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HomeMy WebLinkAbout4613DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 85.07 -2 -30 BOX 35 L :: r 9p ikir r. ' 04613 PUTNAM COUNTY DEPARTMENT OF HEALTH .=1. Y'o. y � V$10, i•':�_'rV = �:1J :1 N :y ='�-�. °N� . 'a+' T� --.ESE.RVICF S....,::.�.y.. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at e5 `ter+ u e Town or Village A Owner /Applicant Name + 1L �. � GCdgrz 51&I Tax Map Block _ Z Lot 30 Formerly Subdivision Name -r4e 0F,40o s Subd. Lot # Mailing Address P-0 BOX f Zip Date Construction Permit Issued by PCHD Separate Sewerage System built by &! rce- T)E\/, Address cL JID(►+'IVr��e. '/. Consisting of Gallon Septic Tank and a-46 tit w- TTrmir-Lo-s Other Requirements:'busi rICi ` I A-rI k Wl FQJ i 17b a5 T. , '7 jo� C.A"iik-i Water Supply: Public Supply From Address or: Private Supply Drilled by Aaogj- t4 Address PS'! X-M !q: , P I A)�y :.... )iuldingc Type Ian erosion control been completed: Number of Bedrooms T 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 ofj he P}tnWr Countypepartment of Health. Date: 7 2 10c) Certified by Address P.E. L-/ R.A. License # SGQM 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 revocati , mo ' ica 'o or c ang i necessary. By: Title: Date: '2.9 V White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �tl PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT ., .-Z —,3>0 Well Location Street Address: ik/ " To illage: ... ITax fn VA A Grid # Ma p!!!, Block 2, Lot(s) 30 Well Owner: Name: Use 'off Well: I'Trimary j-secondary jff igation _;W- Residential /Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby &illing Equipment >e- Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing >< Open hole in bedrock Other L C7 . asing Details Total length ft. Length below grade ft. Diameter in. Weight per foot /& lb/ft. Materials: Steel Plastic Other Joints: Welded � Threaded Other Seal: _24- Cement grout — Bentonite Other Drive shoe: ,,<-Yes No ILiner: Yes "o Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test Bailed Pumped XCompressed Air Yield �pm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet _?00 Well Log If more detailed information . descriptions or Sieve analyses are available, please attach. Depth From Surface Water Bearing Well DiAmeteron, Formation Description ft, ft* Land Surface /r lei If yield was tested 'at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Type Capacity /0 v A4) Model /05,04,_ `/ Depth HP Voltage 4-ii I Tank Type IW-Z-v Volume'/ V, Date 'W 11 Completed 12 /0,0 Putnam County Certification No. L 9 Date of po 4 V/ I L6 Driller (signature) E: t1act location or wen wan aistancus Lout ►udst two punnatFin milUJIMLAa LV U� F—A—M MAI . ­r-- "Oe " Well Drillees Name &4aer_ QI�L Address: `Signature: lol Date: -7 ho White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 5­ , ."I 122 |/ IL YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown '���� N ^ Albert H. Padovani, Director | LAB #: 32.004043 CLIENT #: 7686 NON STAT PROC PAGE 1 QUARTERHORSE DEV, INC DATE/TIME TAKEN: 06/30/00 02:00P PO BOX 402 DATE/TIME REC'D: 06/30/00 02:40P STORMVILLE, NY 12582 REPORT DATE: 07/18/00 PHONE: (914)-628-0971 SAMPLING SITE: LOT #5 MEADOW : PUTNAM VALLEY, NY, 10541 COL'D BY: MICHAEL SCPACCARELLI NOTES...: HOSE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ' DATE FLAG PROCEDURE PUTNAM CNTY 06/30/00 ' 06/30/00 06/30/00 06/30/00 06/30/00 06/30/00 06/30/00 � 06/30/08 06/30/00 06/30/00 06130/00,-` PROFILE MF T. COLIFORM LEAD (IMS) NITRATE NITROG NITRITE NITROG IRON (Fe) MANGANESE (Mn) SODIUM (Na) pH HARDNESS,TOTAL ALKALINITY (AS .TURBIDITY `(TUR SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE . METHOD ABSENT /100 ML <1 ppb 0.35 MG/L <0^01 MG/L <0.029 MG/L 0.029 MG/L 9.97 MG/L 7.3 UNITS 162'MG/L 162 