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HomeMy WebLinkAbout0101DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.19 -1 -83 BOX 2 ''l17 '1. � a -� i7 - '1 IN% ` N � � � �Qlry • r' ''F4�: ���.' ,` I� _, ♦ ; �•� FI. Li ' yam, X� I A al ; „ NN 71 , 00101 ! N0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE AGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # �4� Located at ��� �� '� j11 Town or Village J� 3' o Owner /Applicant Name F-6(1 a Tax Map /� 9) 1 Block Lot Formerly Subdivision Name VAO ' � Subd. Lot # Mailing Address Y�40 p J� T �'� ' � �' N Zip � � `a Date Construction Permit Issued by PCHD Separate Sewerage System built by �QHWA— UO��1�� 1;Q Address f)(3 aox z5 a � � "4� Consisting of t ':111C, Gallon Septic Tank and coo L+ f-\M , Other Requirements: ),.ql �-b b , fio' ) C OKK <I�A p �1 Water Supply: Public Supply From Address or: X Private Supply Drilled by �TO� �4�KTr Address Mob PV' i N -t�ot�, Building Type �JiDem5 Has erosion control been completed? Number of Bedrooms 1,01 Has garbage grinder been installed? .Y ,5� HO 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 De artme t of Health. Date: 0 104- Certified by AT4"L' k J1, P. E. R.A. Address 5�-1IA-� . 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 o modification or change when, in the judgment of the Public Health Director, such revocati n, dific or change is necessary. By: °�� Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Grid # Map �1,►F1�j Block Lot(s) Well Owner: Name: Address: ' Cogs ' .' ;, 2��� � 22 ��WS►�`n -1� IAS�� Use of Well,: 1- primary 2- secondary Res' ntial Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade __3Lft. Diameter 7 in. Weight per foot lb /ft. Materials: Steel _ E lastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Z Compressed Air Hours �6 Yield ,o gpm Depth Data Measure from land surface- static (speechify. ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed . information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface d ` (j ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Z4__GPM Depth 9.0 Modej /C) ts�� 6,5' Voltage ='L) HP 1_ Tank Type,p ( Volume dg (Qk6ri Date Well Co pleted j Putnam County Certification No. C�D7 Date of Report / 3 �() Well Driller (signature) NOTE ,/Exict location of well with distances to at least two permanentAandhtarks to be provided on as sepay0sheet/plan. JaL A�' Well Driller's Name f'c���'t5 Address: A! 13�� 104A !SD Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Mar 01 04 09:00a TOWN OF PRTTERSO 845 -878 -2019 P•1 K ,1 C(� B ;U Cc R. FOLEY LORETTA ZA01.1- A.RI R.N., NUN. P cc!ee f!t rlJh B rte:cr �`'�'F� rtssOdW4 Pwblk NeoL -A Direerer Dir -rer of Prrrtam Servtcrs DEPARTINMI, OF I -MALTH 3 Geneva Road Srewstcr. New York 10509 E4'ri9eurnd9t1k1 Health (914)278.6i20 F=(914) 2711.7921 cumin Servuva (.914i z77 -s33E WIC (914) 279 -5678 Fax (914) 278 . 6(38: tarly Ieterrentlon 1914) 278 -6o1s Prtychoai (914) 278 -4952 Fax (914):79 - 4648 n•� i t E91 1 ADDRESS VFRIVIC'AT10T-4 FOR OWNERS `AylE: ���� 4 6 Y (:�—o-� ST.r •t G: `.L O �✓ TAY MAF i' UMBER.- q3. /G� — — g •3 E911 ADDRESS: • x 3 r� TOWN: AUTHORIZED TOWN OFFICIAL: (S igrsatu re) DATE: 212 (?'% d The Putnam, County. Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal. E911 address i5 assi geed by an authorized town official. This form is to be submitted -9th the application for a Certificate of Coastructxon Compliance. tE911 V'1r{c'ntil; Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 '• 4 March 26, 2004 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Re: Individual SSTS Compliance - Reilly Construction Van Cleef Estates - Lot # 38 989 Route 311 Patterson, NY 12563 Dear Mr. Morris: . Enclosed are the following: 1. Five (5) prints of Drawing S -38, "As Built SSTS ", dated 03/26/04. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 03/26/04. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 03/10/04. 4. Laboratory Report, dated 02/27/04. 5. "Well Completion Report", dated 12/03/03. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Department. 7. "E-911 Address Verification Form ", dated 02/28/04. If there are any questions concerning the enclosed, please call. Very truly yours, Harry WINic ol s Jr., P.E. HWN:gav 02- 095.38 REPORT TO: REILLY CONSTRUCTION ATTN.