '1 ■ 1 1' S 1 F ■ ; 1 1 { iii 1 1 Z i 1•, :. N 4k O 1„ 111 0 11 `.'• N 1 1 , A A-�.; 45, 720 sq. ft. % 1 i09y� 1 r s . 1 A .1 1 ; zo STAKE SET CONC. MOCK KI OD PA 170 , / STEPS 45 8 j i ONE STY: FRAME ` FRAME �' CIIIMNF.Y 71N0 'S1Y: W . A.C. .:' .. ". . O UNITS 2 -GIR DWEWNG: O . IV ✓ GARAGF. KT7 L Z f LOCATION (,_ _ f.1r _ _ _. _ .. .. •. ,•., �•, _ ' _.J .. _. M ... . ' . _\_4 �. -..: �• Y _ .. / .w•- -'4am " _ _ .•v ._ f"E �7.e,.�f .-w. _.:.. .. .4. v . �. .. wo• :w• - -•�,w �... �,..� " �S %'mom •� ®as Ft Ci � W 2 AfACADAM -C 4r C , o J / STAKE '^ ? 1y WALK SET ".— R=43 t ati STAKE SET AfcnrcN enslN A D 0 W EL EC. _-TELF.. R:I CATV v ASBUILT PLAN SEWAGE TREATMENT SYSTEM RICHARD DUDYSITYN CONSTRUCTION LOT #4 MEADOWCREST DRIVE. - 1 `C TM #85.V-2 -29 LYaunro lULLltLy Lfipeu'4Wela4 uI nesaw PUTNAM VALLEY (1) A7161on of Ehvironiental Health Serviod, &"roved as noted for conformanoe with + g DANIEL J. DONAHUE, P.E. aPDlicable Rules and lRegulationg of the CONSULTING ENGINEERS �+ Co th Dar taent:. .� 628-7576 �1 MAHOPAC,N.Y.10541 =" DATE: AUGUST 31 2,000 �� anatnrq Ti #1 s :.: _ t}{L ' SCALE 1 " -30' SURVEY BY: ROLAND LINK, L.S. THIS IS TO CERTIFY TBAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER THE SYSTEM WAS CONSTRUCTED IN ACCORDANCI WR eT c•reerneon.1.-- .— e•nnua ne ..mu...nro nrr ..nre.n.•...,,.�..�...,.,•,• .. ..............�..