MG/L _ ATTU, ABSENT 0-15 ppb 0 - 10 N/A 0-0.3 mg/l 0-0.3 mg/1 N/A 6.5-8.5 N/A N/A WJJTU 1006 9101 9139 9146 2037 2037 COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% 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 dombined 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 is suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street (914) 245-2800 | | | Albert H. Padoyani, Director | LAB #: 32.004o43 CLIENT #: 7686 1 NON STAT PROC PAGE 2 QUARTERHORSE DEV, INC DATE/TIME TAKEN:06/30/00 02:00P PO BOX 402 DATE/TIME REC'D: 06/30/00 02:40P - STORMVILLE, NY 12582 REPORT DATE: 07/18/00 PHONE: (914)-628-0971 | SAMPLING SITE: LOT #5 MEADOW : PUTNAM VALLEY, NY, 10541 COL'D BY: MICHAEL SCPACCARELLI ' NOTES..,: HOSE ~~~~~~~~~~~~~~~~~~~~~~~~_~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE , PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL _ RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. H6 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, DEPENDSON 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 HARD E 70-140 MG/L MG/L MILLIGRA PER. TER - , - — - - '- ' ' - - -- ' - '- -` ' '- -r- * HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L/ SUBMITTED BY Albert H. Padovani, M~T.(ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES i+Yr i...s�:.. `�.: r � iPr' � .. "v ..n.. !^d v.. °� .. '..,,ri .i"aCm a'. .. ,�;..i: "..�::� . .. .,�.Y� ai� r. . >�i ... • � ,. .r ,.. - - ': � �:a 'a •'. vin =.w�•, .,y.. a .�... ,:. Ja -..Sd ii`C,�. GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by 5711 7- X01 Tax Map Block Lot PJTNA,w1le- 9 /ti TownfAllage Location - Street Subdivision N me 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 Year Signature: Title: General Contractor ( wner) - Signature Corporation Name (if corporation) Address: P!> '�jb?< 46,2. 5TI6 1 t tle- State A 4 Zip l 9-L Corporation Name (if corporation) Address: New( vow ��(MuAe,_ State Zip Form GS -97 Public Health Director 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) 279-6085 Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fax(914)278-6648 ..E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP DUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE- The Putman County Department of Heath 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. o ' (E911 VERFRND 0 A r l0lu,r uz :t,tNViRONIIENTAL HEALTR SERVICES FINAL SITE INSPECTION Date: Inspected by: Sir.':[ Loc n ©� CP.�i'J-T Owner Town Permit f t.. , ► ; .a Subdivision iot 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barier Lath. Width Avg.DpCn c. \ =:ural soil not stripped ................ ............................... d. S --one, brush,.etc., greater than 15' from STS area ......... e. 100' from water counsel etlands .... ............................... II. Sewage Svstem a. 'epic tan. size -1,000 .. 1,2" <.:..... other ................ b. S:ptic tan'_{ installed level ................ ............................... c. 10' rrunimum' from foundation ........... ............................... d. istribtuion Box .. A-11 outlets- at same elevation -water tested ................. 2. Protected below frost .................. ................:.............: 3. Minimum 2 ft.Original soil between box &. tenches Junction BOX - properly set......:... �.... : ......................... . - 1 - Len;t_q required Lent h installed 2. Distance to watercourse measured Ft..... 3. Installed according to plan .......... ....... :...................... S!ope ofteach acceptable 1/16 -1/32 "/foot ............. 5. 10 ft. from properly line - 20 ft: found%jons.......... 6. Depth of trench <30 inche su.l a .o' m allot, elfor expa_ ion 100 % ..:................. 8. Si f gray . 31; /'/2.h ia. ter cle n ................... 9. D t of ar el in 12" nimum ................... 