• TOM BIGILIN 2140 ROUTE 22 BREWSTER, NY 10509 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliform (Bacteria) • . Coli (Bacteria) PHYSEICALS: • Color (Apparent) • Odor • pH • Turbidity CHEMISTRY: • Alkalinity • Lead • Chlorine Residual • Nitrite Nitrogen • Nitrate Nitrogen NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN, CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY (Danbury Sample Drop Off Site: 100 Mill Plain Road, Suite 342, Danbury, CTJ TELEPHONE: Toll Free (in CT) 800 - 826 -0105 (Outside CT) 800 - 654 -1230 Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 E -Mail: NELABSCT@AOL.COM www.NortheastLaboratories.com DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: DATE TESTED: LAB I.D. # REPORT DATE: 989 ROUTE 311, PATTERSON, NY WATER TANK WELL WATER NONE RESULTS ABSENT per 100 ml NEGATIVE per 100 ml 5 mg/L ND mg/L . 6.61 mg/L 0.18 NTUs 24 <0.001 <0.05 <0.005 0.57 mg/L mg/L mg/L mg/L as N mg/L as N METHOD # SM 9222B SM 9222B EPA 110.2 SM 2150 ASTM- D1293 -99 EPA 180.1 SM2320B EPA 239.2 4500CIG EPA 354.1 EPA 353.3 Q = 2/18/2004 8:OOPM TOM BIGLIN 2/18/2004 LAB #11471 2/18/2004- 2/26/2004 D0402928 2/27/2004 MAXIMUM CONTAMINANT LEVEL (MCL) OR STANDARD 0 per 100 ml(ABSENT) Negative 15 Not to exceed value of 2 on scale of 0 -5 6.4 to 10 Range 5 NTUs No defined limits* 0.015* 1.0 mg/L 10 mg/L Combined limit for Nitrite plus Nitrate = 1 0mg/L as N DATE TESTED TBIE TESTED WHERE APPLICABLE 2/18/2004 @ 3:30PM 2/18/2004 @ 3:30PM 2/18/2004 @ 3:30PM 2/18/2004 @ 3:30PM 2/18/2004 @ 3:30PM 2/18/2004 2 3:30PM 2/23/2004 2/20/2004 2/18/2004 @ 3:30PM 2/20/2004 @ 11:OOAM 2/20/2004 @ 10:15AM • Hardness 48 mg/L EPA 130.2 150 mg/L ** 2/19/2004 • Iron <0.03 mg/L EPA 236.1 0.30 mg/L* 2/26/2004 • Manganese <0.01 mg/L EPA 243.1 0.50 mg/L * ** 2/26/2004 • Sodium 5.5 mg/L EPA 273.1 28.0 mg/L ** 2/26/2004 ml= milliliter mg/L--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count "`Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3=Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding times (were) met. ONOT SAMPLE, AS TESTED ABOVE: � OTABLE or POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POT AB LE WATER) (V(,,4�� �Zl Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Reilly Construction 13.19 1 83 Owner or Purchaser of Building Tax Map Block Lot Reilly Construction Building Constructed by 2140 Route 22, Brewster, NY 10509 Location — Street Residential Building Type Patterson Town/Village Van Cleff Estates Subdivision Name 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 it 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 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 3 ay 10 Year 2004 Signature: Title: President eral Contractor (Owner f— Signature Corporation Name (if corporation) Address: 2140 Route 22, Brewster State: New York Zip 10509 Burdick Contracting Corporation Name (if corporation) Address: PO Box 532, Brewster, State NY Zip 10509 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Reilly Construction 13.19 1 83 Owner or Purchaser of Building Tax Map Block Lot Reilly Construction Building Constructed by 2140 Route 22, Brewster, NY 10509 Location — Street Residential Building Type Patterson TownNillage Van Cleff Estates Subdivision Name 38 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 it 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 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. QQ nn Dated: Month Day 10 Year 2004 Signature• L3 �G d Title: President G al Contractor (O er) — Signature Corporation Name (if corporation) Address: 2140 Route 22, Brewster State: New York Zip 10509 Burdick Contracting Corporation Name (if corporation) Address: PO Box 532, Brewster, State NY Zip 10509 rU 11vA1V1 %_V UA 1 Y IMrAt(11V EIN 1' M' 11CAL'1'tt DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4 FINAL SITE INSPECTION!'�'2! .: Date: Inspected by: Street Location j4,y,5: ' jZ-� -, 3 j Town 24rre2s ©A/ TM # 13;19- 1 — 03 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................. .. ............................... d. Stone, brush, etc., greater than 15 from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size - 1,000 :....... 1, 250 ......... other ................ b. Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box . 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2.ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. Irenches 1. Length required Length installed 2. Distance to watercourse measured 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 % .......................1. 