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00154
PZJTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
l" Y
7
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # P- 36 - Od
Located at 71 Wes,-t. &'t15eet Town or Village
Patterson
Owner /Applicant Name D o r s e t Hollow B u i l d e r s Tax Map -% � 10 Block -'2— Lot (�3
Formerly Van Cleef Estates Subdivision Name Dorset Hollow Estates
Subd. Lot # 6
Mailing Address 15 West Hollow Road, Brewster, NY Zip 10509
Date Construction Permit Issued by PCHD �- * 0Q ,
Separate Sewerage System built by Dorset Hollow Builders Address 15 West Hollow Road
Brewster, NY
Consisting of 1250 Gallon Septic Tank and 100 L F of 24" wide trenches
and 1007 reserve.
Other Requirements:
Water Supply: x
Town
Public Supply From w a t e r
or: Private Supply Drilled by
Building Type Residence
of Patterson
District Address
Address
Has erosion control been completed?
Yes
Number of Bedrooms 4 Has garbage grinder been installed? N o
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 e 'utnam County Department of Health.
Date: / Certified by P.E. x R.A.
(Design Professional)
Address 3871 Route 6, Brewster, NY 10509 License# 059346
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject to modification or change when, in the judgment of the Public Health Director, such
revocati odification or change is necessary.
By: /�"� Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
1
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PUTNAM COUNTY DEPARTMENT OF HEALTH
\n\ DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
ts
PERMIT # c3 0
F!noLocated at '7( U1�s i 52Jt wn or Village PAT sU:"-)
me— se"'r-
Subdivision name - ,- � Subd. Lot # Tax Map Block 2- Lot i 0 3
Date Subdivision Approved 1 cl 98 Renewal Revision
Owner /Applicant Name pp(_t, rio, ,Loup (6 o., L,De-Y2 -5 Date of Previous Approval
Mailing Address I ; �u f�R-� , (L�-�% i�-YZ , t`3 Zip 05-0
Amount of Fee Enclosed 0 0
Building Type Ria� ?-i Q oJC4L-T' Lot Area 1 2. No. of Bedrooms -4 Design Flow GPD 8,0c -.
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of (;a 5 o gallon septic tank and
Other Requirements:
To be constructed by Dr�('� s G t- 1+a+. Lz L,1 F3 0i L_otF9s Address I S i,ers,t" t4owxg-J Rp, i3 9o!--1s TU-�t
iai..� � O F �l�'� �Z•S vn1 N y �
Water Supply: _ X Public Supply From w p1s�e., c� Address
or: Private Supply Drilled by
Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
&%partment, 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
-c
P.E.
R.A.
Date I &q6 6-o
Address 39-71
f20Ji-E- (—a , 6eeW 511_-gV_,
NV 10 , Z3 fj
License #
o
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 it. pproved discharge of domestic sanitary sewage only.
By: Title: ,�/��°" Date T `/
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
n
P. W. SCOTT
hgjneering & Architecture, P.C.
3871 Route 6
BREWSTER, NY 10509
E- !Mail: pws @bestweb.net
(914478 -2110 FAX (914) 278 -2166
TO putiam County Dept. of Health'
4 Gcieva Road
Brevster, NY 10509
Q
DATE /
/
0 o
JOB NO.
ATTENTION
i
RE:
Septic
As -Built
Dorset
Hollow Estates - Lot #
(formally Van Cleef Estates)
1
Guarantee of Subsurface Sewage Treatment System
3
1
As —Built Septic Plan
WE ARE SENOZ YOU l Attached ❑ Under separate cover via the following items:
❑ �:Iop drawings ❑ Prints b Plans ❑ Samples ❑ Specifications
❑ C)py of letter ❑ Change order ❑
COPIES
HATE
NO.
DESCRIPTION
i
1
Certificate of Construction Compliance
.3
1
Guarantee of Subsurface Sewage Treatment System
3
1
As —Built Septic Plan
Fee: $200.00
THESE ARE TRANSMITTED as checked below:
;91 For approval
X3 For your use
❑ As requested
❑ For review and comment
❑ FORBIDS DUE
REMARKS
COPY TO
❑ Approved as submitted
❑ Approved as noted
❑ Returned for corrections
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
SIGNED:'
It enclosures are rot as noted, kindly notify Lts of orc, -. F
BRUCE R. FOLEY
Public Health Director
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (9.14) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
E911 ADDRESS VERIFICATION FORM
OWNERS NAME: -.Dorset Hollow Builders Lot 6
20 =2
3, A 03
..TAX MAP NUMBER: _ . .