10. Pi e e . ds Deed ........... .......I................ ........ l g. 44.Pump r g,,o :tom-. ins ................ o mp_c ham er................................. .. 7. r low tank %-D.estimated ................... rn, visuaV......... . easily a to grade ................. 5. First box baffl.. ............................... ....... . ..... 6. Cycle v.�itness flovi /cycle........... III. HouS- Building a. Hou-s e l sated per approved plans ... ............................... b Number of bedrooms ....................... IV. Well ..... ..... F V/ell located as per approved plans......... b. Distance from STS area measured ft .......... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... .............................., c. All pipes flush wife inside of box., .. ...................:........... d. B?ckfill material contains stones 4" diameter ............. e. Cumin drain & standpipes installed according to plan f. Curtain drain outfall protected & dir.to exist watercou g. Footing drains discharge away from STS area ............. h. Surface water protection adequate . .............................., i. Erosion control provided ............................................. P, v. 1197 S a COL NT 'r%a s' 1 IaaENY— ` :- g..`TEr' DIVISION ®F ENVIRONMENTAL HEALTH SERVICES ATTENTION AIDAl a GENE REQUEST FOR FINAL IN PECTION For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit # Located: qVeP er- v r : (T) M eLAT44 V4 Owner /Applicant Name: e tf TM Block Lot Formerly: Subdivision Name: w4too J Subdivision Lot # Is system fill completed? Date: Is system complete? Date: L am / 22 0'� ` Is system constructed as per plans? _ Is well drilled? Is well located as per plans? Are erosion control measures in place? M Date: 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. ate. ertified by: PE RA Desi Professional Cad gam. _ Lc. Form FIR-99 �.• Public Health Director April 18, 2000 �'� _, p .=- ."LORETTA '•MOLINAR � it:N; �M:S:N... -r.=� :;= 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 ©Q� Nursing Services (914)278-6558 WIC (914)278-6678 Fax (914) 278 - 6085 ©pp Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 CERTIFIED RETURN RECEIPT REQUESTED Irving Sevelowitz Putnam Valley Building Inspector Putnam Valley Town Hall 265 Oscawana Lake Road Putnam Valley, New York 10579 PLEASE REFER CORRESPONDENCE TO: NAME: Adam B. Stiebeling TITLE: Assistant Public Health Engineer PHONE: (914) 278 -6130, ext. 2157 Dear Mr. Sevelowitz: YOU -ARE HEREBY NOTIFIED that non-compliance of the-PutnarmCounty Sanitar. C�odp; t Article III, Section 2 on the property Meadows, Lot #5, Meadow Crest Lane, TM# 85.07 -2 -30 in the Town of Putnam Valley has been determined. "Such system shall be constructed in accordance with the standards, rules and regulations duly promulgated by the New York State Department of Health and the Department with the terms or conditions of the permit issued therefore or approved amendments thereto." A Notice of Attention was sent on April 11, 2000 recommending the required control measures installation. A subsequent site inspection was conducted on Monday, April 16, 2000 at which time erosion control "silt fence" was observed to be insufficient and installed incorrectly. Erosion control measures are not installed pursuant to the approved plan PV -35 -99 dated December 7, 1999. It is the determination of this office that the Sanitary Sewage Treatment System is not constructed in accordance with the approved plans or PCHD regulations. (T) PV/Meadows, Lot 5 April 18, 2000 This notice is an official request to go work as required by Putnam County Sanitary Health . Code, Article III, Section 2, Paragraph D. I can be contacted at this Department if any further information is required. For the Public Health Director Bruce R. Foley Very truly yours, By: Adam B. Stiebeling Assistant Public Health Engineer ABS:cj cc: Roy Fredriksen M. Spaccarelli BRUCE. k.. TOLEY Public Health Director h:ORE1"Ir` l eCANARI R.N., M.S.N: ' Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914). 