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HomeMy WebLinkAbout0306DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -2 BOX 4 00115 Lq I. O` II �` ,� 00115 01SION TNAM COUNTY DEPARTMENT OF HEALTH OF ENVIRONMENTAL HEALTH SERVICES C IFICATE OF CONSTRUCTION MPLIAN FOR SEWAGE TREATMENT SYSTEM PCH C NSTRUCTION PERMIT # Located at C /&k�,- D)�1 VI,- Town or Village A +77 :f eft Owner /Applicant Name f 2r A 6&W (' Tax Map /3 Block -- Lot Formerly Subdivision Name Subd. Lot # R Mailing ddress �j, jj % _ /� g � �° �� � l � 1'j !�'(% � dh l °� /� GGals !" Y Zip % 6 603 i Date Construction Permit Issued by PCHD '71�1 t! Separate Sewerage System built by Address (9/e�'i 'ear 's- J� y Consisting of Z�j ® Gallon Septic Tank and��i�- Other Requirements: — Water Supply: Public Supply From Address or: X_ Private Supply Drilled by f l k7T Address Q e+-S aA/ /J y Building Type MOIDVW -- Has erosion control been completed? ~- Number of Bedrooms Has garbage grinder been installed? I�( 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 pf the Putnagi County Department of Health. Date: Certified by i P.E. R.A. / 1 y esig t d e � nal) Address d ��J ' LA) License # 3Z 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 ar subject to modification or change when, in the judgment of the Public Health Director, such revocation,,, o ification change is necessary. By: Title: SAL- 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: / Caroline Dr. Town/Village: I oO,�,Ilersvi! Tax Grid # Map 3. Block &� Lot(s) a Well Owner: Name: Address: �G Use of Well: 1- primary 2- secondary _ Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion i/1, Compressed air percussion Other (specify) Well Type Screened Open end casing V Open hole in bedrock _ Other Casing Details Total length ft. Length below grade a 0 ft. Diameter Tin. Weight per foot / % lb /ft. Materials: t/ Steel _ Plastic _ Other Joints: _ Welded _ ✓Threaded _ Other Seal: _ Cement grout V"Bentonite Other Drive shoe: i/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 X Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) 17 re,ct During yield test(ft) Depth of completed well in feet 'QO 4G 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 3 If yield-was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Complete /r 7 Putnam County Certification No. 0®7 Date of Re ort /" .30 Well Driller (signature) . NOTE. Exa t location of well with distances to at least two permanen an ks to be provided on a separat go. eet/plan. Well Driller's Name ,� _AA Signature: Address: Date: 43_�-oA � White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 the se,,3ce disaosal s s da was cronstiu t T.n }s is • to certify that AS -BUILT y `— ed as indicated'on this plan and .that the systea was inspected by me before it was covered over. 1'ne MEASUREMENTS' system was constructed in accordance with all standard rules and • e regulations of the Putnam County Department of health and the New York e state Dzpar"t of Health." Department o ea n7'�A : 1..E', Y'. tnam County th Sei c :' ,d ru tal Real -� .� •y , ° ,...,... i Division oY EnvironmenCe With noted Yor cony the tea"• aX • �' r ` APB ved as lations of 1 ' 1 able Rule an ReBu aitme °sj ^� 1 a gealth DeP nam co 1 Date 1 SignatuTe & Title I �f 0 40 ", ,i ►+ pis- 61vr`i SCIkL� �• 1 I 1i*y1V4f770N Su,pVU y /SY Q ` ' r•;'• f OFAR `ry NP� 00% No A REMARKS I ti -:B 2 I Z. 0 � Sc ri t n► p 31 (oZ 4 ., JD - s5 37 4 qq 3 b y5 33 -7 yl 32 8 38 33 �G 2v 1 Iz In5 �H 13 ► O9 y/��1 14 113 '9q I-S 11"i IOL VO !7 VT ! < i,o .... y . (, ,s� -rM4� 13-1-.2- s bo i I zq 33 tniD N� I 7. Go v ' - i fr 37 3v tic i Av�anl� e x w er- cr.uo. A5- 8� ►e-T sSDs �:' 6Rq/VC� Gib 91 96 �,✓ 7Viz D a: 2oc i v&- lvlf�soA/ (7) 1 vc�r �� �► a �orXt�,D/JGGL�2S r�3o. . JOIN KARELL JR P.E. oen IF- l q a- terra. JAVir10763 � I I aaa Subject to any conditions, restrictions, covenants and right of gays /easements of record, if any. 0 Tn. ; • M ; � o to M . -A rQ o n I 9z' q� A coo VIV a QC �0 ,�•, rf r� J Vn.fan9rauhC utl iitin0 LOT #8 1 1699 acres 2 story_ N frame house ` d ®tFc � anaformor h.'. tip+. . w CLIENT- FRED $4 ETHELTON ROAD - WHITE PLAINS, NEW E : c® i Q t� . ^. REVISED: 7/24, ae PARCEL SHORN DESIGNATED t�O 8 AF „ , ON. A 14AP ENTITLED, FINAL PLAT PREPARED FOR AR .f: c T. ODELL, SITUATE IN THE TOWN OF PATTERSON, PUTNAM CO,.' ORK°, DATED JULY 28, 1987, LAST REVISED AUGUST 27, 9987, FSEP',..ED BY DONALD J. DONNELLY, L.L.S. & RANDOLPH K. LAURENT, P.E.. AND F`.ILED IN THE PUT,INIAM COUNTY CLERKS OFFIC ON OCTOBER 22. 1987 AS FILEEO t?HP 0227 1. CAROLINE 0 I V FAO► ..1 C #i `r' P :3B9 �q. tMi ld�l9eTMIADLMPIVOAAI"IALF A MIM ?MSrtw?AM O�AIMIMFMiAAi". t t0.�6M?MeM7MiMaMiMOM:O. 0 97 S. BROADWAY Phone: (914) 758.6612 N Nchardlones RED HOOK, N.Y. 12571 FAX: same email: professional engineering services for the home - septic - structural - site design March 30, 1998 PUTNAM COUNTY HEALTH DEPT, ENV SERVICES ENGINEERING REPORT: INDIVIDUAL SDS PLAN: LOT 8, ODELL S /D, T /PATTERSON THE ATTACHED APPLICATION IS FOR A 1 FAMILY SDS FOR LOT 8, ODELL SUBDIVISION, TOWN OF PATTERSON. TEST DATA: ORIGINAL DEEP HOLES TO 7 FT SANDY SILT NO BED ROCK, NO GND WATER. ORIGINAL PERC TESTS: 6 -7 MIN. . NEW TEST DATA: I HAVE INSPECTED THE PROPERTY AND FOUND NO CHANGES FROMTHE ORIGINAL PLAN. I HAVE CONDUCTED A NEW DEEP HOLE TEST TO 8 FT WITH NO BED ROCK, NO GND WATER, SOIL A SILTY LOAM. A NEW PERC TEST WAS PERFORMED AS SHOWN ON THE PLAN WITH A 7 MIN RATE. SDS PLAN FOR 3 BED ROOM RESIDENCE: 600 GPD,1,250 GAL SEPTIC TANK, 300 FT LATERALS PER ORIGINAL PLAN. I FOUND NO UNUSUSAL NOR CHANGED CONDITIONS FROM THE 8/87 PLAN. REGARDS, RICHAR S . . DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 April 13, 1998 Richard Jones 97 S. Broadway Redhook NY 12571 RE: :application to Construct a Subsurface Sewage Treatment System at Caroline Drive, Lot #8 (T) Patterson Dear Mr. Jones: 0 BRUCE R. FOLEY Public Health Director The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on April 2, 1998 is incomplete. Please be advised that the following information is required before the Department may commence its review. • Construction permit has not been submitted. 0 Short EAF has not been submitted. 9 Standard Form PC -97 has not been submitted. 