The Putnam County Department : of..Health will not ' issue a Certificate of
ConstructionCompliance unless-the above form is completed- i.e., a legal E911
address is `assigned by an^.a.uthorized, town.:official.:.This form is to. b.e .submitted
with the application for a Certif cafe of Construction Compliance.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Dorset Hollow Builders 3,2-0 12/ (03
Owner or Purchaser of Building Tax Map Block Lot
Dorset Hollow Builders
Bulding Constructed by
let
Location - Street
Residence
Building Type
Patterson
TownNillage
Van Cleef Subdivision
Subdivision Name
1.0/
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 occupant of the building utilizing the
system.
Dated- Mont / Dav (t Year Zoo
General Contractor (Owner) - Signature
SZ��-TK .
Corporation Name (if corporation) Corporation Name (if corporation)
Address:. T COY -S-t, : �����,�t �crzi prtm. fer Address: �� tt,�Sf. Ff 51 R-aa �
State IYY ' Zip ( °P7 2 State 6)r-ec _firer, /YY Zip / �O
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date: $ a e �,
Street Location Inspecte y: G; �,�gb
— sites -�- s?-rZ� T Owner yorz.sET /foGL�L•/ F3ui�T� 5
Town x>,& T ME 7?, e
Permit # P - _3 .�g
TM # 3 , o - - l a 3 Subdivision Lot # _6 " 1/ae 1,,e -
1. Sewage 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 ..... ... 1,250 ........other ................
b. Septic tank installed level ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
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. Trenches - —
71-en-g-th required foo Length installed
2. Distance to watercourse measured �-gyp o 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 %z" diameter clean ...................
9. Depth of gravel in trench 12" minimum ...................
10. Pipe ends capped ........................ ............................... --�i
g. Pump 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 ....................... .. !Z...4V ..........
IV. Well
a. Well located as per approved plans . ........................... .....
b. Distance from STS area measured ...........
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. Erosion control provided ................. ............................... �=
Rev. 6/97
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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
1 I 1
Date: 6/3l LF� O
R2 ' f, "I1A GE e r— If
'40-
E,4 7 72525o/1
From: Gene D. Reed
Putnam County Department of Health
ZFor your information
For your review
As discussed
Fax #:
No. Pages z
(Including cover sheet) -
;.
Please respond
Attached as requested
Please call
Notes/Messages e-mA► M jEAT"S
4/1� 5-5175, T2Givc�C� 170
NOT" / A97 i:T To 2 _ 1 -,4ge—x7
/- i�"/ovrVT.oG Sio�yE 'DUS%
071MEFAR95MMAROMW ►
In the event of transmission /reception difficulties, please contact this office at
(914) 278 -6130 ext. 2261.
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:
nTO:
Re: Field Inspection LET
wes7� ��-
(T)
P -3G_oa Gprz
Dear:".,
The following comments must be corrected in the field:. p,ld�y
� uSffE'i7 gT°�E
• TflE
Irv- On
T9zEN�
�-G `4'Tins��.:':7tiii� =f ,w /71 ✓ i.� .— .._._. _ _ .�� ✓i�l �itw�7.n. :t.i�f
If you have any further questions, please contact me at (914) 278 -6130 ext. 2261.
Gene V. Keed
GDR:tn Environmental Health Engineering Aide
fieldins
BRUCE R. FOLEY
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845)278,-6130 Fax (845) 278 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
August 30, 2000 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
PW Scott Engineering
Peder Scott
3871 Route 6
Brewster, New York 10509
Dear Mr. Scott:
Re: Field Inspection - Lot 6 "Van Cleef'
West Street, TM# 3.20 -2 -103
Permit # P -36 -00 (T) Patterson
The following comments must be corrected in the field:
• The crushed stone used in the SSTS trenches has a large amount of stone dust and,does
not meet current codes. Only washed gravel or crushed stone "(dust free)" may be used
in absorption trenches.
• Install silt fence below system as shown on the approved plan.
