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HomeMy WebLinkAbout0168DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4. -1 -57.2 BOX 2 r1 1 . r , I� �� �or 1 r r1 1 . 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE �``=' CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTE C PCHD CONSTRUCTION PERMIT # P -05 -04 Located at 161 South Quaker Hill Road Town oKAk4kp Patterson Owner /Applicant Name Formerly Mailing Address CaroleA. Kalba Tax Map 4 Block 1 Lot 57.2 Subdivision Name Carole A. Kalba Subd. Lot # B 25 West 81 Street, Apt 12C, New York, New York Date Construction Permit Issued by PCHD 03 -29 -04 Separate Sewerage System built by Sean Kalba Zip 10024 105 GIDLEY ROAD Address PLEASANT VALLEY NY 12569 Consisting of 1250 Gallon Septic Tank and 504LF ABSORPTION TRENCHES Other Requirements: Water Supply: Public Supply From. or: x Private Supply Drilled by Building Type residence Number -of Bedrooms 4 TORLISH & SONS Address Address ARMONK NY Has erosion control been completed? yes Has garbage grinder been installed? no I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putn County artmen of Health. Date: 'Y 00 Certified by Joseph Zarecki P.E. X R.A. (Design Professio Address a ec As oc LLC 11 West Main St. P li N License # 61468 12564 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 priv ater supply shall become null and void when a public water supply becomes available. Such approvals are s bjec o modification or change when, in the judgment of the Public Health Director, such revocatio ific or change is necessary. � f B Y: ' �G^' Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: tip 2 t c� �Z TownNillage: I 1 I �►^ ® N' Tax Grid # Map Block Lot(s) Well Owner: Name: CAPc 7 L Address: �_blIQA) GO. U erz- JCL -R1 2A : 2TZSvN Use of Well: - rima 2- secondary Residential Public Suppl Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion `` A Compressed air percussion Other (specify) Well Type Screened Open end casing--°J Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter _�in. Weight per foot �lb /ft. Materials. Steel Plastic Other Joints: _ Welded Threaded _ Other Seal.-­_ Cement grout _ Bentonite Other Drive shoe v Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped" Compressed Air Hours Yield _P4 gpm Depth Data Measure from land surface- static (specify ft) Q During yield test(ft) 17.S' Depth of completed well in feet G Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface t�'. Gre- �� my t 40 ��� (� '^ tgt�J M't If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Types Capacity Depth IdO ModelM�N /g Voltage 49.3d HP Tank TypdUJYU"C'roLVolume EtewM Com leted Putnam County Certification No. Date of Report 1-5- cur We it r (signatures) - -i-�- NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's N e O Li S4 ek. © M S Address: 14.0. VIV Signature: � ^--zi yam' Date: , `.S O - White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 BRUCE R FOLEY pubix Ffealrh Dtrec:cr DEPARTINI NT OF HEALTH i .Geneva Road Brewster, New York 10509 LORETTA MOLIDiARI R.N.. IAS.N. .l:4ociam Public Hea&A Direuer Dtrecror of Pattant Ssry m $ariroameatal Health (914)278-6130 Foot (914) 279-7921 N slnst Somteea (9141272-6553 WIC (9141 27S .6618 Fut (9W) 278 .6083 Eaily Intervearloa (914) 278 -6014 ?rtachoal (914) 218 -6082 Fax (914) 278• - 6648 3.04 a at ME% I IGIQ i OWNERS NAME- C•r lee e-E TAY MAPiN'U-MBER: y —1 J`^% -2, E911 ADDRESS:' l Sau7-11' TOWN: /�i9 TT�i� S o.v AUTHORMD TOWN OEFICIr1L. y� (Si;riature) 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 -*4th the application for a Certificate of Construction Compliance. cE911*yl- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: {,1. i �� , Town/Village: j'j Tax Grid # Map Block Lot(s) Well Owner: Name: 0A (- Address: _e _)l C9%v� .C3 t4! EiZ- i�.� Ali 2A e—WO/1 Use of Well: - rima 2- secondary Residential Business Industrial Public Suppl Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion­'1-4 Compressed air percussion Other (specify) Well Type Screened Open end casing` Open hole in bedrock _ Other Casing Details Total length < ' . ft. Length below grade Lo_ ft. Diameter in. Weight per foot �lb /ft. Materials---,s Steel _ Plastic _ Other Joints: _ Welded--..s Threaded _ Other Seal tee Cement grout _ Bentonite Other Drive sho�a Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield ?e gpm Depth Data Measure from land surface-static (specify ft) During yield test(ft) /IS- Depth of completed well in feet 4710-5- Well Log If more detailed information descriptions or sieve analyses�sZq>h1 are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surfaced /' /. t -Wv tTe. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 5ttb Capacity'_ Depth 140 Model J 1WL1q/ j Voltage A� O HP 4 Tank Typ4.KW1_ "r4LVolume i _ Date WeiCom Ieted t / ;' Putnam County Certification No. oa_5� Date of Report Y/ _S' We �ri'l. r (signature) NOTE: Enact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's NpCe 12 +fit L L "s- �ZI.Vjv Signature: f r i -77 Date: %5 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 TO ZARECKI & ASSOCIATES, L.L.C. Engineers - Surveyors - Architects 11 West Main Street PAWLING, NEW YORK 12564 (845) 855 -3771 FAX (845) 855 -3772 Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU: ® Attached ❑ Shop drawings ❑ Prints ❑ Copy of letter ❑ Change order DATE: 04 -04 -05 1 JOB NO.: 2000.012 ATTENTION: GN FL —5-- ,6 RE: Kalba South Quaker Hill Road Patterson, New York ❑ Under separate cover via ❑ Plans ❑ Samples the following items ❑ Specifications COPIES DATE NO. DESCRIPTION 1 03 -16 -05 $300.00 Citibank ck #298934697 1 06 -15 -05 WC97 Well Completion Report 1 04 -04 -05 CC97 Certificate of Construction Compliance for STS 1 03 -31 -05 Water Test 4 03 -08 -05 GS97 Guarantee of Subsurface STS 3 02 -28 -05 As built for SDS THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE ❑ Prints returned after loan to us REMARKS: COPY TO ❑ Resubmit ❑ Submit ❑ Return copies for approval copies for distribution corrected prints F If enclosures are not as noted, kindly notify us at once. Client Copy NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN, CT 06037 -9990 (Danbury Office and Sample Drop Off Site: 100 Mill Plain Road, Suite 342, Danbury, CT 068111 o _�M Acoo,RO,y' TELEPHONE: Toll Free (in CT) 800 - 826 -0105 (Outside CT) 800 - 654 -1230 Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 c E -Mail: NELABSCT@AOL.COM www.NortheastLaboratories.com REPORT TO: PAGE 1 OF 1 REILLY CONSTRUCTION DATE SAMPLE COLLECTED: 03/17/2005 ATTN.- TOM BIGILIN TIME COLLECTED: 12:30PM 2140 ROUTE 22 COLLECTED BY: TOM BIGILIN BREWSTER, NY 10509 DATE RECEIVED @ LAB: 03/17/2005 TESTED BY: LAB #11471 DATE TESTED: 03/17/2005 - 03/22/2005 LAB ID# 0504598 -01 REPORT ID# D0504598 REPORT DATE: 03/3112005 SAMPLE SITE: 161 S. QUAKER HILL, PATTERSON, NY SAMPLE POINT: WATER TANK SOURCE: WELL DRINIONG WATER TREATMENT: NONE ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count —Notification Level ** *Action Level <Q= Analyte detected below quantitation limits data deemed estimated. 3= Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or DOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POT AB LE WATER) Approved By: Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 MAXEVIUM CONTAMINANT TEST PERFORMED LEVEL (MCL) OR DATE TIME RESULTS UNITS METHOD # STANDARD TESTED TESTED BACTERIAL: • Total Coliform (Bacteria) ABSENT per 100 ml SM 9223 0 per 100 ml(ABSENT) 03/17/2005 5:OOPM • E. Coli (Bacteria) NEGATIVE per 100 ml SM 9223 Negative 03/17/2005 5:OOPM PHYSICALS: • Color (Apparent) 5 mg/L EPA 110.2 15 03/18/2005 8:30AM • Odor ND mg/L SM 2150 Not to exceed value of 2 on scale 03/18/2005 8:30AM of 0-5 • pH 7.0 mg/L ASTM- D1293 -99 6.4 to 10 Range 03/18/2005 8:30AM • Turbidity 0.14 NTUs EPA 180.1 5 NTUs 03/18/2005 8:30AM CHEMISTRY: • Alkalinity 36 mg/L SM2320B No deemed limits* 03/18/2005 --- • Chlorine Residual <0.05 mg/L 4500CIG - - - -- 03/18/2005 8:30AM • Nitrate Nitrogen 0.66 mg/L as N EPA 353.3 10 mg/L 03/18/2005 3:OOPM • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 1.0 mg/L 03/18/2005 12:OOPM Combined limit for Nitrite plus Nitrate= 1 omg/L as N • Hardness 50 mg/L EPA 130.2 150 mg/L ** 03/18/2005 --- • Lead <0.001 mg/L EPA 239.2 0.015 mg/L* 03/18/2005 --- • Iron <0.01 mg/L EPA 236.1 0.30 mg/L* 03/22/2005 --- • Manganese 0.04 mg/L EPA 243.1 0.50 mg/L * ** 03/22/2005 --- • Sodium 7.9 mg/L EPA 273.1 20.0 mg/L * *3 03/22/2005 - -- ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count —Notification Level ** *Action Level <Q= Analyte detected below quantitation limits data deemed estimated. 3= Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or DOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POT AB LE WATER) Approved By: Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES s,., . , f r Wi M1 Me M Tax Map Block Lot •TOWW"lase,. G 4, Subdivision Name i —B. Subdivision Lot :# I represent that I am wholly ,and completely respao ible for the location, workumuship, material, cautructicm and drainage of he sewage tt ftmt system serving the above- described property, and that i� has bens constructed a s sbawn on the approved pWk or approval sumOmeat iii► to, and accordance with the standard, rules and regalati ons of the Putam County Dcparmvmt of Health, and hereby guarantee to rite owar r, his successoars, heirs or assigns, to place in good operating oondition any pmt of said system o: c by me which faits to operate for a period of two years . I edietely following the dte of approval of dw ``Certificate of Construction Compliance" for the sawaga Uxatmeot syat m o any reps malt by vu to smh system, ww4pt wham the failure to operate properly is caused b,; the wiliftr! or negligtatt ad of the occupant of the bonding utilizing the system. The undersigned fiRSOr ad lees to accept as conclusive the of the Public Health Di imW of the how Coui ►ty Depatim l: of Health as to wbethac or not the failure of the system to operate was caused by 0 ! willful or negHpat act of fbe occupant of the building utilizing the system. ` «i Dated: month 3 -,)Ay !?' Year .2_00 — �Gftiww Contractor (Owner - Signawn Title: err ,i "a —� Corporation Name (if coW. radon). Corporation