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HomeMy WebLinkAbout0282DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -1 -15.1 0ME'll 96 610 -� . kv , 6 1pr Ak 00091 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT #' "' Located at ���'�' C d 5 ji H />- AP Town or QN Owner /Applicant NameefE6;L4E 4 CAHV1 PL'04'I Tax Map 1 %: Block I Lot '16' 1 Formerly �A MNLDi Subdivision Name 60 "w - CZ(M S Subd. Lot # i Mailing Address "VaJ rM oho LkMjo -1O 6T5 -- f Zip to 5 Date Construction Permit Issued by PCHD 2 /2 Separate Sewerage System built by cD Address Consisting of 1'160 Gallon Septic Tank and B P LF �$�' T 11LN Other Requirements: Water Supply: '61p am b4h� 0- Public Supply From 0 or: Private Supply Drilled by App n -E WcLi. 0 l�'��� Building Type -p-e6 i06H(" 6F� Address. Address CLNq N 1� Has erosion control been completed? IL) Number of Bedrooms Has garbage grinder been installed? W 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 d approved plans and the standards, rules and regulations of the Putnam County ep ent of Health. Date: �+ I1 Certified by P.E. R.A. Address P-ON) '�" W4 fl 1 10 c i M License # 05 6 0_� 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 revoc io ,modification or change is necessary. B Title: Date: Y. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 � / | | \ ! .� / i | ' ` ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM f CARD- PX-odef— i 10) i 1 ,� : t Owner or Purchaser of Building Building Constructed by Location - Street K':�\D5V- (,C Tax Map Block Lot pkMH TownNillage Subdivision Name I Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month Day Year Signature: ' Title: Oelt - �t Generd Contractor wnei Signature Corporation Name (if corporation) . Address: A-4 b�EWi- _ State Zip 1M Jl Corporation Name (if corporation) Address: State Rtw Zip Lo 0r Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Directov _ LAB #: 93.904452 CLIENT #: 11170 NON STAT PROC PAGE 2 KOLOSKI, GEORGE DATE/TIME TAKEN: 09/25/99 07:00A 28 BOULDER BROOK LANE DATE/TIME REC'D: 09/25/99 09:00A PO BOX 315 REPORT DATE: 09130199 PATTERSON, NY 12563 PHONE: (914)-878-3282 SAMPLING SITE: SAME : COL'D BY: GEORGE KOLOSKI NOTES...: BATHROOM ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE , SAMPLE TYPE..i POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER �WITH A LOW pH MIGHT BE CORROSIVE TO.METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 865. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICHTHE WATER HAS BEEN SUBJECTED. SOFT WATER: '0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WA/+ ER: 140-300 MG/L 11 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert H. Padovani, M.T.(ASCP) Director ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.904452 CLIENT #: 11170 NON STAT PROC PAGE 1 KOLOSKI, GEORGE DATE/TIME TAKEN: 09/25/99 07:00A 28 BOULDER BROOK LANE DATE/TIME REC`D: 09/25/99 09:00A PO BOX 315 REPORT DATE: 09/30/99 PATTERSON, NY 12563 PHONE: (914)-878-3282 SAMPLING SITE: SAME : COL'D BY: GEORGE KOLOSKI NOTES...: BATHROOM ---------- m --- I -----------������������� DATE FLAG PROCEDURE PUTNAM CNTY PROFILE SAMPLE TYPE..: POTABLE PRESERVATIVES; NONE TEMPERATURE..: COLIFORM METH: N/A ' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD 09/25/99 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 09/25/99 LEAD (IMS) 4.6 ppb 0-15 ppb 9101 09/25/99 NITRATE NITROG <0.2 MG/L 0 _ 10 ' 9139 09/25/99 NITRITE NITROG <0.01 MG/L N/A 9146 09/25/99 IRON (Fe) 0.128 MG/L 0-0.3 