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HomeMy WebLinkAbout0046DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3. -1 -80.3 BOX 1 Is I is ' , ■ , '1 I , J II 7111 A. ' � T, vim L ' 111. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # �' " I " 0� Located at �5 1�'D oy- (�N® Town or Village &��i�f_A Owner /Applicant Name AL H FINN Tax Map 47/1 • Block Lot 40,E Formerly k0c_K tai u- Subdivision Name Subd. Lot # HII L 9 Mailing Address 15 V r,; V, 1+0L�'aj P-4m ` bMw51P_ 0 Zip 1050° Date Construction Permit Issued by PCHD /f ` lol, Separate Sewerage System built by ALW HHN Address 6 Q -1-t Lud "' (i PM-19-0'10" Consisting of 0-60 Gallon Septic Tank and i �`sE U � i JM� GIB WPO- i 04 Other Requirements: Q �� `�� g i �''� r1w.. Water Supply: Public Supply From Address or: C Private Supply Drilled by Mli-V D P 1l -L(NL4 IkL' Address '', PMI Building Type 45 erosion control been completed? Number of Bedrooms Has garbage grinder been installed? MQ 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 County D90artrgent of Health. Date: I g 1 '/ Certified by P.E. R. A. (De Profession Address x-05 Q %• . _ ; 1® >ZO� License #�( 1� 1 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 ^subject to modification or change when, in the judgment of the Public Health Director, such revocatig , m d'ficatio or change is necessary. Y� B ' Title: Date: 2- 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 I Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 A 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 September 18, 2003 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Re: Individual SSTS Compliance - Alan Finn Mill Subdivision, Lot # 3 25 Burdick Road Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -3, "As -Built SSTS," dated 09/18/03. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 09/18/03. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 09/18/03. 4. Laboratory Report, dated 09/13/03. 5. "Well Completion Report," dated 09/16/03. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. E911 Address Verification Form, dated 09/18/03. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN:gav 02- 094.03 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: '1_003) Burdick Road Town/Village: Patterson Tax Grid # Map 1). Block Lots) 0,3 Well Owner: Name: Address: Al Finn Custom Homes 15 Solomons hollow Rd. Brewster, NY 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion __X_ Compressed air percussion Other (specify) Well Type Screened Open end casing X— Open hole in bedrock _ Other Casing Details Total length 51 ft. Length below grade 50 ft. Diameter 6 in. Weight per foot 17 lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded XThreaded _ Other Seal: _ Cement grout X Bentonite Other Drive shoe: X Yes No Liner _ _ Yes _ NoX Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped _X_ Compressed Air Hours __6_ Yield _a!L gpm Depth Data Measure from land surface- static (specify ft) 19' During yield test(ft) 380 Depth of completed well in feet .400 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 2 Top Soil 2 .400. White 1-fine Stone If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 260. 2 Pump Type Capacity S=ft io(�FM Depth VN Model 7 E1415 +L Voltage HP il/- Tank Type MO&t Volume (SAL 400.. 30 Date Well Completed .7/8/03 Putnam County Certification No. 2 Date of Report 7/1:0/03 Well Drille g e) NOTE: Exact location of well wi stances to at least two permanent landmarks ��vided on a separate sheet/plan. Well Driller'sNa a Address: Zr ie., Brewster_ NY Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 DIMENSION CHART (in feet) Number A Q I 113 91 2 108 90 3 1.05 84 4 103 78 5 98 73 6 63 92 6-1 96 g '12 100 9 77 105 10 112 $7 I 1 108 81 12 105 76 13 102 71 14 142 77 I S 139 70 1 6 136 65 17 134 59 E In O "v 0 r- r z II° 52' lo" c -1 °Q 9 i T T i i I 1 1 1 1 � Iml 1 1 Iy hlo� 1 Im1z10 1 IT' 1u�iQ � 1 l01 s s sz1 rr I � I � 1� I l t, C•] 0 F7 JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET M S STAMFORD, CONNECTICUT o69o5 Mailing Information: Name: Mill Drilling Co. Address: 75 Putnam Ave City: Brewster State: NY Telephone: Sample's Information: NELAC, CT and NY State Certified Environmental Laboratory Client: Al Finn Custom Homes Zip: 10509 Fax: 845 - 279 -5075 Collector's Information: Name: Bob Address of site: Lot #3 Burdick Rd City: Patterson State: NY Zip: Telephone: Site: water tank Date Collected: 9/9/03 Date Received: Preservative: HNO3 Time Collected: 15:00 Time Received: Temperature: <4C 9/10/03 13:15 Lab No.: J036565 Date Analyzed Test Name Result MCL Method, 9/10/03 15:00 Total Coliform Absent Absent SMWW 9222B 9/10/03 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 9/10/03 Color ND 15 Units SMWW 2120 B 9/10/03 Odor ND 3 TONs SMWW 2150 B 9/15/03 * Iron <0.03 mg /L 0.3 mg /L SMWW 3111B 9/12/03 Manganese <0.01 mg /L 0.3 mg /L SMWW 3111B 9/12/03 Sodium 10.2 mg /L N/A SMWW 3111B 9/12/03 Chloride 22.0 mg /L 250 mg /L SMWW 4500 Cl C 9/12/03 Hardness 342 mg /L N/A SMWW 2340 C 9/12/03 Nitrate 1.54 mg /L 10 mg /L SMWW 4500 NO3E 9/12/03 10:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 9/10/03 pH 7.06 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 9/12/03 Sulfate 21.4 mg /L 250 mg /L SMWW 4500 SO4F 9/13/03 * Turbidity 0.52 NTU 5 NTUs SMWW 2130 B 9/12/03 Lead <1.0 ug /L 15 ug /L SMWW 3113 B Comments: * Re- sampled on 9/13/03 at 6:45 