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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -93 BOX 2 00144 w l 1' a a\o� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE T STEM PCHD CONSTRUCTION PERMIT # Q — 23 Located at 2.A ) \ L.(_ C O U (IT Town or Village Owner /Applicant Name �OP,5�_T "OL0'W 601 LbEaax Maps 12.0 Block 2 Lot q3 Formerly, Subdivision Name VAJV C LEE-E Subd. Lot # 26 Mailing Address I S7 DES T "QU -O W NY Zip 10 01 Date Construction Permit Issued by PCHD Separate Sewerage System built by CORSET �1V OMW6Address SA MV-- Consisting of Gallon Septic Tank and 500 L , E o � Ag S ' -ERs N G Other Requirements: TONNN OF A TTE(z� Water Supply: Public Supply From CT Address or: % Private Supply Drilled by Address Building Type Has erosion control been completed? I P—S Number of Bedrooms Has garbage grinder been installed? NO 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 regulatiols of the Putnam County Department of Health. Date: ' �� Certified by ---.j Address 2 P.E. x R.A. License # (912 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 revoca on, modifica n or change is necessary. By: Title: Date: White copy HD Ae; Y llow copy - Building Inspector; Pink copy LnPOrange copy - Design Professional Form CC -97 9' BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Aaaoctate Public Health Director Director of Patient Services Environmental Healtb (914) 278.6130 Fax (914) 278.7921 Nursing Services (914) 278.6538 WIC (914) 278.6678 . Fax (914) 278.6085 Early 7oterriutloo-(914) 278.6014 Presebool (914) I7W82 Fax(914)171r-6648 F_,911 ADDRESS VERIFICATION FORM OWIVERSNAME: TAX MAP NUMBER: J X 20 —1A E911 ADDRESS: 2 `1 J 1L1- co UP-A- Ifelu, a AUTHORIZED TOWN OFFICIALL2� ✓'Y (Signature) DATE: � G d The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRM) J a. � DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Aaaoctate Public Health Director Director of Patient Services Environmental Healtb (914) 278.6130 Fax (914) 278.7921 Nursing Services (914) 278.6538 WIC (914) 278.6678 . Fax (914) 278.6085 Early 7oterriutloo-(914) 278.6014 Presebool (914) I7W82 Fax(914)171r-6648 F_,911 ADDRESS VERIFICATION FORM OWIVERSNAME: TAX MAP NUMBER: J X 20 —1A E911 ADDRESS: 2 `1 J 1L1- co UP-A- Ifelu, a AUTHORIZED TOWN OFFICIALL2� ✓'Y (Signature) DATE: � G d The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRM) t rc 8 EkP F y la NS�\ Ito <: ; 1 N 140 34130--e 7' • 7 =�3 r,. ( 4 iiz� L AST ti k. Pr'i t t:t { a H k� �k- k i:. DIMENSION CHART (in feet)' - Number �• .. �'� 1 27 1 2 94' q 9' 3, 84.5' 9 g' 41,5' 4`7' 9 46' 49 12.. 134' ISO' 13 1341, 149,5' 14 ,134, s' 149' l5 X35' � 149' 1491 PUTNADI COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRON1tiI N TAL HEALTH SERVICES 1 FINAL SITE INSPECTION Date: Inspecte y: 64 7;?gF€n Street Location L G 7, Owner -D©TZ5j57- NozLO— '30Z4DE ?S Town Pi .Permit # "P-23-co TM r_ t o Q— q 3 Subdivision Lot # 26 1. Sewage Svstein Area a. STS area located as per approved plans ........................... b. Fill section - date of placement '):1 barrier Lgth. Width Avg.Dpth_,L' c. Natural soil not stripped... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. SeNvaQe System a. Septic tank size - 1,000 ........1,2" .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... .............. .I................ d. Distribution Box 1. All out ets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. renc es I . Length required -S-C? z> Length installed Soa 2. Distance to watercourse measured --t ►ate Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ........ :......... 