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
GDR:cj
Very truly yours,
Gene D. Reed
Environmental Health Engineering Aide
08/25/00 13:15 PW SCOTT � 19142787921 NO.201 D02
PUrNAM COUNTY DEPARTMENT OF HEALTH
DIVIS[ON OF ENVIRONINIENTAL HEALTH SERVICES
REO�U ST FOR FN- IN PECTION For: Fill
Trenches
PCHD Construction Pe-nit # 36, C1�
Located 7 Egt, f. -
Owner /Applicant Nam,: DM-St �TM 3. Block l- Lot Q3
Formerly ��cti � C�`� � iV, Subdivision Name tb-l�$t°
Subdivision Lot # 6
Is system fill complete i? IV A Date
Is system complete ?_ �Ir. Nbf+) Date ?12-f-160
Is system constructed t s per plans? ` e—S
Is well drilled? Date
Is well located as per Flans? Jtf A
Are erosion control mE asures in place? kA
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 d the Standards, Rules and Regulations of the Putnam County Department
of Health.
Date: Certified by: PE 1/ R.A
esign Professional
af7t Rte, e ' 6 , $wwster J J,
Address (o fV I Lic. # Of
Comments: �Cff?1 'zC"'fn- /1gfj -to itll stcI 4 c� cem lrwn !'Dr
G1,8 s � 1
3)
FOR: 13 ADAM VICENE
Form FIR -99
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
❑ Shop drawings
❑ Copy of letter
[LIEUTEa (DIP
DATE
a& t
JOB NO.
99- 159
ATTENTIO
&-70r_ 1A_,1j 8
RE:
Dorset Hollow Estates XO% -716
(formally Van Cleef Estates)
Subsurface Sewage Treatment
System (SSTS)
Application for Approval of Plans (PC -97)
I
C�Attached ❑ Under separate cover via the following items:
�. Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
1
Application for Approval of Plans (PC -97)
I
1
Construction Permit for Sewage Treatment System (CP -97)
I
1
I Letter of Authorization (LA -97)
1
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 #3j5' / /;3 %d2 q for the amount of $ 3pp,C�-D
1
1
Short Form EAF
THESE ARE TRANSMITTED as checked below:
• For approval
• For your use
❑ As requested
X1 For review and comment
❑ FORBIDS DUE
REMARKS
❑ Approved as submitted
❑ Approved as noted
❑ Returned for corrections
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
List Continued:
4 1 Septic Site Plan Drawings
1 1 E911 Address Verification Form (E911 Verfrm)
COPY TO
SIGNED:
If enclosures are not as noted. kindly notify us at once.
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 # 6 15 West Hollow Road
Brewster, New York 10509
Dorset Hollow Estates
2. Nameofproject: ( formally VanCleef Estj3. Location'TN: Patterson
4. Design Professional: Peder W. Scott, P.E. , R.51. Address: 3871 Route 6
6. Drainage Basin: East Branch Reservoir
7. Type of Project:
X . Private/Residential Food Service
Apartments Institutional
Office Building Realty Subdivision
Brewster, NY 10509
Commercial
Mobile Home Park
Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................... ............................... Type I
Type II
9. Is a Draft Environmental Impact Statement (DEIS) required? .........................
10. Has DEIS been completed and found acceptable by Lead Agency? ............ ....
11. Name of Lead Agency Town of Patterson Planning Board
Exempt _
Unlisted X
No
N/A
12. Is this project in an area under the control of local planning, zoning, or other
officials, ordinances? .............. Yes:,.
........................................... ...............................
13. If so, have plans been submitted to such authorities? ........ ............................... Yes- Subdivision
14. Has preliminary approval been granted by such authorities? Yes Date granted: 1998
Type of Sewage Treatment System Discharge ................. surface water X groundwater
If surface water discharge, what is the stream class designation? .................... N/A
Waters index number (surface) ........................................... ............................... . N/A
Is project located near a public water supply system? Yes
Serviced
If yes, name of water supply Town of Patterson Distance to water supplyby 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 l i- i LI -% 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 cPD
25. Is State Pollutant Discharge Elimination System (SPDES).Permit required ?... No
15.
16.
17.
18.
19.
26. Has SPDES Application been submitted to local DEC offices N/A
. ..........................
Form PC -97
2
27. Is any portion of this project located within a designated Town or State wetland? No
28. Wetlands ID Number ........................................................... ............................... N/A
29. Is Wetlands Permit required? Individual Lo.t No
q ................. ................. .............1.........111.....
Has application been made to Town or Local DEC office? ............................... N/A
30. Does project require a DEC Stream Disturbance Permit? .. ............................... No
31. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ............................ Yes/No No
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes/No No
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? ......................... Yes
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? water-'.only
............................. ...............................
35. Are any sewage treatment areas in excess of 15% slope? ............ No
36. Tax Map ID Number .......................... ............................... Map ?.�w Blocky_ Lot 16:5
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
maybe grounds for the rejection of any submission.
