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HomeMy WebLinkAbout0145DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -94 BOX 2 00145 TJ- 1 16 } ` - 00145 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE F REATMENT SYSTEM 0 PCHD CONSTRUCTION PERMIT # 3 —0/ Located at --;�O J i L-A— (L-0 L) Town or Village LA Owner /Applicant Name D G'YZ.S e-,-F Utz +ux 7 P J i L-oa- 'ax Map � , �) O Block 2-- Lot '71 Ll Formerly \1 A-IJ Subdivision Name '0QfZ -s ue i I+a LUOLU LlffaT �rT -5 Subd. Lot # Mailing Address I i,cASS i t-v w' 12 /V-D. ►� i S 1Z�'�2 , NJ ! Zip �. Date Construction Permit Issued by PCHD l l G 0 Separate Sewerage System built by D Yet -z5er }{ ,f.w,,,� 1!��'1 �e� Address 15- �i�T'r- Hv Lt-e)-Li e �-t-+7 Consisting of 1 5 �-' Gallon Septic Tank and -"-(U0 L-17 c F ;,2tt ', L,) +ii Le: Other Requirements: Water Supply: _ ti o Public Supply From bl sT-ei c, r- Address or: Private Supply Drilled by Address Building Type Pt-� t o el j c-' Has erosion control been completed? Number of Bedrooms `i Has garbage grinder been installed? 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 Putnam County Department of Health. Date: Address Certified by P.E. (Design Professional) License # 0 5 9 - +-f �t J R.A. Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of, the private water supply shall become null and void when a public water supply becomes available. Such approvals subject to modification or change when, in the judgment of the Public Health Director, such revocati n, m dification or change is necessary. By: Title: (� /`"� Date: 7i d White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �U N 140 52' 00" W , 5 � , 201 W 100 50,00' - N 76 �r �6 1� X Of 2E5 w AI?E�A - 1,06 5 AC12E5- ,O I� O 00 20 .N, .z �3 \ f'0 \ k ,6 /, z N� ° CD O N� CA z O O N Co J �k\�332 __--�_-_'-_______--___-__- ___-_-_-_-_-'-_'_-,--_ U' -�_���'��~~---�- 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, New York 10509 1- u sN °' O7 T° A H @WOCTULIUI DA FE i JOB NO. A rrEN TIO V RE: Septic As —Built WE ARE SENDING YOU `Attached ❑ Under separate cover via the following items: ❑ Shop drawings ,Eg) Prints ❑ Plans Samples ❑ Specifications ❑ Copy of letter ❑ Change order .❑ COPIES DATE NO. DESCRIPTION 1 I Certificate of Construction Compliance I I Report 3 1 Guarantee of Subsurface Sewage Treatment System 1 As —Built Septic Plan Fee: $200 L:� OY7- .9(n'z Li ;7% THESE ARE TRANSMITTED as checked below: ❑ For approval C� For your use ❑ As requested Cl For review and comment . ❑ FOR BIDS DUE REMARKS Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Resubmit copies for approval C Submit copies for distribution Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: NE NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 LABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) CHEMISTRY: Chlorine Residual DORSET HOLLOW EST., LOT #25, PATTERSON, N.Y. KITCHEN SINK MUNICIPAL NONE RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) ml = milliliter mg/L = milligrams per Liter 0 per 100 ml SM 9222B 0 per 1.00 ml * mg/L - - - - -- ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met. - Sample collected in a sodium thiosulfate bottle. RESULTS BASED ON SAMPLES SUBMITTED: 12/19/2000 SAMPLE, AS TESTED ABOVE: 0 OTABLE 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 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 r ;i / I / r1 I� LABORATORY REPORT REPORT TO: DORSET HOLLOW BUILDERS DATE SAMPLE COLLECTED: 12/19/2000 cc: ALLAN FINN TIlv1E COLLECTED: 11:00 A.M. 15 WEST HOLLOW ROAD COLLECTED BY: A. FINN BREWSTER, N.Y. 10509 DATE RECEIVED @ LAB: 12/19/2000 TESTED BY: LAB #11471 LAB I.D. #: DE -58 REPORT DATE: 12/20/2000 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) CHEMISTRY: Chlorine Residual DORSET HOLLOW EST., LOT #25, PATTERSON, N.Y. KITCHEN SINK MUNICIPAL NONE RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) ml = milliliter mg/L = milligrams per Liter 0 per 100 ml SM 9222B 0 per 1.00 ml * mg/L - - - - -- ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met. - Sample collected in a sodium thiosulfate bottle. RESULTS BASED ON SAMPLES SUBMITTED: 12/19/2000 SAMPLE, AS TESTED ABOVE: 0 OTABLE 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 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 r ;i / I / r1 I� BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R-N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (Q14) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 OWNERS NAME: E911 ADDRESS VERIFICATION FORM Dorset Hollow Builders Lot 25 TAX MAP NUMBER: 3.20 -2 -94 Jill ou E911 ADDRESS: TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 2 Go w� 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 VERFRlv>7 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Dame -c- K l �,w P, I de,,­ Owner or Purchaser of Building Tax Map Block _Pffn.