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 M Early Intervention (914) 278 -. 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 ®�U April 11, 2000 CERTIFIED RETURN RECEIPT REQUESTED Mike Spaccarelli 4 Marina Drive Mahopac, New York 10541 Re: Meadows Realty Subdivision Lot #5 Meadow Crest Lane TM# 85.07 -2 -30 Dear Mr. Spaccarelli: It has been brought to my attention that construction on the above referenced lot has begun. ..This. notice is to advise iliat the required erosion control measures have'not been iristalled'or are installed incorrectly, as shown on an approved plan dated December 7, 1999. 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, -- 1 Adam B. Stiebeling Assistant Public Health Engineer ABS:cj cc: (T) PV Building Inspector a Dan Donahue, PE a 1. ^:: ... � <.�' !'..".�u�;z. �. � ! `✓ PUTNAM COUNTY DEPARTMENT T OIF IEiIIEAIL'll'IEFII DIIVffSffGN OF IEIVWRONv IENTITAIL HEALTH SERVICES APPLICA,TION1 T-O CPNtS'Y'#:><..�T A.WATIER WIEI,L _ } please print or type Y PCHD Permit #� :d Location: Street Address: Town/Village l Tax / Gam' L.cu�a i! /�� Map ock Lots) e1R Owner: N e: Address: � 5 4 � I 7e c a Ose of Well: si d ential Public Supp y Air/ on eat Pump Irrigation I -P rimmair°y Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _ -5' gpm # People Served Est. of Daily Usages gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ,,Xew Supply (new dwelling) Deepen Existing Well Detailed Reason a -5 e ffoir Drilling 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 A(-,. We1q'V6 LJ3 Lot No. Water Well Contractor: 71115 ►P. 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 provi on separate sheet/plan. Date ` lb _ .:. A}iplLnt Sigaiatire: _ ... 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 _IFOR 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 Pu am County. Date of Issue 9q, I Permit Iss ' g Official: 5L Date of Expiration 2. ®d1 ® Title: Permit is Non- Transffe>r>ra e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 d' ,. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES I ,'i..'...'.:Y.O, .�'•. ..i.. LETTER OF AUTHORIZATION RE: Property of Located at TN (Jn Tax Map # Subdivision of Subdivision Lot # Gentlemen: This letter is to authorize � 86-, Block Z Lot 6, - c7o LA) _S Filed Map # Date Filed g Z / rZ a duly licensed Professional Engineer' L/ 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.theiprovisions of Article 145 and/or 147 of the.Education Law,.Tthe Public-Health. Law, and the Putnam C- ounty Sanitary Code. Countersigned: P.E., R.A., #o,5 dS Mailing Address ?o &K qs-o C State Zip �% C. ��4 f Telephone: 31! , Very truly yours, Signed: 1124:t�A, (Owne of Pro erty) Mailing Address: 4 Amoq State_ Zip Telephone: Cad 2 cc:> -J Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH R \,\ DRWSRON OF IEN7sgRONM ENTAL HEALTH S ERVRCCES _ .� V _.,:A�;�:. _:r•� _ _ :..1.. .dam 'r,.': .. ,i���..' ... - .a.,cr r ;- '::i -."X. '@;.i -_ ., i1 .+R'. �� .. �i!:�.: .i.�- UONSTRUCTION PERMIT FOR SE W) PERMIT # Located at 6$oocJ Cf9'r I L we Subdivision name 'Ite poL LS Subd. Lot # Date Subdivision Approve & / t Owner /Applicant Name M14-- Mailing Address L GE TMENT SYSTEM Town or Village PJ � tm 4 P/o 1 ( 2� Tax Map�Block Z— Lot Renewal Revision Date of Previous Approval- Zip /CS 4-1 Amount of Fee Enclosed Building Type &L t4 Lot Area No. of Bedrooms 4- Design Flow GPD Qb Fill Section Only Depth Volume PCID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED 9 gallon septic tank and S�--t aglL Dl�Ttzr'Sgr; �'3 �, Address :Address Address iesign and location