0 Design Data Sheet has not been submitted. • Letter of Authorization has not been submitted. • House plans have not been submitted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Dept. Of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (914) 278 -6130 ext. 166. RM /tn Very truly yours, Robert Morris, P. E. Public Health Engineer 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: 2. Name of project: 4. Design Professional: 6. Drainage Basin: 3. LocatioON: f-1 k7 5. Address: 7. Tvpe of Project: 1 �> S 7/ - 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 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... U 10. Has DEIS been completed, and found acceptable b Lead Age P Y A g Y? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... S 13. If so, have plans been submitted to such authorities? �1 S, ..... 14. Has preliminary approval been granted by such authorities? Date granted: )c)lf 7 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? ............:....... 17. Waters index number (surface) ....................... . .................... ............................... 18. Is project located near a public water supply system? ....... ...........................:... 19. If yes, name of water supply 20. Is project site near a public sewage collection or 21. Name of sewage system 22. Date test holes observed 24. Project design flow (gallons. Distance to water supply reatment sy Xf istance em ................. C) to Y sewage system ame of Health Inspector ) .................................. ............................... 60 C-�' 25. Is State Pollutant Discharge Elimination. System ( SPDES) Permit required ?... 26. Has SPDES Application'been submitted to local DEC office? . ......................... Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ............................ ............................... ............................... 29. Is Wetlands Permit required? ............................................... ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... c� 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 A)-Q 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 fy DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within d 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... C) 36. Tax Map ID Number .......................... ............................... Map Block Lot 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. Ihereby affirm, underpenalty ofperjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Pena Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... e C Se f 106-o3 GENERAL NOTES: 1) All trees within 10' of laterals shall be removed. 2) No garbage disposal units to discharge into this septic system. 3) Distribution box to be baffled at entrance and levelers to be installed in outlets(Tuff-Tite or equiv) 4) Distribution box and septic tank to be installed on 12" bed of pea gravel. 5) Max trench depth for laterals is 18 ". 6) No cellar, roof nor water softner drains to discharge into septic system. 7) This plan is approved as meeting appropriate and applied technical standards, guidelines, policies and procedures for arrangement of sewage disposal and treatment and water supply facilities; and, as a condition of this approval, inspection by the Health Dept shall be conducted to determine that construction at the time of inspection was completed in conformance with this plan & ammendments thereof. No part of the system shall be backfilled until inspected by the Health Dept. 8) The design, construction and installation shall be in accordance with this plan and standards in effect at the time of construction which include: A) APPENDIX 75A, WASTE TREATMENT- INDIVIDUAL HOUSEHOLD SYSTEMS, NYS SANITARY CODE. B) WASTE TREATMENT HANDBOOK, INDIVIDUAL HOUSEHOLD SYSTEMS, NYS DOH. C) RURAL WATER SUPPLY, NYS DOH. D) NYS DOH AND COUNTY DOH POLICIES, PROCEDURES AND STANDARDS. 9) WELL SPECIFICATIONS. A) Well casing to extend 12" above grade. B) A pitless adapter shall be installed 60" below grade. C) Well shall be grouted along entire length of casing. D) Water supply line to be 3/4" "K" copper burried 60" below grade. E) Well location accessable for installation/service of well and water line. 10) If septic tank is delivered in sections, then the contractor shall demonstrate to the Health Dept. field official and /or a licensed engineer that the tank joints are sealed, water tight and acceptable for use. 11) Disturbed soil area to be covered with top soil, seeded and mulched within 2 weeks of SDS completion. Use hay -bale dams as required to prevent soil erosion. 12) Under normal use the septic tank should be pumped out (to remove solids) evey 3 to 4 years. TESTS: 3/10/98: deep holes; #3) 96" no bed rock, no gnd water, soil: sandy silt; perc test #3, 7 min. Above tests performed by R. A. Jones P.E., are supplemental to original tests made 8/87. DAILY FLOW: 600 GPD, 3 bed rooms; 1,250 gal septic tank, 300 ft of laterals(5 x 60 ft) PIPE SPECS: A) 4" sewer pipe, cast iron; min pitch: 1/4 " per ft, min length 10ft. B) 4" solid Sewage plastic pipe ( 3,000 lb test), joints sealed, min pitch 1/8" per ft. C) 4" solid Sewage plastic pipe, (3,000 lb test)joints sealed, min pitch 1/8" per ft min length 4 ft. D) 4" perforated Sewage plastic pipe, (3,000 lb test) pitch: 1/16 to 1/32" per foot Snellifil.11ranca Three bedroom residence desied by: lot 0 Odell s/diu Richard ones P.E. C %7' OF NF4 ,e*f® 97 S. BROADWAY Phone: (914) 758 -6612 Tfflmmom/12/98 RED HOOK, N.Y. 12571 FAY: same email: SHEET 1 OF 2. SDSPLAN - Branca Three bed room _w ^ `� residence designed by: ;_ ar O '. lot 8 Odefl s /diu Richard Jones P.E. ��t ` 97 S. BROADWAY Pbone: (914) 758-6612 ®- r,, -CnsR T FAX: same gd + °Be "5x uie ":GB9°a9?y /� RED HOOK, N.Y. 12571 email: SHEET 2OF2 A,' —�—G -00 — 00 _._. - - -- -- - -- — — -- j — -- SF. / ; � { /��rvltP ! Ik - v N� i I' I 0 tl a. 5C4 ss1�/� j ANS` j _ TTY 1 6 / R a mow Sf�7i *lt�(► JAN -18 -1999 23 =14 TOWN OF CARMEL P.01i01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM zc_�ed zron.60 Owner or Purchaser of Building J 0h e /l Building Constructed by C_0,0-6Z1&"0 Dom- Location - Street Building Type FA Tax Map Block Lot Town/Village )Gt'll Subdivision Name, am 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 beers 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. Address: % 1rC1hMen1'e,_1X�j a State .1v K Zip 1a6-03 Signature: Title: Corporation Name (if corporation) State Zip - Form GS -97 TOTAL P.01 ar.,. e{ 4Ylnl ,'� WW ,I `h 1 � /VSO - ocv -Ov Z 3 M 0 0 3 0 1 I z3o,5 f) , A� = 30 At S�Q. �- oh� ✓ e BRUCE R. FOLEY Public Health Director John Karell 121 Cushman Road Patterson NY 12563 Dear Mr. Karell: LORETTA MOLINARI RN., M.S.N. Associate Public Health Director �Y Director of Patient Services DEPARTNWNT VV HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Re: Proposed Compliance Branca Caroline Drive (T) Patterson January 12, 1999 N 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) Guarantee of Subsurface Sewage Treatment System has not been submitted. Three copies are required. 