At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Signature.. State #: PH -0218 Michael Lapman ELAP M 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH {SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREA Owner or Purchaser of Buuil ding . Building Constructed by Location - Street 9), XT SYSTEM Tax Map -,Block Lot TownNillage Subdivision Name Building Type Subdivision Lot I represent that I am wholly and completely responsible for the location, ' km ship, 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 4 period vof 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 tlib building utilizing the system. d 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 riegligent act of the occu of the building utilizing'the system. Da Day I Year Signature: Title: �E General__.._ ac o wnergn Corporation Name (if corporation) - Corporation Name (if corporation) Address: ��� i � Lo' ,ia Address:. �S. ►�-Q J �'� �� ''�� State N 1 ` Zip al �4�1 State Y Zip` n . 1 Form GS -97 Sep 18 03 07:13a TOWN OF PATTERSO 845 - 878 -2019 P•1 SEP -16 -2003 12:14 PM HARRY W NICHOLS 914 279 4567 P.02 Mutt R„ DOLBY LORBTTA MOU NARI -)t.N, M.3.N. h61k Ntalm DUB ow. < ArowlM hulk it RerHh i Zwec ►. . .. ,..._.... ^" ar+uln • d a�alr Slvrtw -: ' ;. OLI'ARTMW OF HEALTH 1 Qenov� Road • • _. _. Bmwsaer, New Yolk 10509 . ..imr1•r,nat linl�a tp��1� »•trio F «plq �I•ml ' .. N1n11{. irMttl (tium•f19..W1Cf0i /�•l11 -K» A�r�ftl)!fl•!OU '. ....,.. .." ,..: .. L1rb:fterylllfb'f11gt7t•i011 PmehW C914) 2714M AX 0141 17r- "43 P-911 ADDRESS VERIFICATION FORM O WftltS MAKE: /ALLAN F(F+H S_..ft! ,, TAKN14? NUM$EX- `� ' Q • �%j yam._ ...... , . ,. ,., £911 ADDRESS:. TOWIC _.... } _ .. , ,..... A UTYiORIZE>3 'fOW n•D4MCLlI,,: (Signature) ry .. � DATE: ... ...... , .....� /� a� .... .. ... ... The Putnam County Department of health will not issue a Certificate of Construction Compliance airless the above form is completed, l.e., a legal E911 address. is, stslgned by an Authorized town official. This form• is to be submitted With the application for p Certificate of Construction Compliance. {69iiVEB}i - 09/18/2003 11:23 2123853740 NY y.IAPU PAGE W1 BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS 13UREAU OF EL.ECTRICITV 40 FUL.TON STREET — NEW YORK, NY 10038 CERTIFIES THAT Upon the application of WILLIAM PICARELLA PO BOX 158 BREWSTER, NY 10509, Located at 25 BURDICK RD, PATTERSON. NY 12563 Appll001116 Nittmbee 1158515 upon premises owned by ALLEN FINN 25 BURDICK. RD. PATTERSON, NY 12563 CMi,tift Nwbw. 1156519 Section; Block: Lot: 3 Building Permit: 84803 EXX: W11 04 Described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Basement, First Floor, Attached Garage, Outside, was inspected in accordance with the Nationdl Electrical Code and the detail of the installation. as set forth below. was found to be in compliance ftrpwlth on the 18th Day of Scpttrabor, 2W3. vitas QTY B& Ulu Sirsuii 7= N3jspeliapeous 1 • 3 1/2 TON A/C OUTLETS FOR SEPTIC EJECTOR PUMP Appiisneu and Acceatorigs Dish Washer i Micro•vrave i Clothes Dryer 1 4.5 X1V Rangc l 8 XW Exhaust Fan 1 F.H.P. Furnace 1 Oil Water Heater t Plimp/MQ,Qr 1 Bell Transformer 1 Wiring and Devices Receptacle 1 Laundry Outlet 4 Ito GFCI semi Fixtute 24 Incandescent Continued on Next Page 1 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the Iocatim Micated nT•,iir+T�7 -77-M1H`1TJ - CC'aMC)7h TC nr.•7T Cnn7 JOT iC 7 09/18,12001 11:23 2123853740 tw.RiARp PAGE 02 BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET — NEW YORK, MV 10039 CERTIFIES THAT Upon the application of WILLIAM PICARELLA PO Box 158 BREWSTER, NY 10509, Located at 25 BURDICK RD, PAI- ERSON, NY 12563 Appliogla t Nimnbr: 1166519 upon premises owned by ALLEN FINN 25 BURDICK R0. PA7TERSON, NY 12563 Cartificatte Number: 1156316 Seciiort Bftk: Lot: 3 Building Permit, 846 -03 BOC: W 104 Described as a Rcaidential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located Won the premises alt: Baeameat, Fitat Floor, Attached Garage, Outside, was inspected in accordance with the National Electrical Code and the detail of the installation, as set forth below, was found t0 tie in compliance therewith on the 18th pay of Septembet, 2043. Motets: I CT: X 2 of 2 seal This certfiicete may not be altered In any way and Is validated only by the presence of a raised Seal at the location indicated. nrv�n��� HY1711H�'1TJ Q y Bass arose Circa TY91 Receptacle 52 General Purpose Switch 36 General Purpose Paddle Fan 2 Receptacle 1 OFCT Service I Phase 3W Service Rating 200 Amperes service Disconnect: t 200 cb Motets: I CT: X 2 of 2 seal This certfiicete may not be altered In any way and Is validated only by the presence of a raised Seal at the location indicated. nrv�n��� HY1711H�'1TJ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ' FINAL SITE INSPECTION Date: ,2 03 Inspected by: G, REEn Street Location gS gvT dice IZ"12 Owner Town Permit # P-11-0a TM # 3 A — C - gv, Subdivision Lot # 3 1. Sewaze Svstem Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth_�4 c. Natural soil not stripped .................................................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water cou wetlands ...... ............................... II. Sewage System a. Septic tank size 1,000 ..... ...1,250 ......... other ......... ..... b. � Septic�tank iristalle el ................ .......................... :.... C. 10' minimum from foundation ........ ,_,......., ................ d: Distribution Boxes `--�rl . :All - outlets- at'same elevation water tested........... : 2. Protected below frost ................. ............................... 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. reT nc iI es 1. Length required Length installed 2. Distance to watercourse measured -f- i d o Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - VA" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ....... ... .. Pump or DosedSystes _. 1�--Size of pump = chamber.... :. `... : ...................:' -:. .. 2. Overflow tank ............................ ............................... 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baked ......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... M. House/Building a. House located per approved plans......... b. Number of bedrooms ............... ..............?.j.�/C._,....... IV. Well Well located as per approved plans . ......:...........I............ b. Distance from STS area measured_ 10 ft.._.......... well acceptably _ - - - - - -- - - - - -a- - - ---- ..................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ..................... ................. i. Erosion control provided ................. ............................... Rev. 12102 COMMENTS 1® ®eetrl czk . ce. Xp ea f s orm J i - AUG -29 -2003 02:22 PM HARRY W NICHOLS 91.4 279 4567 P.01 f PUTNAM COUNTY DEPARTMENT OF HEALTH DW. SION OF ENVIRONMENTAL HEALTH SERVICES -- RP-QUEST Fes, EjtAL MP CMON For: Fill Date: 0�� Trenches FCHD Construction Permit # Located: b� R° T) �fl Owner /Applicant Name: l41- t.�4M�''� TM Bloch Lot Formerly: Subdivision Name: BUN, 41- Subdivision Lot # Is'system fill completed? Date: Is system complete? yE6) - bate; Is system constructed as per plans? `W:2 Is well drilled? -' ` eis — Date: Is well located as per plans? Are erosion control measures in place? 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 Regulation nam County Department of Health. P��Q� NEW r0R NICH Daie: �°iIO� Certified by; 4� PE RA Ui n Address: 66124 ��� Q1 Cornments:. Q�-ftQ %I To 0A %4­r- 1416E FOR: Cl ADAM -• )(GE 0 (N ) Form FIR -99 LORETTA MOLINARI R.N., M.S.N. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 -_ 6648 September 3, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection — Mill 25 Burdick Road, (T) Patterson Lot # 3, TM# 3. -1 -80.3 Dear Mr. Nichols: ROBERT J. BONDI County Executive The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. Tank connections need to be completed. 2. The well casing needs to be raised up to a minimum of 18" above grade. 3. A pump test needs to be witnessed by this department once the electrical inspection has been completed and notification of such has been submitted to this department. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj SENDING CONFIRMATION DATE SEP -3 -2003 WED 12:09 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES 1/1 START TIME : SEP -03 12:08 ELAPSED TIME : 0014041 MODE G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED.. c a .e LORETrA MOLWAW RN., AS.N. ROBERT I. BOND! A611c Hfcah Dbl- 1q Cawy L'ueulw DEPARTMENT OF HEALTH 1 r301ava R0e4 Brewster, New York 10509 E&A.M.mul Ran (815) 772.6170 P. (845) 7)8.7921 IeutM„a SI Mrs ( 283) 272.6558 W1C (845) 278.6678 A2 (865) 278 - 6025 Cady ftar"aldoWreaeUeel (843) 272.6614 Pay (843) 278.6648 September 3, 2003 , Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection – Mill 25 Burdick Road, (T) Patterson Lot N 3, TMM 1-1-803 Dear Mr. Michels: The above referenced separate sewage treatment system can bebackfilled. The following comments must be corrected in the field. 1. Tank connections aced to be completed. , 2. The well casing needs to be raised up to a minimum of 18" above grade. 3. A pump test needs to be witnessed by this department once the electrical inspection has been completed and notification of such has been submitted to this department. If you have any further questions, please contact me at 845 - 278 -6130, m 2261. I Sincerely, (kne D. Reed Environmental Health Engineering Aide QDR:cj PUTNAM COUNTY DEPARTMENT OF HEALTII DIVISION OF ENVIRONMENTAL I1EATLII SERVICES FIELD ACTIVITY REPORT N ANrF:' N L/ Street Town State Zip PERSON IN CHARGE PUMP TEST DOSE TEST REQUIRED GALLONS RE Signature and Title REL'nRT RCFT FT) RV: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. Title: SgC - STOCKBRIDGE -ROCK OUTCROP COMPLEX ROUJN6 Uc UDORTHENTS,:WET SUBSTRATUM. :` SURVEY NOT i 1. SURVEY AND TOPOGRAPHICAL INFi. SUBDMSION PLAT OF MILL SUBDI BERGENDORFF COLLINS, FILED AS, A[9GNBTC ENDS !OF OISTftiBFl7lON \ / BE / PIP Tis -GAREED 77 ter; — 458__ \ \ ao. 100 T H4r>I I� \• \��,.