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HomeMy WebLinkAbout0134DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -2 -83 BOX 2 00134 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM - OO�s� 20 Owner or Purchaser of Building Tax Map Block Lot oQ�SE�C 1��U�Ow Q� 1L�E�S Building Constructed by � 9 W _S7 Location - Street CUES \DEN \ �Al Building Type PATS EZSO N TownNillage VAN CL�� 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 is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system,., except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned. further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the oc up t of the building utilizing the system. Dated: Mo th Day Year ` Signature: Title: AJ NJ Gen Contra for (Owner - Signature 1DOZSI�-E-7 NO W � U \LIb 1zS Corporation Name (if corporation) Corporation Name (if corporation) Address: I; W ES I- ap �,I.O \N CZD. %�� -W�ti EP_ Address: VS WEST 1 \o�LOw (�D, C'�? E WS�ER State Zip \ 5nq State N Zip Form GS -97 P. W. SCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (914) 278 -2110 FAX (914) 278 -2166 TO Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 WE ARE SENDING YOU EKAttached ❑ Under separate cover via • Shop drawings tv Prints ❑ Plans • Copy of letter ❑ Change order ❑ DATE JOB NO. 99 -159 ATTENTION RE: W 3 Dorset Hollow Estates W f (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) Application for Approval of Plans (PC -97) I ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 1 • As requested Application for Approval of Plans (PC -97) I ❑ I Construction Permit for Sewage Treatment System�:(CP -97) 1 I A. Letter of Authorization (LA -97) 1 2 Design Data Sheet (DD -97) 1 House Plans (2 sets) 2 1 Letter from G & E Development,LLC, Re: Public Water 1 1 Check #3q.<( «-3 7� for the amount of $ 3oo_B� I 1 Short Form EAF THESE ARE TRANSMITTED as checked below: • For approval • For your use • As requested X7 For review and comment ❑ FORBIDS DUE • Approved as submitted • Approved as noted ❑ Returned for corrections • Resubmit copies for approval • Submit copies for distribution • Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS List Continued: 4 1 Septic Site Plan Drawings 1 1 E911 Address Verification Form (E911 Verfrm) 3 c COPY TO SIGNED:w If enclosures are not as noted. kindly notify us at once. 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: Dorset Hollow Builders Lot # 3 15 West Hollow Road Brewster, New York 10509 Dorset Hollow Estates 2. Nameofproject: ( formally VanCleef Est)3. LocationT/V: Patterson 4. Design Professional: Peder W. Scott, P . E . , R._'�. Address: 3871 Route 6 6. Drainage Basin: East Branch Reservoir Brewster, NY 10509 7. Tyke of Project: X . Private/Regidential 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 X 9. Is a Draft Environmental Impact Statement (DEIS) required? T 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N/A 11. Name of Lead Agency Town of Patterson Planning Board 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? Yes: 13. If so, have plans been submitted to such authorities? ........ ............................... Yes— Subdivision 14. Has preliminary approval been granted by such authorities? Yes Date granted: 1998 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... N/A 17. Waters index number (surface) N/A 18. Is project located near a public water supply system? Yes Serviced 19. If yes, name of water supply Town of Patterson Distance to water supply by system 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system Individual Lots Distance to sewage system 22. Date test holes observed 9 - 6 9 6 23. Name of Health Inspector M. B u d z i n s k i P. E. 24. Project design flow (gallons per day) ................................. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? .......................... s00'GPn No Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number ............................:.............................. ............................... N/A 29.. Is Wetlands Permit required? ............... ........... Individual Lot .................... ............................... No Has application been made to Town or Local DEC office? ............................... N/A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... No 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 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 No DESCRIBE: 33. Is there a local master plan on file with the. Town or Village? ......................... Yes 2 ' 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... Water`.only 35. Are any sewage treatment areas iri excess of 15% slope? . ............................... No 36. Tax Ma ID Number .......................... ... ............................. Ma o Block Lot P Pte._ � 83. 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 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. IiSreby affirm, under penalty of perjury, that information provided on this form is true to Me best of my knowledge and belief. False statements made herein are punishable as �a -4#ss A misdemeanor pursuant to Section 210.45 of e Penal Law. SIGNATU RES & OFFICUL TITLES: y Pe er W. Scott Agent for Applicant Mailing Address: ....................... 3871 Route 6 Brewster, New York 10509 g)2S� 0 0 ss_ per.. .. . o \-e o° a .. F 9 0 m S vq 5-T 5- I �, 'k� - --- --- - 1 -3 * ,� a y �r�� zs { FF,, ^�" 7 5 , _ : F ry ?"� -z . 4 �' 'k / _ �, 1 zit •,✓ x I h- rn ty_ - " r >.. _ r 4 ,;, . E ? �+ - ¢ . 11 S r s( a y I 1 711,;), - IIMENSI ®N C- HART(in -feet) fl _ ' `y� -: i f 4 E t; ,, �' Number A -: f % a r _ ;. r /^ /y� F: i d �- i �i 3 (�3' J q5 ` � ' f y `a, s t 4 E 49 90' 11 n 5 x' 5 , ,5 ,5' s�(� 52,5' 9' `� �, ; 1 t ;,..1 r r'�- n ,. ,7 z s a 5 e. r :" 48.5' 7D� w 'q s 120', ` ; > ` 1 1'� r � , y x Rfq ; ;- L 7� '.fO b �����' 7 �f� .J IV'Y Y A ' Zr .GOp���� 4 11, jjjj +! ,, ' - ,' ' V g1' 11 11. s " 11 1 �5 ° t33'r2 '� 11, x mfrs r t2 t c1 !3'� `t30� M' r� } `_ xi - : rrr /��� {h� r me 1 t 4, 4 .y ,'� r 1 l t' 1 r ;� `�— .lt�'�' r a g r '�y _ 'j _ t p. 1 NX '"" r1. .L =� 1 �� �'. , { 2•�, ` � 4,� x , R , v 3 jj r r 0 �� X08' ,< «� t �:� rs S } , r I �. C 3 '. r i V t ;'� _� j .1 i &' r = d �r \ `�` a F '� "' �- '' - r �., $ .'.I ,x., s r a ti._K , 11 4 ,y r ` n } a i J r fr s T �j s .� § S F S F b *� ? i - f < f si' °` S iC z L .' 1 - x a .. :� „" f ,. x1 T S -, z 1R E, y N, �,t ^a, i k - t -�5. 1. 1 19' t k' g E f S .. .; 7< x Y a i . r - .c. eK 4 :My —..�w� ti. i.� . t „: -.. _:+.�._a..,_...�... _..+.. <_. ..._ - - _._.x V _ ....�.n. .'.._.__ .. _ e. .. ..Y a .. „ - .. _ d PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at 84 West Street t TN Patterson Tax Map # 3.20 Block 2 Lot 8 3 Subdivision of Dorset Hollow Estates (formally Van C lee f Estates) Subdivision Lot # 3 Gentlemen: Filed Map # 2 7 71 Date Filed 12/24/88 This letter is to authorize P e d e r W. 3. c o t t, P. E . , R. A. a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Count igned: P.E., R.A., # 059346 Mailing Address 3 8 7 1 R o u t e 6 Brewster State New York Zip 10509 Telephone: ( 9 1 4 ) 2 7 8 — 2 1 1 0 i (Owner o Mailing Address: Dorset Hollow Builders 15 West Hollow Road, Brewster State New York Zip 10509 Telephone: ( 9 1 4 ) 2 7 9 — 1 3 3 9 Form LA -97 I 'MPI TEST P, T DATA RT­`=.� TO BE SMMI= WITE: Al =O'N DESC=1C )F SO= 1a=U,\T=- IN TEST E S m D H= NO. G.L. 21 .41 71 I 10' 1'7 5;Q11:7 HOLE L\rj- 121 13 141 IZ= AT 1-alral GRCUL\TUV,-.=- IS M =- U -MIC -ING '_7\=U1\7_r-= JTE L= TO WHIC-1i W-A= , RIS—r-.-) A=R M1 D= HOLE OBSERVATIONS MAME, BY: DATE: DESMN Soil Rate Used -Min/I" Droo: S-D. Usable Area Provided I Septic Tank- Carmcitv 1,7 5 t) N6. Of Bc--Aroc= I/ - - _ gals. Type R16 Absorption Area Provided By --133 L.F. x 2411 width tre-nda Other Narrc P W. <c 0,V,-IAI tore Address B~/ SF_U se THIS SPACE FOR USE BY IMUTIHI DMIMEMX CNLY; Soil Rate Approved sq.- C,,eaked by Date o CF ._._: �i.= D1'l r S� c :-Zti =r—lR, M. 7Ml r E ...SLR IAI /Vy 3. Z 2 %0605 ZO -..� at l�uC�C� i1eE=a5z w.^.SS S=Za°t. Yr a te ..d GRO4AP r GOT I�acr cr ?r e- scakLng Pate of Pe_- =laticn Test QIaC. t��'tiSaS 7(.. �. -\ TZ.G =LA. ?TON ihin Elapse rept. to - Wats'- - war_-_- Love GrCL:nd S=---ace . in 7ACle.S ' SOir Rata Staztrstco Min. staxt stoc Drco 1r: in /1n L co —Inches !nCles l nChes - Gol 24 3 . 5 1 • 2 I d 1. Tesrs to be - apeatad at saxe depth until apprc cmately egra l soil =at= ` . are' obtained .at eac: pe.