2) Current codes requires that metes and bounds are to be provided on the as- built plan. A separate survey is acceptable, if the survey is part of the as -built plan, e.g., if it is provided as second sheet. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly yours, Robert Morris, P.E. Senior Public Health Engineer RM:tn � .. Documentation,For Certificate Of Compliance �-;..., i^To R Morris ' From: 'Fred BrancA='z ?. i Caroline,Dnve� Patterson, 14Y,', 12`563 Date: 1/08/98 Attached please find the following, - One Cashiers Check For $200.00 - Letter Of Authorization - Certificate Of Construction - Well Completion Report - Water Test - 3 Copies Of The As -Built Septic Plan - 1 Copy Final As -Built Survey Plan Please note that the water test from YML Environmental Services on 10/28/98 passed all criteria except for the Coliform. On 12/18/98 I had an Ultra Violate Light System and Water Softener installed by Culligan. On 12/21/98 I had the water tested for Coliform and the water passed. It is now deemed drinkable. Both water tests and documentation from Culligan are attached to the water tests. If you have any questions or if I have forgotten to include any documentation, please call me at 914 - 641 -3776. To assist me in meeting my closing date of 01/20/98 please call me at the above phone number when the Certificate Of Compliance is available, I would like to pick it up on the same day and deliver it to the Building Inspector. Sincerely, Fred Branca STRE FACILITY NAME- `" '�. n � � s�+� � ADDRESS ! � ��,� \ __ SAMPLING POINT: TOWNS .� '.- SOURCE: INKING iNATER D SU_ RFACE WATER; E] WASTE WATER OTHER TREATMENT D CHLORINATED(` PPM ❑FREE RESIDUAL UV��� ❑OTHER w s D TOTAL RESIDUAL ° COLLECTED BY _ -. DATE LAST SANITIZED NERED BY DEL T RECEIVED A �o PMONE # D MQNITOR(NG SAMPLE HECK AMPLE-, z y DATE SAMP : _i RE I D TIM ICED Y EX TiAINED fIME .� 1' REPS TES TECH AM �� PM S` AM YO M I1— D `MFT A TOTAL COLIFORM'COIINT PER 100 ML < E D MFT D MPN FECAL COLIFORM COUNT - . * R 100 ML PE - ,STEP _COU J, ❑ MFT FECA PER 100 ML I . D HETEROTROPHIC PLATE`COUNT `, "; - - PER 1 MI. COLT ❑ POSIfi1VE ❑. ,NEGATIVE D MISG; { TH,ESE.RESULTS INDICATE THAT..THE WATERSAMPLE DID x - D DID NOT. ` AT t �4..DRINKING t MEET SATISFACTORY SAN1-TARY QUALITY FORD SWIMMING O WASTEWATER (EFFLUENT ^- l 4 WHEN ;THE SAMPLE `WAS COLLECTED. FO.R' 3 INFORMATION " - CONCERNING UNSATISFACTORY SAMPLES ;f AEASE CALL THE HEALTH DEPARTMENT AT l li i ri CUSTOMER :COPY, Documentation For Certificate Of Compliance To: Mr. R. Morris From: Fred Branca 1 Caroline Drive Patterson, NY 12563 Date: 1/08/98 Attached please find the following, - One Cashiers Check For $200.00 - Letter Of Authorization - Certificate Of Construction - Well Completion Report - Water Test - 3 Copies Of The As -Built Septic Plan - 1 Copy Final As -Built Survey Plan Please note that the water test from YML Environmental Services on 10/28/98 passed all criteria except for the Coliform. On 12/18/98 I had an Ultra Violate Light System and Water Softener installed by Culligan. On 12/21/98 I had the water tested for Coliform and the water passed. It is now deemed drinkable: Both water tests and documentation from Culligan are attached to the water tests. If you have any questions or if I have forgotten to include any documentation, please call me at 914 - 641 -3776. To assist me in meeting my closing date of 01/20/98 please call me at the above phone number when the Certificate Of Compliance is available, I would like to pick it up on the same day and deliver it to the Building Inspector. Sincerely, � WE Fred Branca YML ENVIRONMENTAL SERVICES ` 321 Keaf Street Yorktown Heights, N.Y. 10598 ` ` ^ (914) 245-2800 Albert H. Pa^ovani, Director LAB #v 93.901700 CLIENT #: 9867 NON STAT PROC PAGE 2 BRANCA JR.,FREDERICK F DATE/TIME TAKEN: 10/28/98'08:35A 1 CAROLINE DR DATE/TIMERE&Dr 10/28/98 10:00A PATTERSON, NY 12563 ' REPORT DATE: 12/30/98 PHONE: (914)-878-3372 SAMPLING SITE: KITCHEN TAP SAMPLE TYPE..: POTABLE : PRESERVATIVES: 'NONE -CQL'D BY: FRED BRANCA JR. ' TEMPERATURE;.: NOTES...: COLIFORM METH: MF_ ' DATE FLAG PROCEDURE RESULT NORMAL - RANGE ` METHOD moderately restricted diet, a maximum of 270 Mo/L of Sodium - is suggested. ^' pHSCALE 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 |H IS 6.5 TO 8.5. Hd TOTAL HARDNESS 15 DEFINED AS THE SUM OF THE CALCIUM & MAGNESrUM CONCENTRATION, BU|M 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 WHICH THE 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 WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) n ' SUBMITTED BY: Alber H. Padovani, M.T. KIT �P) Director . ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -8 FINAL SITE INSPECTION j� q 1 e,,l y,,, em s Date: o r 9 s C 1 C trn�! Inspected by: -e4 Street Location _ CA o[ /�lG 'Drt � j5 Owner ?,q �/ �} Town ir'.9 *�PPso,y Permit T1\1 r 3 — — �r Subdivision Lot # 8 " ©'T__-) i5c-c'. I. Sen-age System Area a. STS area located as per approved plans... .............. b. Fill section - date of placement 3:1 barrier Lath.-- 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 ............ ............................... j c. 10' minimum from foundation ....... .............................C� 1L d. Distribtuion Box 1. All outlets at same elevation - water tested........Aes- Junction 2. Protected below frost ........... ............................... 3. Minimum 2 ft.Original soil between box & trenc Box - properly set :.. 5' .. ............................?�' I . Le �tFi required Length installed . 2. Distance to watercourse measured + ;Z o d Ft.......... I Installed aceordi Teppg'�p o Sloe och a1/ 6 - 1 /'2 " /foot.....�� �. 10 m prop r� li �01ke - undations.......... 6. Dep• of I in hes from surface .................. %. Roo lfor expansion, 100 % ......................... 8. Size gravel 3/4 - 1'/2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Svstems ISize 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........... III. HouseBuildina a. house located per approved ............................ b. 'Number of bedrooms ........ ....:.. szRe�:y .......... IV. Well a. Well located as per appro lans..... ...................... b. Distance from STS area measured ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area.........., h. Surface water protection adequate ............................� i. Erosion control provided ............ ............................... RPV 1 /Q7 COMMENTS - � 1 e Fru /a// 7 Date 12 - o- g "°) ,I G" 1)1 1 Address City ."Fir o Phone T � 9.1 Bus. Phone Directions to Installation d Price - Model........... Price -. Model........... ._ .........10 :.:. ..... .. G� "�iLtYZJ $............ j ............ $.f�.:.. Other.................... n.................................................................................................. $ ............................... e , Total ' $.... PAYMENT INFORMATION 411 16. COD, THREE CHECKS, OTHER 'ii VISA/MC# Exp. Date BALANCE DUE: INSTALLATION PIPE -SIZE: 1, 1 1/2,2 INFORMATION ,(3A4 / TYPE: opper Galvanized, Plastic HOW MANY FEET? D BYPASS OUTSIDE: Yes N9) Other ELECTRIC: Yes No WHERE? DRAIN TRAP NEEDED: YA) No s TYPE? REMOVE OLD EQUIPMENT: Yes No PSI REDUCER NEEDED? Yes No SALT SETTINGS: 5P lbs. cZ down gallons PSI SINK TYPE: DRILL FAUCET HOLE? Yes No FAUCET LOCATION: FILTER LOCATION: RESERVIOR TANK LOCATION: ICE MAKER: Yes No EXTRA TOOLS: LADDER DRILL SAW SNAKE SOCKET PLUG OTHER i CHECK LIST CUST. ; ORDER APPROVED WARRANTY PR508tS SIGNED INSTALLATION LEFT CLEAN SERIAL DATE ALL PROPER NUMBER INSTALLED INSTALLER PAPERS LEFT =T 0 1 - M-F Name Address k City A07-7—, rr ro /� X1.1 ��! /•�fi� Phone p Bus. Phone Directions to Installation d=am gal / Date J Price - Model ......................................: �............. ...............................� 'c�J $..........� . ............ Price -. Model .. ��.7�� $ Price Model..i. a y . ....... ......... ........ �:--- ........ O_ther .................... .................................................................. ............................... $ ............................... F Total $.....,- ..... PAYMENT INFORMATION COD, THREE CHECKS, OTHER VISA/MC# Exp. Date BALANCE DUE: INSTALLATION INFORMATION PIPE -SIZE: ,(34; 1, 1 1/2,2 TYPE: opper Galvanized, Plastic HOW MANY FEET? / Z) BYPASS OUTSIDE: Yes N Other ELECTRIC: Yes F WHERE? Off/ 4 -02 DRAIN TRAP NEEDED: ) No s TYPE? REMOVE OLD EQUIPMENT: Yes No PSI REDUCER NEEDED? Yes No SALT SETTINGS: 0' lbs. down A gallons PSI SINK TYPE: DRILL FAUCET HOLE? Yes No FAUCET LOCATION: FILTER LOCATION: RESERVIOR TANK LOCATION: ICE MAKER: Yes No EXTRA TOOLS: LADDER DRILL SAW SNAKE SOCKET PLUG OTHER CUST. =: L ORDER APPROVED WARRANTY PREMIS S SIGNED INSTALLATION LEFT CLEAN SERIAL DATE ALL PROPER NUMBER INSTALLED INSTALLER PAPERS LEFT 'L-ACCOUNT NO. 0 ORDER DATE OF THE HUSDON VALLEY CITY ZIP ,CITY RES PHONE, /� ?> 7L OWN LJ RES PHONE BUS PHONE'�2 -t 1 RENT ❑ DIRECTIONS SOCIAL SECURITY NO. EMPLOYER RESIDENTIAL ® COMMERCIAL ❑ OTHER MUNICIPAL ❑ PRIVATE WELL ❑ OTHER OCCUPANTS x;; GPD = ESTIMATED WATER USAGE A HARDNESS '1• Z GPG IRON id PPM SULPHUR bAQ PPM pH L ALKALINITY " PPM TDS PPM OTHER RECOMMENDED TREATMENT BASED ON WATER USAGE AND WATER ANALYSIS AS RECORDED ABOVE AT TIME OF SALE. QTY. POUGHKEEPSIE EQUIPMENT . .,,DESCRIPTION., �„ ,n r ' NEWBURGH SOURCE SVC LOC (800) 334 -0220 OA 131 LITTLE BRITAIN ROAD LITTLE B AI (800) 288 -3728 INSTALLED DATE (914) 454 -4010 NE , 12550 (914) 561 -3728 FINANCE BILL ALL ` NAME _�' /��a_'.�s11 ,-.s �'`ir? o �.r, �+ .: r2 NAME LESS RECEIVED WITH ORDER ❑ CASH ❑ CHECK ADDRESS i �.�' �' =- .'� % ADDRESS TAX CITY ZIP ,CITY RES PHONE, /� ?> 7L OWN LJ RES PHONE BUS PHONE'�2 -t 1 RENT ❑ DIRECTIONS SOCIAL SECURITY NO. EMPLOYER RESIDENTIAL ® COMMERCIAL ❑ OTHER MUNICIPAL ❑ PRIVATE WELL ❑ OTHER OCCUPANTS x;; GPD = ESTIMATED WATER USAGE A HARDNESS '1• Z GPG IRON id PPM SULPHUR bAQ PPM pH L ALKALINITY " PPM TDS PPM OTHER RECOMMENDED TREATMENT BASED ON WATER USAGE AND WATER ANALYSIS AS RECORDED ABOVE AT TIME OF SALE. QTY. MODEL EQUIPMENT . .,,DESCRIPTION., �„ ,n r ' - ;PRICE QTY. MODEL EQUIPMENT =:DESCRIPTION , :.`RATE '- FINANCE TAX ❑ OPEN ACCT. TOTAL $ LESS RECEIVED WITH ORDER ❑ CASH ❑ CHECK TAX TOTAL RATE PER MONTH FINANCE ; :'J .. TAX ui/ ❑ OPEN ACCT =�' �� TOTAL $ LESS RECEIVED WITH•.ORDER 0;-CASH r ZIP BUS PHONE • INSTRUCTIONS NEW CONNECTION REPLACE EQUIP. PRE PLUMBED CULLIGAN AUTOMATIC DELIVERY SERVICE SALT ❑ Y ❑ N RESUP ❑ Y ❑ N BOTTLE WATER ❑ Y ❑ N PEROXYDYL ❑ Y ❑ N INSTALLATION CHARGES INSTALLATIONAIIAOUNT $ ✓�/ QTY. MODEL EQUIPMENT =:DESCRIPTION , :.`RATE '- FINANCE TAX ❑ OPEN ACCT. TOTAL $ LESS RECEIVED WITH ORDER ❑ CASH ❑ CHECK TAX TOTAL RATE PER MONTH $ 30 DAY WRITTEN NOTICE TO CANCEL ZIP BUS PHONE • INSTRUCTIONS NEW CONNECTION REPLACE EQUIP. PRE PLUMBED CULLIGAN AUTOMATIC DELIVERY SERVICE SALT ❑ Y ❑ N RESUP ❑ Y ❑ N BOTTLE WATER ❑ Y ❑ N PEROXYDYL ❑ Y ❑ N INSTALLATION CHARGES INSTALLATIONAIIAOUNT $ ✓�/ FINANCE TAX ❑ OPEN ACCT. TOTAL $ LESS RECEIVED WITH ORDER ❑ CASH ❑ CHECK SPECIAL INSTRUCTIONS IN THE EVENT A DRINKING WATER SYSTEM IS REMOVED, CULLIGAN WILL PROPERLY COVER THE HOLE IN THE CUSTOMER'S SINK. CUSTOMER UNDERSTANDS THE SINK WILL NOT BE REPLACED. A CREDIT REPORT MAY BE REQUESTED FROM A CREDIT BUREAU IN CONNECTION WITH THE RENTAL. YOU, THE BUYER, MAY CANCEL THIS RENTAL OPTION T• PURCHASE TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD 90 DAY OPTION * 100% OF BASIC CONNECTION CHARGE BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE 100% OF RENT ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. 1 -YEAR OPTION * 50% OF RENT CUSTOMER AGREES TO THE TERMS AND CONDITIONS ON THE REVERSE SIDE HEREOF. A (Buyer's Name) • 1 (SELLER'S I4L% NC (SELLER'S ADDRESS) Promotional Code Check if applicable 0 Delayed Payment. Finance Charges computed as described in your Cardholder Agreement, but no Minimum Monthly Payment is due for months. 0 Finance Charges computed as described in your Cardholder Agreement b inning in months. Minimum Monthly Payments will be due. elaved Pavment/Waived Finance Charge. No payment due far____ months. Finance Charges computed as described in your Cardholder Agreement beginning in months. 0 Spme As Cash. finance Charges computed as described in your Cardholder Agreement and Minimum Monthly Payments will accrue monthly. If you pay the cash sale price in full by the promotion due date at least -months following the purchase, no finance charges will be due on the purchase. 