8. Size of gravel 3/4 - 1' /2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends ca ed ........ :. .............................................. g. Pump or Dosed Systems 1. Size of pump chamber ................ ............................... 2. Overflow tank ......................... .... . ......... ..................... 3. Alarm, visual/audio..... ...:........:.. ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D. estimated flow /cycle........... M. House/Building a. House located per approved plans........... b. Number of bedrooms . .............................�5 ... : ,- IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured -�- /&? f> ft........... c. Casing 18" above grade ............................. :................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist waterc r g. Footing drains discharge away from STS area.......... h. Surface water protection adequate.... .... .. ....................:..... i. Erosion control provided ................................................. Rev. 12/02 Owner 2 E/L _ Y Go.Ex Permit # 2 -- / 7 -0 :3 Subdivision Lot # 3 0 NO I COMMENTS m■ o■ 01 No �s Imo! orm r � f � O l 3/I 710 SITE INSPECTIOX FOR FELL PAD Date: Inspected by:� Fill pad located per the approved plan () 14 , Fill Pad Length IqQ Required Length_ / 2 v 2 ® ✓� Fill Pad Width /O 4/ Required Width Fill Pad Depth Required Depth Run -of -Bank Fill Quality Slope from Top to Toe Impervious Layer Installed Erosion Control Installed Sieve Test Results (if applicable) Additional Comments:oe���s ;r,- �j(zr ' h� ✓�,�- ��Ic�� e;,,�.^ Reserved for Field Sketch if Applicable e C-01 RTC t � / �xl<j'(iNCa IME_.° 5�9 � 51oJ -� 2��• �� ' I � •h 10 � / % t Tp -t �\\ •�O t ��eJ' � � r 11 UN fT � 9�rro GAI- f -TAN CUR (R�00�TF,D MY 4 lilt( P 6 %bL_ NC EL. F. � f2 451 60 /. pp N n i FEB -26 -2004 04:43 PM HARRY W NICHOLS 4 914 279 4567 P. 01 _ _- _ _- .. -. - +. �.. -- ....- .-- �..... ..�.- ..- .�- ..�- .. -r... -. PUTNAM COUNTY DEPARTMENT OF HEALTH DIYISYON.OF ENVIRONMENTAL EFA)LTS SERVICES P,F,Q MST_FQFTNAT-1NG . Qhj For:. Fill Date: 122 • e- bw , ".. Trenches I' I PCHD Construction Permit.# X 13-- 0 1 - Located: 4Irq .0-15 OAJ !a 3l1 (T) (V) P� �►�e� Owner /Applicant Name: Qt+ 1. ; =usf Boa - TM . 3t Iq Block_ t Lot B'3 Formerly: Subdivision Name: ty c_Lur_ r Subdivision Lot # :t Is •system fill completed?" _,, IrA Date: Q,,. i's 'systemcomplete? , ---- Date' 1 1��� Is system constructed as per plans? is well drilled? Date: *2-2n. 04 .Is well located as per.plaw? xts Are erosion control measures in place? I certify that the syst*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 pleas and the Standards, Rules and Regulations of the. Putnam C linty Departmerit.of Health. Dafe: Certified by: RA Desi rofessional Address; 20 Ifo4K�zz�Tl ¢. 0-1 10309 Lw, # _ Sd 12y Com raws:. 7. FOR: 0 ADAM GENE Form FIR' 99;:: FEB -26 -2004 THU 17:00 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 • � O LORETTA MOLINARI 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 March 2, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Reilly Construction NYS Route 311, (T) Patterson Lot # 38, TM# 13.19 -1 -83 An inspection of the fill pad at the above referenced project has been completed. Comments are offered as follows. 1. The curtain drain and curtain drain outlet was not found upon inspection. 2. It appears the fill pad is larger than what was approved. 3. The fill pad, from top of fill to toe must have a 3:1 slope. 4. Please note that the toe of slope must be 10 feet from property line upon completion. 5. Although the pad appears to be larger than that on the approved plan, the. trenches would need to be installed in the approved location e.g.: 33 feet horizontally from curtain drain pipes. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, *r.., 0, �W Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj -�A ,� t,; ��� LORETTA MOLINARI 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 April 1, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — Reilly Construction NYS Route 311, (T) Patterson Lot # 38, TM# 13.19 -1 -83 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. • The curtain drain-outlet appears to be under water in the original unfinished Swale. If you have any further questions, please contact me at 845- 278 -6130, ext. 226 L . Sincerely, ' i� �[/ , -9 Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj MAR -26r -2004 02:30 