Name (if corporation) Adjkess' 1?e Address: S-" state ,dfi �4 �,- r Z ;p / State Wk,- Fam CiS 97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE (:I SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Build ing rim 5 a PA Building Constru ted by Location - Street A," Buildin g T YP Tax Map Block Lot Town/Village . l k"A�� Subdivision Name Subdivision Lot # 1 represent that I am wholly and completely responsible .for the location, workmanship, material, construction and drainage of -he sewage treatment system serving the above-described property, and that is has been constructed t s shown one the approved plan or approved amendment utheieto, and in —� accordance with the standard ., rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owns r, his successors, heirs or assigns, to place in good operating condition any' part of said system c,. tnstructed by me which fail;, to operate for a period of two years iraftdiately following the drte of approval of the "Certificate of Construction Compliance" for the sewage treatment systein, a - atly repairs made by me to such system, except where the failure to operate properly is caused b;l the willful or negligent act of the occupant of the building utilizing the system. The undersigned further aLi Tees to accept as conclusive the determination of the Public Health Director of the Putnam Coin ,ty Department of Health as to whether or not the failure of the system to operate was caused by tl : willful or negligent act of the occupant of the building utilizing the System. Daied:, Month 3 ' -.)ay �) Year G'enefal CLodtractor (Owner - Signature Corporation None (if corpr.. ration) Address: f 1, -' -'-. State zip ! p Signature: 3 _ -- Title: Lj,n Rc Corporation blame (if corporation) Address: I o S 61'-d eu t4 UAL I-e ! State 1�1 �� l l r�%Ztp 2- ` �' .r' Form GS-97 PUTNAM COUNTY DEPARTMENT OF HEALTH • DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Inspected by: Street, Location ,ke_e ,/ /// Owner oo Town Permit # Subdivision Lot # 1. Sewage Svstem 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 .................... 6, renc hes 1. Length required ,x; ,moo Length installed .5-,w 2. Distance to watercourse measured 4 o 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'h" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems 1. Size of 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........... IIL House/Building a. House located per approved plans ............. b. Number of bedrooms ........ ..................�..;�'�...... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured 1-3 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 & dinto exist watercourse g. Footing drains discharge away_ from STS area atrolprovided ................. ............................... Rev. 12/02 COMMENTS 1—� /, o ..a L SITE INSPECTION FOR FILL PAD Date: Inspected by: Fill pad located per the approved plan Fill Pad Length Fill Pad Width , Fill Pad Depth Run -of -Bank Fill Quality Slope from Top to Toe Impervious Layer Installed trosion Control Installed Sieve Test Results (if applicable) Additional Comments: Reserved for Field Sketch if Applicable Required Length Required Width Required Depth D PUTIYAM "QQ ',D MR N9NT OF. HEALTH DIVISIONOV11 NR_ ONMENTAL I HEALTH SERVICES ADAM Is] GENE REQUEST FOR FINAL INSPECTION All information must be fully completed prior to any inspections being made. For: Fill - . x Trenches X PCHD Construction Permit# P-05-04 Located: 161 SOUTH QUAKER ROAD. PATTERSON Owter/Applicant Name: CAROT.F xAT,RA TM 4 Block 1 Lot 97-2 Formerly: Subdivision Name: KALBA Subdivision Lot # B Is system fill completed? YES Date: 02-10-0 Is system complete? YES Date: 02-10-05 Is system constructed as per plans? NO Is well drilled? W.R. Date: As of n2-io-m Is well located as per plans? YES ' Are erosion control measures in place? YEs I certify that the system(s), as fisted, 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 epartment - of Health. Date: 02-14-05 Certified by: *nitL PE x RA ig4roftional Address: 11 WEST MAIN STREET. pAWT.TNG, NEW YORK 12SA4 Lic.'# 61468 Comments: CONTRACTOR STRIPPED TOPSOIL PRIOR TO PLACEMENT OF FILL. Form FIR-99 ^ . SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health February 22, 2005 Zarecki &Associates Mr. Joseph Zarecki 11 West Mairi Street Pawling, NY 12564 Dear Mr. Zarecki: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Kalba South Quaker Hill Road, (T) Patterson Lot B, TM #4. -1 -57.2 The above referenced separate sewage treatment system can be backfrlled. The following comments must be corrected in the field. 1. Connection from the house to the septic tank needs to be completed. 2. Erosion control measures must be installed below the well construction area. Please not that all erosion control measures must be installed prior to the start of any construction. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR:cw Sincerely, 44e e / Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health February 22, 2005 Zarecki & Associates Mr. Joseph Zarecki 11 West Main Street Pawling, NY 12564 Dear Mr. Zarecki: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Kalba South Quaker Hill Road, (T) Patterson Lot B, TM #4. -1 -57.2 The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: \ • Erosion control measures have not been installed below the well construction area. This violation may lead to an enforcement hearing and subsequent fines. The violation is to be immediately corrected to minimize the number of days you are out of compliance. Please note that fines may be issued for every day the violation is not corrected. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 161 S. QUAKER HILL ROAD Town or Village PATTERSON Subdivision name CAROLE A. KALBA Subd. Lot # B Tax Map 4 Block 1 Lot 57.2 Date Subdivision Approved 4/12/01 Renewal Revision Owner /Applicant Name CAROLE A. KALBA Date of Previous Approval Mailing Address 25 WEST 81ST STREET, NEW YORK, NY Zip 10024 Amount of Fee Enclosed Building Type RESIDENTIAL Lot Area 1.903 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 1, 250 gallon septic tank and 500 LINEAR FEET — ABSORPTION TRENCHES Other Requirements: To be constructed by TO BE DETERMINED Address Water Supply: Public Supply From Address or: x Private Supply Drilled by TO BE DETERMINED 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: Address R.A. Date -7 �3 O License # 61468 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 whe sidered essary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe proved o ischarge of domestic sanitary sewa only. By: Title: Date: c� - ® ® t White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design - rofessional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # P--o 5 —o "l. Well Location: Street Address: Town/Village Tax Grid # 161 S. Quaker Hill Rd., Patterson Map 4 Block 1 Lot(s) 57.2 Well Owner: Name: Address: Carole A. Kalba 125 West 81st Street, New York, NY 10024 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served 3 -5 Est. of Daily Usage 800 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling x New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling . Well Type �_ Drilled Driven Gravel Other Is well site subject to flooding? ................. Yes No _x Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision Carole A. Kalba Lot No. Water Well Contractor: To be determined Address: Is Public Water Supply available to site? .................................. ............................... Yes No X Name of Public Water Supply: N/A Town/Village N/A Distance to property from nearest water main: N /A. Proposed well location & sources of contamination to be provided on separate shect/plan. Date: ,;)' Applicant Signature: \4'y� PERMIT TO CONSTRU A ATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell ller c ified by Putnam County. ¢ Date of Issue FJ Permit Iss ' Offici Date of Expiration d D Title: Permit is Non- Transfe rab White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 617.20 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 1. PROJECT NAME Carole A. Kalba Kalba SDS 3. PROJECT LOCATION: Municipality: Town of Patterson County: Putnam 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 161 South Quaker Hill Road 5. PROPOSED ACTION IS: ® New ❑ Expansion ❑ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of a 4- bedroom single - family residence with subsurface disposal system and individual well. 7. AMOUNT OF LAND AFFECTED: Initial] 1.903 acres Ultimately 1.903 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) name and permit/approvals: Town of Patterson Building Permit 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes ® No If Yes, list agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION: ❑ Yes E No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MYOWLEDGE Applicant/sponsor name: N 0 Date: '7 Z31 aN Signature: IN If action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment ZARECKI & ASSOCIATES, L.L.C. Engineers • Surveyors • Architects 11 West Main Street PAWLING, NEW YORK 12564 (845) 855 -3771 FAX (845) 855 -3772 TO toll Ln' c losbi WE ARE SENDING YOU ❑ Attached 0 Under separate cover via ❑ Shop drawings ❑ Copy of letter ❑ Prints ❑ Change order ❑ Plans u a the following items: ❑ Samples ❑ Specifications T2 Ar/ Ae2 DESCRIPTION the following items: ❑ Samples ❑ Specifications THESE ARE TRANSMITTED as checked below: ❑ Foy approval ❑ Approved as submitted ❑ Resubmit ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FORBIDS DUE REMARKS ❑ Submit ❑ Return —copies for approval copies for distribution corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED /f enclosures are not as noted, kindly no fy us a n DESCRIPTION w THESE ARE TRANSMITTED as checked below: ❑ Foy approval ❑ Approved as submitted ❑ Resubmit ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FORBIDS DUE REMARKS ❑ Submit ❑ Return —copies for approval copies for distribution corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED /f enclosures are not as noted, kindly no fy us a n Engineers • Architects Surveyors Joseph Zarecki, PE Jeffrey Hecker, LS Curt Johnson, RA David Johnson, CPESC- CPSWA. 