0 Same As Cash/Delayed Payment. Finance Charges computed as described in your Cardholder Agreement and no Minimum Monthly Payment will be due until the promotion due date, at least _ months following the purchase. If you pay the cash sale price in full by the promotion due date• at least months following the purchase, no finance charge will be due on the purchase. BUYER'S RIGHT TO CANCEL YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA) AFTER THE DATE OF THIS TRANSACTION. SEE THE // CWOADD -ON I REP. 10. DELIVERY INSTRUCTIONS 0TAKE 0SEND DATE OF DELIVERY OUAN. I DESCRIPTION CASH SALE PRICE U&DEL SERIAL DATE OF SALE JALITH.CODE SUB TOTAL •� SALES TAX INVOICE NUMBER CASH PRICE WV SELLER'S AUTH. REPRESENTATIVE �� -- CASH DOWN PAYMENT Amount Financed (Unpaid Balance) ------ — �• ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION l OF THIS RIGHT. Buyer cknowI'dges receipt of a completed copy of this sales slip and that the purchase of described merc ndise shall be in accordance with the Cardholder Agreement referenced by the account number a ring above. U A FOR CT (DENTS: THIS INSTRUMENT IS BASED ON A HOME SOLICITATION SALE, WHICH SALE IS SUBJECT TO THE OVISIONS OF THE HOME SOLICITATION SALES ACT. THIS INSTRUMENT IS NOT NEGOTIABLE. FORM 6006 - NATL- SAC/RES (11/96) (EXCEPT AL, AR, AZ, DC, FL. GA. IN. KY, ME. ND. NJ, OK. OR. RI. WA and WI) PAGE 1 OF 2 (ATTACHED NOTICE OF CANCELLATION MUST BE GIVEN AT THE TIME OF SALE) COSTOMER COPY YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 242-2800 Albert H. Padovani, Director LAB #: 93.801700 CLIENT #: 9867 NON STAT PRQC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~�~~~~~~~ BRANCA JR. ,FREDERICK IF' 1 CAROLINE DR PATTERSON, NY 12563 DATE/TIME TAKEN: 10/2B798 08:35A DATE/TIME REC'D: 10/28/p8 10:00A ` REPORT DATE: 12/30/98 PHONE: (914)-878-3372 ` SAMPLING SITE : KITCHEN TAP SAMPLE TYPE..: POTABLE : PkESERVATIVES: NONE " COL'D BY: FRED BRANCA JR.� TEMPERATURE"": ~^^ NOTES : ' COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~y~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT - NORMAL - RANGE METHOD . PUTNAM CNTY'PROFILE 10`28/98 MF T. COLIFORM PRESNT /100 ML ABSENT 1008 10/28/98 LEAD (IMS) 4,2 ppb 0-15 ppb 9101 10/28/98 NITRATE NITROG 1.59 MG/L 0.- 10 9139 10/28/98 NITRITE NITROG 0.082 MG/L N/A 9146 , 10/28/98 IRON (Fe) <0.060 MG/L 6-0.3 mg/l 2837 10/28/98 ` NANGANESE (Mn) 01010 MG/L 070.3 mg/l 2037 10/28/98 SODIUM (Na) 2.36 MG/L N/A 10/28/98 pH 7.3 UNITS 6.5-8.5 9043 10/28/98 HARDNESS,TOTAL 334 MG/L` N/A 10/28/98 ALKALINITY (AS 348 MG/L N/A 10/28/98 TURBIDITY (TUR <1 NTU* 0-5 NTU 10/28/98 MF FECAL COLIF ABSENT 100'ML ABSENT 10/28/98' E. COLI (CONFI ABSENT 100/ML ABSENT COMMENTS: BACT THESE RESULTS INDICATE'THAT THE WATER (WAS A . ' SATISFACTORY SANITARY QUALITY ACCORDING TO THE NI T-YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS . TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits fbr public schools are set at 15 ppb. EPA Lead VCopper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15.ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. ` Fe/Mn If both iron and manganese are present, their total value . combined shall not exceed0.5 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at TN A �&s V1'j Tax Map TF' / Block Lot Subdivision of 0�� --t-- j Subdivision Lot Filed Map # r,�% l Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer or _ 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 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., # Mailing Address State Zip 2. Telephone: `� `" o' Very truly yours, Signed:�`�`-� _:2z� (Owncr of Property) Mailing Address: / 6 "" State /1/� f al eze Zip Telephone: &— �7� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of ��,• �. �j'� �-� A (� Located at ZZ 41 { Tax Map # Block Lot o Subdivision of Subdivision Lot # Filed Map # o Date Filed Gentlemen: This letter is to authorize v �� a duly licensed Professional Engineer � 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 provisions of Article 145. and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Si ed: � t� P.E., R.A., # (Owner of Property) Mailing Address 9 7 _177/ Bhrwoler Mailing Address: State A2 y Zip �/ State �� _Zip /C) Telephone Telephone: C21 �n �Z ~ 7 r7� �lq �Y� — -3�'l 4 4 . ( Plh�e ILI, )A�)_ Form LA -97 A/ VAAtl MI AAYAI!IAAIAAIAAIMIAAIMIADIM1", MA IMiMIAA MAR MCMaMEMeM:n.�!Me A 7 c r Q off OF , tvWl1lYAW7WI1/11[WIWIYNIi / ytllNl1l11lNlll W1WIWIWIWIY/VIWIeJN71lVIWIiN[ � ' IYINTH11IWay' 1 W71I 1' IayyAHl' iIyN1Yl II: Yl 111WI Hy7r yl WIWtWIyV :�IVSifNtlt/VIYI/IWrNVaWi� S G mchaffliones R97 S. BROADWAY ED HOOK, N.Y. 12571 FAY:e: (me) 758-6612 email: professional engineering services for the home - septic - structural - site design SEPT 17, 1998 _b ROBERT MORRIS PE PUTNAM COUNTY HEALTH DEPT, GENEVA RD RT 312 Z BREWSTER, NY 10500 0 RE: BRANCA SEPTIC DISPOSAL PLAN, LOT 8, OtIJELL SUBDIV; T /PATTERSON AS I RELATED TO YOU BY PHONE WHEN I STAKED OUT THE LATERALS PER THE APPROVED PLAN, I FOUND THAT THE GRADE TIPPED UP MORE THAN 2 FT OVER THE 54 FT LENGTH OF THE LATERAL. THIS WOULD NOT PROVIDE A PROPER TRENCH WITH A MAX DEPTH OF 18 ". ACCORDINGLY I HAVE RE- ORIENTED THE LATERAL FIELD TO FOLLOW THE CONTOUR WITH 10 X 37,5 FT LATERALS AS SHOWN ON THE ENCLOSED REVISED PLAN. MR BRANCA WILL APPRECIATE YOUR EARLY REVIEW, IF POSSIBLE, SINCE HIS LEASE IS UP ON OCT 1ST AND HE WOULD LIKE TO MOVE INTO THE NEW HOUSE BY THEN. HE WILL GLADLY EXPEDITE PLANS TO HELP IF IT WILL HELP AT ALL. REGARDS, RI HA D JO PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CO STRUCTION PERMIT PERMIT # r- 0, Located at TREATMENT SYSTEM Subdivision name jown orX44ge 04 112 ,v sd�j Tax Map lock _7 Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name Vie/ h a-,7--, Date of Previous Approval %� Mailing Address � ,e l ! Zip _A3 Amount of Fee Enclosed / j Building Type r _ Lot Area No. of Bedrooms Design Flow GPD_�lj Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED r-• Separate Sewerage System to consist of gallon septic tank and j�4,� Other Requirements: To be constructed f l°I [ t✓iz ��i y " ®IA ddre s i -�, � A�*G Water Supply: �� "U. ' ddress �'d/ 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 Date License #� 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe i Approv or discharge of domestic sanitary s ge only. By Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 h .f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and addres 2. Name of project: 4. Design Professioi 6. Drainage Basin: �� f 7. TvDe of Pro'ect: 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 (SEAR)? Type Status (check one)... Type I Exempt Type II Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... N� 10. Has DEIS been completed and found acceptable by Lead Agency? ...... 0 cc� C'-- .s 11. Name of Lead Agency 1 Lv. 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? 13. If so, have plans been submitted to such authorities ............ .......................y�G ^-e�c �Ys 14. Has preliminary approval been granted by such authorities? Date canted: 7 j PTO s 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? ............ :....... 17. Waters index number (surface) ............................................ ............................... 18. Is project located near a public water supply system? ..... ................. L.0 ...... 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ iy 6 21. Name of sewage system Distance to sewage system 22. Date test holes observed 5 22 R0' 23.' Name of Health Inspector 4 L 24. Proje�ei flow (gallons per day) ........ .......... ............................... �. r. \i^ 25. Is SW6 P'oY.*htDisu- barge Elimination System (SPDES) Permit required ?.. ti —. . 26. Has SPDESppi'i`�a ion: been submitted to local DEC office? ......................... Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? r-) 28. Wetlands ID Number ......:.:.................................................. ............................... 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... v 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 N 32. Is project located within 1,000 feet of existing or abandoned landfill, 'hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with th own ge? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... CD 35. Are any sewage treatment areas in excess of 15% slope? ........................... r% 36. Tax Map ID Number ......................................................... Map 3 Block Lot 37. Approved plans are to be returned to ..... �_ Applicant 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 stormwaterylans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES. Mailing Address: .................................... Lt �c, 4 l2 h -L t 617.20 Appendix C State Environmental Quality FL-view SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only Part 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLIC T ONSOR- 2. PROJECT NAME: S 3. PROJECT LOCATION: Municipality - ,{'��S County 4. PRECIS LOCATION: (Stry ' address and road (n rsections, prominentt 12ndrnarl s, etc., or provida map! ' S. R POSED ACTION IS: j VNew C2Expansion DModificatiomJaiteration 6. DESCRIBE PROJECT BRIEFLY: / _ q � f l S � 7"s 7. AMOUNT OF -AFFECTED: Initially ^ c acres Ultimately y ° acres S. WILL PROPOSED ACTION COMPLY W!TH EXISTING ZONING OR OT HER EXISTING LAND USE RESTP.ICTIONS? iYas DNo If No, describe brieflv 1 i 1 9. WHAT IS PRESENT LAND USE IN VICINiT'r OF PROJECT? j Rgsidentiai Olndustrial OCornm- eroia: OA$ricultural OPark,Forest.-Open space ❑Other .scribe: i I 10. DOES ACTION INVOLVE A PEWAIT APPROVAL; OR FUNDING, NOW OR ULTIMA T ELY FR-OM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Dyes N3 if yes, list agency(s) name and permiltapprovals 11. DOES ANY ASPECT OF THE ACTION HALVE A CURR ENTLY VAUE) PERMIT OR APPROVAL? 1 Oyes C)No If yes, list agency;.) name and permit?approva! i 1 12. AS A E' L T OF PROPOSED ACTION WILL EXiSTING FERMI T iAPFROVAL REC -DIRE MODIFiCATiON? Dyes I CERTIFY TH T E INr RMATION PROS %IDED ;ABOVE IS T UE TO THE BEST OF h�1jY KNGWL DGE Applicant /Sponsor me: AF sgg Signature:�� PART II- ENVIRONMENTAL ASSESSMENT (To be completed by Agency)' A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the . FULL EAF, OYes ONO B. WILL ACTION RECEIVE COORDINATI ED REVIEW AS PROVIDED FOR UNLISTED ACTIONS. IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑Yes ONO C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be nandwritten, if legible.)' C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic_ patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: . C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood. character? Explain briefly. C3. Vegetation or fauna, fist:, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially. adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: _ CS. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: C7. Other impacts (Including changes in use of either quantity or type of snergy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRQRMF,gtT,-"L CFrA:g4CTERISTICS THAT CA OF A ( Rii',r "' �fENTAGppF„ ;ticAl? pYQS ONO If Yes, explain, briefly: • _' ,ENT ,.,NELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Uyes ❑No If Yes, explain briefly: - Part Ill — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwis significant. Each effect should be assessed in connection with its (a) setting (i.e. urban: •oral); (b) probability of occurring; (c '={ duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add a- :achments or reference suppartin materials. Ensure that explanations contain sufficient detail to show that all re!,?vant a::v •r6e impacts have been identified an adequately addressed. If question D of Part II was checked yes, the detarn,]ne. ;on of significance must evaluate the potenti impact of the.proposed action on the environmental characteristics of the CEA. • Check this box if you have; dentified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. • Check this box if you have determined, based on the information and analysis abcve..an,d any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide cn attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Narne of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Date Title of Responsible Officer Signature of Praparar (If different from responsible officer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES D IG DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM led .,2hA Owner G �a e ' Address Located at (Street)(.ccpvll4e ,pk lt; PT Sl.l Tax Map .Block 2- Lot 'ndicat nearest cross street) Municipality Drainage Basin SOIL PERCOLATION TEST DATA jC Date of Pre-soaking ZL Date of Percolation Test &Z Z Hole No. Run No: Time Start - Stop Ela se Time Min.) Depth to Water From Ground Surface (Inches) Start, Stop Water Level Dropp In Inc7�es Percolation Rate Min/Inch 2 2.17��o 34 - 3 3 13, s� �3!� 3v ,2 L31_ / 4 2 5 Z' o Zl0 - �� -Z /- L LJ l '7 C/ 2 3 3 Z ^z3y z _ 2L 3 4 ti 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 st A mchamiffl es RED HOOK, N.Y. 2571 FAX:e: (me) 758 6612 email: professional engineering services for the home - septic - structural - site design July 3, 1998 ROBERT MORRIS P E PUTNAM COUNTY HEALTH DEPT RE: FRED BRANCA APPLICATION FOR SSTS PLAN APPROVAL, LOT 8 CAROLINE DRIVE, T /PATTERSON DEAR MR MORRIS, THIS PACKAGE IS RESUBMITTED TO REPLACE THE ORIGINAL PACKAGE. THE CHECK HAS BEEN APPLIED, I BELIEVE. PLEASE PROCESS THIS AT YOUR EARLIEST CONVENIENCE. GENE REED, WITNESSED THE PERC'S, THERE ARE NO STREAMS NOR FLOWING WATER WITHIN 200 FT OF THIS SITE. THE SITE IS OPEN, ROLLING WITH NO UNUSUAL CHARACTERISTICS THAT WOULD AFFECT THE SSTS. NO FILL IS REQUIRED. REGARDS, RICHARD JO E m L 0 :C 1!