__ "` --�/ ���\ y J 2 c a•m PVC \ \ /8'/FT MIN 4F do 11'LS�EL\BOWS � \ 1 ST-8 _ o -eo1� FORCE- MAIN 50 _ 1 I \_ \ ry \\ 1250 4 BEDR — — % — • \ � HOUSE _ _ -' — 4Y dP a'm OR as'Pv �w/Fr irk _ — — — — — -- T 1250 CAL 250 FF. =4 N _ TAW U►+v BE0WR�OM SEp_e9 -2003 01:17 pM BRUCE R FOLEY Publtc Nealth.,.Dirtclor ATTEN"rIOti': HARRY W NICHOLS 914 279 4567 P.01 �a DEPARTMENT of BEALTH 1 Geneva - Road Brewster, New York 10504 a ADAM STIEBELI G' GENE REED LORSTrA MOLINARI R.N., M.S,N, Associate Public Xtatth Dlreclor Director of . Patient Servloei , 11"42- A] 1 information below must be completed prior to any scheduling. DATE: --9 ~0 x ENGINEER OR MMI: Ilk 11 i WU w PHONE #: REASON: DEEPS: a PERCS: C3. PUMP TEST: ROAD/STREET: TOWN; G4 t4 TALC KAPlf: _ �— Et � �_ � 3 SUBDIVISIO • LOTh: 3 ONVNER: 1� EYCDEP CRITERIA jrQE JOINT RF.3aEV AND1TNF RIL T,ESTING YES NQ ❑ Proposed SSTS- within the drainage basin of West Branch or Roy& Corner Resei vvoirs. C Proposed SSTS within $00 feet of a reservoir, reservoir stem or control lake. ❑ 1 Proposed SSTS within 200 feet of a watercourse or a DEC wetland.' ❑ e� Proposed SSTS design flour greater than 1000 gallons /day-or SPDES Permit required. v Proposed SSTS for a Commerical Project. It is thei responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered ya to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for Geld testing with-the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with MOM FOR co6rrY usl: oNLY DATE: (FILDTEST) TIME: A V1MC • M1 JTrj"nM rrll 11.ITV I.1C0nDTM=WT M P 1 \� PUTNAM COUNTY DEPARTMENT OF HEALTH Ro DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 25 R., icx Town or Village ��rTT�25y rI Subdivision name III LL ,SUR.D►gkSj 0�J . Subd. Lot # -- Tax Map ' Block I Lot 00, 9 Date Subdivision Approved sapi I45 -_-l2 0"00 1 Renewal Revision Owner /Applicant Name Ffol3E -g ht j U_ Date of Previous Approval Mailing Address 2 )-O 1 �15 LJS`i�2 t N'y Zip I q Amount of Fee Enclosed 4 -300 . 0,0 Building Type V-�)QF- nkz Lot Area 239 No. of Bedrooms 3 Design Flow GPD 6041 Fill Section Only X— Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED. Separate Sewerage System to consist of 2So gallon septic tank and 12,,E �;A � (��1hP 24 v Other Requirements: - of: Lj- To be constructed by -FRO Address Water Supply: Public Supply From Address t Nui-aS or: ]� Private Supply Drilled by IM L- _721 LLB IJ� Address � V A h 1* , _T" I -- - I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the se crate 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 th,9, issuance of the approval of the Certificate of Construction Compliance of the original system or any repaireto. Signed: Address P.E. ' \/ R.A. License # �• i APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme ystem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified whe co sidered ne essary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. A roved f ischarge of domestic sanitary sewage o y. By: '� Title: Date: Z d-2— White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit �— Well Location: Street Address: Town/Village Tax Grid # a �VYz -b 1C� �c Map 3 Block j Lot(s) 89,3 Well Owner: Name: R06e-(2:- .tu Address: - R.ve-r-o Da )07) Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm 'Test/Monitoring Other (specify) 2- secondary Industrial Institutional. Standby Amount of Use Yield Sought gpm # People Served 5 Est. of Daily Usage 37 al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason i 1P-&z5 ► . A-L- uJ A--T L 5U e for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding. .......... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes—,Y, No Name of subdivision M&U, S V *V Etc Lot No. 3 Water Well Contractor: fK I L-L- b]R.A LAA W6 Address:' V` N A-h AA&) -- VMS-XR M/ Is Public Water Supply available to site? .................................. ............................... Yes No 1G Name of Public Water Supply: 0 /A- Town/Village Distance to property from nearest water kain: N Proposed well location & sources of contaminatio t e p ovided on separate sheet/plan. Date: 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. An revision or alteration of the approved plan requires a new permit. Well to be constructed by a water wel 'ller certified by Putnam County. Date of Issue ?- o- Permit Issu' cial: Date of Expiratio Title: Permit is Non- Transf ab White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 0- BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 March 6, 2002 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster, NY 10509 Re: Mill 25 Burdick Road, Lot #3 (T) Patterson, TM# 3 -1 -80.3 Reservoir Basin Dear Mr. Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on February 21, 2002 is complete. The Department will notify you by March 26, 2002 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of ,. Letter to: Peder Scott, P.E. - March 6, 2002 -2- Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. RM:tn Very truly yours, e,t.e-,ut /Z7 o�� (�I�) Robert Morris, PE Senior Public Health Engineer BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster, NY 1.0509 Re: Proposed SSTS: Mill 25 Burdick Road, Lot #3 (T) Patterson, TM# 3 -1 -80.3 Dear Mr. Scott: March 6, 2002 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. The elevation index line contours are to be noted at elevation increments of 10 feet. 2. The fill system, as proposed creates a drainage channel through the center of the system. Revise the design to provide a more level pad. 3. The outlet d -box is to be labeled in the plan view. The construction of this sewage disposal system maybe subject to local wetlands regulations. You should contact local wetlands officials in this regaid. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, eg_ea- M CT-) Robert Morris, P.E. Senior Public Health Engineer V9 _UT NI PUTNAM COUNTY DEPARTdIENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS ,R VIEW SHEET FOR CONSTRUCTION PERMIT- NAIAE OF OWNER: STREET LOCATION: VIEWED BY: RM, OR, AS, SRDATE: Ti TAX 1`LAP =: (CONL M%IED) PEM,11T DOCUMENTS Y �' (REQUIRED DETAILS ON PLANS CONT'D) . APPLICATION HOUSE SEVER -' /�' FT. -t "0'; TYPE PIPE CAST IRON ELL PERMIT OR PWS LETTER (_)NO- BENDS; AIAX BENDS -f5° W7CLEANOUT C -97 RENEWALS LETTER OF AUTHORIZATION ,• �_TI E NOTE (NO CHANGE) (__)DESIGN DATA SHEET (DDS) T FILL SYSTEMS CORPORATE RESOLUTION () HORIZONTAL; PAST TRENCH SLOPES 3.1 TO GRADE SHORT EAF ( )( )FILL SPECS.' FILL NOTES 1 -5 Vy )PLANS -THREE SETS ()[___)HOUSE PLANS -TWO SETS UUVARLANCE REQUEST SUBDMSION LEGAL SUBDMSION SUBDMSION AUROYAL CHECKED UUPERC RATE �- U(-_)FILLREQUIRED • , . UUCURTAIN DRAIN REQUIRED GENERAL LOCATED IN NYC WATERSHED OPLANS SUBMITTED TO DEP - (;,�Ij__)DELEGATED TO PCHD (" DEP APPROVAL, IF RE. tL)(�DEEP TEST HOLES OSERVED C,6LLJPERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ, LOTS . - L,0,LL.)NV- ETLANDS (TOWNIDEC PERMIT .REQ'D ?) DATA ON DDS PLANS &.PERMIT SAME (_( )PRE 19G9 NEIGHBOR NOTIFICATION C,2( LETTER BUZBA . 100 YR. FLOOD ELEVATION W/I200' (_jLj, St}L.TESTING LOTS>10 YEARS OLD. AGE-SYSTEM PLAN - (NORTH ARROW) ; HYDRAULIC PROFILE YITY FLOW )ESIGN DATA: PERC & DEEP RESULTS !'CONTOURS EXISTING & PROPOSED ). jWEWAY & SLOPES, CUT - FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES TITLE-BLOCK; OWNERS NAME ADDRESS PM#, PE/RA; NAME, ADDRESS, PHONES DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. (PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS SWELLS & SSDS'S WAN 200' OF SSTS WI OPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE CONRYIENTS: (REVSHEET)09 /01100 ILL PROFILE & DIMENSIONS FILL Lei EXPANSION AREA FILL GREATER T7T.4V 2 FEET IEVEPARATION LAY BARRIER ILL CERTIFICATION NOTE EPTH GAUGES OL. ON PLAN FOR R.O.B., UN CLASSIFIED & IDIPERVIO JS DISTANCE FROM TOE OF SLOPE / TRENCH ( x� LF TRENCH PROVIDED LOFT MAX. l PARALLEL TO CONTOURS U EXPANSION PROVIDED - .. 100'% DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL GEOTEXTILE COVER SEPARATION DISTANCES ON, PLAN - FROM SSTS X10 TO P.L. DRIVEWAY,. LARGE TREES, TOP OF FILL ........:. ''0' TO FOUNDATION WALLS 0'00' TO WELL, 200' IN DLOD,150' TO PITS 00'TO STREAIII, WATERCOURSE, LAKE (inc: expia) C._},,_,-j'50' TO CATCH BASIN, 35' STOR�IDAAL\, PIPED. WATER....- U 10' TO WATER LINE (pits - 20) - ( 50' LNTERtiIITTENT DRAB )AGE COURSE 2007500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (__)10' MDI TO LEDGE OUTCROP SEPTIC TANK (_�10' FROM FOUNDATION; 50' TO WELL WELL ( DIMENSIONS TO PROPERTY LI? iES -`- "- — - - - - -- - ( LOCATION OF SERVICE CONNECTION l / 1LJNIIN 15' TO PROPERTY LINE SLOPE U SLOPE IN SSTS AREA (S20 %) c . REGRADED-TO 15 %, IF REQUIRED DOSE/PUr1P SYSTEMS PUMP NOTES OSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPX, ETC.) (� PIT AND D -BOX SHOWN & DETAILED AY STORAGE ABOVE ALARM CURTAIN DRAIt STANDPIPES, 5' BOTH SIDES, DETAIL 15' MIN. to CDS = >5 %, 20' -•� %, 25'-3%,35'-1%, 100%-<I% 20' MIN to CD DISCHARGE 1100' with 182 cons day discharge 10' hIL`i to NON-PERFORATED PIPE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM, Owner ��t_EA u 44,4-1- Address Located at (Street) Tax Map _� Block / Lot , (indicate nearest cross street) Municipality P�47 5L'c,v Drainage Basin ng 6A5t t�14�A1P.6! LoT 3 SOIL RERCOLATION `TEST DATA Date of Pre - soaking Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at eacn percolation test hole. (i.e. <- 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 De th to Water Water from Ground Level Percolation Hole No. Run No. Time Start Stop Ma se Time Surface (Inches) Start Stop Drop In Inches Rate Min/Inch - (Iin.) l - : z 1V = vbl 2-'e '' 2 /o Za 2 3 4 5 .6 CY Aim ..i 2 It It , 3 y 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at eacn percolation test hole. (i.e. <- 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 . M 1t_L�S�LO►� 1�,1cra ZEST PIT L1ATA RML= 2U HE SuPMI=- ;Y -L7-H APP%I=CN DESC_=ION Or. SOILS ENCCUNI= IN TEST HO= - DEPTH HOLE NO. 3 1 HOLE M. 3 Z HOLE W. 3 G.L. - o N L O M -• $fa�wr� �%4M l � SAtJ yY G. RaV E L _ spat -+ tom( G 2PcV F L - IZ P,Ro W N l,o s�'M 2' 3` 41 5' 6' • 7' r 8' 10' Y �°rtP�G"C e-L-#-Y Type ROCK P1h�TE(�P�L �i�ar1 ot= Pt"i , ` 4'IoTT L-,FD 14' INDICATE LEVEL AT WBICd GRCCM IS ENOOUN'IEBED INDICATE T.E"VEL To WHICH WATER LEVY RISE'S, AFTER B.EPl G M=UNTERED S DEEP HOLE OBSERVATIONS MADE BY: mSymMt►rtcte— t A Kea► --it -t DATE 19-7 _ DESIGN Soil Rate Used 4 Min/1" Drop: S.D. USable Area Provided No. of Bedrooms, Septic Tank Capacity gals. Type Absorption Area Provided By L.F. x 24" width trench Othert . • ti 9 Name ezw<�- W- �� -��` r _F ,�'/�f Signature r • L Address G�/ _S.�rr� Nr /� /tfF? � Y. C:/iT�i:>/.��E SEAL OF nom, THIS SPACE FUR USE BY SEALTH DEFAMEDU ONLY: = Soil Rate Approved - sq:ft/gal.. ' Checked by r Date _ 14.16-4 (2187)—Text 12 PROJECT I.D. NUMBER 617.21 SEOR Appendix C State Environmental buslity Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT (SPONSOR 2. PROJECT NAME � I LIB c� -n 13 (,621 hYt L 3. PROJECT LOCATION: ��T►� V�1 Municipality 01_� County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: U iZGroC_At, Stt-nC., IJV- (2G�)G - 2 wlnG ( 'r"�2�N Crtt✓S ��taiMAS?4� A Nb L-F 7t Z411 W) Dr- -t-IZZ Q C(>o-;✓S ((Zees-? 1FE> opt 1.1, 7. AMOUNT OF LAND AFFECTED: Initially 01-10 acres Ultimately 0,-7o acres 8. WILL - PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes C1 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 5 Residential ❑ Industrial ❑ Commercial ❑ Agriculture .. ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes No If yes, list agency(s) and permitlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yes, list agency name and permit/approval C�AF-1 1:' A -fLI 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes 510 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE name: c �� ApplicanUsponsor W117 Signature: I if the action is. iri the Coastal Area, and you are a state agency, complete* the I Coastal Assessment Form before proceeding with this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. C] 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 patterns, solid waste production or disposal, potential -for erosion, drainage or flooding problems? Explain briefly. C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: F «. 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 action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified In C1-05? Explain briefly. 07. 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 (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. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency. 10 :6 WV 61 93A ZD Print or Type Name of Responsible Officer in Lead Agency Title of Responsi a Officer A S [111Vi H1-AQ-1,- signature of Responsible Officer in Lead Agency s_rej�AfE1(1r different from responsible officer) Q3A13T Date 2. i r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION �^ 1+ RE: Property of d� 1 _ Located at T/V P� Tax Map # Block Lot V13 Subdivision of M t 6 Su .blut!SLot�% Subdivision Lot # Filed Map # 2900 Date Filed 26 V Gentlemen: This letter is to authorize :i�' uj s C .a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supp y permits) 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 treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Coun 'gne P.E., R.A., # Mailing Address 3 '2% 1 etc: r State Zip 105-0 9 Telephone: 0 Very truly you , Signed: (Owner of Property) Mailing Address: oc pG D Q State Zip 50 Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: P_g_q-) fb 0 -?.T 2. Name of project: MiuL 5i5 T (_ I_vT 3. Location TN: PATi 4. Design Professional: y. t-0 • S c67r-07P 5. Address: 38' 7 I r2,vJ, 6. Drainage Basin: .A n1 7. Type. of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park 'Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... .............. .................. Type I Exempt Type II Unlisted - 9.-..- Is a Draft Environmental Impact Statement (DEIS) required? ................................. _ _0s0 _ rso 10. Has DEIS been completed and found acceptable by Lead Agency? ............... P 11. Name of Lead Agency --.90"s., 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............:.:................ L S 13. If so, have plans been submitted to such authorities? ........ ............................... Y 0-5 14. Has preliminary approval been granted by such authorities? t� Date granted: 9 Z,o%�,v 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... IS 17. Waters index number (surface) ........................................... ............................... P 18. Is project located near a public water supply system? ....... .................:............. M o 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ 1s 0 21. Name of sewage system Distance to sewage system q 22. Date test holes observed 1 Z 2 q 23: Name of Health Inspector R, �3aJ P21i✓v,C/ 24. Project design flow (gallons per day) ................................. ............................... 6p 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? ......................... orm PC -97 8/99 2 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number ............:............................................. ............................... 29. Is Wetlands Permit required? .............................................. ............................... N D Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... , 3 y 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/Nop 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/N.o 90 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .......................... YJ 34. Are community water and/or, sewer facilities planned to be developed within 15 years in or adjacent to project site?... ................................................................. h 0 35. Are any sewage treatment areas in excess of.15% slope? .. ................I...:.......... 36. Tax Map ID Number .......................... ............................... Map 3 Block I Lot So. S 37. Approved plans are to be:returned to ..... Applicant _ X Design Professional NOTE:.All applications for review and approval of a new SSTS 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 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 I .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission.. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. Falsos�tem nts made here mare punishable as a Class A misdemeanor pursuant to Section th al Law. SIGNATURES & OFFICIAL TITLES: P C Mailing Address: PH 3 �d 13 2 tiH r v_so 9 • 1 • a°""`°'a°'""°"p FIELD NnrFc • Ln Ed 1a .m 45I �+ 1m m mtN v ED x �+m coos rat Fina • ___ -� - __ -__-- -- . 