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HomeMy WebLinkAbout0143DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -92 BOX 2 .1 1' ; q�i 00143 JL 00143 t� CS PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTIOI PCHD CONSTRUCTION PERMIT # _ Located at � I J I L-�- G Q *0 Owner /Applicant Name- 1Uli,t� Formerly i COMPLIANCE FOR SEWAGE THE M Town or Village IA�T���N ►J��GIi Tax Map ^��� Block. Lot Subdivision Name ID0"% �401-Loj E � Subd. Lot ,# Mailing Address �� '�`� t`"� ?--0 PQ 1�`� Zip flo Date Construction Permit Issued by PCHD 1 fir A� Separate Sewerage System built by DOM, w mlizo 5- 44 0W� Address K' WWI �.p . � - t :k0N Consisting of i��9 Gallon Septic Tank and $��' Other Requirements: 21(4 o � �b rIN. t Water Supply: Public Supply From ,T-O."r4N Qt to c 0 Address Cam-*J g . oil 12%-6-� Qr. Private Supply Drilled by Address Building Type K '5 ,XHCO Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? �A I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- 'built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnpm Cqunt� Department of Health. Date: 1 Certified by Address U s o ?0!� 7-`, P.E. x R.A. License # 95 WA 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 revocatio mo ificati or change is necessary. i By: Title: Date: va-- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy , Design Professional Form CC -97 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 Dorset Hollow Estates 3. PROJECT LOCATION: (forma 11 Van C.leef Estates) Municipality Patterson. County P u iyn am 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) Lot# L"7 - Dorset Hollow Estates (formally Van Cleef Estates) 5. IS PROPOSED ACTION: El New ❑ Expansion ❑ Modification /alteratlon 6. DESCRIBE PROJECT BRIEFLY: Construction of subsurface sewage treatment system - for single- family resid*emce and connection to public water supply. 7. AMOUNT OF LAND AFFECTED: Initially . 2— acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Q Yes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® 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 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 ® No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: P.W. Scott, P . E.. ) R.A. - Date: 0 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 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by F.gency) 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, 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 C1-05? 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 III— DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail.to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check. this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lea Agency Name of Lead Agency Date OA Title of Responsible Officer Signature of Preparer (if different from responsible officer)- BRUCE R. FOLEY Public Health Director LORETTA _ MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Seryices DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 . May 17, 2001 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster NY 10509 Re: Proposed SSTS: Dorset Hollow Builders Jill Court, Lot #27 (T) Patterson, TM# 3.20 -2 -92 Dear Mr. Scott: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. House plans are considered to have four potential bedrooms. SSTS is designed for a three bedroom house. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regards._ _ Upon receipt of a submission, revised to reflect the above - comments, this application -will be -- -- - —considered-fu — VeYyVly.yours Robert Morris, P.E. Senior Public Health Engineer RM:tn PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at 21 Jill Court TN Patterson Tax Map # 3 .2 0 Block 2 Lot 9.2 Subdivisionof Dorset Hollow Estates ( formally Van Cleef Estates) Subdivision Lot # 27 Gentlemen: Filed Map # 2 7 7 1 Date Filed 12/24/88 This letter is to authorize P e d e r W. s. 