mg/1 2037 09/25799 MANGANESE (Mn) 0.077 MG/L 0-0.3 mg/l 2037 09/25/99 SODIUM (Na> 8.41 MG/L N/A 09/25/99 pH 7'2 UNITS 6.5-8.5 9043 09/25/99 HARDNESS,TOlAL 9840 MG/L N/A 09/25/99 ALKALINITY (AS 86.0 MG/L N/A 09/25/99 TURBIDITY (TUR 3.6 NTU 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE LATE S NOT) OF A ' SATISFACTORY SANITARY QUALITY ACCORDI E NEW YORK STATE-` ' AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. jblic schools are set at-15 ppb. Rule for Public Systems requires that no more distribution points h ave a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are-present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a . moderately restricted diet, a maximum of 270 mg/L of Sodium . is suggested. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES q WELL COMPLETION REPOR'�y� �-� S- q Well Location Street Address: Tow illage: G rid # EMap jjq Block ` Lot(s) [S+I Well Owner: Name: Address: / ,) � b S16 046 D W, Use of Well: 1- primary 2- secondary R sidential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion *'-J Compressed air percussion Other (specify) Well Type Screened Open end casing _�� 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 Sea : _ Cement grout _ Bentonite Other Drive shoe: Yes No _ Liner Yet --No Screen Det s Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Se Well Yield Test Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data MlIeasure from land surface- static (specify ft) f� DujrL'nA yield test(ft) Depth of completed well in feet 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 Lo b cL., 6 UO 1 ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Stora a Tank Information Pump Typ Capacity ` Depth I'D-0 Model [ 4 VoltagQWY HP t Tank Type WO 02-volume -2647 Date Well ompi ted P foam Coun ertif ti yqdjqi Date of p Well Driller (sig+ ature) NOTE: Exact location of well with distances to at least two p 9 manent landmarks to be providedi6n a separate sheet/plan. ANDREWS WELLDRILLING Well Drilleep Name A RUMP SERVICE INC. Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES f79 FINAL SITE INSPECTION Date: .2 % Inspected 6 y: Street Location Owner Town 2ft *„may Permit # — 9 TM # [ 3 — / — 15. / Subdivision Lot # P,, Bra e".�oa3�• 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 ........... ............................... f. Trenches 1 . Length required Gxn Length installed 2. Distance to watercourse measured4 zv- Ft.......... 3. Install e g to 4. Slop Vrom nepta e ] 1/32" /foot .:........... 5. 10 ft proper ty line - 20 - oundat'ons.......... 6. Dep511 ren h <30 ; c s f u ace. ......... 7. R o e nsio 0 ° ...................... 8. Siz a . - 1 /z' iamete clean .................... 9. Depgravel in trench 12" minimum ................... 10. Pipe ends ca ped ........................ ............................... g. ose stems Size bfrTmp c am er ................ ............................... 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... 0., III. House/Buildin a House located per approved plans ... ............................... b. Number of bedrooms ............... ....... IV. Well ;Z WO&VA s e e N't n� .. a. Well located as per approved plans . ............................... b. Distance from STS area measured _-I- /DD ft........... c. Casing 18" above grade ................... d. Surface drainage around well acceptable ............ 6.......... V. Overall Workmanship a. Boxes properly grouted ................... .....................6......... 