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 -1%" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .................................. :.................... g. PumD or Dosed Svstems 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. House/Building 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 & dir.to exist watercourse g. Footing drains discharge away from STS area ............:.. h. Surface water protection adequate ... ........................ :....... i Frncinn rnntrnl nrmArIPA AUG -20 -2001 10:12 AM HARRY W NICHOLS 914 279 4567 ' I Rootstt�ata a�soQ --,u 74, as "-w uuog P.03 lo lao=mdaQ blanoo mind ot<1 jo sQOptgnBag poa selfft lgnpmg mp paa fold quoidds pvs 1p=d Ca!r�c o� 7d pvnssi o pt000� 1pi rind Paton poB . povOdscq a«q I p= $623M=00 tra *q H q oo"*Jd QAO" OT 11 'QM N %0MA Mp 3sgt AY,%W 1 S �;7. pmgd to=mnW lo2moo Comm osy --- ,,timid god h 1*1ex; Venn 11 6ps1NP UW(u tt Ltwnid and w po9 nnvaw =%LU ti 07 C c..� :a�sa 5 3 tpoldato� ng caatsti si IF 101 aopwpga$ �— :oraaH oo�urpgnS :�t�mlod 3 �5- 1 NV n �atn %vnnddy /j*umo `" RaolH f'11,I 55341~ t\ D M 570\\ ��S`� °= �V t1 X05 W� 0()C;] 1.17 Tr, :Posrro� 'Gnu �c© Allr- pn -psm mnN 10:22 -opm smoq suowadim, lot�aaa�tL taa oz jopd polatdwo JMV oq tonm tlopiwop liv jr :JOB %920 p WVav p- Nots.g=v 9=1&= H.ttTM'iVDaKt omAm Ao How= mm to uummo 'Ad R.LH,lloo y1tymma kso n ham) P-z TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 3 AUG -20 -2001 10:25 AM HARRY W NICHOLS 914 279 4567 P.01 . 66''13 ms0d oaJ paopea3aad aAls Q � YV ld ,Aq po ** �ioaH 10 %Vaw sndaa /41noz) wmna otpao monnin pol 42in'spnpmS p" stmld p Aoldd4 pa 11=4 troMa MC) C1M4 patuci Mp IRpA oatrtp Mll tq t;ai3 l&= JpTp P*gUSA Poa ps"adM a^'rq I M pmtumw uoq c q tom .W @mq stp u Von a J*mW mp pT 4.mm t -� 2A*tld tq rA rmw Immoo cotl= ory --., Lid nd n po*-101 VIM tt yid rd as potopstsaoo =191 st p :osOQ w Zasa[ w" =,JAC fl 4po ftao maar,fa # saZ vots}�spgas KAID N n ;asaeK oonu►tpgn� ;oma strap dd j »nh+� —"'� • iiiL S-�3t�'t�(1� M t 1�5� -.ca H tI V/ • V�J� L�;1G'J ll c �Z :poivo0'� opoaatc �nvq soo;padra� logacall Ras of sopd poiatdmw XMv oq sattut uopararom. (tr m3 �to3 ' axa5 p 3vaV p . No.rt3.�wc luTnaac 3o ixmuvata U000 Iimu niir- ara -aaal MnN 1 a,!7A TP - R4S- P7R -79Pl NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 V BRUCE R. FOLEY Public Health Director August 22, 2001 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 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 # 26, TM# 3.20 -2 -93 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: No comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide Iry F . t $ a REFER TO THIS NUMBER FOR PROMPT SERVICE Tr IersEspress{ z fSji Frer5dl��n�5 /�' "�2TkR k 1 i r tryF `� DATE "'� { =� Aiw i3RCHASER S RECEIPT S - x I # TO THE " mQ fu4 Ti i 1 6 , BORDER OF a K sy F No -NEG 0 TIABLE� *„ 4 'ter L- r3 KY 4 i DOLLARS �c {AMOUNT ro ' hJIS� PLEASE READ THE TERMS OF;:THIS MONEY ORDER;ON THE "REVERSE SIDE a ER 4 - . Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509. Telephone (845) 2794003 Fax (845) 2794567 August 10, 2001 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: ' Individual SSTS Compliance 24 Jill Court Van Cleef Subdivision, Lot #26 Town of Patterson T.M. #3:20.2.93 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -14, "As -Built SSTS," dated 8 -8 -01. 2. "Certificate of Construction Compliance for Sewage Disposal System, dated 8 -9 -01. 3. Three copies of "Guarantee of Subsurface Sewage Disposal System," dated 8 -9 -01. 4. Laboratory Report, dated 6 -8 -01. 5. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 6. "E -911 Address Verification Form," dated 11- 27 -01. 