of the proposed system(s) and that the cted as shown on the approved amendment thereto and in im County Department of Health, and that on completion y to the Public Health Director will be submitted to the __r, his successors, heirs or assigns by the builder, that said ......... w,., Fiace 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 o Signed: Address R.A. Date Io zz P License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. In Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 D 14.16 -4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEOR Appendlx.0 ^ 41" =;, . „,;: _.�;, Stela E�1vl�eilin'rsTi8i1E�71'te11 ew� SHORT ENVIRONMENTAL ASSESSMENT FORM.. For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. • APPLICAN%T� �ISPONSOR 2. PROJEC NAME 3. PROJECT LOCATIO : Municipality A h County 4, PRECISE LOCATION (Streit address and road intersections, p minent landmarks etc., or provide map) , 5. IS PROPO� .,,,TION: 0411-Ar 0 Expansion ❑ Mcdificatiordaiteration 6. DESCRIBE F =OJECT BR,EFLY: 7. AMOUNT OF LAND AFf ^TED: r /2 / lZ Initially acres Ultimately acres 8. WILL PR MEO ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Qdres ❑ No If No, describe briefly 9. WHAT IS P ,ESEIti'T LAND USE IN VICINITY OF PROJECT? identia! t nCustrat • . Q ParklFor5s U0perr.space•-• "�• • • • .. ;• ..- . _: _� Gt1ier•; •_ _. �. , . ,.. 1C. DOES ACTION INVOLYE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR AL)? QY'e0s ❑ No. If yes, list agency(s) and permiUapprovals 11. DOES ANY AS ?ECT THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes. 0+10 If yes, list agency name and permll/approval 12. AS A RESULT OF PRO' D ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑ Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponscr name: Date: /6 7 kdf Signature: rr• If the action is In the Coastal Area, and you are a state agency, compiete*the . Coastal Assessment Form before proceeding with this assessment OVER < 6 PART If— ENVIRONMENTAL ASSESSMENT (To be completed by agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.121 If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No _ EI;tC °'tiJG tDiis :TEE) Ri:'v.iEW AS Fk6ViDEU FOR'UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another; Involved agency.. • . ❑Yes ❑Nb 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 patterns, solid waste production. or disposal, potential for erosion, drainage or flooding problems? Expfain brlefty C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: 0 C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: • s Cd. 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 C5. Growth, subsequent development, or related activities likely to be induced'by the proposed action? Explain briefly. Co. Long ter,-, 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. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (ro be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether It.ls 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 (i) 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'slgnificant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a•positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency. Title of Responsible Of icer rte• , Signature of Preparer (if different from responsi le o ricer) Date 1'-784 00 k/s - PUTNAM COUNTY DEPARTMENT OF HEALTH �oTs DIVISION OF ENVIRONMENTAL HEALTH SERVICES E'€"' -'S� 35L `tiCE•S,EWA '-E -T'. -EA- ME- Nr,...SYSI" Owner LY/4 6 L 6,W- p Address 43& eat 61 44669 ` � 0 ( Z3 Located at (Street) WD0� f�72� Tax Map &5% Block Z Lot 6, ,7 OjT" ndicate nearest cros street) Municipality _ /�� Drainage Basin C) —so tJ f SOIL PERCOLATION TEST DATA Date of Pre - soaking 5"�(�f �� Date of Percolation S Hole No. Run No. Time Start -Stop Ela se Time Min.) NDe th to Water rom Ground Surface (Inches) Start Stop Water Level Dro In Inc�es Percolation. Rate Min/Inch 1 2:50 3: Zo 0 2 G 2 1 30 2 3: ZZ 3 :,SZ 30 2S �Z 2, 6 YZ, 3D 3 :.Z5" 4:L- 30 2,5A 26 /,e 30 4 5 2, l Z.,5-5, 3:25' 30> 2� 3 14 3 4 do -2 33 -314 D 3 1.05 Q: s 3o 22 %Z 23/ 3 4 5 1 2 3 5 1-4 v i tb: L. 1 ests -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 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' 9.0' 10.0' 2 TEST PIT DATA IIDIES CRt MON OF SOILS ENCOUNTERED HN TEST HOLES �:..a w. -:.. �: °. --H�LI✓'N _ �.... (�Ll✓` V0.. Ar �2�t". D941/-J , v v Indicate level at which groundwater is encountered % Y2 Pr, Indicate level at which mottling is observed��� Indicate level to which water level rises after being encountered F' Deep hole observations made by: 12. Date 12 3 �� Design Professional Name: Ro �/ A • �RF OR ! K5 6 J� P Address: Po x 9:5-;D T� Signature: Design Professional's Seal M�M-�M/ `-TUTNAINI COUNTY DEPARTMENT OF HEALTH DIVIISION OF ENVI]IONMENTAL ITEALTH SERVICES! T '-f zAJ'VL1QA 40N CrR A WASTEWATER WEATMENTSYSTEM Name and address of applicant: ''N trw of'project:', 4z 4. 6. Drainage Basin: DC 3. ..Locatio.n T/V: it,]:Ln� 5. . Address: Typ -�L - of P oiect: —I t✓ h i vate/Residential Food Service A 1),artments Institutional Q Iffi c e B i i i I (I i n g Keal!Y'S�tjbdivision Commercial Mobile Home Park (spec.iify) Is 111is projec -it subject to State Environmental Quality Review (S✓QR)? Tvpe 9(cill►s (check- one) ................................ ....... Type I Exempt Type 11 Unlisted isted 9.1 Is a I)rafl F'jivirotimental Impact Statement (DE.1S) required? ............... j 0..:1 lay DF-.IS completed and f6mid acceptalble by Lead Agency? ............... 11. Name of Lead Ag(.-.ncy area llnilei tlfe edtiff6l.61.166il-plann [fig, Zoning, or other officials, ordinances? ......................................................... .............. 13. 1(' so, li,(.ivtl)lanslicen submitted to such autlio,il-ities? ........ ........................ +...... Vlec ► 4. Has preliminaryapprov'a'I been granted by such authorities? IA?& Date granted: 11,12 5. Type of 8�.-.wage'Freattnent System Discharge ................. __— surface water groundwater 16. If surface Nvater discharge, what is the strearn class designation? .................... 17. Waters index number (surface) ............................................... .......... I ........... R. Is project located near a public water supply system? ............ ................... J1,yes, waine of Neater supply Distance to water supply' Is 1)roJe(,:1 site near a public sewage! collection or treatment system? ................ _ 1-4b 1. Name of'sewage system Distance to sewage system 'LL DfAte test holes ot-)served 23. Name ofl[eiltlilnsper for ... L� :A. Project dc-sign flmv (gallons per d5y) ........................................ i ...................... 'Soo, 5. Is State. Po'llutant Disicharge Elinflnati6h Sy''s'te',in (SITY S) Pei -,rnit required!... ' 26., 1 his, S111,111."S been submitte"d to If. OCal DEC offil x',' ............. En, ate, Num.lher ................ ........................... ........................... .............. -;-Mt .-duired? ............ ................... -.v'j 0'� ........... ........ ap7�.licdtior. .e�--n -naae to -t or —!Ocai i Et'- -Oftflice? ........................... a DEC- Str°arn Disrurbanl-� P--,-mit? . ...... ................ ........... i)r WIS.;project :ite used for aL-icultural acts -vin, involvirig applicat*,.,ri of i- ,esticidii---', to orcM rds,. or other crops, solid or hazardous ' ..,�vaste disposal, tarujfillnn.�, sludt�.t al)Dlication or ;jidustrial activitv? ............................ Yes/No 2. Is !)reject located within 1,000 feet of existing or abandoned landfill, zu,�-,rdoiL� waste site, salt stock-pile, landfill, sludge disposal site or any Other potentially known source of contamination? ................................ Yes/No DI7--'-CR.[BE: here,,; local master plan on file with the Town or Villa�!e? ........... ........ 34. ..Are com.rnuuiit,,J %vater and/or sewer facilities -lamied to b.. dev'-loped �vithin I years in or adJact-nt to project site? ... ............................... ................. ......... Are any st-wage tv,.,atrnent areas in excess of 1.5% slope ?: ........... ............ ac Aa '6- Map ID Number .................. ..................... ................ Ma dock .:Maul., �ot 80 - 4 Y. 7 Ai rove i -plans an� to be returned to ..... Applicant Design Professional A411 applliC'afions Rot review and approval of anenv SSTS to be located within the NYC Watershed shall if-;Htl i& dhd6d' b "�O' project ER er h not e sent in d li" �h-�;DEP- call approval of the :;STS prior to final approval by the Department. Projects within the watershed may also require DEP revievi and approval of other aspects ofaproject, such as stormwater,,plans orth . e creation of impervious surfaces-, and the project applicant should obtain the appropriate fonns for such activities from DEP and submit those forms to DEP for review and approval. if the ar"P.';ication is signs by aperson o her than the applicant shown in Item L,the application must be accompanu.-d by a Letter of Authorization (Form LA-97). Failure to comply with this provision may be gp-ourlds for the rejection of any submission. I hereby al i tr .Tirm, under penalty ofperjury., that information provided on this s ue to the iesf of my knowledge and belief. False statements made herein are punishable tzs for Class A misdettivanor pursuant to Section .2] 0.45 qf mfe Penal Law. Si A4.'T1,,TR.LKS'& OFT*T('UL-T1TLr1S-- ................... _ ... 1• L- RvlL-�--. ruwuuu county Lepartiment or hee.ita .lion of Environmental Health Servios► ,owed as noted for conformance with .loable Holes and Reffl4latione of the Co th atp � % 2 atur4 A Tit 1n 4p 11.+ AS&Ll\ LAJO� biME,�S/ot.lc m.�,.'�:,•'". e -1;11 .: "_ •d7:.ra%c a,. "rw'ia�w`6 1 I A I f, I I 77 .�1 R.G-Qb I-F-"GTq= BopFf Peca'rz> a !✓i tc�1d= �°�`1�r. L�I� T/l /S /S TO CCRTIPy 'FNAF co�Sr 1c A 9 L'S S� PJ DrC FFL: 0,J rd/-5 PLA-.I /a!J 7,.A . 7 WAS 11SP .� - y � Mrc.FREPO(-Ivlr Y /AS Cp/d�2£vpy6," 7'r/Er s/I�etoi Co�ts}a�l ->� /rJ gcco2pn�lcc_ q o R6C��1lA�io�1S OF E- P,��I�AM COVtt� tfE�C7y t'T /4rlo TI¢&. NY�poy kOy �. FREPf2I KSEtJ, Pte. G o,.lsa ! l 7-44 G EI-I (:�W C-6 — PO 6OX %S-0 M9Ht7p�iL, I�l �f. /os41 T /4 - Z3- o37(o So 6. 1L-T SEPTc- LA/0,JT FI�-IgL.sap.(c j e-,/ 1zOe,EY l M ja,6 Fb-:2. MIIer>; 'S pACCAV.E(,C. i Gocaror� MLcApory rfIE57- D21VE- TO 4•{1.1 nc G),1r,iAm Vn(/ P16 OF NEW — SiPHou TAKLK 56' 2(0` — — p1�T- 2 85 Poo 3 g9 /00 — 4 — 9L 1.01 — s — 9� /o I - - y�l lDZ _ 1 eke �•� e — 3e 43 60 Fr — 42' 40 !00 ar 10 — 5c�0��1 0." "I / 4 2 Fr I� •— 5 3 Fr .416 44 OF.r C!� 1Q — 4-7 jwA Fr /S — 1 Qo koo (SF, I(0 _ 4Z A'O 6oFr 1 414 {�00 �DCjFr 16 — 144 19.- --- 14e lCo (opfr ZQ :2.; � - !.5 Z . J -_ L(i �• .. =.'.(pp C:r � mac; R.G-Qb I-F-"GTq= BopFf Peca'rz> a !✓i tc�1d= �°�`1�r. L�I� T/l /S /S TO CCRTIPy 'FNAF co�Sr 1c A 9 L'S S� PJ DrC FFL: 0,J rd/-5 PLA-.I /a!J 7,.A . 7 WAS 11SP .� - y � Mrc.FREPO(-Ivlr Y /AS Cp/d�2£vpy6," 7'r/Er s/I�etoi Co�ts}a�l ->� /rJ gcco2pn�lcc_ q o R6C��1lA�io�1S OF E- P,��I�AM COVtt� tfE�C7y t'T /4rlo TI¢&. NY�poy kOy �. FREPf2I KSEtJ, Pte. G o,.lsa ! l 7-44 G EI-I (:�W C-6 — PO 6OX %S-0 M9Ht7p�iL, I�l �f. /os41 T /4 - Z3- o37(o So 6. 1L-T SEPTc- LA/0,JT FI�-IgL.sap.(c j e-,/ 1zOe,EY l M ja,6 Fb-:2. MIIer>; 'S pACCAV.E(,C. i Gocaror� MLcApory rfIE57- D21VE- TO 4•{1.1 nc G),1r,iAm Vn(/ P16 OF NEW Box. PtK7114 6 TA il K\— Z-50 (AL. -C v r �- I /yam I V p eq �_ - - - - -- - -___ __ L 74.. -cam` e E A T) 0 Z cDT �L -co) �L L /. 44 1 q,) Uti ci