11 West Main St. Pawling, NY 12564 (845) 855 -3771 (845) 855 -3772 Fax Website; zorecki,com email: zoreckiassoc @earthlink.net 31 Bailey Ave. Ridgefield, CT 06877 (203) 438 -7094 (203) 438 -7157 Fax July 23, 2004 Robert Morris, PE Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 Re: Kalba STS Dear Mr. Morris: I have enclosed the following for your review: 1. Short Environmental Assessment Form 2. Application to Construct a Water Well 3. Construction Permit For Sewage Treatment System 4. Site Plan for Sewage Disposal System All of the above documents have been revised to show the correct property address: 161 South Quaker Hill Road. Pursuant to our conversation no review fee is required. If you require anything further please feel free to call. Sincerely, David H. Johnson, CPESC, CPSWQ Project Manager DHJ:al Enclosures o`( PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # V " 05 - O 7 rN, i I Located at l-= S. QUAKER HILL ROAD Town or Village PATTERSON Subdivision name CAROLE A. KALBA Subd. Lot # B Tax Map 4 Block 1 Lot 57.2 Date Subdivision Approved 4/12/01 Renewal Revision Owner /Applicant Name Carole A- Kalba Date of Previous Approval Mailing Address 25 West 81st Street New York NY Zip 10024 Amount of Fee Enclosed Building Type residential Lot Area 1, 903 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 500 Other Requirements: 1,250 gallon septic tank and rntion trenches 4- OF le, a.• To be constructed by to be determined Address Water Supply: Public Supply From Address or: x Private Supply Drilled by to be determined 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: Address 11 P.E. x R.A. Date ,5 S41reet, Pawling, NY 12564 License # 61468 APPROVED Fd# C"STRUCTION: 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 nsidered ne essary by the Public Health Director. Any revision or alteration of the approved plan requires a new per ge domestic sanitary sewage only. By: �% Title: Date: Z ' v 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 APPLICATION TO CONSTRUCT A WATER WELL _ please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # 175 S. Quaker Hill Rd, Patterson Map 4 Block 1 Lot(s) 5 7. 2 Well Owner: Name: Address:25 WEST 81 STREET, NEW YORK, NY 10024 Carole A. Kalba Use of Well: X_ Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served 3 -5 Est. of Daily Usage 800 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Constructing a 4- bedroom single-family dwelling for Drilling Well Type x Drilled Driven Gravel Other Is well site subject to flooding? ....................:............................ ............................... Yes No x Is well located in a realty subdivision? ...................................... ............................... Yes x No Name of subdivision Carole A. Kalba Lot No. B Water Well Contractor: to be determined Address: Is Public Water Supply available to site? .................................. ............................... Yes No x Name of Public Water Supply: N/A Town/Village N/A Distance to property from nearest water main: N/A Proposed well location & sources of contamination to be prow' ed on separ a sheet/plan. Date: 1 - - 014 Applicant Signature: PERMIT TO CONSTRIkT �WA�ER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated represegtative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. / revision or alteration of the approved plan requires a new permit. Well to be constructed by a water w 11 ller c Tied by Putnam County. 1&_-A. Date of Issue 2G Permit Iss ' fficial: Date of Expiration Title: Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Dec 10 03'05:02p Manitou Rrchitects 617- 451 -6187 p.2 Fl- '00 . ij • y. 1 r- J 1 . r. 1 ZARECKIo & ASSOCIATES, L.L.C. Engineers • Surveyors* Architects 11 West Main Street PAWLING, NEW YORK 12564 (845) 855.3771 FAX (845) 855 -3772 TO lJ f`a 2 22 i5 ? 'hg- ( 0 WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via • Shop drawings ❑ Prints ❑ Plans • Copy of letter ❑ Change order ❑ Iff ffU M @[F U D ° 1HQMUU DATE ' N JOB NO., _ I Sun ATTENTIO (XJ RE: _5 r�)e2 We. ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION lj d f S THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ 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 SIGN l�lsL/ G if enclosures are not as noted, kindly L6 us at Ice. ZARECKI Engineers • Architects Surveyors Joseph Zarecki, PE Jeffrey Hecker, LS Curt Johnson, RA David Johnson, CPESC- CPSW®. 1 1 West Main St. Pawling, NY 12564 (845) 855 -3771 (845) 855 -3772 Fax Website: zarecki.com email: zareckiassoc @earthlink.net 31 Bailey Ave. Ridgefield, CT 06877 (203) 438 -7094 (203) 438 -7157 Fax March 16, 2004 10 ' Robert Morris, P.E. Senior Public Health Engineer Environmental Health RE: Application for Approval of'SSTS Kalba,161 S. Quaker Rd, Lot "B" Town of Patterson, TM #4 -1 -57.2 Dear Mr. Morris: The following is a response to comments offered in your February 26, 2004 letter. Enclosed are three sets of the following plan: Sheet 1 of 1, "Site Plan for Sewage Disposal System ", last revised 03/15/04 1. The scale of the SSTS plan has been changed to 1 " =30'. 