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 Y L' 1V V 1. V 1V11V1L' 1V 13 K - V I Need Zafglbogy e be i Gd ;' phe o r d✓a Cdr C►.N�- 4/i'l // 5 S, orm 3 -� ok )-. 75-.. 'Prop l 54et r 4. 09 -10 -1999 12 :56PM FROM TO 92787921 P.01 a PUTNANX COUit7Y DEPARTMENT OF HEALTH Tr DIVISION OF ENVIRONMENTAL HEALTH SERVICES G NCO RREQ1 EST FOR FINAL M5FEC_ TM-y For: Fill `fRFN7-- �j7U /% Trcncbes�. / PCHD Construction Permit' —5 Located �(V) a47M05MI Owner/Applicant Name C 6,vp y oS�Li TM R' 1.1 Lo: Formerly Vx�If.D�i2 Awk Ca,%Ma'Subdivision Name Q 42 is system fill completed? S Date 0� / Is system complete? ` Date Is system constructed as per plans . ^ Is well drilled ?_ F S Date Q Is well located as per plans? W.5 Are erosion control measures in p ce? 46-45 1 certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance u ith the issued PCHD Construction Permit and approved plans wid the Standards, Rules and Regulations of the Putnam County Department of Health. Date:_ /0 _Certified by:_ �'� /�� �-J Z PF 1 RA oe Design 1'rofessioae! Address Vii ; I /�✓.1 ±� C,•S Lie. 0 �� - Comments, Form FIR -99 TOTAL P.01 FLOOR PLAN /�,r �e RECORD OF PHONE CONVERSATION DATE: TIME: PERSON CALLING: PHONE #: Z %6"G /© g3 REASON wnspection: h`Ov.6 gf L��t <+ Deeps and /or Peres: SCHEDULED FIELD MEETING DATE: TIME: �C9 r ROAD /STREET: TOWN: �'T'�� TAX MAP #: SUBDIVISION: OWNER: COMMENTS: LOT #: rc?> a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PE in AGE TREATMENT SYSTEM .r PERMIT # F V 5 q'I Located at C;vl? 1-1^m �o A Subdivision name F►o4t,DP--Q- 6WL.COM*46 Subd. Lot # Date Subdivision Approved ?� C - Ii Owner /Applicant Name GI0F%L(4E+ 64ko{ j- OLA,5K -I Mailing Address SZVEM t)AV-6 L ACNE Amount of Fee Enclosed 4 *) o 4- Town or Village rRTTa K,#�)0N Tax Map Block i Lot l Renewal Revision Date of Previous Approval N`{ Zip I O's E) I Building Type Lot Area4•6i9A,(- No. of Bedrooms 4 Design Flow GPD 600 Fill Section Only Depth Volume Separate Sewerage System to consist of 405114G C- tfAm Other Requirements: To be constructed by Water Supply: • -26 -9, Public Supply From or: � Private Supply Drilled by 1250 gallon septic tank and $M 1-f A66 + RE�,cH Address Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: P.E. iC R.A. Date Address 2D i i - OWN PAP MWST5 -+ k'� �pso`� License # 6 (01" 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 when idered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permi . oved for arge of domestic sanitary sewage only. By: t.� Title: J�%� -- Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES a DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner GIF—oF -GE * Gi N DY )�_o L-0 5k-) Address $EVEN o AI 6 t,aHE NLEW'�I HK 1 oTD� Located at (Street) CO;"W MA R I lhMAE� NVILA,9-0, Tax Map 00• Block I (indicate nearest cross street) Municipality PNr'rEP-6©M Drainage Basin Lot 1 � , I EttST BR AI-4CH SOIL PERCOLATION TEST DATA Date of Pre - soaking ��'�� �� (9°� Date of Percolation Test 10 Hole No. Run No. Time Start - Stop se Time �n.) De th to Water from Ground Surface (Inches) Start Stop Water Level Drop In Indies Percolation Rate N in/Inch 1-6- 26 ^1H, ` oh 2 10,111 - 11ti" W_ 9-0,� 1114," 401 i 4 5 ,( { p ��s - 10 ..'1 /�o - IL1W 2 40 h% l 4 s' M0 211 19 /�° J 1 3 Ili'- ���� �aa 2� "_ 21`1 %� 1114, X411 4 5 1. 