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HomeMy WebLinkAbout0140_ � w PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR S MENT SYSTEM PCHD CONSTRUCTION PERMIT # p -,24 Located at 8 („ ik.105-r' Siy-eL--�zr' Town or Village Patterson Owner /Applicant Name D o r s e t H o 11 o w B u i 1 d e r s Tax Map Block 2- Lot 66 Formerly Van Cleef Estates Subdivision Name Dorset Hollow Estates Subd. Lot # Mailing Address 15 West Hollow Road, Brewster, NY Zip 10509 Date Construction Permit Issued by PCHD 11 ill Separate Sewerage System built by Dorset Hollow Builders Address 15 West Hollow Road Brewster, NY Consisting of 1250 Gallon Septic Tank and -5-00 L F 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 Address Building Type Residence Has erosion control been completed? Y e s Number of Bedrooms 4 Has garbage grinder been installed? Y� i lertify 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 reg7esign he Putnam Coun Department of Health. Date: % /60 Certified by P.E. x R.A. Professional) Address 3871 Route 6, Brewster, NY 10509 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 subject to modification or change when, in the judgment of the Public Health Director, such revocatio , m dificatio or change is necessary. /° B Title: Date: c� Y White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 ti 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 r [LIT4 "TIF0 W 4 ° s H93NOCTITQIL, DATE JOB NO. ATTENTION RE: Septic As —Built Dorset Hollow Estates — Lot (formally Van'Cleef Estates) I Certificate o`f Construction Compliance 3 WE ARE SENDING YOU Attached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO, DESCRIPTION 1 ❑ I Certificate o`f Construction Compliance 3 ❑ 1 Guarantee of Subsurface Sewage Treatment System 3 1 As —Built Septic Plan Fee: $200.00 THESE ARE TRANSMITTED as checked below: 1 For approval 11 For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS COPY TO ❑ 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 SIGNED: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Dorset Hollow Builders 3, d-10 9 g. 8 Owner or Purchaser of Building Tax Map Block Lot Dorset Hollow Builders Patterson Building Constructed by . TownNillage Dorset Hollow Estates (� 4uz:� S']YL�'2Z'� ( formally Van Cleef Estates) Location - Street Subdivision Name Residence 5 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 er or not the failure of the system to operate was caused by the willful or negligent act of t e occupa of the building utilizing the system. th 7 General -Contractor Day 5-- Year 6 -z) Corporation Name (if corporation) Address: State Zip Title:, 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 (9,14) 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: -p-rS TAX MAP NUMBER: 10 00 E911 ADDRESS: 4✓ ,5571 - TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 7Z o v 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 VER ZM) 9'00 E Z Ar lo i 21 D � 2 L. GpAV�L nplV� • .ice, � ®. . n/ I V, Q�✓ "/ - 21 O o� w 4, o v J 19 � ly 3 14 � 13 � 12 II 'V LOCATION DESCRIPTION FROM POINT A B 1 D$ -1 35,33 73,0 2 DB -2 35.0 68,8 3 DB -3. 34.6 63,6 4 DB -4 35,0 59,25 S DB -5 36,6 55.33 6 DB -6 39,2 . 52,3 7 DB -7 42,0 49,7 8 DB -8 47,0. 48,0 9 DB -9 51.8 47.1 10 TRENCH -1 9310 126,0 TRENCH -2 90,5 121,8 12 TRENCH -3 8810 117,8 13' TRENCH -4 86.5 114,0 14 TRENCH -5 85.0 110,7 15 TRENCH -6 840 107,6' 16 TRENCH -7 84.1 104,8. 17 TRENCH -8 84.4. 102,4 18 TRENCH -9 85.2. 100;3 19 ST 35,0 70.9 20 ST 30.4 67,7 121 ST 39,7 -78,6 35,7 75.7 PUTNAM COUNTY DEPARTMENT OF HEALTH - a DIVISION OF ENVIRONMENTAL HEALTH SERVICES. FINAL SITE INSPECTION Date: 45V Inspected 5y. Street Location Owner •DemsE"r 1%oz -ew Town P.a r- r__2esd v Permit # 'P— a- 6--99 TA 4 :S, 2.0 --- g-- se Subdivision Lot # -3( ` U,4n4GL eg F 1. Sewage Svstem Area a. STS area located as per approved plans ........................... b. Fill section - date of placement ):1 barrier Lath. 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. Sewage System a. Septic tank size - 1,000 ........ ; 250. ...... other ................ b. Septic tank installed level ................ ............................... . c. 10' minimum from foundation .......... ............................... d. Distribution Box 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 ........... ............................... I Trenches T- Legth required 6-o© Length installed Se�� 2. Distance to watercourse measured 4- rvoFt.......... 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'V2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........ ......:......... ....................... ........ g. PUMD or Dosed Systems . Size of pump c am er ................ ............................... 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 ............................... ............. 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 & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. I Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 06/02/00 17:22 PW SCOTT 19142787921 NO.023 i 1 PUT XAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENWRON>vIENTAL HEALTH SERVICES RgQ MST FOR FINAL '!NSP - .TION For. Fill Date: 6 QO Trenches PCHD Construction Pern it t P-26 ! Located:. 1n%S t rtYE"e -t (T) (y) Po tt f/ 671 Owner /Applicant Name-... %'t 1404W 13(414dtrS TM 3, l O Block Lot Formerly: Subdivision Name: VOMC {'e eT Subdivision Lot 9 31 Is system fill completed? Date: Is system complete? .,,yja . _Sge Cormla�yt � Date: �- 60 Is system constructed as per fans? *, sa'p G r0ems Is well drilled? Date: Is well located as per plans? Are erosion control measires in place? • ,Sr+e (wrmfttc,., I certify that the system(s), as listed, at the above premises has been constructed and I have inspected 1 and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: G DO Certified by: PlEd J1'. W • <JCXrVG PE RA Design Professional Address: 3 97 f gut_ �C P'.Ws e r . ff Y Mof ic. # os- Comments: f-- tM4,Vk +S rle(oCafet . C0� {rGc�tri" Sllal•( lvt SfFit'i S1,1 t. 6'tC� aDAI'�Xirt+AY�� to' a w� dol"M s /oar A V-f fr:°H CIN as S�otiy K t h f�� p � dan FOR: O ADAM GENE O (NAME) Form FrR 99 1. r" <37 000 LO 0 Oi yu Q Ff 16 / 225g 00 \ N I_ �S B 36.74 J 22 4O• G 225 p' \ / ,9`),p -•�' VA 7 4 6 �. \\ yl: W FILL DEPRESION �' \ AS NOTED o \ \ - 12' DEEP LL TAPER 1- 462' aVel/ - r ENDS TO / R OVERFLOW `�5 9E CAPPED B�07Pj X _ 464 -- -�- - -_ -- -.� \ \ ��O hog• •`` �4v _ • p _ -11' .. -. \ \ E 1` ` e TYP It • � A \ - \ _ 466' \ \;. 1250 GAL. SEPTIC '-4 TANK_, . _ ��, -• _ - i 3 0 CIP o 1 /4'/Ff t Q, ' x°468" tl G-468:o \\ r FF -470.0 ' °•S`e\ 4 70 It 20 - i W 43 - i S�nncnrR� n/,1eMtM- MA�1ntMsM'A!l�iM:..M MSM/ M. nr fnr; M: M7M4A n2/ 11. AiM; M: MfA1/. Mk/ V�IM:MSA/lsManr <nftMiMSM.MrM:!l ninf;n n: /�qnr. M:��nr nrnn'n�1 c so - i ® s a - ® MMUMILZIOUNMralwo �ytievti:Wf WF1lHP V1fY�' iiiliiii liiRYJYyti7GlNilliiiWiYliiYVe W i WA' Y3Ci�li7YGYYfiAiNii/ �7: itGii/ 11dWPVS7C1/ 17A11�i:�I1�eV'GFiAiiWlslYFilF3 W ^. WSiINYW eYVF V � -'.l! ��ll'Nl+' YV =. W e V\IYNtiY� 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # - j (" CP wvnw Located at R'* , u,, R nn d rMillage Patterson Subdivision name y a n c 1 e e f Subd. Lot # __3L Tax Map 3.2 0 Block 2 Lot 2-,T69 Date Subdivision Approved ( `r 18 Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road, Brester, New York Amount of Fee Enclosed $300.00 Building Type Residence Lot Area ..g 2, No. of Bedrooms 4 Design Flow GPD Zip 10509 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 00 z_ r- gallon septic tank and Other Requirements: To be constructed by Dorset Hollow Builders Address 15 West Hollow Rd.,Brewster,NY Town of Patterson Water Supply: Public Supply From Water District Address 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 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 r�system or any repairs Aereto. Signed: P.E. x R.A. Date (U U-I Address 3871 a 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 w c )nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit A proved r discharge of