2. The proposed expansion area on Lot "A" has been shown on the plan. 3. The fill has been shown extending 10 feet horizontally past the edge of any trench. 4. The basement elevation has been provided in the plan view. 5. The proposed well location has been dimensioned from two property lines. 6. As requested, three sets of plans has been submitted. We have confirmed that the construction of this sewage disposal system is not subject to any local wetlands regulations. As previously submitted, Gene Reed from your office witnessed the percolation tests on May 10, 2000. We trust the enclosed information and revisions is sufficient for your office to issue an approval. If you have any questions or require additional information, do not hesitate to call. Sincerely, 2000.012 ZARECMI & AS. SOCIATES, L.L.C. Engineers • Surveyors,* Architects 11 West Main Street PAWLING, NEW YORK 1'2564 M (845) 855 -3771 FAX (845) 855 -3772 TO WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ IMUU M OL U ° e HMOTT&A, DATE JOB NO. ATTENTION. RE: V� �' Q _ l C L��u % S-' 3 ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION V� �' Q _ l C L��u % S-' 3 - o', Lft q-7 of THESE ARE TRANSMITTED as checked below: • For approval • For your use ❑ As requested ❑ For review and comment ❑ FOR BIDS 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 COPY TO SIG tf D: If enclosures are not as noted, klndlyY,otlfy usa once. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner CAROLE A. KALBA Address366 S. QUAKER HILL ROAD, PATTERSON, NEW YORK Located at (Street) Tax Map 4 Block 1 Lot 57. Z (indicate nearest cross street) Municipality PATTERSON Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test Hole :N Run No Time Star Stop El a se Time Min) Depth to Water From Ground : Surface (Inches) Start 'Stop : Water Level Dropp In Inches Percolahoil. Rate Miu/Inch. 1 1 1:36 -2:06 30 22 23 1 30 2 2:09 -3:09 60 22 23 1 60 3 3:11 -4:11 60 22 23 1 60 4 5 2 1 1:4241:51 231 261 3 3.0 2 1:53 -2:04 11 232 261 3 3.7 3 2:06 -2:22 16 231 261 3 5.3 4 2:24 -2:40 24 232 261 3 8.0 5 2:50 -3:14 24 232 261 3 8.0 3 1 1:43 -2:13 30 261 294 2 3/4 10.9 2 2:15 -2:45 30 262 281 2 15.0 3 2:47 -3:17 30 264 281 2 15.0 4 5 NOTES: 1. Tests to be reneated at same denth until annroximatelv eaual percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min /inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' I t TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. 1 HOLE NO. 2 HOLE NO. 3 TOPSOIL TOP SOIL � TOP SOI L MEDIUM_ BROWN LOAM MED. BROWN LOAM MED. BROWN LOAM Indicate level at which groundwater is encountered 615" Indicate level at which mottling is observed ,i n Indicate level to which water level rises after being encountered 6' 5" Deep hole observations made by: WALTER ARTUS /GENE REED.PCDH Date 5/10/00 Design Professional Name: J�,��� Address: :-)G Signature: al 2 LORETTA MOLINARI Public Health Director ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Zarecki and Associates 11 West Main Street Pawling, NY 12564 Dear.Sir: February 26, 2004 RE: Proposed SSTS: Kalba, 161 S. Quaker Rd, Lot "B" (T)Patterson, TM #4 -1 -57.2 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. Current codes requires that the minimum scale of SSTS plans are 1 " =30'. 2. The proposed expansion area on Lot "A" is to be shown on the plan. 3. Fill is to be shown extending 10 feet horizontally past the edge of any trench. 4. Basement elevation is to be provided in the plan view. 5. Proposed well location is to be dimensioned from two property lines. 6. The minimum of three sets of plans are to be submitted. 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 Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. .Vepmuly y0 s, Robert Morris, P.E. Senior Public Health Engineer RM:Im LORETTA MOLINARI Public Health Director DEPARTMENT. OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 'Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 February 26, 2004 Zarecki and Associates 11 West Main Street Pawling, NY 12564 RE: Kalba, 161 S. Quaker Rd, Lot "B" (T)Patterson, TM #4 -1 -57.2 Reservoir Basin Dear Sir: ROBERT J. BONDI County Executive The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on _January 27, 2004 is complete. The Department will notify you by March 18, 2004 of its determination. X The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department 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 Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. 4 y Letter to: Zarecki and Associates — February 26, 2004 -2- If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. RM:lm Ve t ly yo Robert Morris, PE . Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: VIEWED BY: RM, GR, AS, SRDATE: TAX MAP #: (CONFIRMED) Y N DOCUMENTS Y E UIRED D TAILS ON PLANS CONT'D PERMIT APPLICATION OUSE SEWER -1/" FT. 4 "0'; TYPE PIPE CAST IRON LL PERMIT OR PWS LETTER UU NO BENDS; MAX BENDS 45° W /CLEANOUT C -97 RENEWALS LETTER OF AUTHORIZATION C_) ZORIZOXTAle-PIST NGE) ' DESIGN DATA SHEET (DDS) al -LL SYSTEMS )(,/)CORPORATE RESOLUTION TRENCH SLOPES 3:1 TO GRADE ( (_ - - (_,Z HORT EAF U FILL SPECS/ FILL NOTES 1 -5 (_) PLANS -THREE SETS PROFILE & DIMENSIONS HOUSE PLANS -TWO SETS (_)FILL IN EXPANSION AREA __)C_—)VARIANCE REQUEST FILL GREATER THAN FEET SUBDIVISION LAY BARRIER (LEGAL SUBDIVISION �S (FILL CERTIFICATION NOTE "LOCATED IVISION APP OVAZ CHEC __)DEPTH GAUGES CRATE ( UNCLASSIFIED & IMPERVIOUS REQUIltED DEPTH �U� —)VOL. ON PLAN FOR R O.B., TAIN DRAIN REQUIRED — EPARATION DISTANCE FROM TOE OF SLOPE GENERAL dE C IN NYC WATERSHED LF TRENCH PROVIDED 60FT MAX. / PLANS SUBMITTED TO DEP PARALLEL S CONTOURS L—) �) 00% EXPANSION PROVIDED ELEGATED TO PCHD DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL �) DEP APPROVAL, IF REQ'D GEOTEXTILE COVER DEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSTS PERCS TO BE WITNESSED 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL EX- APPROVAL SSDS ADJ, LOTS 0' TO FOUNDATION WALLS WETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 200' IN DLOD,150' TO PITS DATA ON DDS PLANS & PERMIT SAME 100' TO STREAM, WATERCOURSE, LAKE (inc. eapan) PRE 1969 NEIGHBOR NOTIFICATION 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER LETTER BUZBA )10' TO WATER LINE (pits - 20') jam, 100 YR. FLOOD ELEVATION W/I200' �( 50' INTERMITTENT DRAINAGE COURSE ;_ /(_)SOIL TESTING LOTS >10 YEARS OLD `7" 00' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS E U ED DETAILS O PLANS �) 1 ' TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK SSDS HYDRAULIC PROFILE FROM FOUNDATION; 50' TO WELL GRAVITY FLOW WELL CONSTRUCTION NOTES 1 -15 (C.—�DIMENSIONS TO PROPERTY LINES DESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNECTION T CONTOURS EXISTING & PROPOSED �)(�MIN 15' TO PROPERTY LINE fp/�� DRIVEWAY & SLOPES, CUT SLOPE FOOTING /GUTTER/CURTAIN DRAINS SLOPE IN SSTS AREA 520 %) USDA SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME ADDRESS U)U )REGRADED TO 15 %, IF REQUIRED ATM#, PE/RA; NAME, ADDRESS, PHONE# DOSE/PUMP SYSTEMS )DATE OF DRAWING/REVISION )DATUM REFERENCE )LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS )WELLS & SSDS'S W/IN 200' OF SSTS )PROPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01/00 (__) UMP NOTES �� OSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED �) ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) U� 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' -1 %,100 % - <1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge YNjlO'MIN to NON - PERFORATED PIPE ZARECIa & ASSOCIATES, L.L.C. Engineers • Surveyors • Architects 11 West Main Street PAWLING, NEW YORK 12564 (845) 855 -3771 FAX (845) 855 -3772 TO��G A-Y14 I WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter DATE JOB NO. NO. ATTENTI G RE: � IIII F k ❑ Attached ❑ Under separate cover via the following items: ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Change order ❑ COPIES DATE NO. DESCRIPTION i THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ 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 i COPY TO SI N If enclosures are not as noted, kindly tify us once. i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Carole A. Kalba Located at 175 South Quaker Hill Road T/V Patterson Tax Map # 4 Block. 1 Lot 57.2 Subdivision of Carole A. Kalba Subdivision Lot #Parcel B Filed Map # 2858 Date Filed 4/12/2001 Gentlemen: This letter is to authorize Joseph Zarecki, PE 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., # 6 Mailing Address 11 Wess Main street Pawling Very trul ours, Signed: (O (Owner of Property) Mailing Address: New York State NY Zip 12564 State NY Zip ,n,4 Telephone: 845- 855 -3771 Telephone: 212 - 686 -1203 Form LA -97 ¢ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'J. APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Carole A. Kalba 25 West 81st Street, Apt. 12C New Yokki NY 10024 2. Name of project: . Kalba SnS 3. Location TN: Patterson. 4. Design Professional: .TcIRPn}t Via, e�k; , PE 5. Address: 11 West Main Super 6. Drainage Basin: Croton Pawling, New York 12564 7. TVUe of Proiect: x Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt _ Type II Unlisted x 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency N/A 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? ........ ............................... N/A 14. Has preliminary approval been granted by such authorities? Date granted: N/A 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? ....... ............................... No 19. If yes, name of water supply N/A Distance to water supply N/A 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system N/A Distance to sewage system N/A 22. Date test holes observed 5/10/2000 23. Name of Health Inspector Gene l Reed 24. Project design flow (gallons per day) ................................. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... :2 No N/A Form PC -97 4 - r.. 27. Is any portion of this project located within a designated Town or State wetland? No J 28. Wetlands ID Number ........................................................... ............................... N/A 29. Is Wetlands Permit required? .......................... ...... ............................................... 