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HomeMy WebLinkAbout0138DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -87 BOX 2 I,IIL I '• r ' i, rr , 1 { LI ., 1 11 oil I lot A- NMI MEN 00138 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . FINAL SITE INSPECTION Date: 2 0 Inspecte y: �; �EFD Street Location W�s� ST�EE°T- Owner 7> e,r�+ bWlegg Rzyders6 Town _7'4rn5u se,N Permit # P-27 —2 �j . TM #_ B , l p — T Subdivision Lot # a* 2 ' 1. Sewage System Area 4. 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. 1DO' from water course / wetlands ...... ............ .................... I1. Suva e S stem a. Septic tank size - 1,000 ........1 2 .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box I. 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 ........... ............................... Trenches enches I.Eegth required -, Length installed 2. Distance to watercourse measured. -f - moo 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, 1000 P ............. 8. Size of gravel 3/4 - 1'/2" diame cle............ 9. Depth of gravel in trench 12" mi ............. 10. Pipe ends capped .................................. :.................... . g. _P�u_mm_or Dosed Systems 1. Size ot 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 - 1buseBuildine a. House locat6d per approved plans ................. IV_ b Number of bedrooms ............. ..........t.% C................ . Vell a. Well located as per approved plans . ............................... b. Distance from STS area measured ft........... c. Casing 18" above grade .............. ............................... ci Surface drainage around well acceptable ....................... V. !gcrall Workmanship a Boxes properly grouted ................... ............................... I All pipes partially backfilled ............ ............................... < All pipes flush with inside of box ... ............................... t Backfill material contains stones <4" diameter .............. F Curtain drain & standpipes installed according to plan.. J Curtain drain outfall protected & dinto exist watercourse I Footing drains discharge away from STS area ............... I Surface water protection adequate .. ............................... Erosion control provided ................. ............................... 1. iI 07/11/00 15:22 PW SCOTT 4 19142787921 NO.183 D06 PU'NAM COUNTY DEPARTMENT OF HEALTH DMSI ON OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ❑ ADAM GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be f ully completed prior to any Trenches inspections being made. b G PCHD Construction Pen nit Located: r' S-t r t- (r) (V) - Owner /Ap cant Name: r s.�t ���� %.n TM 3.20 Block 2- Lot _.L Formerly: U C�- I StO r( Subdivision Name: pIt 91faw L�s Subdivision Lot # -32— Is system fill completed? } _ Date: L 00 IS system complete? _. YZ& — Date: _.2- . ._ -0 is system constructed as ?er plans? Is well drilled? _ __. - -__.- A Date: Is well located as per plat is? Are erosion control meal ures in place? I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and veriSed their completion in accordance with the issued PCHD Construction Permit and approved plans and the standards, Rules and Regulations of the Putnam County Department of Health. f Date: Certified by: L-�PE X RA esign Professional Address: 9&14t t` 8MwSt= WY (m,M Lic. # D S JNG Comments: JA 4:�-- Y ��i'1't 2rYt -tlh� P�G Form FIR -99 0 t. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # c>, /0� 3) q6 Located at Town or Village Patterson Owner /Applicant Name D o r s e t Hollow Builders Tax Map cDQ Block Lot `�� Formerly Van Cleef Estates Subdivision NameDor s e t Hollow Estates Subd. Lot # o� Mailing Address 15 West Hollow Road, Brewster, NY Zip 10509 Date Construction Permit Issued by PCHD 1 I l 1 Separate Sewerage System built by D o r s e t H o 11 o w B u i l d e r s Address 15 West Hollow R o a d Brewster, NY. 10509 Consisting of 1250 Gallon Septic Tank and 500LF of 24" wide trenches and 100% reserve. Other Requirements:_ Town of Patterson Water Supply: X Public Supply From Water District Address. or: Private Supply Drilled by Building Type Residence r Address Has erosion control been completed? Yes Number of Bedrooms 4 Has garbage grinder been installed? N 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), i P ordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulat s o the Putnam Cgiu ty Department of Health. Date: –11 l-o 1 U Q Certified by J P.E. X R.A. Address 3871 Route 6, Brewster, NYDesign10509nal) License # 059346 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocat' odific ' n or change is necessary. Q By: lam" Title: J 1 /X - 