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Moen mOl OIP!)mOp. alma. m M �a U 1>T'Wm f+II a¢r'a. mUIL 9d+� jP wtryt ' m S pf9 4 a•LL ft at!4 Rl TIS UU �1�v �1 lIDrt' YVa��[0� N N7RIbL ntt Mlltflt P M610 . Z � ' � • N•1 Iq+ S LWIIfa p IRIT OCrm! rn. • nac Ianevt P Wn... • + ra ve as® as : cane aW .. " AP PROVED- M1 F- Oit IIEDR 0.L , L O - '- ta]O 11 n uew. rz + 8�A w t�1t��icmy eyep �a•c�ttm oe oc�am ro Iml LL PmvmUl Raet nM >Cw u6i nRl NM BED, - 0027 ?S --�— - ® 10 oVufton " .WTvO � 5- o Dz = W L C w n ca l i � :5 t0 TFESE ROM t: r 1l iiii _.. . a a APPROIVh�I Wtc rve srcm aenms a xr r 1A �g`•ld7 FS�RB Yd'd: �°' ALL SUB PCDOH FOR n nm emN •v sane : o•: anmvn _ t PI TERIATE STAIRS R aJ w /TYP OPT FM] FNiRT' m wnvts nC mIM� Iot Cxtel IIOAYEiIQ evmcsoln fM LOOt SCALE 1/4.1'-0• 9CA.E 1/41r-(r v. llm COSLT 11R S @Ifilm m R orntm as tenor aQ FLOOR PLRN NOT S' ONT MPG 4' }Sf S ' R �T�R �DIOO M�RtRl6L p III IMR Wrz .a WT Ira< aT3 ;' - b mxm +riW"t [NIRT. et _ FanRT moo a ITY PI>DIL [L[MT06 a£ a1/. 5.+. bc 0 m R ea um• a cm omn 1 1/ MR paY rz0 s' H l l wren v. Icu nw aW mf aysnc en•aul k' YZ - KrMm OD t 1D W. . :- -- -- $]7{ a 0 01RPZ we W>x T i :: Pl_RN W/TYP OPT. OFFSET SEE 5NT 7F-2 FOR OPT. UZVRTTON5 FRONT EL EVATION anm we x anL s rmn � Ve'r-v accuac 1p[T m v. Wa Nacecrtal . SCRs: 114 +1'-0• pp� ppl�j �i,p iRl TO 0.' W+IR i 'To the best of my knowledge, belief and profession ludgemerd f goo � � r 1. this Factory Manured Home (FMH) plan has n approvedi,��""� E from a system set of FMH plans pleviousty approved by D IYL of State, Application No. M1387- 97 -024, Manufacturer's No. M1 B#ratlon MASTER SERIES Date 5 - 5 - 2000, which has not been modified in y manner. 2. the energy portion of this FMH plan has been prepare using Part RArsED RANCH rooET_s © or Part 6 of the New York State Energy Coiservallon -Wr DMr � . ELEVATIONS s NOTES REAR E: nW Construction Code (Energy Code) and is in Nn Mnli'nu 1567 PR ROUTE I 442 EAST. P.O. BOX 24E with the Energy Code MLDICY, PA 17756 DRN BY DATE SCALE REV. . W .. _ Oa?c L ,ti }71 -91 9a 2 -is-ae 1 is 38' -T' 25 -i1" IT-4" 7-1 1/2, 2C'- 61/2" 14'- 11/2' f" -0 SHEATHING SHEATHING AP VAL LIMITED: MASTER SERIES 44' -Q" MII NCY "CWAr DEC 1 2001 SIDEWALL$ - 2x6 CEILING HEIGHT - 8'-0" CUSTOM HOUSE PA Bar 325 M■�er• P. i7155 A QMdM of. LREMLS - ■ 121D el-o Y� "UTr=sMTW" DATD CHRISTY BUILDERS - -MER 1 fMIN. TI2F*Qnl SITE LOCATION,_ PRTTERSON, NY 37' -4 1/2" - 27V x 44' RAISED RANCH PLfN K 15 -9 3/4" 2 -4257 �ULL EUj WENCI SGD 12' -3° LO' -2 t/4" DC 24.30 - - -' 9' -6 3/4�� s;47 3D" BATH 2 '-.( 7 QZ�olOO1 19 ."lo 7 FILL o DINING ROOM BEDROOM 1 Lo' -3 o I z FuTUM I ,� cn cn 1 I vr VENT I I - 1 _ KITCHEN I 6D" I BATH I I � I 1 I I is 3lr' �„ - -_ -_ -- COLL " ----- - - - - -- � _ -- --- - - - -- I CLG I I 3'-0 . L- r 6-0 L i j ACC F 30' PNL - -- 30 ��' FLOOR I - -__ -_ �>u' "To the my knowledge, belief and professional fudge r 1. this F Manufactured Home (FMH) plan has been apprc e cn BEDROOM 2 30" LIVING ROOM from a syste et of FMH plans previously approved by Dept of S it Application o M1387- 97-024, Manufacturer's No. MIRL Ex *,ir 'I BEDROOM 3 1 Date 5 - 5 which has not been modified in any man e I 2. the ener portion of this FMH plan has been prepared using F a 0 or Part i of the New York State Energy Conservati n 30" Constuctlor ( Energy CA, T" it In full compliat c I with the E i Code 9' -10" 2' O 10' -0`1 W 13-3" _. I it - fV: 4 7 4 7 2 =4257 ULLED via - 38' -T' 25 -i1" IT-4" 7-1 1/2, 2C'- 61/2" 14'- 11/2' f" -0 SHEATHING SHEATHING AP VAL LIMITED: MASTER SERIES ADVRNTAGE HOUSE MII NCY "CWAr DEC 1 2001 SIDEWALL$ - 2x6 CEILING HEIGHT - 8'-0" CUSTOM HOUSE PA Bar 325 M■�er• P. i7155 A QMdM of. LREMLS - ■ 121D el-o Y� "UTr=sMTW" DATD CHRISTY BUILDERS - -MER 1 fMIN. TI2F*Qnl SITE LOCATION,_ PRTTERSON, NY mftr.rLlegt mTx,, CAM - 27V x 44' RAISED RANCH PLfN K 1zfg - 1 ♦ S ♦ I \ li \ 4 9� \♦ I ♦ 5 � ♦ I 1 I ♦ I \ I f \ I ♦ I y -+ ♦ 1 � 1. ♦ i ° t I \ 1 1 I / V-3 \ 1 1 1 ♦ 1 `/ / 1 1 1 I 1 6 7 r- -2 - -- -I--- . 6 � 7 - I -• I IL�1 I 4_ 7JL ®7' - -_ -- $� eJ7. 117 / I � / 1 \ / I \ / I . / 1 \ / I \ / 1 / 1 \ / I \ / 1 \ 'To the best of my knowledge, belief and professional judgement 1. this Factory Manufactured Home (RVIH) plan has been approved from a system set of FMH plans previously approved by Dept of State, Application No. MlW - 97 -024. Manufacturer's No. MIRL Expiration Date 5.5.2000, which has not been modified In any manner. 2. the energy portion of this FMH plan has been prepared using Part © or Part 6. of the New York State Energy Conservation -Construction Code ( Energy Code) and Is In full compliance with the Energy Code' I mm� 3 S -- -� adz z � zn - - - i Y3 1 i `\ i I I \ I I 11I \ I I I \ 2 /l \ / I \ / I / I / / 1 \ 3 / I / I / / / I I 2_ / / / I I / / I 1 f I I t I ----------- t \ \ \ \ 1 I 8 \ �\ I I \ �\ � I II 1 \♦ \ PPMa- BOX L14XR FLOOR NW ARE . MASTER SERIES —� pEC 1 0 2001 RDVRNTAGE HOUSE MIUFt�V N®ag _ CUSTOM HOUSE ra eoo< ss "'""', "` 1710 I . — 3K R OAYon dMmey -n°uw. inc a.oruoewL. anmwnm DAM CHRISTY BUILDERS - M 1 u C L 44'- FOUNDATIOW.P.LRN NOTE; L THIS FOUNDATION DRRWING AND NOTES ARE FOR REVIEW ONLY. ACTUAL. MRSTER SERIES FOUNDATION,bESIGN TO BE APPROVED BY R PROFESSIONAL ADVANTAGE HOUSE ENGINEER; OR REGISTERED ARCHITECT. X _ CUSTOM HOUSE 2. THIS DRRWING`TO BE USED FOR DIMENSIONS ONLY. TM 3. SEE FLOOR PLAN FOR DIMENSIONS OF UNITS & STAIR LOCATION, 4. SEE MASTER SERIES DWGS., SHT. NO. 4n, FOR wr�r. ninarmarloK MUNCY "Gall! PA an = Wewy. P. t1nm A DMdm of M- A lfomw. Ln CHRISTY BUILDERS - MI a" -t M DR1L' 17_G_M 0 ..