- wlat:on test hole. ' 'dl'_ data to be sutra, —,=d for review. Z. Dept-, mea_sur--mnts to be ra. ^:e f--= t^p cf hole. rev. 9/85 I G &E DEVELOPMENT, LLC Gregg Macaluso 914 - 878 -4355 March 17, 2000 Robert Morris P.E. Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow Estates Lot # 3 (formally Van Cleef Estates) Edward Bloes 914- 234 -2281 This letter is to serve as a notice that I as the contractor for the Dorset Hollow Water District, currently under construction, can provide adequate pressure to serve the proposed lots. This water plant shall be inspected and approved by PCDOH for use to meet the demand requirements for the subdivision. G &E Development PO BOX 352 BEDFORD, NY 10506 14.16 -4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 'SEAR Appendix C State Environmental Quality 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 Dorset Hollow Builders Dorset Hollow Estates 3. PROJECT LOCATION: (f O r m a 1 1 Y Van C l e e f Estates) Municipality Patterson. County P u t n a m 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Lot I 3 - Dorset Hollow Estates (formally Van Cleef Estates) 5. IS PROPOSED ACTION: F] New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of subsurface sewage treatment system -­for singie- family resid'emce and connection to public water sypply. 7. AMOUNT OF LAND AFFECTED: 2 Initially a 3 acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? U Yes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential ❑ Industrial El Commercial El 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-permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yes, list agency name and permit /approval Subdivision.approval from Town of Patterson Planning Board /PCDOH 12, AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE �L Applicant /sponsor name: P.W. Scott , P . E . , R.A. Date: v Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER Y 1� R 'ART 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. f ❑ 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 of 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•C5? Explain briefly. C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART Ill— 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 (aj setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irrevesibiliiy; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explariatio ss, contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. - heck 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. 1: •Cheajothis. 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 abvide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsi le O ficer in Lead Agency Date Title of Responsible Officer Signature of Preparer (If different from responsible officer) 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 (914) 278 - 6130. Fax (Q14) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) Dorset Hollow Builders Lot .3 3.20 -2 -83 . 89 West Street Patterson DATE: 3/Z c' The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E91 I VERFRIvi) I PUTNAM COUNTY DEPARTMENT OF HEALTH DNISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT #P—T7-00 e44 o/ Located at g9 W E<,-:T S 7 RE E 1 Town or Village PR T .T L ES ON Owner /Applicant Name n©RSF T jQUJDW gU JLWF !;Tax Map Block 2 Lot g Formerly Subdivision Name V A N C LE E F Subd. Lot # Mailing Address Nf F_ � )CJLL 0'v\J C A (ZE WS i E C' NY Zip )00 . Date Construction Permit Issued by PCHD I:x % 00 i � wESi ��Lov �b' Separate Sewerage System built by � Q�'; � I�L�Ln � U 10�11ress GR2 _ w '�_ i E ?y N `/ 10509 Consisting of � 25 0 Gallon Septic Tank and !� 0 Lp Other Requirements: Water Supply: Public Supply From [V\ Q N' 0 c t p J\L_ Address P{ 1} L- K- SON i NY or: Private Supply Drilled by Address Building Type R �_'- 7-, � �,) 'E_ N) T � AL Has erosion control been completed? Number of Bedrooms A Has garbage grinder been installed? _ Ks AJ O 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 .'tans and the standards, rules and regulatiogs of the Putnam County /Pepartl lent of Health. Date: l Q " — 0} Certified by Address 2- P.E. R.A. o�oq License # tD 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 approval V'60 subject to modification or change when, in the judgment of the Public Health Director, such revoca 'o , dificP;r change is necessary. By: Title: Date: 4. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 NE LABS NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 www.NORTHEAST LABORATORIES.COM REPORT TO: DORSET HOLLOW ESTATES Attn:ALLAN J. FINN 15 WEST HOLLOW ROAD BREWSTER, N.Y. 10509 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: LABORATORY REPORT DATE SAMPLE COLLECTED: 7/12/2001 TRVIE COLLECTED: 8:00 A.M. COLLECTED BY: A. FINN DATE RECEIVED @ LAB: 7/12/2001 TESTED BY: LAB #11471 LAB LD. #: JULY -159 REPORT DATE: 7/17/2001 1N AccOgOA�� e , DORSET HOLLOW ESTATES, LOT #3 KITCHEN TAP WELL NONE RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/]L - - - - -- m1= milliliter mg/L = milligrams per Liter ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED: 7/12/2001 SAMPLE, AS TESTED ABOVE: OPOTABLE or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI- RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914)278-6130 Fax (914) 278.7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278.6085 Early "Iiterveuiion (914) 278.6014 Preschool (914) 278.6082 Fax (914) 278- 6648 OWNERS NAME: S1�- `. TAX MAP NUMBER: ,20 _ 2 — S E911 ADDRESS: Vj 95T . 5-V TOWN: Pry T S CAS® N AUTHORIZED TOWN OFEICIA -L- ��( r (Signature) DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERB" PUTNAM COUNTY DEPARTMENT OF HEALTH ' DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 6 / Inspecte y: Street Location Owner r>,rsg'T NoLto ✓ :a0j un j;;r Town `P* TTg TZ soAv Permit # '?—a7 -- o 0 TM 91 3, Z _ ;Z — 0:3 Subdivision Lot # 3 1. Se`vaQe Svstetn 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 ...... ............................... II. SeivaQe 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 ........... ............................... f. Trenches T.ength required © o Length installed yoG 2. Distance to watercourse measured -t- i oo 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 -1 V7." diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped......... ................ ..........:.................... 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........... III. House/Buildin a. House located per approved plans ... ....:.......................... b. Number of bedrooms .......................: .. ..Z................ . IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured 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 & dir.to exist watercourse g. Footing drains discharge away from STS area ............:.. h. Surface water protection adequate... .. .....................:........ i. Erosion control provided ...........:..... ............:.................. BRUCE R. FOLEY Public Health Director June 12, 2001 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 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 Hang Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Dorset Hollow Builders West Street, (T) Patterson Lot #3, TM# 3.20 -2 -83 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: No comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide JUN -12 -2001 09:58 AM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTHENT OP ISEALTS DIMON OF 75MONMZNTAL EL41TH SERVICES ATTENTION 0 ADAM XGYENZ MQT ZS ' E „ R MNAL iNSPE=M1 For:. Fall All information moot be My =Mplctod prior to say inspections WAS made. PCHP Coasuvctloa Permit # Located: W M Owaer /Applicaat Name: ="-i l. . Pormerly: Subdivision Name: Subdivision Lot # _..,. Is system All completed? _ 41A Date: 13 system complete? .._.-., �"rJ Date; Treacbes _ ✓ -- P9) 'G r a% ._ Block a. Lpt .$u is system constructed as per plans? L.._ Is wet drilled? Date: (`G_ -o_��____� Is well located RS par plus? Are erosion control wemat a in phce? i certify chef rasa gaem(s), is »a4 st the above premises has been con=Cted oad I have laspccted Lad verified their completion in accordance with the issued PCHD Constmotion Permit tad approved pians and the Standards, Rules and Regulations of the Put= Gouaty Department of HcaitlZ Date: - • -��,. CertMed by: PE } �( Det Professional CoMM= Form M-99 i �, i i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FO WAGE TREATMENT SYSTEM PERMIT # 1- 37-00 �_� Located at 89 West Street;;, TownorVillage Patterson Subdivision name D o r s e t H o 11 o w E s5ubd. Lot # Date Subdivision Approved 1998 Owner /Applicant Name Dorset Hollow Builders Tax Map 3.2 0 Block 2 Lot 8 3 Renewal Revision Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, NY Amount of Fee Enclosed $300.00 Building Type Res i d e a c e Zip 10509 Lot Area . 