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. i Ve Countersigned: Signed: P.E., R.A., # 059346 (Owner of Property) Mailing Address 3 8 7 1 Route 6 Brewster State New York Zip 10509 Telephone: ( 9 1 4 ) 2 7 8 - 2 1 1 0 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 - LO r'C7T`r'Ad CvU:7I"_ D�'...r Cr - . - 171 S-, CN or '-- rv=VCRx= -m rte:... :L Soil � E � : � CCI A=- GN CAM. �P�CCVS 'L cf Pra-scp -k ng CLI,3, y ra%e of Pe -cola t:.cn Test � f�� /Cf % 1tJ� rn -Pad ZiNs HOLc. , Nt.'s? E-2 C(" % 2 nun al arse Depth to 3 3: aC) - No. T`-ne at (S t:eet) ` Sec_ 13 9 *Blcc: i So...:! Rate S t;st -S t ^o Mir.. S 3 75�. Drop I:. Soil � E � : � CCI A=- GN CAM. �P�CCVS 'L cf Pra-scp -k ng CLI,3, y ra%e of Pe -cola t:.cn Test � f�� /Cf % 1tJ� rn -Pad ZiNs HOLc. , Nt.'s? E-2 C(" % 2 nun al arse Depth to Wa ter From Welter 1_,eve No. T`-ne Grcur_c S=--ace Ln inches So...:! Rate S t;st -S t ^o Mir.. S 3 75�. Drop I:. Ir.crles -- nchP5 llnc:ieS NC7L�S: 1. Tests to he repeater at saw repth until apprcxi nately equal sail =tes ~are•obtai.nea .at each percclation test hole. ' 'rill data to' to for review. : 2_ Depth roa suY-acenis to be mare frcn top of hole_ - 2 4 i� `l /2 �' 3 0 1' 3 75�. ►'`, 30 NC7L�S: 1. Tests to he repeater at saw repth until apprcxi nately equal sail =tes ~are•obtai.nea .at each percclation test hole. ' 'rill data to' to for review. : 2_ Depth roa suY-acenis to be mare frcn top of hole_ - t•.� TEST PIT DATA RI3 . TO BE SUMMIT= W-M-H APPLI-C:T. � CI 1N TEST HOLES DEPTH HeLE, ro. HOLE ro. cx: rte. 3 G.L. _ j'o p scq i 2' S ar.cl vt )-- o (-vv) Sa.nc0 `O a.,,Jl r, 0,4 3' _ 41 ��y�e �ViVi W�1' Px�(1 ,v1 P !�0.y1 C� i 5' � se %6 6, 7' r 9t 11 . NDI= I,=L AT WHIM MIX9 M\rA TZ IS EtiMUNT = .IN -DI= IZV- W TO WHICi PaT-\ ! vM RISES AE"I - BENG I'tiaG'N7-17�R LJ' DEi° HOLE OESERVATIONS MZ.DE BY:.�, �!% Low,_ �?�� %I'✓I� f3dlin sYi' .�OI% DATE: DESIGN • Soil Rate Used .Mi.n /i" Droo: S.D. Usable Area Provide3 No. of Bedroms �j Septic Tank Caracity /2 gals. Tie Absorption Area Provided By 37 r1'` : L.F. x 24" width trench Narr c (,� x�J� S Address SGj71 THIS SPACE FOR USE BY HEALTH DEP. ��IT ONLY: Soil Rate Approved sq.,.-Et/gal SF-u j Zi7 aVk 0? Checked by Date G &E DEVELOPMENT, LLC Gregg Macaluso 914 - 878 -4355 March 17, 2000 Edward Bloes 914- 234 -2281 Robert Morris P.E. Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow Estates Lot # 27 .(formally Van Cleef Estates) 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 PCDOV,for use to meet the demand requirements for the subdivision. Very tr�lyjou Edward Yloes G &E Development PO BOX 352 BEDFORD, NY 10506 i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FO REATMENT SYSTEM .gyp PERMIT _ Located at : I CO LL rt Town or Village Pei f "e,rs -16 s tctf'e . ,- Subdivision name Do S T �" �1 Subd. Lot # '2-7 Map '� ,� Block -)—_ Lot Date Subdivision Approved 119f b Renewal Revision Owner /Applicant Name D�� i� a j I� ga i jG Date of Previous Approval s- 16 O Mailing Address 1E�- t%lest Hn(9m IVY Zip -10 " g Amount of Fee Enclosed ! r<z) , C _ Design Flow GPD Building Type `� � �'�� -� Lot Area � � No. of Bedrooms Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and r :�%.- )-T- 0 ?& F f Other Requirements: To be constructed by - of i,i i + Address �� � {. r( -6ll�pvv & - la►" S. (C'r, At Water Supply: _Public Supply From �,,f V1 -r C - 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 system o Signed: Address r any rep ' ereto. P.E. R.A. Date License # 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 permit. Approved for discharge of domestic sanitary sewage only. M. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 P. W. SCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (845) 278 -2110 FAX (8 r455) 278 -2166 1 TO (,t f V1GIVV\ 4 WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ dIEVUl a @1P DATE °'7 DATE JOB NO. ATTENTION RE: mr -t V-a C- ` ' � Vq f Sy S the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION 7 mr -t V-a C- ` ' � Vq f Sy S 5 T- 2- 7/3 Cefrt � - -V- / THESE ARE x TRANSMITTED as checked below: For approval ❑ Approved as submitted El Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO SIGNED: ti If enclosures are not as noted, kindly notify us at once. .1-it 41, 4 b V July 3, 2001 Robert Morris Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow Estates — Septic Lot #27 Dear Mr. Morris: The following are response to your comment letter dated June 6, 2001. • A new construction permit is attached with this letter (CP-97) • A check of $150.00 is. attached with this letter • 2 copies of house plan with three(3) bedroom design is attached 9 The address, zip code and town noted in the letter of authorization is checked and no errors found. If you need any additional information, please call to discuss. Ve , yours yours' ederW. Scott. P.E., R.A. President ARCH ITECTURE*ENGIN EERING*SITE PLAN N I N \?',';ecretary'WY ')OcultAENTS"'Open Po,iectv"DO~SETA IOLLOW. ESTATE'S; 0 , R R ESPON DEN CE\LTR. r. morris, septic lot 27.doc PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of Located at LETTER OF AUTHORIZATION Dorset Hollow Builders 21 Jill Court T/V Patterson Tax Map # 3.2 0 Block 2 Lot 9 2 Subdivisionof Dorset Hollow Estates ( formally Van Cleef Estates) Subdivision Lot # Gentlemen: 27 Filed Map # 2 7 71 Date Filed 12/24/'88 This letter is to authorize P e d e r W. Scott, P . E . , R.A. a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply'perrnit(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. i Ve Countersigned: Signed: P.E., R.A., # 059346 (Owner of Property) Mailing Address 3 8 7 1 Route 6 Mailing Address: Dorset Hollow Builders Brewster 15 West Hollow Road, Brewster State New York Zip 10509 State New York Zip 10509 Telephone: ( 9 1 4 ) 2 7 9 — 1 3 3 9 Telephone: (9 14) 278-2110 t . . =`,P' W SCOTT X'. IM44IE12 W l �BW044Q1L Enbinee &Architecture. P.C. 3871 Route 6 BREWSTER, NY 10509 E. Mail: pws @bestweb -net (914) 278 -2110 FAX (914) 278 -2166 TO ��- �s'z f-1 ' WE ARE SENDING YOU Shop drawings Copy of letter C(7PIFS °�- 1 DATE I ❑ Attache r7l rate cover via ❑Plans nge ❑ NO. DATE JOB NO. ATTENTION RE: `EG. -e be `Z ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Samples DESCRIPTION Me ►Nl ❑ Resubmit ❑ Submit ❑ Return the following items: ❑ Specifications —copies for approval copies for distribution corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: If enclosures are not as noted, kindly notify us at once. 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 PC WE ARE SENDING YOU gAttached Under separate cover via ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ FUT l M @[r' if ° 1H @W0c 1 ffL 1 ❑ Samples ❑ Specifications > THESE ARE TRANSMITTED as checked below: or approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Resubmit ❑ Submit _ ❑ Return — K _copies "for approval" t —copies for_;distribution' corrected prints i.� ,4. ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 June 6, 2001 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System at Dorset Hollow Builders 21 Jill Court, Lot #27 (T) Patterson, TM# 3.20 -2 -92 Dear Mr. Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on May 31, 2001 is incomplete. Please be advised that the following information is required before the Department may commence its review. • A Construction Permit has not been submitted. • A $150.00 revision fee has not been submitted. • SSTS approval is for a three (3) bedroom design. The latest house plans submitted have four (4) bedrooms. • Letter of Authorization notes incorrect town and zip code. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested,information as to the completeness of your application. Please be. advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. V ruly you�r�s, Robert Morris, P. E. RM:tn - Senior Public Health Engineer enc. j P. W. SCOTT I� Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net DATE JOB NO. (914) 278 -2110 FAX (914) 278 -2166 TO i n ita2�C" 1 V\ C R9=A `T WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items: ff,0op drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications I];};Gopy of letter ❑ Change order ❑ DESCRIPTION ARE • M •, FINE ME O THESE ARE TRANSMITTED as checked below: For approval ATTENTION RE: i � 1 As requested • For review and comment • WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items: ff,0op drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications I];};Gopy of letter ❑ Change order ❑ DESCRIPTION ARE • M •, FINE ME O THESE ARE TRANSMITTED as checked below: COPY TO ❑ Approved as submitted ❑ Resubmit copies for approval • Approved as noted ❑ Submit copies for distribution • Returned for corrections ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: If enclosures are not as noted, kindly notify us at once. For approval ❑ For your use • As requested • For review and comment • FOR BIDS DUE REMARKS COPY TO ❑ Approved as submitted ❑ Resubmit copies for approval • Approved as noted ❑ Submit copies for distribution • Returned for corrections ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: If enclosures are not as noted, kindly notify us at once. 4 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH - 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N.; M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 March 22, 2001 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster NY 10509 Re: Proposed SSTS: Dorset Hollow Estates 21 Jill Court, Lot #27 (T) Patterson, TM# 3.20 -2 -92 Dear Mr. Scott: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1) The proposed SSTS is in direct line of drainage to the neighboring wells. (Sketched enclosed). Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly yours /I Robert Morris, P.E. RM:tn Senior Public Health Engineer enc. 3,6 rn AT a rA 90 C%l Olt r 47 14 (9 66) tb 0 78,00 Z,.O,z zf mm 77 �,77 252.4 0 r Tj f t `J 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 97 15 West Hollow Road Brewster, New York 10509 Dorset Hollow Estates 2. Name of project: (formally VanCleef Estj'3. LocationT/V: Patterson 4. Design Professional: Peder W. Scott, P.E., R.;�. Address: 3871 Route 6 6. Drainage Basin: East Branch Reservoir 7. Type of Project: X . Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Brewster, NY 10509 Commercial Mobile Home Park 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? .......................... ............................... 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 19. If yes, name of water Supply Town of Patterson byrsystem pp y Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system Individual Lots Distance to sewage system -I- 22. Date test holes observed. 23. Name of Health Inspector M. B u d z i n s k i P. E. 24. Project design flow (gallons per day) ...... ....... Cv00 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 2 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number ................... 29. Is Wetlands Permit required? Individual Lo.t ............................................. ............................... 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 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 .......................... ... ............................. Map 3..