=1 -n-- I I I I I of I � I im I I I I I COLUMN SPACING CAN BE ADJUSTED AS LONG AS MAX. CLEAR SPAN (SHT-3c) IS NOT; EXCEEDED, COLUMNS AT MANDATORY LOCATIONS ARE NOT MOVED. AND q L/2 "x9 'x17' STEEL PLATE IS INSTRLLED ATOP COLUMNS. I I SEE SHT.3c FOR COLUMN RND BSM'T WALL LOADING INFORMATION. I I I I I I I I I 1 I 1 I 0 I I 0 I I 0 I I 1 I I I I I I 1 I I I I 9 -0" T -11 1/2" I Sl; To the best of my knowledge, belief and professional Iudgement I 1. this Factory Manufactured Home (FlWH) plan has been approved I I o) from a system set of FMH plans previously approved by Dept. of State, N I No. M1387-97-024 I o�enmmodified DDateltc5 -5 2000 which has In3anyEmanner. 2. tithe onrt d or Part 6 New York State Energy Conservation and is In full rxunpliance I Iwith me�Energy Code') FOUNDATIOW.P.LRN NOTE; L THIS FOUNDATION DRRWING AND NOTES ARE FOR REVIEW ONLY. ACTUAL. MRSTER SERIES FOUNDATION,bESIGN TO BE APPROVED BY R PROFESSIONAL ADVANTAGE HOUSE ENGINEER; OR REGISTERED ARCHITECT. X _ CUSTOM HOUSE 2. THIS DRRWING`TO BE USED FOR DIMENSIONS ONLY. TM 3. SEE FLOOR PLAN FOR DIMENSIONS OF UNITS & STAIR LOCATION, 4. SEE MASTER SERIES DWGS., SHT. NO. 4n, FOR wr�r. ninarmarloK MUNCY "Gall! PA an = Wewy. P. t1nm A DMdm of M- A lfomw. Ln CHRISTY BUILDERS - MI a" -t M DR1L' 17_G_M 0 ..=1 -n-- P. W. Scott email: pwscott @rcn.com Engineering & Architecture, P.C. 3871 Route 6 (845) 278 -2110 Brewster, NY 10509 FAX (845) 278 -2166 April 16, 2002 Robert Morris Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 RE: Mill Subdivision Lot #3 Dear Robert, t Our-plans for SSTS on Lot #3 of Mill Subdivision have been changed as follows: Elevation index lines have been labeled at elevation increment of 10'. 2. The fill system has been redesign to create more level pad. 3. The outlet D -Box has been labeled in the plain view. If you have any questions, please do not hesitate to call. With re r s, f Peden . S oft, P.E., R.A. President A R C H I T E C T U R E * E N G I N E E R I N G * S I T E P L A N N I N G C: Mly Do cuments\L.- FRHEAD.doc P. W. SCOTT t Engineering & Architecture, P.C. 3871 Route 6 f BREWSTER, NY 10509 E -Mail: pws @bestweb.net (845) 278 -2110 FAX (845) 278 -2166 TO WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter ❑ Attached - ❑ Under separate cover vii ❑ Prints ❑ Plans ❑ Change order ❑ ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION ❑ Approved as noted ❑ Submit copies for distribution • As requested ❑ Returned for corrections ❑ Return corrected prints Z ❑ f ❑ FORBIDS DUE Z ❑ PRINTS RETURNED AFTER LOAN TO US S 3 THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution • As requested ❑ Returned for corrections ❑ Return corrected prints • For review and comment ❑ ❑ FORBIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS SIGNED:L2z11;�� If enclosures are not as noted, kindly notify us at once. BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 March 6, 2002 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster, NY 10509 Re: Proposed SSTS: Mill 25 Burdick Road, Lot #3 (T) Patterson, TM# 3 -1 -80.3 Dear Mr. Scott: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. The elevation index line contours are to be noted at elevation increments of 10 feet. 2. The fill system, as proposed creates a drainage channel through the center of the system. Revise the design to provide a more level pad. 3. The outlet d -box is to be labeled in the plan view. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, "ur /V" :' 07-0 Robert Morris, P.E. Senior Public Health Engineer INUVI 1 W, Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 VAY 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 To: Attention: to ip, f= . Date: G'-4-0 --&R— Job No.: o a -0 1 Project 13 uxl rl Gentlemen: We enclose (copies of V"/B/W Prints Reproducibles Reports Tracings Specifications Memorandum Copy of letter Description: Revision/Date No. Sent Via: Our Messenger Blueprinter Your Messenger V'Hand Delivery Copy to First Class Mail Special Delivery Very t ly, yours, Harry W. Nicho r., P:E. 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM n PERMIT Located at 25 )k) ,ZJkCK. P AD Town or Village ,q r`I p<o 6,1 Subdivision name HILL S)- �J)jq�Sj otj Subd. Lot # Tax Map �� Block I Lot 8n, Date Subdivision Approved I Renewal Revision Owner /Applicant Name �08E g T lU i LL, Date of Previous Approval -� Mailing Address l �C, . lJSS NY Zip ! OS'.)u Amount of Fee Enclosed . I X00 . 0-0 Building Type iL'eS ►DE NCB Lot Area ?,. 39 No. of Bedrooms Design Flow GPD G �� Fill Section Only _ Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED.. Separate Sewerage System to consist of 1257o gallon septic tank and 12L: ;) ,. ? &Q 15'24 LF X 2411 wi liF. T(2,:L, Other Requirements: - 6 01= -j LJ-- To be constructed by Address Water Supply: Public Supply From Address or: Private Supply Drilled by M { LL �;2i l�l �G AddressR�1/� T-" IArJtj A'l%IAV; /WWSTv I tv 102 +C*) 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 ts stem 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 Ate date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repai / L -reto. - Signed: P.E. V R.A. Date 2. Z Address 3�'� j SOU 6 7_) � WSme N y 10509 License # Q Cj Cl' 8 4 6 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatmejnt�ystem has been completed and inspected by tl e`PCHD and is revocable for cause or may be amended or modified.when considered n essary by the.Public Health Director. Any revision or alteration of the approved plan requires a new permit Approved f r ischarge of domestic sanitary sewage only. Y / ` J 2— B y: f- *,t/ Title: Date:�� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97