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 GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Dorset Hollow Builders Owner or Purchaser of Building Dorset Hollow Builders Building Constructed by I Location - Street Residence aa a IS1 Tax Map Block Lot Patterson TownNillage Dorset Hollow Estates (formally Van Cleef Estates) Subdivision Name s� Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the cupa f the building utilizing the system. k,. r-_,— -I �4 >�_ Day U Year O C) Si -S QO FR56_:-y tA0 L_LCO CZ_) Corporation Name (if corporation) Address: State Zip Title: Cog-se-y' 1A©Lt_0('D X01 LrDEJZ S Corporation Name (if corporation) Address: State Zip Form GS -97 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 (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: Q e 12 5 c---T- 1'�-o C-4- 0� (b L3, L-0 L--2.S TAX MAP NUMBER: -5, a c V 2— E911 ADDRESS: 9 4 W rs T" �T Z='►� TOWN: F, AUTHORIZED TOWN OFFICIAL: (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 VERFRM) ft- 3 2 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 Attached ❑ Under separate cover via _ ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ DATE JOB NO. ATTENTION RE: Septic As —Built Dorset Hollow Estates — Lot # (formally Van Cleef Estates) 1 Certificate of Construction Compliance 3 ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 1 1 Certificate of Construction Compliance 3 1 Guarantee of Subsurface Sewage Treatment System 3 1 As —Built Septic Plan Fee: $200.00 /IVY" i THESE ARE TRANSMITTED as checked below: 1 For approval X7 For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS 1 COPY TO SIGNED: /f onr /ncuroc nro nnf �c nnfnr/ 4:..rUa ....f:f....� ..♦ ...,.... r� �.G rt otr X ri? Z ✓,. � 7 't• F[,�F �',,.;3 -�' f 4"57. 7'F � . . 4 .y r i ' f, ^"w^ d �'$:+ Ci'fi twr> A. if 9 ,F. ?`y$" t sw ' }'- S t ,zsrr•Sr° `�?ir ds� e+Jx n a '::� r yp k', s£ k7 Vi ,.I. a: +4.: i n +µ �Y.Y�"� ah '� 'F at``'`�.<•' D f - .r.F�, ? °- j r`, "y .3G Yta' n',y tee , - t-tr 3' "+ j a '.` `' r, t F� f^3 w •s. 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TNAM COUNTY DEPARTMENT OF HEALTH PU C O U p DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT F REATMENT SYSTEM PERMIT # %� %' �1 _ �P - �7- I Located at R ou. ` - Town or Village Patterson Subdivision name V a n c l e e f Date Subdivision Approved 1998 Subd. Lot # 32- Tax Map 3.2-0 Block Z Lot Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, NY Amount of Fee Enclosed $300.00 Building Type Re s i d en c e Lot Area Flo. of Bedrooms 4 Zip Design Flow GPD So 0 Fill Section. Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED O •, 10509 7101` Separate Sewerage S sY tem to consist of J a.SO ..gallon septic tank and Joy, S� Lr 'K -r9AFA J c t+cF-3- A tJ 0 0 % R-03 =-y Other Requirements: To be constructed by Water Supply: Dorset Hollow Builders Address 1.5 West Hollow Road, Brewster, NY Public Supply 1 From Town o f Patterson Address Water District or: Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatmentsystem 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:.. P.E. X R.A. Date 10 Address 387 oute 6, Brewster, NY 10509 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 wh nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new perry} t A proved r discharge of domestic sanitary sewage only. 1�. A By :.✓ Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 G&E DEVELOPMENT, LLC Gregg Macaluso 914- 878 -4355 October 21, 1999 Robert Morris P.E. Putnam County Dept of Health 4 Geneva Rd Brewster, NY 10509 Re: Van Cleef Estates — Subsurface Sewage Disposal Systems Edward Blocs 914- 234 42281 This letter is to serve as a notice that I as the contractor for the Van Cleef water district, currently under construction, can provide adequate pressure to serve the proposed lots. This water plant shall be inspected and approvedby PCDOH for use to meet the demand requirements for the subdivision. Very Edward G&E Di PO Bog 352 Bedford, NY 10506 BRUCE R FOLEY Public Health Director October 15, 1999 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 PW Scott Associates 3871 Route 6 Brewster, New York 10509 Re: Proposed SSTS, Deer Hollow Road West Street, Lot 32, Town of Patterson 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: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department of Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1. Street address is incorrect on the Construction Permit Application. 2. , The lot area, 2.5 acres, noted on the application appears incorrect. 3. The Tax Map number 3.20 -2 -91 noted for Lot #32 is also noted as the Tax Map number for Lot #28. Please rectify. 4. Drainage basin noted on Form PC -97 is incorrect. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very t ours, Robert Morris, P.E. Public Health Engineer RM:cj 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 (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 October 18, 1999 P W Scott Engineering 3871 Route 6 Brewster, NY 10509 Re: Dorset Hollow Builders West Street, Lot 32 (T) Patterson 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 October 13, 1999 is complete. The Department will notify you by December 1, 1999 of its determination. The Project has been delegated to the Putnam County Heath Department for review 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 Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2159. Ve ly yo Robert Morris Sr. Public Health Engineer RM/jp l PC IT AM Ca= DEPAFM 17T OF mum DIVISION OF ENVIRJXZ4EZ= HEALTH SE=C ES >..:_......:...... APPENDIX I D_^•SIGy DATA �SHEE-T- SJBSMCE SSq7�GE DISPOSAL SYSTIM FILE M. Owner SRG AaalsiTionI ooyce Address' 237 1s9.4- Aeam—lc Atle L44 lrxeuivs,vy 3 zv 2 106oS Zo Located at (Street) , CV-A ✓�4 If /GL" - Sec. Block / Lot (indicate nearest cross street) �-7o ST 6fz 4•sv C1W Manicipality )5¢77-270A/ Watershe3 ER s j:11 Jill Date of Pre- Scaking Date of Percolation Test HOLE Na,jam C= TIME PERCOLATIM PErZ' COLATIGN Run Elapse Depth to -Water Fraa Water Level No. Time Ground Surface. In Inches Soil Rate Start -Stop Min. Start Stop Drop In Yin /In Drop Inches Inches Inches j 3 5 1 ' 2 3 2�7CL'ES: 1. 'Nests to be repeatad at same depth until approximately dual soil rats are *obtained.at each percolation test hole. *'All data to* be suhnitted for review. 2. Depth measure Tents to be 1rzde frcrn top of hole. rcv_ 9 /SS I TEST PIT DATA RETIRED TO BE SL7PMZT2`LD WITH APPISC'?TION L oT DESC P =. ON : ' SOILS ENCODNTIl?•'D IN TEST HOT « DD.m"H HOLE NO. / HOLE M. Z HOLE NO. G.L. .2' 4' 3 7' COi?SE 8' s,a,/v�y Gov 9' '%l PSe/L OC'OGG� ca) 'D " 11' • i INLLCATE LD7M AT WHICH GROUNI i= IS Eh'COUN=1ED INIICATE Lc-v= .T . WHICH WATM Lr"V`LL RISES AF'T'ER BEING =UM= DFP HOLE 0135 FRVATIONS MADE BY: /11. 4 () O %J- AJ 1; 6� j DATE: G9 Z, �/ Q DESIGN Sol Rate Used -K-49 Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity uQ gals. Type Ab.=ption Area Provided By y _ L.?. x 24" width trencn N� � �✓ �o7T , ENGiNEEi2 /NG�.I,ec.{,�ir��r�.vF��Jnature �.i ` � A-dress rn F ~� v 0A �o• 0593n6�P RTES SPA=S FOR USE BY MUTH DEPAXND71 ONLY: . Sol Rate Approved sq:ft /gal. Checked by Date 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 Jo be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME Dorset Hollow Builders Vancleef Estates 3. PROJECT LOCATION: Municipality Patterson County Putnam 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) Vancleef Subdivision = Access from Route 311./ Cornwall Hill Road For Lot # 3Z- 5. IS PROPOSED ACTION: O New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction single lot septic - Connection .to public water supply. 7. AMOUNT OF LAND ^^AFFECTED: Initially .dam acres Ultimately • 2 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? (3Yes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Q 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•permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yes, list agency name and permltdapproval Subdivision approval-from Town of'Patterson.PB /PCDOH 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes [3No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE P.W. Scott, P.E., R.A. - (d — Applicant /sponsor name: Date: Signature: I_, If the action Is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by F;gency) A. DOES ACTION EXCEED ANY TYPE 1 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. ❑ 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, of 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 -CS? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. t� 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) a-2 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) 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 Lea2 Agency Print or Type Name of Responsible Officer in Lead Agency Title o Re5pon;iBl—eofficer Signature ot Responsible Officer in Lea Agency Signature of Prepaler (if different from responsible officer) Date 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at Vancleef Estates, Route 311 & Cornwall Hill Road T/V Patterson Tax Map rl 3.2 0 Block 2 Lot Y 8 Subdivision of Vancleef .. Subdivision Lot #. 