-O Block a Lot 99L 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 Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES. Mailing Address: ................................... Peder W. Scott Agent for Applicant 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 (914) 278 -2110 FAX (914) 278 -2166 TO Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 WE ARE SENDING YOU C Attached ❑ Under separate cover via ❑ Shop drawings } Prints Plans ❑ Copy of letter ❑ Change order ❑ DATE JOB NO. 99-159 ATTENTION RE: Dorset Hollow Estates 1 (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) I ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 1 Application for Approval of Plans (PC -97) I I Construction Permit for Sewage Treatment System (CP -97) I ] I Letter of Authorization (LA -97.) 1 2 Design Data Sheet (DD -97) I House Plans (2 sets) 2 1 Letter from G & E Development,LLC, Re: Public Water I 1 Check #tAo',S45"f12-3 for the amount of $ !g j,00 1 1 Short Form EAF THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested X1 For review and comment ❑ FOR BIDS 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 I 1 E911 Address Verification Form (E911 Verfrm) COPY 70 SIGNED: If enclosures are not as noted, kindly notify us at once. BRUCE R. FOLEY Public ffealth Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 = 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 . February 8, 2001 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster NY 10509 Re: Proposed SSTS: Dorset Hollow Builders 211 Jill Court, Lot #27 (T) Patterson, TM# 3.20 -2 -92 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. 1) Please submit all E911 Address Verification Forms with the Certificate of Construction Compliance (enclosed). 2) House plans are considered to have four potential bedrooms. 3) Fill plan titled box is always to be labeled as "Primary Design for Fill Section Only ". 4) The proposed SSTS is in direct line of drainage to the N/F Martin, N/F Pestey and N/F Tremblay wells. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further.. Very ruly yours, Robert Morris, P.E. RM:tn Senior Public Health Engineer enc. BRUCE R. FOLEY Public Health Director 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 (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 NAINIE: Dorset Hollow Builders Lot 27 TAX MI AP NUIMER: 3.20 -2 -92 E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 21 Jill Court Patterson Mai 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) d b1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TS,Y TEM 'i PERMIT # Located at 21 Jill Court Town or Village Patterson Subdivision name D o r s e t H o 11 o w E sSubd. Lot # 27 Tax Map 3.20 Block 2 Lot 9 2 Date Subdivision Approved 1998 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 Res i d e n c e Zip 10509 Lot Area 1 .4 No. of Bedrooms ' S, Design Flow GPD & 0 0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1 2 5 0 gallon septic tank and 3-ZS LF Of' S j--r tg-- FfU Other Requirements: To be constructed by Dorset Hollow Builders Address 15 Town of Patterson Water Suunly: X Public Supply From W a t e r District or: Private Supply Drilled by West Hollow Rd.. Brewster. NY Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or thereto. Signed: P.E. X R.A. Date .26 c 7 Address 3871 Route 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 n onsidered ecessary by the Public Health Director. Any revision or alteration.of the approved plan requires a new perm' . pprove r discharge of domestic sanitary sewage /only. By: Title: Date: d lx% 16 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 BRUCE R. FOLEY Public Health Director 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 Environmenta[ Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 July 17, 2001 Peder Scott, P. E. PW Scott Engineering 3871 Route 6 Brewster, NY 10509 Re: Proposed SSTS: Revision Dorsett Hollow Builders 21 Jill Court, Lot 27 (T) Patterson TM #3.20 -2 -92 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. 1. House plan are considered to have four potential bedrooms. SSTS design is for a three . bedroom flow. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very ruly yours, Robert Morris, P. E. Senior Public Health Engineer RM/jp a- PUTNADI COUN`rY DEPARTMENT OF HEALTH DIVISION OF WMONMENTAL HEALTH SERVICES "- FINAL SITE INSPECTION Insp cte y, izE�n Street Location a GT, Owner Iio7ZSET t�ortor✓ T iyz�� Town Permit # = ;Z ::Z - o/ TM r -3,.2 Subdivision Lot # 9 7 1. Sewage SvsteM Area - ---- a ©fie fo * � o :K'� °— yES SOS COMMENTS , - ? _ ,, 2_ lit.7- 7t' "ve O o a. STS- �area,l-ocate- " "d -�as-" era roved lans.. y� ► wf� -1 r��P P PP P b. Fill section - date of placement ,���tdA r� 3:1 barrier Lgth. Width Avg.Dpth c. 'Natural soil not stripped ......:............ ............................... d. Stone, brush, etc., greater than 15' from STS e. 100' from water course/ wetlands ...... ............................... II. SeN age Svstem a. Septic tank size -1,000 .......:1,2 0 ........other ................ b. Septic tank: installed level ................ ............................... c 10' rrurumUm from foundation ffi . d = �� � tn uttt�$Ox�_�8-- 1 A out —lets at " °sameryelevation =water tested::::' :..... 2. Protected below frost ............. ............................... 3. Minimum 2 ft.Orig'inal soil between box & trenches e. Junction Box - properly set ........... ............................... f. Trenches es Length required ��g2 ,10 Length installed 2. Distance to watercourse measured + 1 o o Ft.......... J. 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%" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 1 t ends capped .. '. ^+c - ...yam. ^" P,umo 0 osed';Svsterns �� �r� -PWR, Y .� tea.. e o pump c M er.�:. ................:........... �. ., _ /D'� ° :o 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .........:.......... ........:...................... 4. Pump easily accessible, manhole to grade ............:.... 5 First box baffled.a x� 6� clevntnessed byI'D estunatedflow /c cle "� III. House/Euilding ��� a. located per approved pl ................................. 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 .................. ............................... 11Z _1 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 ... ............................... TV a NOV -.16 -2001 01:09 PM HARRY W NICHOLS 914 279 4567 P -02 Fuum CaVI n 01P ="= - - AZ'TEN' ON Ci ADAM GENE • AR�±t 11:4'P FDA F�iTt�L�DBGmii For:. Fill All iaiottloa mast b�lftll�►oompletad prior to nay is�mah01 _,_.(.�,..._._ Wpecdons b@W made. W PCHD Consu 9dw Permit 0 Located: ItL • ce Qr Owner /Appllcad Nate 19 9SATT For erly: -lubOlA&o t+lama: - bo 1s ff Ko uOO R arm Subdivision Lot d '2 7 ,,.. Is system till aamplatod? -- Data: - Is syicm COMA" , ytt Data: l s system em u% as pa pma is wmU drUW? Date: Is well loWed u per pined N7 are erodon control maatvru is piece? .,�,,,.,�,. 1 ca* the the ****I 1a U4 st do *on pceaaisas bas been eomtetued and I haw laspected and verified tbeir oompledon In aocosdWs %M *e issued PCi D Consttaetioa Patmit and .- Hued plans and the SuWudh Bobs trod 1tsVhdoos of t!m'Pu County Deputmeat of th Due 61.=16eg—Ot C•dd pir, iEtA,._ DJ . - - Profwsio Arid eu1 ' UI. Comm , r Fora M -29 0 d - 1 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 oj'Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 November 28, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Dorset Hollow Builders Jill Court , (T) Patterson Lot # 27, TM# 3.20 -2 -82 Dear Mr. Nichols: An inspection was made of the above referenced property. The following comments must be corrected in the field: 1. The SSTS must be a minimum of ten feet off the driveway. 2. The distribution box must be water tested. 3. A pump test must be witnessed by this Department once the electrical inspection has been completed and notification of such has been submitted to this Department 4. The pump tank must be exposed for measurements. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261 Very truly yours, E��E - R1 Gene D. Reed GDR:cj Environmental Health Engineering Aide BRUCE R. FOLEY Public Health Director 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 (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 December 21, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Dorset Hollow Bldrs. Jill Court, (T) Patterson Lot # 27, TM# 3.20 -2 -82 Dear Mr. Nichols: A reinspection was made of the above referenced property. The following comments must be corrected in the field: 1. The distribution box must be water tested. 2. A pump test must be witnessed by this Department once the electrical inspection has been completed and notification of such has been submitted to this Department. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, i•�� -`Z`V � G C Gene D. Reed GDR:cj Environmental Health Engineering Aide SENDING CONFIRMATION DATE DEC -24 -2001 MON 10:25 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 92794567 PAGES 1/1 START TIME DEC -24 10:24 ELAPSED TIME 00'41" MODE G3 RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... BRUCE R Pat" t.O1tMA MOL NAR1 R.N., W", P.M. A& WI DWnor Anode" POW Ilm01 hit- ' n6.dw of Pa kw S-,(- DEPARTMEI�1 T OF HEALTH 1 Geneva Rand Brewster, New York 10509 flhH' 1ld Bnnl (2!5)279.6120 Fa(NA279 -7411 xwr.o seN6a (245)279.6531 WIC (942)278.6671 Fa(945)2711•60113 fully ull —Abs (9451279.6016 1"(845)271.6606 Iisa.M 1145)221.3911 Fa(M)22J -6117 December 21, 2001 Harry Nichols, PE Patterson Park, Suite 106 DASD Route 22 Brewster, New York 10509 Re: Field Inspection - Dorset Hollow Bldrs. Jill Court, (1) Patterson Lot # 27, TM# 3.20 -2-82 Dear W. N- ichols: A tcinspcction was made of the above refarerteed property. The following comments roust be corrected in the field: L The distribution box must be water tested. 2. ' A pump teat trust he witnessed by this Department once the electrical inspection has been completed and notification of such has be= submitted to this Department. If you have any further questions, please contact me at (845) 278 -6130 CU. 2261. very truly Your . / 9 Gene D. Read GDR:cj Enviroomental Health Engineering Aide PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM �0�� }Aou,OO b 1Ilo� Owner or Purchaser of Building Building Constructed by raj J m-, �oJ Location -Street 9_156I D5, �A L,(5, Building Type Tax Map Block Lot Town/Village Subdivision Name 2�I 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 gccuMt of the building utilizing the system. I tra ctor i1 ay Year Owner) - re M1;(5_ �Ou sjo j Corporation Name (if corporation) Address State Zit) 195 °1 Signature: Title: P OVT Howod J I IJ oD� Corporation Name (if corporation) Address: MS '40A'� }0Uk� P W Wyj � State Nq Zipl O jO° Form GS -97 • J�� y BRUCE R. FOLEY LORETTA MOLINARI- R.N., M.S.N. Public Health Director �+ OQ� Auociate 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) 218.6678 . Fax (914) 273-6035 Early'TterViiff6o- (914)171.6014 Preschool (914)278 082 F4x(914)21r -6648 _E911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: 41 E911 ADDRESS: ;II W_ C 0*T - - - - TOWN: 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 E91 I- address is assigned by an authorized town official. This form is to be submitted with the application,for a Certificate of Construction Compliance. JAN -04 -2002 03:34 PM HARRY W NICHOLS .BRUCE R FOLEY ..