domestic sanitary sewage only. By: Title: Date: 1711E White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 0 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 WE ARE SENDING YOU ?1'*-Attached ❑ Under separate cover via _ • Shop drawings Prints ❑ Plans • Copy of letter ❑ Change order ❑ DATE f( I JOB NO. ATTENTIO DESCRIPTION RE: - _7 �_P'� ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: • For approval • For your use • As requested • For review and comment • FORBIDS DUE REMARKS ❑ 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 COPY TO SIGNED: lf enclosures are not as noted, kindly notify us at once. BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (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 P.W. Scott Engineering 3871 Route 6 Brewster NY 10509 RE: Dorset Hollow Builders West Street, Lot #31 (T) Patterson, TM# 3.20 -2 -86 Reservoir Basin Dear Mr. Scott: October 19, 1999 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on October 10, 1999 is complete. The Department will notify you by November 7, 1999 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address, This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation Pty "6 Letter to: P.W. Scott - October 19, 1999 -2- of impervious surfaces, and the project applicant should contact'the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call meat (914) 278 -6130 ext. 2166. RM:tn rly yo s, obert Morris, PE Senior Public Health Engineer G &E DEVELOPMENT, LLC Gregg Macaluso 914. 8784355 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 LO-T- 3 t Edward Bloes 914 -234 =2281 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 approvA4 by PCDOH for use to meet the demand requirements for the subdivision. 1UN Edward Bloes G &E DeveloD PO Bog 352 Bedford, NY 10506 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road . Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (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 19, 1999 P.W. Scott Engineering 3871 Route 6 Brewster NY 10509 Re: Proposed SSTS: Dorset Hollow Builders West Street, Lot #31 (T)Patterson, TM# 3.20 -2 -88 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 regards. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) A letter from the owner of the Public Water Supply is to be submitted stating that the property can be served with water at adequate pressure. 2) The incorrect drainage basin is noted on Form PC -97. 3) Incorrect address is noted on Construction Permit Application. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve t ly your Robert Morris, P.E. RM:tn Senior Public Health Engineer 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# 3.20 Block 2 Lot � Subdivision of V a n c l e e f Subdivision Lot # 31 Filed Ma p . 7 %/ Date. Filed-.... �...._.._......._ 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 abcordance 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 t ly yours; Peder W. Scott ". ) ; Countersigned: Sig-ned: P.E., R.A., # 059346 (Owner of Property) ; Mailing Address 3871. Route 6 Brewster, State New York Zip Telephone:( 9 14) 278-21 10 10509 Dorset Hollow Builders Mailing Address: 1.5 west Hollow Rd State Telephone: _ Brewster NY 10509 Zip (914) 279 -1339 Form LA -97 P. W. SCOTT ,ineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net /14) 278 -2110 FAX (914) 278 -2166 Putnam County Dept. of Health 4 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU )1 Attached O Under separate cover via ❑ Shop drawings ,9, Prints O Plans O Copy of letter O Change order ❑ RJACTCTIF.Q @[F C[T ° H@WOCTCT l DA o JOB NO. ATTEENTI N I - RE: VAN G[i,-�� 5,�5rl7 cs J-07- Drawings ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 3 Drawings Construction Permit for Sewage Treatment System ( "form CP Letter of Authorization (form LA -97or CA -97) Design Data Sheet (form DO -97) % Short Form EAF House Plans (2('setss) Check ��(��.�� %+�r for the amount of $ 3�O THESE ARE TRANSMITTED as checked below: • For approval • For your use ❑ As requested $1 For review and comment ❑ FOR BIDS DUE REMARKS O 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 COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. 97 PcrNUTA%: C CON171" DE`? -9T OF EEALM - DIVISIC OF 4=.L HEUT:? S Mc _C APPENDIX I D.rrSIGia DATA SciE- - SuTSZ)n, C SE-sq, .Gi DISPOSAL SYST1 F? F- m C Wmer SRG AQc/iSITioN G04" Address _237 I''IArN.4i2o�y�!< AV,5 l Wlrx 3. za 2 JO6OS ZO L✓cated at (S treet ) 2frJ11 e CV-AM ,✓,4w tfAW .Pv Se--- Block > Lot (indicate nearest cross s`:.eet) M,unici_rality Pi¢rr�,�sonr Watershe3. 6ReQ70 I som P 2COiATIC-7 TEST CAM OFD To BE S� TTY . w APPL%CATICNS Go r. 31 Date of Pre =Soa). J g Date of Percolation Test HOLE - NC'sER 9= TIME Pr.4C T�'1'T`IC�1i P. "�C�I�TiC�i Run Elapse Deptn to.Water Frcm Water Level No. Time Ground Surface. In Inches ' Soil. Rate Start -Stop Min. Std Stop Drop In Y -in /:n Drop Inches Inches Inches - tz Z P "d 1 2 3 N�='°.S: 1. Tests to be repeated at same depth s until approximately equal soil rat . are • obtained at each percolation test hole. * 'All data to' be sulzni.tte3 for review. _2. Dept's rez ureuents to be made "M tap of hole_ rorr 4 /AC; — Q TEST PIT DATA RI HOLE NO. / G L. HJIRM TO BE SUPMI=.L WITH A ? SOILS R COUNT=- IN TEST HOLE M. Z HOLE NO. 2' d S6-N� 3' 4' Go,� 5' 61 5-+/1/ 7) 7' 8, g1 9' lo' 12' 13' 14' INDICATE LV7EL AT WH.ICH GROUNI71L%TM IS alCOU,=M INDICATE I= TO WHICH wATER IZVEL RISES AFTER BEING EI3COUNTE ED D=- HOLE OBSERVATIONS MADE BY: /)1 00 "ZI N _ DATE: DESIGN] Soil Rate Used /_� -/5 Min /1" Drop_ S.D. Usable Area Provided Na. of Bedrocros Septic Tank Capacity 2 o gals. Type oG caNG - Absorption Area Provided By L.F. x 24" width trench Other _ - •. Name /1-, W. 5'607T 4NGiNE9e -1V 64A?c&iT0�F �Jnatur _ 4- Address 3l y/ Rovr-✓ ti SFAi, 100 0. 05QSA N THIS SPACE FOR USE 13Y HMUTH DLPA=1F1T ONLY: Soil Rate Approved sq .,ft /gal., Cfiecked by Date 14.16.4 (2/87) —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 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 # 1f 5. IS PROPOSED ACTION: L_rNew ❑ Expansion ❑ Mod ificatIon /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction single lot septic — Connection to public water supply. 7. AMOUNT OF LAND AFFECTED: Initially li.. acres Ultimately f 1 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? [ayes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ industrial. 0 Commercial 0 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)? 0 Yes ® No If yes, list agency(s) and-permiUapproval6 , 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes 0 No If yes, list agency name and, permitlapproval Subdivision approval•f•rom Town of Patterson.PB /PCDOH 12. AS A RESULT PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? r1O--��Ffr 0 Yes tNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE P.W. Sc tt, P.E., R.A. - Applicant /sponsor name Date: p Signature: omJ 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 -4 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑ 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. ' E ' 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-Cl-05? Explain briefly. 07. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART 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 (al setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive. declaration. ❑ Check. this box' if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Date 2 Title of Responsibi ficer Signature of Preparer (If different rom responsib e officer) 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.11.. Address: 3871 Route 6 6. Drainage Basin: 6 -0 -AW" �- Brewster, NY 10509 7. Type of Project: X . Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 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 ervi.ced 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 plIg 21t, — 23. Name of Health Inspector m . P�Oz) z. , , J sAy 24. Project design flow (gallons per day) ................................. ..................:....:....... 800 GPD 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