PM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DMSXON .OF ENVIRONMENTAL HEALTH SERVICES For: Fill Date: _ ,mac z' 14 . Trenches PCHD Construction Permit # -1 Located. gn - mys RQ6% 3tl (T) M Owner /Applicant Name: 9&1Ll hhL4aWkSA,&11 _ TM at MV Block l -- Lot .1_ Formerly: Subdivision Name:; Subdivision Lot # Air - is 'systeo fill completed ?' Date: 1's system complete? ygs Date: 0 -RIG 0 ; Is system constructed as per plans? Yes Is well drilled? -.X91 Date: --P"- 6 -iWd Is well located as per plans? s Are erosion control measares is 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 PCIHD Construction Permit and approved plans and the Standards, Rules and Regula • r utna.m County Department of Health. �a'��.�. Daie: Certified by: Address: PE -- /_. RA 6124 FOR: 0 ADAM S/GRNE fl (NAME) _. Form FIR -99 MAR -26 -2004 FRI 14:47 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # 7 - O •..J Located at % q k S• 1716- -3 I MI or yikbage Subdivision name Va., Subd. Lot # Tax Map 3Block , Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name a : Date of Previous Approval � Mailing Address I -t6 ]' Zip o �, Amount of Fee Enclosed Building Type A 5; 1) Lot Area 1i 3 61 No. of Bedrooms _3_ Design Flow GPD 6e66 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 16610 Other Requirements: u 1, gallon septic tank and To be constructed by "7- a /) Address Water Supply: Public Supply From Address or: Private Supply Drilled by 1 1,6 1, Q Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and, that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. ,I Signed: Address R.A. Date 3 o 0 License # i!' - 17-4 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 wh co sidered nece sary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm' A prove fo ` ' harge of estic sanitary sewa ;11y. B t�� Title: Date: Y• White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 r' Hang W. Nichols Jr., P.E. Patterson Park, Suite 106 FVAY 2050 Route 22 Brewster, NY 10509 Telephone (845) 27914003 Fax (845) 279 -4567 Date.- C� To: C /* 1� . J Attention: j /L' a , Gentlemen: We enclose (`) copies of ?t,B[W Prints Reproducibles Specifications Memorandum Job No.: Project )10L- T ej Reports .Tracings Copy of letter Description: Revision/Date No. k') . �t PV t - ip,14 Ell/ r -].(*%A *%A L S-c o ' e_ 1 rte,. w,,r'L -- O Sent Via: Our Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to Very 1t , ly yours H rry WINic s Jr., RE, PUTN A,M -.11C. ,V, N-T DEPARTMENT QF -�.,qALTH DIVISION OF.ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGEIREATMENT SYSTEM Owner Address' 3- t4d ; Tax M B40'ick L6V -6 -3�- Located at (Street) (indicate nearer cross stye t Municipality. r 'Watershed erlo SOr-L., • PERCOLATION TEST DATA Date of Pre- soaking:.. Date of-Percolation Test : t th R,.. .......... U :7 1.1, j0fZ6 12, J.�- -2 3 1 1:ol -2— g ,1. 1. b0 4 5 Q4 I U j 3. Off flu A 01 56124, 5 T NOTES: 1. Tests -td be repeated at same depth until approximately equal Percolation rates are obtained at each ' 2. percolaflon test hole. (ix, ,5 1 min for 1: -30 min/inch, s 2 min for 31-60. min/inch) All.. data to be. submitted for review.. Depth measurements to be made.from tQp.of hole. I Form DD-97 DEPTH G.L. 0.5' 1.01 1.5' 2.0' 2.5' 3.0' 3.5' 7 -777777777-. Indicate level'at whi&-gr*oundwat&*[s encountered - Indicate levelaf which* mottling.,is observed Indicate. level to which .w,atdr. le.yr..I.rises after bein.g.e.nc.oun.tered Deep -hole obseryati ons'.MadC-by.-. Date Design -Profess ional.Nam'e:,. Address: Signature:. Design Pro''fess'io" n'a'l's Seal B TF, r .`o �� o0 c ,t b 10 a J i t O O o�N 21 woo ILA 13 I 2Z. 21, 20 5 19 1� ll t5 a � I W rN v O Zlof u � w 1 1 I v 6 9 co it 12 I i S L I I S�, I l a SEP1'IGTAN14 Ar . I eE 5 DIMENSION CHART (in feet).. Number A Q 35 28 2 80 49 3 80 53 4 76 54 5 69 57 6 72 59 7 71 63 $ 70 b6 9 69 7I 10 7o 75 I I ? 1 79 12 72 94 13 1 22 1 26 14 121 123 15 j20 120 16 120 1 1'7 17 120 114 18 120 III 19 120 109 .20 121 107 21 122 106 22 123 104 i I � i O , / o I ^o i I / / r I r } i � 0 � m DOC I i a , � r / r r r r r r / rL, / N01 °`S'0! °! EV(ISTING CURTAIn /"NStALLED "TIHE op gUBDIVt510H A P 2.75.100 i m X NI qp Iz e I I t I {Iliii�lill has° �fl c jaw ymw� C.64. t Q/RTAIN pROp 'rsn/N ��SlA @ "cs i8,e (AA 6i 6 aF�1 41 `4A6) Fng If P , r r 1� r , M i r r r i i' r As d^? " Hnl3 PROP. WELL , QI r / CP 15� z o 00" E' 102.10 "0 2 108° 0.3 9" E _ — 142.70' Fng If P , r r 1� r , M i r r r i i' r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P' l 3— Located at 91 1-j `Y S —K Town or Village Subdivision name YM4 C i l; F- P- Subd. Lot # '3 6 Date Subdivision Approved l a� l '2�4 M4, Owner /Applicant Name Mailing Address V9 AV Amount of Fee Enclosed Building Type ►`Era 0E-14� 1 Abow'! Tax Map i : lq Block 1 Lot Renewal Revision Date of Previous Approval W4 Lot Area l-t" No. of Bedrooms tP Zip !