I herehy affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge and helief. False statements made herein are punishahle as
a Class A misdemeanor pursuant to Section 210.45 of the Venal Law.
SIGVATURES & OFFICL4L TITLES.
Mi%ingmA ddress4� ... ...............................
Old
-y CD
Peder W. Scott Agent for Applicant
3871 Route 6
Brewster, New York 10509
14 -16.4 (2187) —Text 12
PROJECT I.D. NUMBER
617.21
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)
SEQR
1. APPLICANT /SPONSOR
2. PROJECT NAME
Dorset Hollow Builders
Dorset Hollow Estates
3. PROJECT LOCATION: ( formally Van Cleef Estates)
Municipality Patterson County P u t n a m
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map)
Lot'# - Dorset Hollow Estates (formally Van Cleef Estates)
5. IS PROPOSED ACTION:
L' I New ❑ Expansion ❑ Modificationlalteration
6. DESCRIBE PROJECT BRIEFLY:
Construction of subsurface sewage treatment system - for single- family
residence and connection to public water sVpply.
7. AMOUNT OF LAN AFFECTED:
L'
Initially acres Ultimately ", acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
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- permit1approvals
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 Pat terson.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 name: P • W . Scott,- P . E . , R.A. Date: d--(� o
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)
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 of fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: !:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly.
C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly,
C6. Long term, short term, cumulative,'or other effects not identified In-C1-05? Explain briefly.
C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain briefly.
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes ❑ No If Yes, explain briefly
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant.
'Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.
❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EA'F and/or prepare a positive declaration.
Q Check -•this box' if you have determined, based on the information and analysis above and any supporting
Ld &unWhtation, that the proposed action WILL NOT result in any significant adverse environmental impacts
°AND Rfigvide on attachments as necessary, the reasons supportfng this determination:
-" p Name of Lead Agency
C�!
:` Print o _*pe Name o Responsible Officer in Lead Agency Title o Responsible Officer
• `-1 --j _ -LC]
Signature of Responsible officer in Lead Agency Signature of Preparer (if different from responsible officer)
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 # 6
(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.
Very tr , Y, . ours,
Edward Dloes '--
G&E Development
PO BOX 352 BEDFORD, NY 10506
of
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Data cf P-- Date of Pe=latic n lest toI��9S
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r are'cb`�ainea -at each :...iat::cn test hole_ ' 'Al- rata to' be
for review.
Z. Depth =a..st ----mP _ s O be sG a z--=, cp of hole.
TEST PIT DATA R1 '= TO BE SUR ilT I'L'K tiYi'M '0x L_ "�,TICLN
DESCP ?'TOE. 2 SOT=S ECCUNr=_ IN TEST HC'_ .3
DzO':� fiC"=. NO. nOL. Imo. f HC=- M.
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INDICATE LUM AT M-11CH GRCON9,,9 M IS aN'COUVT.:aNED _
LEVY TO WHICH WA =, 1= RISES AFTER BEING .=TjJN1?_=
DEB° HOLE OBSERVATIONS MADE BY: DA=-
DESIGN
Soil Rate Used S - -7 Min /1" Drep: S.D. Usable Plea Provided
NS. of Bed owns y Septic Tank Capacity /? :: gals- Tyre P!
Absorption Area Provided By X012 L.F. x 24 "' width trench
Ot1her
Name ;�'W. SCo7' em /Ayr!w /NG�,�,PL.siT�ar�it� igrature
Address :997/ Cock 4 SE<i1L
3 = ���r¢• �i`! to so 9
TFZS SEA= FOR USE BY Er-UTH DEP.Ui= r ONLY: .
Soil Pate Apprcved sc:ft /gal. CheckC3 by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of Dorset Hollow Builders
Located at 71 West Street
TN Patterson Tax Map# 3.20 Block 2 Lot 103
Subdivision of Dorset Hollow Estates (formally Van Cleef Estates)
Subdivision Lot # 6
Gentlemen:
Filed Map # 2 7 7 1
Date Filed 12/24/88
This letter is to authorize P e d e r W. S. c o t s, P. E . , R. A.