-P_� - r­� t t, PC( (--(erS6a\ Building Constructed by Town/Village Location - Street dgsl�-avlvt Building Type Lot ArSet_ f ` /nV Fs -Fafes Subdivision Name ZS_ 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 occu t of the building utilizing the system. Date Month Day Year Z °O ( Signature: Title: (I n actor caner) '-Signature ��rse -� Ufa y /gLv �u ; ate �� �`��n -v �'� f-S Corporation Name (if corporation) Corporation Name (if corporation) h Address: h- Va&L f� v,, &I-d , &,tvSfNX Address: (1- k6t_ K11� Rd . Pre.(V_%ft State . /y Y Zip �1 State N Y Zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: t/ L.'. n.FD Inspecte y: a, 0 D Street Location ,Z Owner orsgr 11c,44oe.. Town 'P,47 -7- l s o Permit # -P - 3 z/ - oc9 TM 9_ '3, ;2- o - 2 - 9,5y Subdivision Lot # 2 6- 1 owgsFr 1. Sewage Svstetn Area a. STS area located as per approved plans .........................:. b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. SeNtAge System_ a. Septic tank size 1,000 .... .1,250. :...other ................ b. Septic tank installed level . c. 10' minimum from foundation .......... ............................... d. Distribution Box 1A outlets same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. Trenches T-.L—eng-th required Yoo Length installed ocv 2. Distance to watercourse measured + i on 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. PumR or Dosed Systems Sizeot 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 ................... :Y ... rPIKK..�:................. . 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 HrnQ;nn rnntrn1 rrnvirlael 5 MIMI IMAM IMAM ICS ICS ICa ICS ION— ICS C C) 0- 57 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Date: z2 0 z� v .I To:f- DGiZ�� T `l�,� Lty7— a� ��,zSiT �{ctLGc✓ A - ff a a V cj' From: Gene D. Reed Putnam County Department of Health For y our information For your review As discussed Fax #: Z7 8 ° �2-1 (9 6 No. Pages (Including cover sheet) Please respond Attached as requested Please call Notes/Messages 0, k'r 7-0 -214-0 ?-sr-iCI -L- In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 ext. 2261. * COUNTY:DEPARTMENT OF HEALTIi:PUTNAM :DIVISION OF ENVIRONMENTAL IiEATLII SERVICES FIELD ACTIVITY -R'E R c 1 MAM,M. PAPW -!5 ,67 _ }i041,0,+1 ROM- 64z�k TP1.:T if.!�64 3 A1�T?R R:C C AL L cA.7:y t�°I pi41 Tir�i25e.�t/ I� - Street_ Town State Zip -, PERSON IN CHARG_ E JN a Name and; Title w TYPE -OF FACILITY g =: nisi7rG�"�a�/ FINDINGS. y - -. 4_ � Y f L ,.' s • f �. .:off =j7 '.mac" �'�r�c�Ji�� �� 1�'C2 %�ii�iZ�Y '� �/� � C"":.�'t '- - • ,. w —y'. A6*k E p n 15. lG 't/�CGr l• . - - r w 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 (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 Date: To: PeZ7i5�P W, 5G o-77- -Re; 2,& -r 2 S Tr -L e— -7-. P ° 3 41 - en cs G From: Gene D. Reed Putnam County Department of Health Fag #: -Z7 E5 ° :21 6 6 No. Pages i2- (Including cover sheet) . ZFor your information Please respond For your review Attached as requested As discussed Please call __.------ ._--- - - - - -- Notes/Messages In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 ext. 2261. 12/18/00 11:36 PW SCOTT -) 19142787921 NO.041 002 PUfNAM COUNTY DEPARTMENT OF HEALTH DIVIS.:ON OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FINAI, INSPECTION For: Fill Trenches_ PCHD Construction` Pe; mit # 3� Located 40 J 1(1, 660, (T) (V) Owner /Applicant Namt UOW &a W TM 3. W BI ck Lot lip n Formerlyi� ' JV Subdivision Name Subdivision Lot #~ Is system fill completed? `6epl& Date _ Is system complete ?_ Date j2 ( cn Is system constructed es per plans? Is well drilled? A Date Is well located as per F tans? Are erosion control me asures in place? I certify that the syster i(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans an I the Standards, Rules and Regulations of the Putnam County Department of Health. Date: i Certified by: PE)CRA esign Professional f Address-�� ID Z�� ►" 1 ��� Lic. # 03 -13 -b Comments: FOR: ❑ ADAM XGENE Form FIR -94 12/01/00 11:56 PW SCOTT 4 19142787921 PUZ NAM COUNTY DEPARTMENT OF HEALTH DIVISII )N OF ENVIRONMENTAL HEALTH SERVICES ATTENTION 0 ADAM GENE REQUEST EUR FINAL.. INSPECTION For: Fill NO.063 002 All information must be filly completed prior to any Trenches inspections being made. PCHD Construction Pere Sit # t 3 1 D Located: i-a —� T (V) Pegs, Owner /App 'c t Name: 'I Block -2- - Lot ' Formerly: g oaf Subdivision Name: +ez Ko //st�y ASS Subdivision Lot # Z Is system fill completed? Date: 0 Is system complete? 111A Date. Is system constructed as per plans? NA Is well drilled? Date: t ,��o a ` Is well located as per pla is? Are erosion control mean ures in place? �3 i certify that the systems), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued .PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: l y° f i 1 Certified by: PE RA Design Pcrofessional Address: b t . 4T"tC4, Lic. # Comments: Form FIR -99 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 # di5 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.5.. 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 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 Frown 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? .............................................:........... ..:............................ Ye6:1 13. If so, have plans been submitted to such authorities? ........ ............................... Yes— Subdivision 14. Has preliminary approval been granted by such authorities? Yes Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... N/A 17. Waters index number (surface) ........................................... ............................... N/A 18. Is project located near a public water supply system? ....... ............................... Yes Serviced 19. If yes, name of water supply Town of Patterson Distance to water supply by system 10. Is project site near a public sewage collection or treatment system? ................ No H. Name of sewage system Individual Lots Distance to sewage system ?2. Date test holes observed _ 1 o- A9 - 9 6 23. Name of Health Inspector M. B u d z i n s k i P. E. A 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 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ........................................................... ......... ....................... 29. Is Wetlands Permit required? ............... Individ. ..ual ..Lat .......................... ............................... 2 No N/A 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 DESCRIBE: 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 gala Block 9, Lot -q 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 of lrm, 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 Scott Agent for Applicant 3871 Route 6 Brewster, New York 10509 1 rQ 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 CCAttached ❑ Under separate cover via • Shop drawings ❑ Prints ❑ Plans • Copy of letter Cj Change order ❑ DATE JOB NO. (Q. � 99 -]59 ATTENTION RE: Dorset Hollow Estates (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 1 Application for Approval of Plans (PC -97) 1 1 Construction Permit for Sewage Treatment System (CP -97) 1 1 Letter of Authorization (LA -97) l 2 Design Data Sheet (DD -97) 1 House Plans (2 sets) 2 1 Letter from G & E Development,LLC, Re: Public Water 1 1 Check #3ys /r.�3 72-c-for the amount of $ 3enz9.-`-D I 1 Short Form EAF THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested Z7 For review and comment ❑ FORBIDS DUE REMARKS List Continued: ❑ 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 4 1 Septic Site Plan Drawings I I E911 Address Verification Form (E911 Verfrm) COPY TO SIGNED: If enclosures are not as noted. kindly notify us at once. i PUTNAM COUNTY DEPARTMENT OF HEALTH 1 1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 20 Jill Court EM Town or Village Patterson Subdivision name D o r set Hollow N sSubd. Lot # 25 Tax Map 3. 2 0 Block 2 Lot 94 Date Subdivision Approved 1998 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 $300.00 Building Type Residence Lot Area 1 .0 7 No. of Bedrooms 4 Design Flow GPD 800 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1250 gallon septic tank and Other Requirements: To be constructed by Dorset Hollow Builders Address 15 West Hollow Rd., Brewster, NY Town of Patterson Water Supply: X Public Supply FromW a t e r District Address or: Private Supply Drilled by Address .;t 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 any repairs thereto. Signed: P.E. X R.A. Date 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p i Appro for discharge of domestic sanitary sPewag By: 7 Title:, "Date: 1 t White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at 20 Jill Court T/V Patterson Tax Map 3.20 Block 2 Lot 94 Subdivision of Dorset Hollow Estates ( formally Van Cleef Estates) Subdivision Lot # 25 Filed Map # 2 7 7 1 Gentlemen: This letter is to authorize P e d e r W. Scott, P. E . , R. A. Date Filed 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. Very Countersigne Signe P.E., R.A., # 059346 Mailing Address 3 8 7 1 Route 6 Brewster State New York Zip 10509 Telephone: (9 14) 278-2110 Mailing Address: Dorset Hollow Builders 15 West Hollow Road, Brewster State New York Zip 10509 Telephone: ( 9 14 ) 2 7 9 - 13 3 9 Form LA -97 p B=S7LCNL CF CwT:.arr SR4, • 3. ZO 2 /0605 yo at (S l aet )_ �r� /i E` �xn���,/.9� , /� .Pa Se--- Bicck Zct N+•r.. jC.; f 4-6- �iGL.�...a.er GI��r�i/�• GQ / Z�J qtr cf g;e-;czay^c Date of Per =latic n Test S SOLI.' Run Elapse Dept. to ..Kate- rYca War---- Level Nc. T•:*zkm Grand Su... =ace. in L:c•.es ' Sei? Pate St r -S :oc Min. Start Stop Drop In M n/zr. ircp inches inches L: . 3 Z U '? 2 .. 3 NODS : 1. Tests to o be- repe ,teal at same de -,+—Ii ants appr=d=tell y equal soil =3t= _ are*ebtaine3 .at eacz peralaticn test hole. • 'All data to' be su.'--ni.tter for review. __ 2. Dept's maasuraD=t; to be made f: c:. tOp of hole. : TEST PIT DATA RF ?�:� TO BE S�'r�?•LZ= W-ME AP LT"kTION? DESCRZ .!ON -jF SOIIS EN 4U IN TEST H0. - Dpi ECF,r, M. EOLi M. Z HOLE NO G.L. T— �OP50 i Ci TOPS O/G ' S7',r20MG j27N/�i SIRGVG 8,�:1w � Z • 3' 4 o�c 5' 6' 111177-7 e' 7' 8' 9' l0'' ,+1 12' 14' INDICATE 107M AT WHICH GROUND 4�r Tit IS rN''COU=,,E0 Ni DICATE LF.Ul:Z, M WHICH TEAM Jsc"VP.L RISES AFTER BEING M=M\ ER D DEEP HC-'AE OBSEERVATIONS MADE BY: _ DATE: /0 V1 9 DESIGN Soil, Rate Used / ,5 ' . Min /1" Drop: S.D.' . D. ' Usa.ble Area Provide No . of Bedrooms Septic Tank Capacity /ZSO gals. Type e/r- �^Vc - Absorption Area Provided By �J:33 L.F. x 24" width "-ench Other Name 117 W o7T 9nature Address 3)67/ oar--• 6 SEAL . THIS SPACE- FOR USE BY BrMTH DEPA=dENT ONLY: - Soil Rate Approved sq:ft /gaL. ' C`iec�CO3 L-y Date 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 # 25 (formally Van Cleef Estates) Edward Bloes 914- 234 -2281 This letter is to serve as a notice that I as the contractor for the Dorset Hollow Water District,. currently under construction, can provide adequate pressure to serve the proposed lots. This water plant shall be inspected and approved by PCDOH for use to meet the demand requirements for the subdivision. PO BOX 352 BEDFORD, NY 10506 14.16 -4 (2187) —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: (f p r m g 1 1 y Van C.1 e e f Estates) Municipality Patterson County Putnam 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) Lot I �� - Dorset Hollow Estates (formally Van Cleef Estates) 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 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 .� acres Ultimately 3 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? U Yes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential ❑ Industrial ❑ 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. S c O t t , P . E . , R.A. - Date: I b_8 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 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) Ct. 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 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 (aj setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ' ❑ Check. this box* if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Resp onsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsib a of icer) Date N BRUCE R FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New . York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental .Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW PROJECT: DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED TOWN: C Ha PV DATE SUB'D APPROVAL: to 5 r NOTICE OF COMPLETE APPLICATION DATE: PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: TAX MAP': (CONFIRMED) Y N . DOCUMENTS (_J(UPERMIT APPLICATION "C —)WELL PERMIT OR PWS LETTER (_)(_)PC -97 )(_)LETTER OF AUTHORIZATION UJ(_JDESIGN DATA SHEET (DDS) (_J(—)CORPORATE RESOLUTION (_)(SHORT EAF (_)(,_)PLANS -THREE SETS L_)(_)HOUSE PLANS - TWO SETS C--)C—)VARIANCE REQUEST SUBDIVISION ( ) / )LEGAL SUBDIVISION APPROVAL CHECKED RATE REQUIRED DEPTH TAIN DRAIN REQUIRED GENERAL ATED IN NYC WATERSHED vS SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED CS TO BE WITNESSED LPROVAL SSDS ADJ, LOTS 'LANDS (TOWN/DEC PERMIT REQ'D ?) A ON DDS PLANS & PERMIT SAME 1969 NEIGHBOR NOTIFICATION )LETTER BI/ZBA )100 YR. FLOOD ELEVATION W/1200' )SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS )SEWAGE SYSTEM PLAN - (NORTH ARROW) )SSDS HYDRAULIC PROFILE )GRAVITY FLOW :ONSTRUCITON NOTES 1 -15 iESIGN DATA: PERC & DEEP RESULTS 'CONTOURS EXISTING & PROPOSED AY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES 0TLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# (DATE OF DRAWING/REVISION TUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. FINISH FLOOR AND BASEMENT ELEVATIONS LLS & SSDS'S W/IN 200' OF SSTS )PERTY METES & BOUNDS COMMENTS: (V F V4ZUP ATl Y N. (REQUIRED DETAILS ON PLANS CONT'D) (___)()HOUSE SEWER - %" FT. 44% TYPE PIPE CAST IRON U(NO BENDS; MAX BENDS 451 W /CLEANOUT �/ � RENEWALS U(_JSITE NOTE (NO CHANGE) FILL SYSTEMS �10'HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS / FILL NOTES 1 -5 (FILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA 17LL GREATER THAJV 2 FEET C_JL_) CLAY BARRIER (__)(__)FILL CERTIFICATION NOTE C) DEPTH GAUGES •-- (_� -N PLAN FOR RO.B.,.UNCL' SSIFIED & E%IPERVIOUS �)PA�2ATION DIS> ANC EROM-`I"OE OF SLOPE R NC (_ )LF TRENCH PROVIDED 60FT MAX. (— d(—.d( TO CONTOURS (—J(_)100% EXPANSION PROVIDED ( l)(_)DETAIIJDUST FREE CRUSHED STONE OR WASHED GRAVEL (_(, JGEOTEXTILE COVER % SEPARATION DISTANCES ON PLAN - FROM SSTS . 6�(�,J10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (_j20' TO FOUNDATION WALLS C__)C)100' TO WELL, 200' IN DLOD, 150' TO PITS (__)(__)100' TO STREAM, WATERCOURSE, LAKE (inc. expan) L!)L)50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER (__;C__)10' TO WATER LINE (pits - 20') Lam( _j50' INTERMITTENT DRAINAGE COURSE L)(_)2007500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (_)(_)10' MIN TO LEDGE OUTCROP SEPTIC TANK (_)L_)10' FROM FOUNDATION; 50' TO WELL WELL (_))DIMENSIONS TO PROPERTY LINES (__)(__)LOCATION OF SERVICE CONNECTION (_)L)MIN 15' TO PROPERTY LINE SLOPE (_)(_)SLOPE IN SSTS AREA (520 %) (__)UREGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS U( .. JPUMP NOTES L_)C_)DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (_JUDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) (_)(_)PIT AND D -BOX SHOWN & DETAILED (_)L_)1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN UUSTANDPIPES, 5' BOTH SIDES, DETAIL (_)x)15' MIN to CDS = >5 %, 20'4 %, 25' -3 %, 35' -1 %,100 % -<1% (_)(_)20' MIN to CD DISCHARGE /100' with 182 cons day discharge (__)x)10' MIN to NON - PERFORATED PIPE TO:(,J .stag Dear DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 DATE BRUCE R. FOLEY Public Health Director (T) Reservoir Basin The Putnam County Department of Health (Department) has determi ed that the above referenced application, including fee, and receive by t 's Department on is complete. The Department will notify you by I b-o of its determination. The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCEP will commence pusuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This.notice must include your name, the location.of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. Very truly yours, Robert Morris, PE RM:tn Public Health Engineer ws2