-0! Z d d0 1N3W18Ud30 A1N100 WdNind : 3WdN 54 �. August 22, 2003 Robert Morris, P.E Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 p. �}' a�,�. 5..••• .. " Re: Van Cleef Estates. Lot 38 NX'S Route 311 Patterson, Putnam East Branch Reservoir DEP Log # 12872 (Joint Revie 'kR�+i . 5r' •s Dear Mr. Morris: This letter is to :inform you that the Protection (Department) has deT complete. In addition, the Departmen above - referenced regulated activity. 4 � rs submitted documents including the p p;. Subdivision Lot # 39", dated 02/21/0 Sincerely, V. Danny Shedlo, P.E. t1• -:.. w.` ; ` Project Manager Project Review Group K. xc: John M. Dunn, P1, NYSDOH . P -1, RE 1- ,y. Bi3�'f•.,�.• -yir7u 1Mn�t'•n:�i.. :ai:.S.rJ�Pti "j .. ...w.r.. _.. .. ' ZO 'd ma �m ZZ E T26L- 8L2-Sb8 :131 82:9T IdA 2002- 22-onu W) l 'ew York City Department of Environmental emuned that the above- referenced application is t has no objection to the approval of the This determination is based on the review of Ian titled "Proposed SSTS Van Cleef Estates 3, and last revised 07/25/03. The applicant must contact Sissy Jae La Ossa of my staff at (914) 773 -4416 at least 2 days prior to the start of construction of the SSTS so dim a Department representative may inspect and monitor the installation. 9NI2 NI9N3 d3Q DAN �econo rIUC)f Firs z. F 11bor ' ` cy DIHIHG Root( 1 G' X 13, - G' I " 1.(AS-#ER 8EOR0011 -` LIYIHG R00)4. 1 4 ' -1 X 15' -G' �_ j•iJ 1<'- G'X1:' -G' UP i PUTNAM COUNTY DEPARTAI r f NT OF HEATH I HOUSE PLANS APPROVED FOR BEDROOM COUNT QNLY, BED R6014S ALL SUBS z T?ESE HOUSE PLANS P lJ5' �i,: �J� ; `''• " ;; .4, ,;__ *OVAA� .. �DRoaM ,X NATURE & TITLE DATE i S I , / / / / / / / i W/ m°1 n `/' PROP• J I l2s - / / i / I Z ' Exlyt• Z6t5 / I \ 1 ' I I �pPryeVAl- j0 ExIhtIHU clu l0 5u8 \ SION I p �-fINE 215 TP•\ Ak i \ �Rr4,, �Op (Rgy�4T �4,H h 8 es; FS/ ad . Gp / �) h Hnl3 / i I•tz. /U Pi i I n � 1 I 0 1 / i i F I L L VOLUMES R•o• �• 11000 C.Y. IMPE12�VIoUs s6o e•Y. Z'g •t ' vvao0 INSTALL ON vrrl&HT- MARtK W IN ` GOM(AGTCt� ICCQJ\RGO LBV�L �jURI'AGG PfLL LGVEL ' (1.'IW090 NAILGO - TO 95 fom OP 2•,i 4,; OE i°TH GAUGE 17ETA1 L F I L L VOLUMES R•o• �• 11000 C.Y. IMPE12�VIoUs s6o e•Y. 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: Toywn[Village Tax Grid # gg9N� "0�1 I ATTO.6VH Mapl -bti11 Block Lot(s) $0 Well Owner: Name: Address: X1a io' Use of Well: X 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 to gpm # People Served f) -5 Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type X Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No 'A Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision 'vAH (-EF-F Lot No. 161% Water Well Contractor: . 6i) Address: Is Public Water Supply available to site? .................................. ............................... Yes No Y. Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: Z'00-4� /44L4--- PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well asset 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. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell driller c ified by Putnam County. Date of Issue Permit Iss ' Official: 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 e Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax(845)279 -4567 July 25, 2003 Putnam County Department of Health 1 Geneva Road Brewster, NY 10509 Att: Mr. Robert Morris, P.E. ,Re: Proposed SSTS: Reilly Construction 989 NYS Route 311 - Lot #38 (T) Patterson, T.M. #13.19 -1 -83 Dear Mr. Morris: In response to your April 15, 2003 review letter, we note the following: A revised Plan and Permit reflecting 2.5' of R.O.B. Fill is now enclosed for review. Kindly continue with your review and issuance of the Construction Permit. Very truly yours, q, H W. jNicis Jr., P.E. HWN:gav 02- 095.38. ^-UII IUJ V4VII.LI 10 -.:3V4V#'l August 21, 2003 r� : ° Re: Carmel Park Lot 36/Eric Arell SSTS, (T) Kent, Putnam County Boyd's Comer Reservoir Drainage Basin DEP Log #14019 (Joint Review) Dear Mr. Morris, P - V P I IFI-L e-uUt- Pt- . I 1W This letter is to inform you that the New York City Department of Environmental Protection (JDEP) has no objection to the approval of the aboye- V,. 