a duly licensed Professional Engineer x or Registered Architect to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and/or water supply systems in
conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
Countersigned:
P.E., R.A., #
059346
Mailing Address 3 8 7 1 R o u t e 6
Brewster
State New York
Zip 10509
Telephone: ( 9 1 4 ) 2 7 8 — 2 1 1 0
Mailing Address
Dorset Hollow Builders
15 West Hollow Road, Brewster
State New York
Telephone
Zip 10509
(914) 279 -1339
Form LA -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERMIT
NANIE OF OWNER: lmat STREET. LOCATION: Sd'
REVIEWED BY:/I Iv GR, AS, SRDATE: L TAX MAP =: (CONFIItMED)
DOCUMENTS
'ER�`ITT APPLICATION
VELL PERMIT OR PWS LETTER
?R OF AUTHORIZATION
•N DATA SHEET (DDS)
ORATE RESOLUTION
T EAF
5 -THREE SETS
E PLANS - TWO SETS
(VARIANCE REQUEST
SUBDIVISION
U(__)LEGAL SUBDIVISION
L_)(_)SUBDIVISION APPROVAL CHECKED
UUPERC RATE
UUFILL REQUIRED DEPTH
(—)( CURTAIN DRAIN REQUIRED
GENERAL
ATED IN NYC WATERSHED
!iS SUBMITTED TO DEP
EGATED TO PCHD
APPROVAL, IF REQ'D
P TEST HOLES OBSERVED
CS TO BE WTTNESSED
1PROVAL 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/I200'
)SOIL TESTING LOTS >10 YEARS OLD
REQUIRED DETAILS ON PLANS
)SEWAGE SYSTEM PLAN - (NORTH ARROW)
)SSDS HYDRAULIC PROFILE
)GRAVITY FLOW
)NSTRUCTION NOTES 1 -15
',SIGN DATA: PERC & DEEP RESULTS
CONTOURS EXISTING & PROPOSED
AY & SLOPES, CUT
,"r/GUTTER/CURTAIN DRAINS
SOIL TYPE BOUNDARIES
( lei UTITLE BLOCK; OWNERS NAME ADDRESS
! TM#, PE/RA; NAME, ADDRESS, PHONE#
U(i___)DATE OF DRAWING/REVISION
Z ( DATUM REFERENCE
LOCATION OF WATERCOURSES, PONDS
LAKES,WETLANDS WITHIN 200' OF P.L.
(JPROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
WELLS & SSDS'S W/IN 200' OF SSTS
PROPERTY METES & BOUNDS
COiIMENTS:
Y (REQUIRED DETAILS ON PLANS CONT'D)
(1/ HOUSE SEWER -' /� FT: 4 "0'; TYPE PIPE CAST IRON
NO BENDS; MLA--X BENDS 450 W /CLEANOUT
RENEWALS
(c:::isITE NOTE (NO CHANGE)
FILL_ SYSTEMS
10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
FILL SPECS / FILL NOTES 1 -5
FILL PROFILE & DIMENSIONS
UUFILL IN EXPANSION AREA
FILL GREATER THAN2 FEET
CLAY BARRIER
(_) FILL CERTIFICATION NOTE
DEPTH GAUGES
VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS
UC-JSEPARATION DISTANCE FROM TOE OF SLOPE
T E C
LF TRENCH PROVIDED 601FT MAX.
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED..
Y
DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL
U(�GEOTEXTILE COVER
SEPARATION DISTANCES ON PLAN - FROM SSTS
(�j10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL .
�E20'TO FOUNDATION WALLS
100' TO WELL, 200' IN DLOD, 150' TO PITS
&�100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
10' TO WATER LINE (pits - 20')
C_50' INTERMITTENT DRAINAGE COURSE
( 6 )200'1500' RESERVOM ETC. _ 150' GALLEY SYSTEMS
CZ( _J10' MIN TO LEDGE OUTCROP
SEPTIC TANK
C-:�L10' FROM FOUNDATION; 50' TO WELL
WELL
DIMENSIONS TO PROPERTY LINES
LOCATION OF SERVICE CONNECTION
VIII t 15' TO PROPERTY LINE
/ LLOOP�'
�)(_JSLOPE IN SSTS AREA (520 %)
(_)()REGRADED TO 15 %, IF REQUIRED
DOSE/PUMP SYSTEMS
(_j PUMP NOTES
U DOSE 75% OF PIPE VOLUMEMOSE VOLUME NOTED
U DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
PIT AND D -BOX SHOWN & DETAILED
1 DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
STANDPIPES, 5' BOTH SIDES, DETAIL
15' MIN to CDS = >5 %, 20'4%,25'-3%,35'-l%, 100%-<I%
20' MIN to CD DISCHARGE /100' with 182 cons day discharge
110'MIN to NON - PERFORATED PIPE