-j 9 - inp 0 ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM �0. el a �fa�er Owner Address G ,49z o z 1 ,v z! `D g l vg Located at (Street) Tax Map 15 Block Lot _q_ (indicate nearest cross street) Municipality p g Drainage Basin T R!P�. AJ f, H SOIL PERCOLATION TEST DATA Date of Pre - soaking �:/_-2 1 /F 15 Date of Percolation Test 5Y ;t z Z 98 Hole No. Run�No. Time Start - Stop Ela se Time illin.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Dro In Inc�es Percolation Rate Min/Inch 2 3 4 5 2- 3 ��`� .10, /7- X33/ d2, 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are ontamea at eocn 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 IBM il�o7 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM O,wner - F2-F,4 GA Address e14. R ©L! A1,g -D -eI yF_ Located at (Street) ..2 ± 3 Tax Map Block Lot_ (indicate nearest cross street) Municipality F A'TTE i26eq Drainage Basin fAST a / A NGH SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test, /fig Hole No. Run No. Time Start - Stop Else Time De th o Water ro Ground Surface nches) Start Stop Water Level Drop In Inces Percolation Rate Min/Inch 1 �1' 1 ,_ Y 6 Y 1y� 2 /o e� 60 3 �. 4 5 3 27 37 60 3 4 ti 5 1 2 3 4 L - 1 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are ontalnea at eom 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: 911"''3 aL �_ Date: %?? Person calling: IC ,j �/���� Phone #: / 7 15 Reason () Inspection: W-Deeps and /or 6P Scheduled Field 1/feeting Time: /. Date: Y N Tentative /to be confirmed ( ) ( ) 2_ _ -t y. Town: Road /Street: P eye 5 Tax Map #: Comments: c r-r_ k 9. 78 AC. 3 AC. c 5092 e AC. 8.132 AC, CAL. 134.25 3'.33 j 6 7 A - x 67 A II ,oAc. 124 AC 41.2 AC. 7.38 5 14.57 AC CAL.' -8 ja lb 2.1 AC. 1.15 AC, 4 I § ODD. .2, 1.30 AC. j ° $ 3 %fl • \ I ( \ % Z. fu 1.45 65. --- — — — L s At o AC —7p /-0 23-1-1 1 P/0 2.39 XVA .34 23-1 -9 P/0 23. 1- 11 At. – LEGEND j�-,;UD AXhS .............. I W ILMDS LINE C71�1LOPM LOT DISTRICT INFURMA DEED DIMMIM I -MIEL CEPTRAL 5D17OL DISTRICT STATE .TAE CCUNTI till.- toll —WRLINX SCALED DIVENG ME FROIECTION DISTRICT 14 1 TOAN LINE RIU`' "Im, Diliftici UNE —F-- C/-LCULATEO A.1C VILLACE LME -,cM DISMICI LINE =SCH— VSUA L CENTROI BLOCK LIMIT -&,,l Do ?Ar.CEL UDUWAly PARCEL NWDCR MPEATT LINE %Iv;L LOT LINE " —, ? t l .acknowledge .receipt of this report: SIGNATURE: , t. 02/96 _ Title: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 April 27, 1998 Richard Jones 97 South Broadway Red Hook NY 12571 RE: Application to Construct a Subsurface Sewage Treatment System at Brancia Caroline Drive, Lot #8 (T) Patterson, TM# 12 -2 -8 Dear Mr. Jones: 0 BRUCE R. FOLEY Public Health' Director The Putnam County Department of Health (Department) has determined that the above referenced resubmitted application, received by the Department on April 20, 1998 is incomplete. Please be advised that the following information is required before the Department may commence its review. • Design data sheet has not been submitted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Dept. Of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (914) 278 -6130 ext. 166. RNUtn Very truly yours, Robert Morris, P. E. I ^� Public Health Engineer AUG 03 197 15:33 JOAN JONES DESIGN RED HOOK NY 914 758 6612 TO: 914 641 3730 P01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION Located at c_ Q Y J z GLr° N/_ ( v -� Tax Map # c� Block Lot Subdivision of Subdivision Lot # U Filed Map #' o� r Date Filed �d 0 Gentlemen: This letter is to authorize )e • A ' v C) N -,V-S a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supp y or 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 nutter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: P.E., R.?►., # (Owner of Fropcny) Mailing Address „ 7 t77 4 /~=mod 11!Mailirg Address: t , State 2D y Zip .;2-s 7/ Telephone state Ale-c/ Telephone: %J� �� 1 6'X2 7 -73 Form LA -97 •`o h • DEPARTMENT OF HEALTH BRUCE R. FOLEY Public Health Director Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 F (914) 278 - 7 21 Ap it 3, 1998 (!§ �'-' Jones oadway r k NY 125 s Application to Construct a Subsurface Sewage Treatmenl at Caroline Drive, Lot 48 (T) Patterson Dear Mr. Jones: ouo$4 The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on April 2, 1998 is incomplete. Please be advised that the following information is required before the Department may commence its review. Construction permit has not been submitted. r-� ® Short EAF has not been submitted. �® Standard Form PC -97 has not been submitted. nn �® Design Data Sheet has not been submitted. .( Letter of Authorization has not been submitted. �•� House plans have not been submitted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Dept. Of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (914) 278 -6130 ext. 166. RM/tn Very truly yours, Robert Morris, P. E. Public Health Engineer 1 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: 2. Name of project .,,.,,/. 7�' ac�e �� S- p 3. Location-T-4: 4. Design Professional: 6. Drainage Basin: 7. Type of Project: Private/Residential Apartments Office Building ,S. Address: Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Exempt Unl' ted t S c.ccar 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... -Ps 13. If so, have plans been submitted to such authorities? ............................./� /,�� A 14. Has preliminary approval been granted by such authorities? Date % 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? ............:....... 17. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... e(/ y 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ Ail c> 21. Name of sewage system Distance to sewage system 22. Date test holes observed 4IF7 23. Name of Health Inspector ?. 24. Project design flow (gallons per day) .....................3 al.. G !1!12- 5....... le)o 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 9+ b 2 27. Is any portion of this project located within a designated Town or State wetland? J a 28. Wetlands ID Number ........................................................... ............................... Q 29. Is Wetlands Permit required? ......................................:....... ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... /J m 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, �N�o landflling, sludge application or industrial activity? ............................ Ye1 c� 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope ?� 36. Tax Map ID Number .......................... ............................... Map `?, Block Lot 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP.review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is. true to the best of my knowledge and belief. False statements made herein are punishable as a Class A. misdemeanor pursuant to Section 21A45 of the Penal4aw. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... If G- RoJECT LD. NUMBER __ - _ R . State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only - - -. RT I— PROJECT INFORMATION (To be completed by Applicant or Project soonsor) APPLICANT /SPON O I 2. PROJECT NA `� PROJECT LOCATION: n �''L �`� MunicloaIIty r� —e— (/' S G County l PRECISE LOCATION (Street address and road interseC:lon3, rominent landmarks, etc, or provide map) IS PROPOSED AC7ffIIO-01N: New t. Ezoansion 0 Modlflcation/alteration DESCRIBE PROJECT BRIEFLY: In �+ D j r 1 J S CY -e �c C C:3 (U (e }I� AMOUNT OF LAND AFFECTED: 7 Initially , . l acres Ultimately /� acres WPROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? es C No It No, describe briefly V4HJT IS PRESENT LAND USE IN VICINITY OF PROJECT? esldentlal ❑ Industrial Commercial ❑ Agriculture ❑ Park/Forest/Open space LJ Other EJ escribe: DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAQ?rr�� C7 Yes ILA No If yes, list agency(s) and permiVapprovals DOES ANY ECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? _.. ❑ Yes �No If yes, Ilst agency name and permit/approval - , AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? U Yes o 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGc' ;oplicant/sp `P I,ce ere / r name. Date: Signature:. ✓ If the action is in the Coastal area, and you are a state agency, complete the I Coastal Assessment Form beior e proceeding with this assessment OVEN PART II— ENVIRONMENTAL ASSESS,ftENT (To be completed by Agency) °' °- A. DOES ACTION E(CEED ANY TYPE_ I THRESHOLD IN 6 NYCRR, PART 617.12? It yes, coorcanate the review process and use the ❑ Yes ❑ No E. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNL:S T Z:) ACTIONS IN o NYCRR, PART 617.6? ; . If No, a negative oectaratton may be SUoerseded by another involved agenC/: " 1 :j�si "ir. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOC :ATED WITH THE FOLLOWING: (Answers,, may be handwritten, it legible) .. �.. , Ct, Existing air Quality, surface or groundwater quality or Quantity, 'noise`levefs, existing tt7tftf _ patterns, solid waste prccuc :ion Or disposal, ._potential for erosion, drainage or flooding problems? Explain briefly, _ C2- Aesthetic, agricultural, archaeological. historic, or other natural or cultural resources; or community or neignbomood wtarac :er? Explain briefly. CJ. Vegetation or fauna. fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly, C-1. A community's existing plans or goals as officially adopted or a change in use or lntertsity of use of land or other natural rescurces ?,Explain briefly. CS. Growin, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly, C5. Long term, short term, cumulative, or other effects not Identified In C!- CS7'Explain briefly. - C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. _ 0. IS THERE OR IS THERE LIKELY TO 8E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes ❑ No If Yes, explain briefly PART III—DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each pyerse effect Identified above, determine whether it is substantial, large. important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. tirban or rur-ft, (b) probability'of occizi ::1g; (c):duratlon; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. Q_Check this box if. you have identified one or more potentially large or significant adverse impacts wi�ichfAY occur. Then proceed directly to the'FULL-EAF and /or prepare a' positive deciarafion - r ❑ Check this- .box. if. you have _determined, based on the information and analysis above and any supporting documentation, that -the- proposed action WILL.-NOT result in any - significant adverse enviroririental impacts AND provide on at:actlments as necessary, the reasons supporting this determination: Name of Lead Agency Print or rype Name or Responsible Officer an Lead Agency _._._ __.Tide of Resoonsaole Ortrcer Signature or Resoonsaole Officer an Lead Agency _ Signature or Prevarer (it different tram resconsa_le officer, Date 2 R 97 South Broadway Red Hook NY 12571 Dear Mr. Jones: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278 - 6130 Fax (914) 278 - 7921 April 27, 1998 RE: Application to Construct a Subsurface Sewage Treatment System at Brancia Caroline Drive, Lot #8 (T) Patterson, TM# 12 -2 -8 BRUCE R. FOLEY Public Health Director The Putnam County Department of Health (Department) has determined that the above referenced resubmitted application, received by the Department on April 20, 1998 is incomplete. Please be advised that the following information is required before the Department may commence its review. • Design data sheet has not been submitted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Dept. Of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (914) 278 -6130 ext. 166. Very truly yours, V obert Morris, P. E. RM/tn ublic Health Engineer Z' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DAT SHEET - SUBSURFACE SEWAG TREATMENT SYSTEM -( �tk �c -loll 9j,�2- tid.FX:k:,,- 0«ner Address Located at (Street) Ca*zd l-we 01-,- �f 31 / Tax Map Block 2 Lot Z- 3 (ind'ca a ne rest cross street) Municipality rc -P/'So Drainage Basin �- s �' g SOIL PERCOLATION TEST DATA Date of Pre - soaking c,�� f 2-t J! d' Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time Min.) De th to Water >rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 7.7 2 227 3,C 2a% - ' 3 Z 3 3as` -�� 3d 21 �13z Z�Z Z- 4 2 5 zG S- z! 0 5- �2 t- z 3 /, 1 2) 1 -z )P �� , z 3 23 2 21'7 _Z�f % 2�% -Z3 /y 3�y z, 3 23c--1-231--:- -21 3 3rC) 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. 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' 6.5' 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. _� HOLE I>10. o _ �U 17 H Z HOLE NO. Indicate level at which groundwater is encountered �v Indicate level at which mottling is observed Indicate level to which water level rises a er being encounte d Deep hole observations made by: D I M I C Design Professional Name: Address: %1? < " , Signature: Design Professional's Seal y., � 2,00 j •Y •' �� v�� <i �:«{{�fc'`:ss. -•�tv �� �� ten— ? >� 0ry4 . Indicate level at which groundwater is encountered �v Indicate level at which mottling is observed Indicate level to which water level rises a er being encounte d Deep hole observations made by: D I M I C Design Professional Name: Address: %1? < " , Signature: Design Professional's Seal y., � 2,00 j •Y •' �� v�� <i �:«{{�fc'`:ss. -•�tv �� �� ten—