1: xeferenced regulated a6dirity. This deteunination is based on the review of submitted documents including the drawings titled "Septic Site Plan - Arell Residence", and revised 10/02/02. The applicant must contact the undersigned at (914) 742-2055 at least two (2) days prior to the start of cowtmcdon of the SSTS so that DEP may inspec t and monitor the installation. Sincerely, 5- Danny Shedlo, P.E. Civil Engineer 11 Project Review iU��i�iP�r`J1 XG: John Davin, P.E., NYSDOH OAM TO 'd 92:vT 20, TZ 6nu 2V20-2ZZ-VT6:x22 9NI833NI9N3 d3G DAN Mr. Robert Morris, P.E. Putnam County Health Department I Geneva Road Brewster, New York 10509 r� : ° Re: Carmel Park Lot 36/Eric Arell SSTS, (T) Kent, Putnam County Boyd's Comer Reservoir Drainage Basin DEP Log #14019 (Joint Review) Dear Mr. Morris, P - V P I IFI-L e-uUt- Pt- . I 1W This letter is to inform you that the New York City Department of Environmental Protection (JDEP) has no objection to the approval of the aboye- V,. 1: xeferenced regulated a6dirity. This deteunination is based on the review of submitted documents including the drawings titled "Septic Site Plan - Arell Residence", and revised 10/02/02. The applicant must contact the undersigned at (914) 742-2055 at least two (2) days prior to the start of cowtmcdon of the SSTS so that DEP may inspec t and monitor the installation. Sincerely, 5- Danny Shedlo, P.E. Civil Engineer 11 Project Review iU��i�iP�r`J1 XG: John Davin, P.E., NYSDOH OAM TO 'd 92:vT 20, TZ 6nu 2V20-2ZZ-VT6:x22 9NI833NI9N3 d3G DAN v Department of Environmental Protection 465 Columbus Avenue Valhalla, New York 10595 -1336 Christopher O. Ward Commissioner i, Bureau of Water Supply Michael A. Principe, Ph.D. Deputy Commissioner Tel (914) 742 -2001 Fax (914) 773 -0343 KpTY DEPARTiyF T N 2 a 0 R �`'gONMENTAL PRO�'�`O� www.nyc.gov/dep (718) DEP - HELP. April 9, 2003 Robert Morris, P.E Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Van Cleef Estates. Lot 38 989 NYS Route 311 Patterson, Putnam East Branch Reservoir DEP Log # 12872 (Joint Review) Dear Mr. Morris: Please note, the following comment regarding the system design: 1. Fill must be at least 2.5' to meet the required 4' separation between trenches and groundwater. If you have any questions regarding this matter, you may contact me at (914) 773 -4416. Sincerely, sSC� Sissy De La Ossa Assistant Civil Engineer Engineering Design & Review xc: James Covey, P.E., NYSDOH { tF LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services 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 April 15, 2003 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive t� t� Re: Proposed SSTS: Reilly construction 989 NYS Route 311, Lot # 38 (T) Patterson, TM# 13.19 -1 -83 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: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. NYC Department of Environmental Protection states that a minimum of 2.5 feet of fill is required to meet the 4 foot separation distance between trenches and groundwater (see enclosed letter). Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:cj enc. Very ly yours, Robert Morris, PE Senior Public Health Engineer Z 'd JO 1N3WiNdd30 J,1Nnop WdNind:3WdN ZZ6L- 8L2- Sb8:131 '�� max;' .... • .. ..__,._. __ _..�..... -.._ 'f , Y.' is N At i L:•' a A,• April 9, 2003 Robert Morris, P.E Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Fte: Van Cleef Estates. Lot 3B 989 NYS Route 311 Patterson, Putnam East Branch Reservoir DEP Log # 12872 (Joint Review) Dear Mr. Morris: vv.:vT nH1 2002- 0Z -NdU Please note, the following comment regarding the system design: 1. Fill must be at least 2.5' to most the required N separation between trenches and groundwater. if you have any questions regarding this matter, you may contact me at (914) 773-4416. Sincerely, Sissy De La Ossa Assistant Civil Engineer Engineering Design & Review xc: James Covey; P.E., NYSDOH xtu6M_ Nn_ _'qtr ZO'd 8 0:9I i0, OT Ada �b,20- .2ZL- V16:xe3 9NIN33NI9N3 83Q DAN LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services 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 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Reilly Construction NYS Route 311, Lot #38 (T) Patterson, TM# 13.19 -1 -83 Dear Nichols: ROBERT J. BONDI County Executive June 16, 2003 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. Groundwater has been recorded at 3' 9" therefore, a minimum of 2' 3" of fill is required. 