7. "Well Completion Report," dated 8 -6 -01. If there are any questions concerning the enclosed, please call. Very truly yours, 40_1Z iu Harry W. Nichols Jr., P.E. HWN:his 0l- 026.26 I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM D�2sE�0 L�y,� ,,20 - 2 -- q Owner or Purchaser of Building Tax Map Block Lot �)OQSI�_,� \COL_ 'w �ATTF 2 O, Building Constructed by TownNillage 24 JILL- CQQ<. VA ICJ CLa Er Location - Street Subdivision Name �IN �__' N_\ \KL_ r2_( C) 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 o upa . t of the building utilizing the tem. Date r,N\4o�kh g Day ` Year Q (Owner) - Corporation Name (if corporation) Sigr. Title: O VV N '�1P_ OP �� \�\OL_LOyi r U IX-QS Corporation Name (if corporation) Address: i 5 WE S 0 L-LD W Pb EWI T�-- PAddress: w EC T 110zLOln1(�D, C R State N Zip State A/ Y Zip 1Ogoq Form GS -97 N� NORTHEAST LABORATORY of DANBURY I.rABS 39 MILL PLAIN ,ROAD - DANBURY, CT 06811 CT Cert: PH-0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 SAMPLE SITE: DORSET HOLLOW ESTATES, LOT #26 SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE o %N ACC0902� U � a x 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 COINUvIENTS= - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED: 5/23/2001 SAMPLE, AS TESTED ABOVE: DOTABLE or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 LABORATORY REPORT REPORT TO: DORSET HOLLOW ESTATES DATE SAMPLE COLLECTED: 5/23/2001 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: 5/23/2001 TESTED BY: LAB #11471 LAB LD. #: MAY -146 REPORT DATE: 5/24/2001 SAMPLE SITE: DORSET HOLLOW ESTATES, LOT #26 SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE o %N ACC0902� U � a x 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 COINUvIENTS= - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED: 5/23/2001 SAMPLE, AS TESTED ABOVE: DOTABLE or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 VA y r t PUTNAM COUNTY DEPARTMENT OF HEALTH ' DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERM WAGE TREATMENT SYSTEM 0 PERMIT # Located at 24 Jill Court Town or Village Patterson Subdivision names o r set Hollow E sSubd. Lot # 26 Tax Map 3. 2 0 Block 2 Lot 93 Date Subdivision Approved 1 9 9 8 Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, NY Zip 10509 Amount of Fee Enclosed Building Type Residence $300.00 Lot Area 1.5 No. of Bedrooms 4 Design Flow GPD 8 0 0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of � y w i c e -tVeA&es a Other Requirements: To be constructed by Dorset H o l low Water Supply: X Public Supply F or: Private Supply Drilled by 1250 gallon septic tank and 500 Builders Address 15 West Hollow Rd., Brewster, NY Town ofPat�erson rom Water Di.stri.ct 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 treatments sY tem 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: 1� �_- -� P.E. X Address 3871 Route 6, Brewster, NY 10509 R.A. Date !S-- 8 ` d 0 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe, 't. Approved discharge of domestic sanitary sewa a only. I ` By: Title: r !1 / ✓ <�G �Uate: J 1 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 March 17, 2000 Robert Morris P.E. Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow Estates Lot # 26 (formally Van Cleef Estates) Edward Bloes 914- 234 -2281 This letter is to serve as a notice that I as the contractor for the Dorset Hollow Water District, currently under construction, can provide adequate pressure to serve the proposed lots. This water plant shall be inspected and approved by PCDOH N use to meet the demand requirements for the subdivision. Very trylfygNrs Edward Bloes G &E Development PO BOX 352 BEDFORD, NY 10506 f. RE: ku'?Jw Date: (T)%�� 3. " a - 53 / 0 -14- 6 Reservoir Basin ej Dear The Putnam County Department of Health (Department) has determined that the above referenced .application, including fee, and rec 'ved by this Department on A4 /6, ,2cvp is complete. The Department will notify you by S of its de ermination. 