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are ootamea at eauu percolation test hole. (i.e. s 1 min for 1 -30 min/inch, _< 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' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. t HOLE NO. ' ; S HOLE NO. f� 2 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered °- Deep hole observations made by: Date Design Professional Name: RA Wr Ni�1to►fj ; JQ- QEr Address: 20 Miw?owH �-oAD N� �oSoA Signature: Design Professional's Seal mIt. �'�© No 56.24 , <f", fdf? PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Gds' .0)11 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTE Owner Address IN�1 �/ GysgyAN Located at (Street) Z 1Qo V,5 y (/G1— 7W, Tax Map 13 Block 1 Lot (indicate nearest cross street) Municipality P A`T'T 7Z6eAI Watershed eA- i �I2A NGff SOIL PERCOLATION TEST DATA Date of Pre - soaking /2, 91 Is Date of Percolation Test Ig, //S/ g NOTES: 1. Tests to be repeated at same depth until approximately equal 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 WV" ter Water Hole. No Run No Tune Mart Alaps_e Time From r n G ou d Surface (Inches) Start Stop e L gel Drop In Inches Percola on ti Rate :Stop M�n(Inch ; 3 1 9.5',2— /0,'2 1 2 3 1 /SSG - / 5�� X"a 4 5 1 9 "6.? - /®; ;i 30 6 -27% /'z Q-o 2 /9'3© ° / /;oo 3 o - ? l 3e> 3 1/i 0J — /l113 30 .2- 6 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal 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 T7�7C`DL'./"I'111�, �III�r.O_ 1 /!:: �n�� �i, ..� � ..�__ _ _ ��. �I^:T�T � �'��7� •"' /� 7�.��C �9 :.T � �f� I WITHIN Zcd OF THE Flt rlLT'{ LINE 814)_ (g,6) ` � N aw r d) \ \ (8yo) LOT � bl / 4 1. $22 L0,4 � cc m PROPOSED � Y � _ \ 0! F op FC �1 Ft..�e sY '�+4gD W�TLM+DS� I \ qp � Do,' TP.Z T SM4 L / _ z I l � ,p i 0 R 1)V E V I A Y �0 ! Nl� WDEN1tW Tygpg 'AfLe wo WELA op- ti-PTIC'. wTHI> 20o OF THE 7WIpERTY LIWF PROPOSED k` 4 R,fiDitcm RES�DE►JGE i 83C� rol �I / / j el4q °02, Y / moo.. op 1. I 7 V / / Do,' TP.Z T SM4 L / _ z I l � ,p i 0 R 1)V E V I A Y �0 ! Nl� WDEN1tW Tygpg 'AfLe wo WELA op- ti-PTIC'. wTHI> 20o OF THE 7WIpERTY LIWF PROPOSED k` 4 R,fiDitcm RES�DE►JGE i 83C� rol �I / / j el4q °02, Y / moo.. op 1. I ��mayy 30 ,ravel S t7 °f eJ �p�tVB� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM # Owner Address LUSNMAN 1Z�P, L Located at (Street) ltj"o Tax Map 13 , Block 1 Lot (indicate nearest cross street) Municipality FATT67:5,elV Watershed --A57- 137tM 6Z e-# SOIL PERCOLATION TEST DATA Date of Pre - soaking —It/9F,/20 Date of Percolation Test 0/9 g 1 0:0 132 3 22A-- 3 4 5 2- 3 4 v' 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal 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 RECORD OF PHONE CONVERSATION Time: �. Date: j/ -a Person calling: Phone #: Reason (} Inspection: Deeps and /o eres: Scheduled F Time Date Tentative /to be confirmed () ( ) Town: i i I Tax Map 9: Comments: 2 lNA L`� 4 Pecksvil "•- \t White Pond MU pie Use R _S.I,o040S alp P!W Denton; Hoirne Lake JU \41 Solomon Lake j Ii Brews .0..P.Y :'1 1 43 7 12531 V. J� Motu n Yale Corner Be e Terr S.C. 42 iE ESO Buck Mtn 52 84 'ond fiirdP.d C31 May 2 �ft— Corn moomm w N dL 2�1 &.0, Le Y H SF 311 i MTEM LA Town Vine Pbiid J I , " I " r- - ndia d Pon aK Car m I 46 Droo U Dean(. Pond 4 ners 44 48 1, �Arlz�-N I A RECORD OF PHONE CONVERSATION. Time: // L O a Date,: Person calling: Phone #: a _ G (0 Reason ( ) Inspection: (yc.Deeps and/or erc . /drys Rre y,`ou-i per.--:5 Scheduled Fiej- Meetii Time: Date: y Tentative /to be Town:, Road /Street: G O -t2 U,14 ALL2 dl , Tax Map Comments: "14- 1 TRWRERf a s a s SCALE IN tj 1- 800 -345 -7334 a eN l7 0 567.37 19 M ___— ______ 130.5613�v _._r. -r I 1 i' I. J i 14 1< I I gnif -- %� 3. 