• -. Public Health- Dvecter 914 279 4567 P.01 DEPARTMENT OF IEALTH I Geneva Road Brewster, New York 10509 UQUEST FQR FIELD TESTIN LO ETTA MOLtN41Ri R:N.; M,S-N. .t nw(ate Pubho Mrafth Di.ecrer Director of • Patlenl Strvtc :s ATT) MON: © ADAN! STIEBELI;NG YQENE REED All information below must be juU completed prior to any scheduling, DATE: '1 'Oq '0 2 ENGINEER 0R FIM1: PHONE #: REASON: . DEEPS: o PERCS:.0 PUMP TEST: ROADISTREET: aLl a FVI (,.12(4r TO W N: 104*+rrd!3 . ` TAX MAP#: 2— SUBDIVISION:� LOTN: Ny D .P &IT. FRIA EM -101NI REVIEW AND W11NESSINGy OF SO(L TESTING ITS NO 0 0� Proposed SSTS-within the drainaje basin of West Branch or B.oyds Corner Reservoirs. ❑ S( Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ tat Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 0 s� Proposed SSTS design flow greater than 1000 gallons /da)ror SPDES Permit required, D Proposed. SSTS for a Commerical Project. �. • - It is the responsibility of the design professional to provide the above Information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yj,= to any of the questions, NYCVEP must witness the soil testing, This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. �_ • • -- If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility or the design professional to schedule re-witnessing of the soil testing with NYCDEP. FOR COU*Y USE ONLY DAYE: At ;Z- 1 Od TIME; 1�1i ion WAZ9Y L2 61;K- fyl'i P... L �„ 7���t���� -i � °/�Fy r.. (FLLOTEST) _ - _ _ __. .,-," -�r��• A1f1MC • DI ITAIf'1M 1-nI IAITV r)170nDTMi=mT nr P 1 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 M A Brewster, NY 10509 Li IUEEEii" Telephone (845) 2794003 Fax (845) 2794567 January 11, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance 21 Jill Court Van Cleef Subdivision, Lot # 27 Town of Patterson T.M. # 3.20.92 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -27, "As -Built SSTS," dated 11/12/01. 2. "Certificate of Construction Compliance for Sewage Disposal System," dated 1/11/01. 3. "Three copies of "Guarantee of Subsurface Sewage Disposal System," dated 1/3/02. 4. Laboratory Report, dated 7/17/01. J' 5. Application Fee in the amount of $ 200.00payable to Putnam County Health Department. V 6. "E -911 Address Verification Form," dated 1/3/01. 7. Electrical Underwriters Certificated, dated 12/28/01. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN:JM:jmm 01 -026.27 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM P�� "Ou,00 BU UO_� . � b -u 2- q �l Owner or Purchaser of Building Tax Map Block Lot Building Constructed by TownNillage Location -Street X61 D5�A Building Type kOLWIJ T 5 Subdivision Name �__l 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 f the building utilizing the system. .! i t 2�� 0. o day Year ®� Gene' ContractorTOwner) - Sigtgure MI;C 00c c, o�j b j Corporation Name (if corporation) Address: State 1�► ` Zip �`� �� 11 g�\ 1 P© -5c�- Hoo.'CO Corporation Name (if corporation) Address: State lU Ziposo° Form GS -97 NE "O 1tl A C C 0#014 NORTHEAST LABORATORY of DANBURY LABS 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert:. PH -0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 www.NORTHEAST LABORATORIE5.COM LABORATORY REPORT REPORT TO: DORSET HOLLOW ESTATES DATE SAMPLE COLLECTED:. 7/12/2001 Attn:ALLAN J. FINN TIME COLLECTED: 8:00 A.M. 15 WEST HOLLOW ROAD COLLECTED BY: A. FINN BREWSTER, N.Y. 10509 DATE RECEIVED @ LAB: 7/12/2001 TESTED BY: LAB #11471 LAB I.D. #: JULY -159 REPORT DATE: 7/17/2001 SAMPLE SITE: DORSET HOLLOW ESTATES, LOT #27 SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/L - - - - -- ml = 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 CINOT 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 r yG�,� �._.�� b �,� 5.t ,��s -� ss t, IR , U Nit} EtR W R I�T #ER S GE' �� qp Qpg( Jt, qg ^yy g§ ff g b J , ; .� t ,'r`'- ..oq��,-s,' I 3, Fe".`.n° dk �1 j #^%3 345055.. ja t. $� E, ;rq3 7 @f Et�BUREAM %U QFt�ELEIrTRICJgTY)yn - s_g ,a, F 8.r ti. ;itl Pti 1� �Y, w.,C:.B �Dil a A.�'n`ll`"i 0 *C'N ri X329601r.%0]r�.:� :t€I, �a w G!R`200; ' §'� r }- a Date- r, A lu No won �ile 2 � , a N _5797.776' PP "a " lj ,- , v Y ° v �t� # r A T T i ggw$ "'� of «„ [FS rn :4THISCERTIIESte££T.H,1T 3 §� wwC a^A ° °'G` ls 'a J. :§ q �a«E43 xy p, g _�+lu. n.ait:..w;l�ffi° =k..�1,. 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