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, RX #6t:0 Robert Morris, P.E. Senior Public Health Engineer RM:tn ,r- r� LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services 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 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 RE: Reilly Construction 989 NYS Route 311, Lot #38 (T) Patterson, TM# 13.19 -1 -83 Reservoir Basin Dear Mr. Nichols: ROBERT J. BONDI County Executive March 24, 2003 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 6, 2003 is complete. The Department will notify you by April 13, 2003 of its determination. El 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 prof ect, such as stormwater plans "I Letter to: Harry Nichols, P.E. - March 24, 2003 -2- or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environ nental Protection review and approval is required. If you.have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Very ti�ly your &/) Robert Morris, PE RM:tn Senior Public Health Engineer Harry W. Nichols jr., P.E. 14164 (9195) —Text 12 PROJECT I.D. NUMBER .617.20 SEQR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or. Protect saonsor,) 1. APPLICANT /SPONSOR £� CoMj, r�cri�i� 2. PROJECT NAME 3. PROJECT LOCATION- P�T�i"' /6QN ✓� VT"M%M Municipality Municipality County ! 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) �JI1 N G� to�H�+�w 1-41 Li, Vii: li- +rER- �c�►oM 5. IS PROPOSED ACTION: RNew ❑ Expansion ❑ Mod lflcatlon/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND FFFrTED: '_, ' Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? p5yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ICI 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)? 9 ❑ Yes No If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes L7 No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes &o. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: W ' t(il'4 j i J fl Date: ©7'' `i "1 Signature: ` If the action is in the Coastal Area, and you are acsi`ate agency,: complete the . Coastal Assessment Form before proceeding with this assessment v.vtrt 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate'the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION 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. ❑ 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: 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. G7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb 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. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse 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 Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Otticer in Lead Agency Signature of Preparer (If different from responsible officer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL -HEALTH SERV10ES!` .' :'. : APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM `- 1. Name and address of applicant: —kit-4 2. Name of project: L�� �j3 `'`��� 3. Location T/V;�!rr1Z$c''y 4. Design Professional: !i-A(ZQ W Wl Y L-� Je- 5. Address: 2,0,,5-o F-F 7-2- ...- 6. Drainage Basin: 7. Type of Project: at Privat&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 lunliked 9. Is a Draft Environmental Impact Statement (DEIS) required? ............ I............. ND 10. Has DEIS been completed and found acceptable by Lead Agency? 11,.. Name of Lead Agency r' 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .......................................................... ......:........................ r ..... 13. If so, have plans been submitted to such authorities. .: N.n... 14. Has preliminary approval been granted by such authorities? No Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water k groundwater ..16. If surface water discharge, -what is the stream class designation? ...... d 17. Waters index number- (surface) !� 18. Is project located near a public water supply system? ....... ............................... 00 1.9. If yes, name of water supply Distance to WaTer: supply­! $ A 20. Is project site near a public sewage collection or treatment system? ::....:.'.`....... n�o 21. Name of sewage system Distance to sewage system •S I� 22. Date test holes observed 23. Name a � Iealth Inspector 04 BoD'Z414 1 24. Project design flow- (gallons per day) Cv�s,:.:.