5 103.86 AC. CAL. N I , 1' 6 ' II 102.98 AC. CAL. I I I f •1 \83.92 AC. CAL. I fl I I 11 I 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: '�IFDR6E + GNDY py05�-1 SEVEN 00-6 LINE BP -EWSTEPL ti'y t oSo°I 2. Name of project: LO' I 190NIDUN- YTS 3. Location TN: PAiTER60N 4. Design Professional: its' i�'c,+to�5, J� YE 5. Address: 1-o MIL-LT-00-1 6. Drainage Basin: E;A-6-r 7. Type of Project: X Private/Residential Apartments Office Building FANG}} PJAD BP- �NSi�R NY 106 09 Food Service Commercial Institutional Mobile Home Park 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 "A 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N A 11. Name of Lead Agency N A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... ICES 13. If so have plans been submitted to such authorities? No 14. Has preliminary approval been granted by such authorities? Ko 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 Distance to water supply NA 20. Is project site near a public sewage collection or treatment system? ................ MO 21. Name of sewage system NA Distance to sewage system NA 22. Date test holes observed 23. Name of Health Inspector M� ��aZ�NS►� -1 24. Project design flow (gallons per day) ................................. ............................... 8 °0 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? ......................... H A Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? Y65 28. Wetlands ID Number ......................................................... ............................... (�ccA�- t11+uJr�gt^aEB 29. Is Wetlands Permit required? ......................................:....... ... ............................. No Has application been made to Town or Local DEC office? No 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 1`tA 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 N ° DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... �� S 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... N o 35. Are any sewage treatment areas in excess of 15% slope? . ............................... No 36. Tax Map ID Number .......................... ............................... Map 1d7 t Block 1 Lot i 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 I.,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I.hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 10.45 o the Penal a aw. ' 7 SIGNATURES & OFFICIAL TITLES: /,,. �✓� /./ Mailing Address: ................................... �o Ml►_►_Tovw 9A Ap gt w6rERt t4 ,Y 105M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # ' J Well Location: Street Address: Town/Village Tax Grid # CVLj KOAH 4AD P0,Tft- ON Map 141 � Block Lot(s) Well Owner: Name: 4EOP -4E+ OoQ' V—oLuSw! Address: -EVEN 5AV-0a 1_AHN Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Faun Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought r + gpm # People Served lb -6 Est. of Daily Usage 003 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling Y- New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type 'V- 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 69-°aV- C,octmMNA Lot No. I Water Well Contractor: T, 6 -P . Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: N A Town/Village µ R Distance to property from nearest water main: N Proposed well location & sources of contaminatio to be provid d on s p ate sheet/plan. Date: Applicant Signature: PERMIT TO CONSTRUCT A WATER 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. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wat 1 driller ce ifed by Putnam County. ' , w 42 Date of Issue � dl � Permit Issu1� icial: Date of Expiration _14 ;!w l Title: C/ Permit is Non- TransferrAble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 M!@ fl. V1lA7Ml M7MIMIMSMIMIMfMIMIMSM7Me�JIgMSMS@ 1P@ MIMIM' M! MI MIM( M@/ 1t! USMA! 1A1 ................ l/ 1eMIMSMiMtM {MfMIMIMi/.V1dMAM9MlMilIRM' ?I1A 5 �� ry I DINIYI lrVlJ11 ;4 Geneva Roe ;ere_ ws Received of. .. The Sum Of For ❑ Cash ❑ Cheek If ALTH DEPT " (9 14).2e -6130 NY 10509 - s :Dollars $ - Tl -1AlV YOUR ✓ �M O ., ❑Credit Card ' . By .' � a PUTNAY COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of GFOP45 GI NDJ o L O's wl Located at G0 AD T/V p�TTC� -�ot�l Tax Map # lfb Block 11 Lot �!1 Subdivision of BoyLPEiP— CAS.. C0'1\M 4 Subdivision Lot # i Filed Map Date Filed Gentlemen: This letter is to authorize H�A 'y \,N, WCAtok-6, JP-' PE a duly licensed Professional Engineer _ 4 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 treatment and/or water supply systems in conformity with the prao�is�ns of Article 145 and/or, 147 of the Education Law, the Public Health Law, and the Putnair.- �i1�7yS`�tary Code. ti1, - l•y*1. Countersigned: ', V P.E., R.&' # '�� va. 5612 �tJFESSO Mailing Address 20 Very truly yours, Signed: (Owner of Property) h R.oAD Mailing Address: 5E JElA oRV", l LAWS !State N `� Zip IO f3t y telephone: State Telephone: Zip Form LA -97 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only 'art 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR: CIEFOP4E t Glwci � V_OL0,�gC-J 12. PROJECT NAME: iVI�J}!L- 3. PROJECT LOCATION: h Municipality PATTjON County p�1TNI�M 4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map) _ C O; H M #+4 12•u /',p lj . ()F- r \ Q9 N£i H' I l�-L, p-0 A'Q .5. P ❑POSED ACTION IS: MNew ❑Expansion ❑Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: I�DIvIpJa,•L 55T5 7. AMOUNT OF LAND AFFECTED: Initially 1, 0 ± acres Ultimately Hof acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? %Yes ONo If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? CAResidential ❑Industrial..._. OCoLnmercial OAgricultural OPark /Forest /Open space 00ther Describe: A)INk>x FAMII. i 0. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FRO1A ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? OYes •§No If yes, list agency(s) name.and permit /approvals 1 1. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? OYes �,I;Vo If yes, list agency(s) name and permit /approval 2. AS A RESULT OF PROPOSED ACTIOiJ WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Oyes l41(go 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF f.1Y KNOWLEDGE 7 Wi N40L,5i X P5 A(4FHT U :.. I 11I t� II r, I. the action is in a Coastal Area, and you are a state agency, comp:a*-2 a Coast:: AS'sess t..:It Form befora proceeding with this essessm .. I' SEOROOm A 12%0- SEDROOAA 3 13' -0" x 10'•0" Ifl BEDROOM 2 OPEN 13' 0" >< 1 MASTER BEDROOM 17,-0 x 18'-8** i SECOND FLOOR =.-1344SF J7 01 > KITCHEN DINING ROOM MORNING ADOAA 13'0" w 12*•0" F-1 OPE N ABOVE LIVING ROOM uo I FAL41LY ROOM 13'.0-st 10'•0" r 1 13* 0• a 17' 0*, FOYER FIRST FLOOR 4828 BATH DRESSING- WALK' CLOSET Ifl BEDROOM 2 OPEN 13' 0" >< 1 MASTER BEDROOM 17,-0 x 18'-8** i SECOND FLOOR =.-1344SF J7 01 > KITCHEN DINING ROOM MORNING ADOAA 13'0" w 12*•0" F-1 OPE N ABOVE LIVING ROOM uo I FAL41LY ROOM 13'.0-st 10'•0" r 1 13* 0• a 17' 0*, FOYER FIRST FLOOR 4828 ...... .... ............ ............... . .... .. ... ..... . ........ . .... ..... . . :�.:.:. ::tip:... J...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECOND FLOOR 4828 = .-1344SF 000, of- - _ s .: KITCHEN :t ji DINING MOOAA p MORNING HOOM 13' 0' • 1 2'•0' L ---� it ir.... orE N , ABOVE LIVING AOO&A i.. FAMILY ROOM FOYE11 �. FIRST FLOOR — 4829 SATH ..L L_. -'�-.1 MASTER BEDROOM a BEDROOM Z OPEN 17'-0 x 16'•B" 11' 0 x tS'•8' = — �i BEOROOM 4 �� �, 1 51'•8'• �c 1 ?' -0' \ DRESSING' BEDROOM 3. WALK' 1 3' -0" x 10' -0' — IN CLOSET SECOND FLOOR 4828 = .-1344SF 000, of- - _ s .: KITCHEN :t ji DINING MOOAA p MORNING HOOM 13' 0' • 1 2'•0' L ---� it ir.... orE N , ABOVE LIVING AOO&A i.. FAMILY ROOM FOYE11 �. FIRST FLOOR — 4829 ..L L_. -'�-.1 MASTER BEDROOM a BEDROOM Z OPEN 17'-0 x 16'•B" 11' 0 x tS'•8' = — �i SECOND FLOOR 4828 = .-1344SF 000, of- - _ s .: KITCHEN :t ji DINING MOOAA p MORNING HOOM 13' 0' • 1 2'•0' L ---� it ir.... orE N , ABOVE LIVING AOO&A i.. FAMILY ROOM FOYE11 �. FIRST FLOOR — 4829 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL IIEALTII INDIVIDUAL WATER S UPPLY&SUBSURFACE SEWAGETREATMENTSYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION C!%5/,1NI A �OAT� NAME OF OWNER Cjgj 1, 69 o4 Of h -r REVIEWED BI RM, GR AS, MB, BH DATE aZ/II TAX MAP # Y N DOCUMENTS Y N PERMIT APPLICATION . PC -I WELL PERMIT_ PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) RATE RESOLUTION SHORT EAF PLANS­. THREE SETS VARIANCE REQUEST FEE SUBDIVISION t/ LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED _,PERC RATE = /6 - 3- d FILL REQUIRED DEPTH URTAIN DRAIN REQUIRED STANDPIPES GENERAL OCATED IN NYC WATERSHED Pal-+ amvwb PLANS SUBMITTED TO DEP ELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PE-RCS= TQB6YWITTIESSEO= Al- :rA -X- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BI /ZBA 100 YR. FLOOD ELEVATION OTI IER REQ'D PERMII'(S) REQUIRED DETAILS ON PLANS SWAGE SYSTEM PLAN- (NORTFI ARROW) 5SDS HYDRAULIC PROFILE GRAVITY FLOW EROSION CONTROLMOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED TION MAP s IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W /IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER- 1/4" FT. 4 "0; TYPE PIPE . NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS CLAY BARRIER HORIZONTAL;SLOPE 3:1 T D FILL SP L NOTES FILL C ERTIFIC E DEPTH GAUG FILL PR & DIMENSION FILL IN EXPANSION AREA TRENCH FTI 13F- T:RENCH :PROVIDED" PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 2 2O': TO FOUNDATION-WALLS� 15' W ELL TO PL - -j h em �)�i r/ 100' TO WELL, 200' IN DLOD, 150' PITS -77100' TO STREAM WATERCOURSE LAKE (inc. cxpan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. 150' GALLEY SYS CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT C FOOTING /GUTTER/CURTAIN DRAINS SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAML'•,ADDRESS TM #,PE /RA; NAME,ADDRESS,PHONE# DATE OF DRAWING /REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. ttiv11'M-to CDS=> 5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,1 *'kf Nle CD discharge /100'with 182 cons day disch SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION COMMENTS- �u Y"��/,�' p!`,ii � 'L, ✓ir� (✓' �OJC . W>=L -1_ `s OAi 12j2 G4414d ? r UO (� � �JGj - pKyfpi9uT1Mi J�Pn�Tq?! O lo.: A�m� 5-E 1 .44 LL o4 22 ►� ,,_aox 44 r. 'lA' �.r • ' � � �, . ��. ,.., f � � ice" , � .�. _, �� - •: X27 s e s�L.'i, D /l - E)VSJD/U Gl AX (iN FC�T A l 2 4 % g 45' 33' 69' 103'2' 58 9' 28' 79' 2-11 i� S4'` Li Iq 51'� 27. IZD` -TV 24 !42' . ►05' ' . s,: ; sops��yy ` 2 s� "g y i4 ! X24 '- ' 2.7