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 apprrval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2159. Very truly yours, Shawn Rogan SR:tn Public Health Technician ws2 Tr.:ST PIT QAnA RE DL',SCRZ 1M- . G.L. 11 2' -ZL� C'� T.�.T'D TO BE Su"aHl —LTL APPISrz0I0Z\1 ? SOUS 1a\1CC•UNI= IN TEST E0. HOI, M. % HOiZ . NO. _ _/oar.✓, y �� JV r� ..: - 3 ol_ BQONN SANG Z1� w TtE sorn� �K _ 41 G, 2£Y SAN � 51 6 � j20G� Rot�O Nl 7' -o" r ,� ....... _ . ............ . 11' INDICATE 1,07= AT WHICH GRCUNUNA= IS a''COUNTE M M INDICATE L —,,v= TO WHICH WATT% =VM RISES AFTER BEING M==M DEEP HOLE OBSE.QVATIONS MP.DE BY: DATE : DESIGZN Soil Rate Used / -/S Mm/l" Droo: S.D. Usable Area Provided No.. of Bedroars L Septic Tank Capacity / ,5 O gal . Zoe P16 Absorption Area Provided By _ ,5iVO L.F. x 24" width ` ench Other NE Name If7W. SGa7T' EuG/ NE�� /N�.�,PL.yiTs�a�ir�ignature w Address aB•71 focrro- S SEAT, m � w � m Wit. THIS SP.A= FOR USE DX Hr -UT:: DEPAMIENT ONLY: :.,.. E:S ' `J�''.R ' Soil Rate Approved :q:ft /ga.1 ' Cieck by Date Pf'1'�Tri. =U 77--' 7r CF A. ,'^' it Cr - ........_ ... _ .... �.�...ilJlY �.aYY �'� �� +�.: Uir•U� yL..:. �YC� ✓L�^r.�..`SLJ i�C�'� i•�T'y: LAJ. Cwre =' SSG .•�Cc/ /s /T /O.y ��2.° �"�:�SS � �7 i?'/,�rr1�4Y2oN,u�t A•r/.� rf//�,T� P��,ys,vy S ZO 2 /0605 yo at ( C `eet: J�Lf 3// G9irNt�./i4t.G h' /GG �P9 Sec. / 3 • Blcc : 1 :ct (.L.7C_C✓w e= st Goss sz:eeLi C__ a 14 / hate --Zhe'd SG? , ?MIC✓L.'T'TrN TSST T-'t PEC-j, TC BE Tel APP:Z(z7=CVS GOT Wit= of Pr -•-sca king Pate of Pe_rwlaticn Test EOIZ ,,us-ca �C 'I'IM� I 4C1r 'T'1'C�i ?� COLn`f'ICii RM Flapse Deptz to -Water F--= Wate -r Level- Ti-Me Ground S=-Eace. Ln Inches Soil Rate sta.'rt -stop M.in. stx-1. stop Drop In M.la /in Drop inches 1., 1C.'les inches I " •2 `2 = /�� 2 %Z� -�� . 23•, ..��., - err .... � 3 ZEN �2�3y -l0 Z3 - ..... ��„ 3,•.. 3 1 1.'07 -7 %37 2. 3''04 - 3> 23'` 5 i 2 3 I. Tests to be repeat,= at same 3e -,-.ti unt-? apprc. ==te? y egml soil =a:-,= are • obtai.ne3 .at each pe==Iation tzst hole_ ' 'AL data be su.-- i t--Lmdd for review. Z. Depth. meal irem* is to be mace f-CI t^p cr hole_ rev. 9/85 - BRUCE R. FOLEY Public Health- Director a s •c . LORETTA MOLINARI R.N., M.S.N. �CC► Y O�� 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 TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREAT`1ENT SYSTEM PROGRAM DELEGATED PROJECT: TOWN: C SE C K PV DATE SUB'D APPROVAL: -fool NOTICE OF COMPLETE APPLICATION DATE: PI 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: �-�'r �' alkiJ ay J,'/( Ce� � REVIEWED BY: RM, GR, AS, GATE: /� TAX MAP--: (CONFIRMED) ' � { a Y N DOCUMENTS ,% ( _)PERMIT APPLICATION , / L/ )(_)WELL PERMIT OR PWS LETTiHI CUUPC -97 (,eJ'ULETTER OF AUTHORIZATION (}(_)DESIGN DATA SHEET (DDS) L,L/ )CORPORATE RESOLUTION C/ ))SHORT EAF (!!!!�)UPLANS -THREE SETS (!!�_)L_)HOUSE PLANS - TWO SETS L_)(/)VARIANCE REQUEST SUBDIVISION (�✓) - _)LEGAL SUBDIVISION %LUUSUBDIVLSION APP OVAL CHECKED L/)(_)PERC RATE v_)FILL REQUIRED !DEPTH L_)CY)CURTAIN DRAIN REQUIRED GENERAL VJL_)LOCATED IN NYC WATERSHED (/)(___)PLANS SUBMITTED TO DEP (Z)L_)DELEGATED TO PCHD V C-)(/)DEP APPROVAL, IF REQ'D UDEEP TEST HOLES OBSERVED (/)(__)PERCS TO BE WITNESSED ( /)(EX- APPROVAL SSDS ADJ, LOTS Lam( )WETLANDS (TOWN/DEC PERMIT REQ'D ?) (/JL_)DATA ON DDS PLANS & PERMIT SAME L_)(,IJPRE 1969 NEIGHBOR NOTIFICATION L_)( )LETTER BUZBA (f)U100 YR. FLOOD ELEVATION W/I200' L_)/)SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS C f (_)SEWAGE SYSTEM PLAN - (NORTH ARROW) Cf - ( SSDS HYDRAULIC PROFILE // L _)GRAVITY FLOW (_)CONSTRUCTION NOTES 1 -15 (__)(__)DESIGN DATA: PERC & DEEP RESULTS (,gnL_-_)2' CONTOURS EXISTING & PROPOSED (,/)L_)DRIVEWAY & SLOPES, CUT (�, L_)FOOTING /GUTTER/CURTAIN DRAINS (j!!