32- Filed Map_ # -. -- 77. Date- Filed_..I. Gentlemen: This letter is to authorize P e d e r W. Scott 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. Very tru y yo>5, Peder W. Scott Countersigned: Signed: P.E., R.A., 9 059346 (Owner o Mailing Address 3 8 7 1 Route 6 Brewster, State New York Zip. Telephone: (9 14) 278-2110 10509 Dorset Hollow Builders Mailing Address: —15 Wa s-t Hollow Rd ,-, State Telephone: _ Brewster, NY 10509 Zip (914) 279 -1339 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: Dorset Hollow Builders Lot # 15 West Hollow Road Brewster, New York 10509 2. Name of project: Van Cleef Estates 3. Location TN: Patterson 4. Design Professional: Peder W. Scott, P.E., R.9,. Address: 3871 Route 6 6. Drainage Basin: GA-St- fb-r, we b} Y� Brewster, NY 10509 7. Type of Project: X . Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building; Subdivision Other (specify) 8.. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Town of Patterson Planning Board Exempt _ Unlisted _X No N/A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ........................................................... ............................... Yeg:,. 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 19. If yes, name of water supply Distance to water supply y system Town of Patterson 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 I/ 1 23. Name of Health Inspector A. /3yoz. oisLq 24. Project design flow (gallons per day) 800 GPn 25. Is State. Pollutant Discharge Elimination System (SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? N/A Form PC -97 2 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 Lo.t . 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 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 in excess of 15% slope? No --�, 36. Tax Map ID Number ............ ............................... Map3. Block o2 Lot 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. I hereby affirm, 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 SQskon 210.45 oj:1he Penal Law. SIGNATURES & OFFICL4L TITLES: ✓ - Pe r W. Scott Agent for Applicant Mailing Address: 3871 Route .6 Brewster, New York 10509 P. W. SCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net i (914) 278 -2110 FAX (914) 278 -2166 TO Putnam County Dept. of Health 4 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU Attached ❑ Under separate cover via ❑ Shop drawings Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ UA/0 108 NO. ATTENTI N RE: A�j C' �,� 7 cs ` � s Application for Approval the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION Application for Approval Construction Permit for Sewage Treatment System (form CP Letter of Authorization (form LA -97or CA -97) Design Data Shee "t (form DO -97) % Short Form EAF House Plans (2sets) 3 Drawings Check #64,6 /gfor the amount of $ 3vp THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections For review and comment ❑ ❑ FORBIDS DUE REMARKS COPY TO ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: If enclocuroc Ara not as noted. kindly nntifv tic at nn 97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION REVIEWED BY RM, GR, AS, MB, BH Y N DOCUMENTS Y PERMIT APPLICATION , WELL PERMIT _ PWS LETTER ETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION 7 SHORT EAF PLANS - THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION DIVISION APPROVAL CHECKED PERC RATE --L REQUIRED DEPTH TAIN DRAIN REQUIRED GENERAL LOCATED IN NYC WATERSHED mrle—_ LANS SUBMITTED TO DEP ELEGATED TO PCHD EP APPROVAL, IF REQ'D EEP TEST HOLES OBSERVED R CS TO BE WITNESSED X- APPROVAL SSDS ADJ. LOTS NAME OF OWNER DATE EROSION CONTROL:HOUSE,WELL; SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE -NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. 1ROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS C AY BARRIER 10111111, FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA TRENCH L TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED TAX MAP # M #,PE/RA, NAME,ADDRESS,PHONE# ATE OF DRAWING/REVISION ATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: TLANDS (TOWN, EC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME RE 1969 NEIGHBOR NOTIFICATION BI/ZBA 00 YR. FLOOD ELEVATION OTHER REQ'D PERMIT(S) DETAILS ON PLANS EWAGE SYSTEM PLAN - (NORTH ARROW) DS HYDRAULIC PROFILE AVITY FLOW NSTRUCTION NOTES SIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME,ADDRESS ON PLAN - FROM SSTS V TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL ' TO FOUNDATION WALLS _15'WELL TO PL 0' TO WELL, 200' IN DLOD, 150' PITS 0' TO STREAM WATERCOURSE LAKE (inc. expan) ' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATERLINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 %,10'- 4 %,25'- 3%,30'- 2 %,35'- 1%,100' - <I% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION ,-'LETTER #20 fjREQUIRED M #,PE/RA, NAME,ADDRESS,PHONE# ATE OF DRAWING/REVISION ATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: