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HomeMy WebLinkAbout0146DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -95 BOX 2 00146 NEI rr' ' r T VNN 16 ly IN 00146 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWA T SYSTEM PCHD CONSTRUCTION PERMIT # P-2-1 Located at LL. CD 1) 2:� Town or Village Owner /Applicant NamebQW� Iry)' LO Vi I LVERSTax Map Block Lot . Formerly Subdivision Name Subd. Lot # Z Mailing Address i G \wssT vy')LIsm � O N b N-4 Zip N 0 5o -1 Date Construction Permit Issued by PCHD Separate Sewerage System built by 'WWS�J KUMN Q Q `QWW kddress) S WEST ST, P>021P- WSTE? Wy Consisting of Z , � Gallon Septic Tank and 4 DO LT- P� 96 j .T IPL IE N C Other Requirements: Water Supply: _ Public Supply From M U W (-\ � K L- Addres L R-() A), 1W or: Private Supply Drilled by Address Building Type (?, V �j \ N Q U-,- Has erosion control been completed? y Ef> Number of Bedrooms -4� Has garbage grinder been installed? ! v d 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 Pepartment of Health. Date: l - 6-0- 1 Certified by Address 'Z)-)G 0 P.E. i< R.A. License # 5 (o 2 Any person occupying premises served by the above systems) 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 approvalyaN subject to modification or change when, in the judgment of the Public Health Director, such revocat' dificati or change is necessary. f By: Title: ��°' �° - Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM JUNTY DEPARTMEN OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM T'>c R,_-& G :r HOLLOW 3, Zo Z 9S Owner or Purchaser of Building Tax Map Block Lot _K>h R 30-- Z- 1+, L to W i L 'i7 C 1Z S Building Constructed by S JILL CoyttT Location - Street P G-s ) n Cti1 GE _PATTER-!!;oN Town/1k' VAN QILEF-E Subdivision Name 24 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 up of the building utilizing the system. D ed: Mon �Q Day �Q Year Signature: General i-H o L_ w w 'R Qj L D'_R :S Corporation Name (if corporation) Address: is wfs7-jjaLLcyw i2D. Bjtk ,jcy State t,)j Zip ► 05 0 2 Title: o W N c rt r'�RS��" NoLtoW 3VIL`��:�5 Corporation Name (if corporation) Address: Is we,., l4oj_L ,a mp, a zcwss*jt State �_J> Zip f oso Form GS -97 �s �srssrmmssrr�nurlb` REPORT TO: NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT 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 I.D. #: MAY -145 REPORT DATE: 5/24/2001 SAMPLE SITE: DORSET HOLLOW ESTATES, LOT #24 SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE �'O,N ACCO90 gyc� U a TEST PERFORMED RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCQ BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/L - - - - -- m1= milliliter mg/L = milligrams per Liter ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED:5 /23/2001 SAMPLE, AS TESTED ABOVE: X or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) a 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 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 1z Telephone (845) 279 -4003 Fax (845) 2794567 June 6, 2001 Robert Moms, P.E. Putnam County Health Department One Geneva Road Brewster, NY 10509 Re: Individual SSTS Compliance Van Cleef Subdivision Lot #24 8 Jill Court Patterson, NY 12563 T.M. #3.20 -2 -95 Dear Robert: Enclosed are the following 1. Five (5) prints of Drawing 5 -24, "As -Built Plan," dated 4/20/01. 2. "Certificate of Construction Compliance for Sewage Disposal System," dated 6/06/01 3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System," dated 6/06/01. 4. Laboratory Report, dated 5/24/01. 5. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 6. "E -911 Address Verification Form," dated 4/20/01. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HWN: JM: jm 01- 026.24 L° 1 J_ 't BRUCE R. FOLEY Public Health Director LORETTA MOLINARI -R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278.7921 Nursing Services (914) 278.6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early literveo6n-(914) 218.6014 Preschool (914) 278.6082 Fax (914) 279'- 6648 OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: P,o ire-" . TOWN: P1� AUTHORIZED TORN OFFICIAL - (Signature) DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town-official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRM) �e V W C$ 4' 12 W 101, 1250 GAL SEPTICT� c I ZXiSTING 4 BE r, RESio c y' k j i ` t ' x,_00' , EXPANSI0N ARE A moo' 1250 GAL SEPTICT� c I ZXiSTING 4 BE r, RESio c DIMENSI ®N CHART (in feet) Number 2 0% S�S' -3 4 5 -71.5' G 100.5' �2 104,5' colt t0 535' 0.5' I I 585' i2' 12- PUTNAI�I COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: fi o Inspecte y: 'eq, �> Street Location T /Ll Gc��y 7ZT Owner _Iiirsc:�- Awlaae ��. %1e► -s To«n - Permit # TM = —2 9 Subdivision Lot # �� 1. Sewase System 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. Sewage System a. Septic tank size - 1,000 ........ ,250 ......other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ................. ............... d. Dist 'bution B x 1. All outlets at same elevation -water tested ................. 2. Protected below frost ................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. i renc es tength required o o Length installed �'o o 2. 'Distance to watercourse measured 4/oo 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 X30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 -1' /Z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .......:................ ............................... g. PumR or Dosed Systems 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 ............ I.......... V. Overall Workmanship a. Boxes properly grouted .................................................. b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain .outfall protected & dinto exist watercour., g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... BRUCE . R. FOLEY Public Health Director May 4, 2001 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH A 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 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 # 24, TM# 3.20 -2 -94 Dear Mr. Nichols: The separate sewage treatment system can be. backfilled. The following comments must be corrected in the field: • Needs cast iron pipe connection. 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 APR -30 -2001 01:30 PM HARRY W NICHOLS 914 279 4567 P.01 01- 026.7+ . -v PUTNAM COUNTY DEPART1t "OF iEIfRALT» DIMON OF =VWNl0&" BMTS URVIC98 AT'Y'II:NTiON 0 ADAM ■ GENE &BQt EQ E For:. Fill All lafonuattoa must be stilly ampkted prior to any Tract" - „— x . - inspecdoas being made. PCHD Construction Permit # P 2'1 ' 91 Located: a -J►ue. • c. ax t I M (w P YY�tzss:Ha ;� v Owner /Applicant Name: TIVI 3. :2_ Block . L _ Lot Pormaly. SubdivWoa Naama: UAW . Lfl i;.F�_a.� Subdividoa Lot 0 Is system 511 conoipieted? . _ w.�_w Ls Date: —' Is system eomplate? r�. e a Date: Is "am constWc.%d as par pleas? Is wen drilled? aLIS. gz - Date: �, 4A Is well located a par plans? ti IA Are erosion control mewirw in place? �, 7 I certify that rite sys co*j to Us* at the above p= 6w has beta constructed and I have Inspected and verified thak completion is amf6 ate with the issued PCHD COWWation Permit and approved pleas and the Standards, Rules and Regulations of the Putnam County Deportment of HWOL Dins 4 - z 4 - o_i Corded by: tia rt, --U -w- PE .. RA r Design Professional Address: 26-An �;z ry 7-7- f3 eVU S Y-gX,._ z%371 10_ sQ2„ UC. # AS l &4--. Commt= . Foray FIR -99 5 011111' iFi lbF�iYli/Y:i/Yl1lY�1/MC1fViV1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES t CONSTRUCTION PERMIT FOR SEWAG T SYSTEM PERMIT # F,9 1-7 9 10,71y y ,J I L,t, co J fz--T" Located at Town or Village Patterson Subdivision name y a n c 1 e e f Subd. Lot # Tax Map 3. 2 0 Block 2 Lot "2'9-- Date Subdivision Approved 19 q? Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, New York Amount of Fee Enclosed $300.00 Building Typell e s i de e c e Lot Area °q Ac. No. of Bedrooms 4 Design Flow GPD Zip 10509 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S, stem to consist of I aVo gallon septic tank and .400 I-F W i DLT TYwTJott S LV- (' -orJS @ ,5Q1 , A-fJ Q 100 °zn R- 651 -,-"Cr Other Requirements: To be constructed by Dorset Hollow Builders Address 15 West Hollow Road, Brewster, of Patterson Water Supp: Public Supply From W a t e r District Address or: Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: P.E. X Address 3871 Route 6, Brewster, NY 10509 R.A. Date 0( 3,0 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 en onsideredAecessary 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: 1 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 NY ,y G&E DEVELOPMENT, LLC Gregg Macaluso 914 - 878 -4355 October 21, 1999 Robert Morris P.E. Putnam County Dept of Health 4 Geneva Rd Brewster, NY 10509. Re; Van Cleef Estates — Subsurface Sewage Disposal Systems Lc.) i oP-a Edward Bloes 914 -234 -2281 This letter is to serve as a notice that I as the contractor for the Van Cleef water district, currently under construction, can provide adequate pressure to serve the proposed lots. This water plant shall be inspected and approved by PCDOH for use to meet the demand requirements for the subdivision. Very G&E PO Bog 352 Bedford, NY 10506 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION REVIEWED BY RM, GR, AS, MB, BH Y i DOCUMENTS AERMIT APPLICATION 1 70 WELL PERMIT _ PWS LETTER TTER OF AUTHORIZATION D IGN DATA SHEET (DDS) CORPORATE RESOLUTION 151HORT EAF PLANS - THREE SETS 7flOUSE PLANS - TWO SETS VARIANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL OCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP LEGATED TO PCHD P APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED RCS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS IVEtLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BIlZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMITS) EWAGE SYSTEM PLAN - (NORTH ARROW) SDS HYDRAULIC PROFILE RAVITY FLOW NAME OF OWNER TAX MAP # EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE fy, PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE -NO.OF BEDROOMS HELLS & SSDS'S WAN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS FUSE SETBACK NECESSARY (TIGHT LOT) USE SEWER - 1/4" FT. 4 "0; TYPE PIPE BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS LAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES (FILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100 % EXPANSION PROVIDED ON PLAN - FROM SSTS $1-0- TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS _15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 0' TO STREAM WATERCOURSE LAKE (inc. expan) 0' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATERLINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS CONSTRUCTION NOTES 'MIN to CDS= >5 %10'- 4 %,25'- 3 %,30'- 2%,35' - 1%,100' - <I% SIGN DATA: PERC & DEEP RESULTS 20'MIN to CD discharge /100'with 182 cons day discharge 2 ONTOURS EXISTING & PROPOSED SEPTIC TANK RIVEWAY & SLOPES, CUT 0' FROM FOUNDATION; 50' TO WELL DOTING /GUTTER/CURTAIN DRAINS ` 7 WELL OIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION TM #,PE/RA; NAME,ADDRESS,PHONE# ATE OF DRAWING/REVISION .ATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: BRUCE R. FOLEY Public Health Director Y-=' LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 PW Scott Engineering 3871 Route 6 Brewster, NY 10509 Dear Mr. Scott: October 18, 1999 Re: Proposed SSDS: Dorset Hollow Builders Jill Court, Lot 24L (T) Patterson TM #3.20 -2 -94 Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department of Environmental Protection on this lot, percolation test must be witnessed by a representative of this Department. 1. Design data sheet does not note date of percolation test. 2. Form PC -97 notes incorrect drainage basin. 3. A letter from the owner of the Public Water Supply is to be submitted stating that the property can be served with water at adequate pressure. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very t ly yours, Robert Morris, P. E. Sr. Public Health Engineer RM/jp BRUCE R FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 October 18, 1999 PW Scott Engineering 3 871 Route 6 Brewster, NY 10509 Re: Dorset Hollow Builders Jill Court, Lot 924 (T) Patterson Dear Mr. Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on October 10, 1999 is complete. The Department will notify you by November 7, 1999 of its determination. The Project has been delegated to the Putnam County Heath Department for review pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with Section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. _ Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 148. Very t y yours, Robert Morris RM/jp Sr. Public Health Engineer PCTIN� CNI' DE_? � r OF aF-Aj- M-T 1 D=s:L -cN OF FsE3LTT? Sr' tV?CES °t _ ..... APPENDIX I DISIG.� t'AT,'� SHr.. - Su'FSur?,C. Sr:�rezZ DIS201SyL SYSTIMI-m F? �, UJ_ c wme- SRG 4Qy 1s,1 -f Gore o Mdress 237 Avg L,01,r�- 3. zv 2 10605 yo I, -ested at (Street) E` Sec. i3. sr Block > Lot _L (indicate nearest cross st:eat) ►�.:niciFal.it;� P,�,r�,�son/ Wate.• -she:i G�2ori>ni • . SOIL PTmRCO=C -,.g MST DATA En TO BE Sure= .wm APPLIo'rlais 1-07 - Date of P- -e- =Scaking Late of Percolation Test HOLE, Damp -M 9C L= ZrlTIF. p.ERCO=C�i P-17RCO=C1NT Run Elapse Depth to .Water Frcca Water Level fto. Time Ground Surface. In Inches Soil Rate Start-Stop Min. start Stop Drop In yin /In Drop Inches Inches Inches - i 2 ff;9 .3 % 01 - 12 %0/) 7 5 2 .. 3 NOZiS: 1. Tests to be repeated at sacra_ depth until apprauimately equal, soil rates r are • obta fi ned .at each percolation test hole_ - All data to* be suhmitted for review. 2. Depth fr - aaurements to be made fran top of hole. DEP'lld G.L. 1` 21 3` 4' 5' 6' 7' TEST PIT DATA REOUIRM TO BE SUPMITTED WITH APPILICATION DESa=IOF 7 SOILS MKnUNI'ERI;D IN TEST HOT HOLE NO. / HOLE NO Z HOLE NO. r.c, a :.i Tnfx'oil —./ V — 3 ly" 8` u© 7'0" 9` INDICATE. 10M AT WEIC'd GROOM= IS aCOUNTE= - LNDICATE LE'VL'L TO WHICH WATER LEV :L RISES AFTER BEING =UNT= DEEP HOLE OBSERVATIONS MADE BY: /y), j3 U V -4- i N S JG DATE : J , DESIGN .Soil Rate Used Min/l" Drop: S-D. Usable Area Provided 6?u,6fL No: of Bedrecros Septic Tank Capacity gals.. Type Absorption Area Provided By L.F. x 24" width tench Other �o� a,Name EG r ? 4ec.iT�� Jnat Address SEAL ° W mr�• LLI O Au- THIS SPACE FOR USE BY HEALTH DEPAR" M ONLY: Soil Rate Approved sq:ft /gal.' Checked by Date � P• W. SCOTT ;ngineerin& & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (914) 278.2110 FAX (914) 278 -2166 Putnam County Dept. of Health 4 Geneva Road Brewster, New York 10509 .l `.COPY SIGNED: ---- _ • ne noted, kindly notify us at once. the following Itemb. WE ARE SENDING YOU )1 Attached ❑ Under separate cover via ❑ Samples ❑ Specifications ❑ Sho p drawings Prints ❑ Plans ❑ Co py of letter C:3 Change order ❑ DESCRIPTION COPIES DATE NO. (form CP 9 Drawings Sp Treatment System Sewage Construction Permit for CA_g7) LA —LA, of Authorization (form Letter Sheet (form Do -97) Design Data Short Form EAF House Plans (2sets) Check for the amount of THESE ARE T ,ANSMITTE0 as checked below: copies for approval Resubmit --- M Fir approval ❑ ❑ Approved as submitted copies for distribution ❑ Submit ---- e, ❑ Approved as noted corrected prints 0 Far your use Q ❑ Returned for corrections ❑ Return �-- ' AS Te4U0ted ❑ TO US AFTER LOAN b and � For nevi, comment ❑ PRINTS RETURNED Q IFOR BIIDUE REMARKS # E t I 8 .l `.COPY SIGNED: ---- _ • ne noted, kindly notify us at once. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at Vancleef Estates, Route 311 & Cornwall Hill Road T/V Patterson Tax Map " 3-20 Block 2 Lot -_A� 94' Subdivision of V a n c l e e f Subdivision Lot # `� Filed Map. it7 Date. Filed ...�.a -,� Gentlemen: This letter is to authorize P e d e r W. Scott a duly licensed Professional Engineer. x or Registered Architect to apply. for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in abcordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145- and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very tru y yourrs,,` Peder W. Scott ,� 1 Countersigned: Signed: t' P.E. R.A. # 0593 (Owner of Property) Dorset Hollow Builders Mailing Address 3 8 7 1 Route 6 Mailing Address: H Q_ 11 AR d Brewster, Brewster, NY 10509 State New York Zip. 10509 State Zip Telephone: (9 14) 278-2110 Telephone: (9 14) 279-1339 Form LA -97 14.16.4 (2J87) —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 Vancleef Estates 3. PROJECT LOCATION: Municipality Patterson County Putnam 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Vancleef Subdivision — Access from Route 3111 Cornwall Hill Road For Lot # 5. IS PROPOSED ACTION: l New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction single lot septic — Connection -to public water supply. 7. AMOUNT OF LAND AFFECTED: Initially O, I11c/. acres Ultimately a(0 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? LRYes ❑ No If No; describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑Agriculture ❑ Park/ForestlOpen 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 o.f Patterson.PB /PCDOH . 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE P.W. Scott, P.E., R.A.jQ Applicantlsponsor me: Date: Signature: If the action is in the Coastal Area, and you are a state agendy, 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) Ci. 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? Expiain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1 -CS? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. 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 Name of Lead Agency Title of Responsib e OT icer Signature of Preparer (If different from responsible officer) Date 2 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: Lot # Dorset Hollow Builders 15 Wett Hollow Road Brewster, New York 10509 2. Name of project: Van Cleef Estates 3. Location TN: Patterson 4. Design Professional: Peder W. Scott, P.E. , R.-'�. Address: 3871 Route 6 6. Drainage Basin: " L-�-I- 6 a6ftc -o¢ 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? ......................... Exempt Unlisted No X 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? ......................................................... ............................... ... Yep: 13. If so, have plans been submitted to such authorities? ........ ............................... Yes- Subdivis ion 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 erviced 19. If yes, name of water supply Town of Patterson Distance to water supply by system 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system. Individual Lots Distance to sewage system 22. Date test holes observed 111/ q 1 47 41 23. Name of Health Inspector 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 27 28 Is any'portion of this project located within a.designated Town or State wetland? WetlandsID Number:` ............................:............................ ............................... 29. Is Wetlands Permit required? Itzdividual 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 2. No N/A 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: LA 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 ................ ing..........I................ Map B. J Block a Lot. 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 211%45 of the Penal Law. SIGNATURES & OFFICLAL TITLES: Mailing Address;; sd ..... 14 , Pe err W. Scott Agent for Applicant 3871 Route 6 Brewster, New York 10509