�)L-)USDA SOIL TYPE BOUNDARIES UUTITLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# (_4L_)DATE OF DRAWING/REVLSION (_4L_)DATUM REFERENCE (Z( _)LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. (L)LJPROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (�L_)WELLS & SSDS'S WAIN 200' OF SSTS (f)L_)PROPERTY METES & BOUNDS COMMENTS: (BEVSHEETI Y N (REQUIRED DETAILS ON PLANS CONT'Dl UUHOUSE SEWER -' /." FT. 4 "0'; TYPE PIPE CAST IRO_ N (_6LUNO BENDS; MAX BENDS 450 W /CLEANOUT RENEWALS NOTE (NO CHANGE) FILL SYSTEMS (%(__ )10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (___)FILL SPECS / FILL NOTES 1 -5 U(__)FILL PROFILE & DIMENSIONS ((___)FILL IN EXPANSION AREA UU c B� C—)(—)FILL c (_UL _)DEPTH G ;,0'TPLAN FOR.RO.B., UNCLASSIFIED & IMPERVIOUS ARATION DISTANCE FROM TOE OF SLOPE UULF TRENCH PROVIDED 36D' 60FT MAX. (-,LejL_)PARALLEL TO CONTOURS L/UU100% EXPANSION PROVIDED CZJL_)DETAM/DUST FREE CRUSHED STONE OR WASHED GRAVEL ([JLJGEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS (!)U10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (UU20' TO FOUNDATION WALLS (j6( _J100' TO WELL, 200' IN DLOD, 150' TO PITS L/JL_)100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan) ( JC_ j50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER (x(__)10' TO WATER LINE (pits - 20') (,/)Lj50' INTERlvIlTTENT DRAINAGE COURSE ((__)200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS U(__)10' MEN TO LEDGE OUTCROP SEPTIC TANK OM FOUNDATION; 50' TO WELL WELL IMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION MIN 15' TO PROPERTY LIME SLOPE (U —6 k U�REGRADED T015 %, IF RE %ED (__)(__)DOSE 7 PIPE VOLUbIE/DOSE VOLUME NOTED ( J(_)DE F FORCE MAIN, (PIPE TYPE, ETC.) DH(--J(--JP )P SOWN & DETAILED ""l STOG OVE . ALARM CURTAIN DRAM (J(__)STANDPIPES, ' ES, DETAIL LULU15' MIN to CDS= -0 , 20'4%,25'-3%,35'-1%, 100 % -<1% _ (_ (_)20' MIN to CD GE /100' with 182 cons day discharge (_)(�10' MIN to 1�JRiN- PERPARATED PIPE \•: r •:•:•:: • ..\ ::.tip: -:� �: :; r {:; �::•:• :� �'.:•:r• ..\ . •.\ . . J.. Y::: I. � I:: ' r BATH 01 } BEOAOOM < ' \� •�� DRESSING- 4J.-S" x 12'.0 - BEDROOM 3. WALK' 13• -0" x 10' -0• �1�� j !N CLOSET _ �r MASTER BEDROOM BEDROOM 2 _ OPEN 17'•0 1 PUTNAM COUNT' 1PARTME NT OF HEALTH f USE PLANS APPROVEDO.1,•DEDROOM COUNT ONLY, SECOND F L 0.0 R AU i ., 4828 •1 S ll x... LE KITCHEN F • t I ...may • . �) DINING ROOM p (� - •.I MORNING AGOM -4-a 13' 0' r 12'.0• OPEN ABOVE LIVING ROOM w FAMILY ROOM I FOYER �•' FIRST FLOOR r MR = tZaa�F 14 -16-4 (2/87) —Text 12 PROJECT I.D. NUMBER 617.21 'SEOR 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: (formally Van Cleef Estates) Municipality Patterson, County Put n a m 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) Lot'# 26 - Dorset Hollow Estates (formally Van Cleef Estates) Cv(,trt 5. IS PROPOSED ACTION: El New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: ' r Construction of subsurface sewage treatment system -for single - family resid'e:nce and connection to public water sypply. 7. AMOUNT OF LAND AFFECTED: [-- I� �' J Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? El 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 permitlapproval Subdivision approval from Town of Patterson Planning Board /PCDOH 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor e: P• W• S$:2 t t, P. E., R. A. �'. j o o Date: "— Signature: 1� 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 ,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. C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. C:) C6. Long term, short term, cumulative, or other effects not identified in-Cl-05? Explain briefly. �- r r•, - : 171 3::v C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain briefly. C.J Cr i 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 (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: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency F Name of Lead Agency Date 2 Title of Responsible Officer Signature of Preparer (if different from responsible officer) BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (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: Dorset Hollow Builders Lot 26 TAX MAP NUMBER: 3.20 -2 -93 E911 ADDRESS: 24 Jill Court Patterson TOWN: G' t AUTHORIZED TOWN OFFICIAL: (Signature) DATE: L-7 G4 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) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at 24 Jill Court TN Patterson Tax Map # 3.2 0 Block 2 Lot 9 3 Subdivisionof Dorset Hollow Estate$ (formally Van Cleef Estates) Subdivision Lot # 26 Filed Map # 2 7 7 1 Date Filed Gentlemen: This letter is to authorize P e d e r W. Scott, P. E., R. A. 12/24/88 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 Countersigned: P.E., R.A., # 059346 Mailing Address 3 8 7 1 Route 6 Brewster State New York Zip Mailing Address: Dorset Hollow Builders 15 West Hollow Road, Brewster 10509 State New York Telephone: ( 9 1 4 ) 2 7 8 - 2 1 1 0 Telephone Zip 10509 (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 # '16 15 West Hollow R6ad Brewster, New York 10509 Dorset Hollow Estates 2. Nameofproject: (formally VanCleef Est;3. LocationT/V: Patterson 4. Design Professional: Peder W. Scott, P.E. , R.-';�. Address: 3871 Route 6 6.. Drainage Basin: East Branch Reservoir 7. Type of Project: X Private/Residential Apartments Office Building Food Service Institutional 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 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 19. If es name of water supply Town of Patterson byrsystem yes, 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 22. Date test holes observed i 1 -14 - y(g 23. Name of Health Inspector M. B u d z i n s k i P. E. 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 N 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? ............... Indiv.id. ..ual .. Lot ............ :............ ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: No N/A No No No .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.ao Block_ Lot 93 37. Approved plans are to be returned to ..... Applicant X Design Professioral 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 Pgnal Law. SIGNATURES & OFFICL4L TITLES: Mailing Address: Peder -V. Scott Agent for Applicant .......... ... ....... A ROO l7tir`s �, =i'j d 3 `1�` 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 0XAttached ❑ Under separate cover via • Shop drawings ❑ Prints ❑ Plans • Copy of letter ❑ Change order ❑ DATE 9 7 M 01) JOB NO. 99— 1 5 9 ATTENTION i W bt.!n ,-s RE: ^ Lo Dorset Hollow Estates (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) Application for Approval of Plans (PC -97) I the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION 1 ❑ Approved as submitted ❑ Resubmit copies for approval Application for Approval of Plans (PC -97) I ❑ Approved as noted 1 Construction Permit for Sewage Treatment System (CP -97) I ❑ Returned for corrections 1 Letter of Authorization (LA -97) I 2 Design Data Sheet (DD -97) I ❑ House Plans (2 sets) 2 ❑ 1 Letter from G & E Development,LLC, Re: Public Water 1 I Check # :4 - ((23 %, for the amount of $ 300 1 I Short Form EAF THESE ARE TRANSMITTED as checked below: • For approval ❑ Approved as submitted ❑ Resubmit copies for approval • For your use ❑ Approved as noted ❑ Submit copies for distribution • As requested ❑ Returned for corrections ❑ Return corrected prints X1 For review and comment ❑ ❑ FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS List Continued: 4 1 Septic Site Plan Drawings _ 1 I E911 Address Verification Form (E911 Verfrm) COPYTO SIGNED: If enclosures are not as noted. kindly notify us at once.