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 pesticid:;s to orchards or other crops, solid or hazardous waste disposal, landfill] :, -, sludge application or industrial activity? ............................ Yes/No No 32. Is prcje:;t located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potc.ntially known source of contamination? ............................... Yes/No No DESCRU E: 33. Is there a local master plan on file with the Town :or Village? ......................... Unknown 34. Are comanunity water and/or sewer facilities planned to be developed within 15 years or adjacent to project site? ................................ ............................... Unknown 35. Are any scwage treatment areas in excess of 15% slope? . ............................... No 36. Tax Mal, "ID Number .......................... ............................... Map 4 Block 1 Lot 57 N 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All appli:.ations for review and approval of a new SSTS to be located witlun 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 rcvicw 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 subn:;i 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 accompam cd by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grout;:.:;, for the rejection of any submission. I hereby .r frm, under penalty of perjury, that information provided on this form is true to the be:;'' of my knowledge and belief. False statements made herein are punishable as a Class;` :rrisdenrearror pursuant to Section X10.45 of tlzAPerral4aw. SIGNATURES & OFFICIAL TITLES: Mailing Addre,, i :.... ............................... ZareckA& Associates, LLC 11 West Main Street Pawling, New York 12564 617.20 a 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 1. PROJECT NAME Carole A. Kalba Kalba SDS 3. PROJECT LOCATION: Municipality: Town of Patterson County: Putnam 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 175 South Quaker Hill Road 5. PROPOSED ACTION IS: ® New ❑ Expansion ❑ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of a 4- bedroom single - family residence with subsurface disposal system and individual well. 7. AMOUNT OF LAND AFFECTED: Initially 1.903 acres Ultimately 1.903 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) name and permit/approvals: Town of Patterson Building Permit 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes ® No If Yes, list agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION: ❑ Yes ® No I CERTIFY THAT THE INFORMA N PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: ! Date: I — R - 04 Signature: 31 If action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment 09/21/2004 15:00 FAX 845 855 3772 ZARECKI AND ASSOCIATES 1,11,A Ll "A 1,14 4� PROPOSE'O SEPTIC AREA I'UTNAh9 DEPAR.7MEN T OF HEA TH �4 APPROVED 5,`1011,04 G�' I 1 ��:: � ,�/ "J DECK - ` ✓ PROPOSED 4 CEO cO0(N / + , DWELLING f L } C) t4�M�r T ur a /Y M'EC w 256 5 _ „'�,JP --x— wIRr rENC'f- QUAKER HILL ROAD �I002 H"MF- PI ITNQM CYII INTY npPAPTMFNT f1P P q 09/21/2004 15:00 FAX 845 855 3772 ZARECKI AND ASSOCIATES ZAJDLXECKI ASSOCIATES, L.z.._c. Consulting Engineers, Land Surveyors, Architects 11 West Main Street Pawling, NY 12564 (845) 855 -3772 fax (8451. 855-3771 11 .. - To: , Robert P/lorlis, P.E. From: Dave Johnson Fam 278 -7921 Pages: 2 Phone: Date: 9/21/04 Re: - Kalba Job #: Z Urgent [] For Review ❑ Please Comment ❑Please Reply ❑ For Your Use • Comments: Rob, Enclosed is an Excerpt from Kalba's Plot Plan as given to the Town of Patterson Building Inspector. paul'Piazza. The dashed line shown .is the proposed'housa as shown on the approved septic plan. The solid line is the actual proposed house. As you can see, it falls entirely within the approved footprint and actually provides more separation to the proposed septic area. Could you please call Paul and explain to him that a new PCHD approval is not required? Let me know how you make auL -Dave rc �ti V I�t t Uf M c < 6 U& 'SURVEYING _� la 001 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 FAX COVER SHEET Date: 12-2--bq To: TAOL— l a2- A From: Robert Morris, P.E. . Senior Public Health Engineer —ZFor your information For your review As discussed Fax #: Z-V f I No. Pages (Including cover sheet) Please respond V Attached as requested Please call Notes/Messages (4 � �` ��"sU l QUA 4Z- ­Mf- aN4, PLAA W-06C o sJeAly" I 5w&L-c/t- -5- C tj Oc3�� o_ � JJ tj --M v_d:Lf 41Itl)A i�.,IC 04-, 0 -%q4 T VLA 05 APB_ rklE�- In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 ext. 2166. J FILED MAP #1316 . NIF ANDRE (L. 745, P. 889) I RIMARY SYSTEM ROWS AT 56 LF PTION TRENCHES 4 SOLID PVC (TYP.) Of, � JUNCTION - BOX (TYP.) 54 FA EXIS77NG 4 BEDROOM RESIDENCE 4 "o PVC SOR35 - 1,250 G.� SEP TIC TANK 4"0 CIP r-B DIMENSION TABLE A B 1 35.0' 18.5' 2 30.5' 36.0' 3 32.5' 43.0' 4 36.0' 50.0' 45 39.5' 55.0' 6 43.5' 61.0' 7 48.0' 67.5' 49 52.5' 72.5' 57.0' 78.0' 10 63.0' 85.0' 11 91.5' 71.0' 12 92.0 75.0' 13 95.0' 80.5' 14 97.0' 84.5' 1 99.0' 89.0' �- 103.0' 94.5' 17 105.5' . 99.0' 1 108.5' 105.5' 1 111.5' 111.0' 20 245.0' 233.0' DIMENSION TABLE