-...: 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?..:-- - 26. Has SPDES Application been submitted to local DEC office? ......................... 14A Form PC -97 27. Is any portion. of this project located within a designated Town or State wetland? 28. Wetlands ID Number .......................................................... ...........................:::. .29. Is Wetlands Permit required? ....... .......................................................... .............. Has application been made to Town or Local DEC office? ...... ...... 30. Does project require a DEC Stream Disturbance Permit? .................................. 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or.abandoned landfill, hazardous waste site, salt stockpile; landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 2 P4 NA fu D NP. 33.. Is there a local master plan on file with the Town or Village? ............:.:.......... 34. Are community water and /or sewer facilities planned to be developed within 15 years. in or adjacent to project site? ................................ ............................... 3�. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number ........................................................... Map lrh� I `� Block ( Lot 37. Approved plans are to be returned to ..... Applicant 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 thz application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby afftrm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Peal Law. SIGNATURES & OFFICIAL TITLES: tjm-kot'15 PE, Mailing Address .................. e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES." LETTER OF AUTHORIZATION RE: Property of0 Located at 'b i l TN ply► oi-c . Tax Map # 1 Block - _Lot 001�. Subdivision of Subdivision Lot # .g Filed Map # Date Filed.'.-.*! iled._ Gentlemen: This letter is to authorize W ° �JkL'40i'5 , Jo- f5. — - a duly licensed Professional Engineer or Registered Architect to apply for the. required wastewater treatment and/or water supply permit(s) to serve the above - noted - property in•accordance with the standards, rules or regulations as promulgated by the Public Health Director ofthe..Putnam ' County Health Department, and to sign all necessary papers on my behalf in connec . on - with-this . . matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions. of Article 145 and/or. 147 of the Education Law;- -the Pu_blic Health Law, and the Putnam County Sanitary Code. C.ountersigined: P.E., R.A., # _ Mailing Address .r+t••w State Zip I) o Telephone: 046) Very truly yours, Form LA -97 1 i OWNER'S NAME K "e4 SITE LOCATION MAILING ADDRESS, PERSON INTERVIEWED DATE ,LI l lD PUI'NAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR h g PHONE 7' `� b 4 - fr-- .� PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) s1 TYPE FACILITY "I K. � � Se, PROPOSED INSTALLER PHONE REGISTRATION #9� Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. Proposal Inspector's Signature & Title Proposal Disapproved r000sal anvroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Date (e.g. house corners). three precast 6' diam. x 6' deep I, as, owner, or reported agent 9f,-owner gree'to the above conditions. SIGNATURE C- EP E4S: White (PC D); Yellow (fin SI); Pink (Applicant.) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: -1 1 e 3// Town/Village: P e, Tax Grid # Map �, I `9 Block I Lot(s) V Well Owner: Name: Address: Rely/ Cf;nS .46';-\ 2. o 22 W W�U - cJ 1 10501 Use of Well: I- primary 2- secondary Res' ntial Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade �� ft. Diameter ! in. Weight per foot Llb /ft. Materials: Steel _ Elastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes Y No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Z Compressed Air Hours Yield 60 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. p4 1 {� Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface (j ` iu�nS'1S If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity ()'PM Depth 17.0 Mode /C) 065" Voltage J36 HP _ Tank Typeo j Volume Date, Well Co pleted / Putnam County Certification No. 007 Date of Re ort Well Driller (signature) r NOTE /Exict location of well with distances to at least two permanentAandtnarks to be provided on sepa sheet/plan Well Driller's Name 5 Address: A na l , 31% AA !'�Sl�►T. Signature: Date: � 3 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97