9 2 No. of Bedrooms 4 Design Flow GPD 8 0 0 Fill Section Only Depth Volume Separate Sewerage System to consist of 12 5 0 gallon septic tank and 40 (– !„ Other Requirements: To be constructed by Dorset Hollow Builders Address 15 West Hollow Road, Brewster,NY Town of Patterson Water Supply: x Public Supply From W a t e r D i s t r i c t Address ' or: Private Supply Drilled by Address 4 I represent that I am wholly and completely responsible for the design and location of the proposed systems) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Q _ .�-�_ w7�— P.E. x Address 3871 Route 6, Brewster, NY 10509 R.A. Date -1 V- --V License # 059346 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. pprove o discharge of domestic sanitary sewage only. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design P ofessional Form CP -97 PUTNAM COUNTY DEPARThIENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: �t�1J�^'� �N T LOCATION: %01 L ak' �f REVIEWED BY: Y . i +�R, AS, SRDATE: �O> TAx hLQ-: (CNFRME) '63 DOCUI TEENTS Y (REQUIRED DETAILS ON PLANS CONT'D) PERbITT APPLICATIO U� HOUSE SEWER -' /," FT. 4 "0'; TYPE PIPE CAST IRON L SdL )WELL PERNIIT OR P ERN 0 BENDS; BENDS 45° W /CLEANOUT (—)2—)PC -97 RENEWALS C( LETTER OF AUTHORIZATION (=t=j5R-E NOTE (NO CHANGE) DESIGN DATA SHEET (DDS) FILL SYSTENIS CORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE EAF THREE SETS PLANS - TWO SETS (__) VARIANCE REQUEST SUBDIVISION ULEGAL SUBDIVISION (_)(SUBDIVISION APPROVAL CHECKED (__)(__)PERC RATE UUFILL REQUIRED DEPTH C--)(—)CURTAIN DRAIN REQUIRED ✓ GENERAL (__)LOCATED IN NYC WATERSHED (�L--)PLANS SUBMITTED TO DEP tom/ DELEGATED TO PCHD (, DEP APPROVAL, IF REQ'D (et6L DEEP TEST HOLES OBSERVED UPERCS TO BE WITNESSED - APPROVAL SSDS ADJ, LOTS iTLANDS (TOWN/DEC PERMIT REQ'D ?) .TA ON DDS PLANS & PERMIT SANE 1969 NEIGHBORNOTIFICATION LETTER BUZBA 100 YR FLOOD ELEVATION W/I200' UUSOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) U SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 ( _0�DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED (_-) DRIVEWAY & SLOPES,'CUT (FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES (_5( JTTTLE BLOCK; OWNERS NAME ADDRESS TM ;, 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 �WELLS & SSDS'S WAIN 200' OF SSTS (— ( )PROPERTY METES & BOUNDS COMMENTS: U FILL SPECS / FILL NOTES 1 -5 FILL PROFILE & DIINIENSIONS (� FILL IN EXPANSION AREA . FILL GREATER TA.4 N 2 FEET CLAY BARRIER FILL CERTIFICATION NOTE U DEPTH GAUGES VOL ON PLAN FOR R.O.B., UNCLASSIFIED & Ii IPERVIOUS (�(JSEPARATION DISTANCE FRONI TOE OF SLOPE / T U LF TRENCH PROVIDEDYV" 60FT MAX. (�PARAI,LEL TO CONTOURS (� f� 100% EXPANSION PROVIDED U�)DETAILMUST FREE CRUSHED STONE OR WASHED GRAVEL C/ ( )GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 100' TO WELL, 200' Pit DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (mc. ezpan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits - 20) ( )L/f50' INTERMITTENT DRAINAGE COURSE U 00'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS ( —J10' `ILN TO LEDGE OUTCROP SEPTIC TANK ' FROM FOUNDATION; 50' TO WELL (_�iI3IENSIONS TO PROPERTY LINES WELL 0CAT10N OF SERVICE CONNECTION C )-,]N 15' TO PROPERTY LINE .SLOPE U/ SLOPE IN SSTS AREA (520 %) (REGRADED TO 15 %, IF REQUIRED DOSE/PU?vIP SYSTEMS PU1NIP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (� DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL (� 15' MIN to CDS=>5 %, 20'-4 %, 25' 3 %, 35' -1 %,100 % -<1% 20' MIN to CD DISCHARGE 1100' with 182 cons day discharge 10' NIIN to NON- PERFORATED PIPE r/u w - - �:�fl� �� 4=50.7 r # t ,._.— .- .J_-1` � i,�� /j' �' .�<' °�h'i. ;'h �f�,,,�<`! C>T SJ.R+�th �,.�• eo a t Lr 1 \ ( 4 t i t _ llN,N `;- .,-. o °ate � � > ..� e, � f �. -•,� t' TIC PL J SF TIC PL J