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HomeMy WebLinkAbout0356DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -66 BOX 5 00165 Mr �� T A -� �„� ti, r ,r1 I 00165 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # GI O Located at 10 U l-A 0p<H P-D/AI) Subdivision name Date Subdivision Approved Owner /Applicant Name Subd. Lot # — Mailing Address 9 a GQ ,5 1-� 9,4,H Amount of Fee Enclosed Town or Village PA--rT-0 -6 o H Tax Map ICI % Block 2- Lot (�, (o Renewal Revision DoYL p," Date of Previous Approval P-0, P Nll -vm0H , Hy Zip Building Type k9-6l 6TPU Lot Area �• °1� No. of Bedrooms NA Desig Flow GPD �00 (PC-5»,J �'d 0 1 6 R�� Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: 10,00 gallon septic tank and 11► Lf A65, T40W To be constructed by r939 Address Water Supply: Public Supply From or: x Private Supply Drilled by 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: Address R.A. License # Date a) 151 ok . 5CI24- 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 consider necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. ed of domestic sanitary sewage only. By: Title: �/`�� Date: White copy- HD File; Yellow copy - Building Inspector;, Pink copy - Owner; Orange copy - Design P ofessional Form CP -97 PUTNAM -COUNTY DEPARTMENT OF HEALT .. OF ENVIRONMENTAL HEALTH -S DIVISION S... LETTER OF AUTHORIZATION RE: Property of EJIZASM BOYLAO Located at no cost4mA,#.3 9*A� PAwresoo 12543 T/V Tax MAP # 13. Block 2 Lot 66 Subdivision of Subdivision Lot # Filed Map # Date Filed.--. Gentlemen: This letter is to,authorize NA122Y 0- O%C%401tS sa•, a duly licensed Professional Engineer ✓ or Registered Architect to "Ply for the, required wastewater treatment and/or water supply permit(s) to serve the above-noted-property. m.' accormce with the standards, rules or regulations.as promulgated by the Public 14e'alfh Director ."o-'f,'t*h**"e-'.-N"�t'"a."t'6n,-.,*.,. County Health Department. and to sign all necessary -'papers on my behalf in .*:. ; _ connection-with.-this matter and to supervise the construction of said' wastewater tretment and/or water supply systefn8 in conformity with. the pro\,isions. of Article 145 and/or 147 of the Education. Law,the Public Health­- Law, and the P uthan _ S'anitay Cod e. -Gountersi P.L, R.A. Mailing ,A. State. Wt - q01LK zip. 105oct Telephone: 9�45--z-7ct�4po3- Very truly yours, Signed: (Owner of Property) Mailing Address: 90 60SHHAO 96,Ah ?A <C"r z 5 0 wts. qc>cm Zip State 0,1 L�, )OSL le- P Teleplfbne: V46- r7y Form*LA-97 December 15, 2004 Putnam County Health Department 1 Geneva Road Brewster; New York 10509 ATT: Mr. Bill Hedges Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 2794567 Email: hnengineer@aol.com RE: Individual SSTS - Bathroom for Horse Stable 90 Cushman Road Town of Patterson T. M. #13. -2 -66 ,Dear Mr. Hedges: Enclosed are. the following: 1. Five (5) prints of SS -1 "Proposed SSTS ", dated 012/15/04. 2. "Short EAF ",.dated 01211504: 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 12/15/04. 5. "Design Data Sheet ". 6. "Letter of Authorization ". 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W.,Nich�t Jr., P. E. HWN:gav 04115.00 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: ZLIZAKWN 66LAO tIC? - COS HHAIJ 120A> PAM 2500 - fSLO "OY- 1266-3 2. Name of project: i1400JIDYAI., 3. L . ocation TN: - &rma-soo 4. Design Professional: '14AP-21 W. Mit4cAs n P. E 5. Address:. . so aogy-r 27 6. Drainage Basin: I 10 Sol 7. Type of Project: Private/Residdritial. Food - Service Commercial Apartments Institutional Mobile Home Park Office .Building . Rialty 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? ......................... NO 10. Has DEIS'been completed and found acceptable by Lead'Agen*cy? . ............... .0 11. Name of LeadAgency 12. Is this project in., an area under the control of local planning, zoning,- or other. officials, ordinances? ........................................................ I ........ .......................... Ye5 13. If so, have plans been subrditted-to such authorities? ... ........ .................... 14. Has preliminary approval bee n* granted by such authorities? 0 0 Date granted: NA- 15. Type of Sewage'Treatment System Discharge ................. surface water groundwater 16. 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index. number (surface) ...................................................................... N:N 18. Is project located near .a'public water supply system? .......................... ........... 19. If yes, name .of Water supply N Distance to water supply 20. Is project site near a public sewage collection or treatment system? ............... 21. 'Name of sewage -system Distance to sewage system 22. Date test holes observed 23.. Name of Health Inspector 24. Project design flow (gallons per day) ................................................................. -Q b 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?... No 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 Stat,we and? N D 28. Wetlands ID Number. ..: ......................................... .............................. 29. Is Wetlands Permit required? ,,. ............................ ............................... cr►.�....: HRP/1 n Has application been made to Town.or Local-DEC'bffice? .............................. 30. Does project require a DEC Stream Disturbance- Permit? ................................... 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 t�A 32. Is project located within .1,000 feet :of existing or abandoned landfill, "'. hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ..................:............ Yes/No 'DESCRIBE: 33. Is. there a local master plan on file with the Town or Village. 1 34. Are community water and/or sewer facilities planned to be developed within 15 'ears in or, adjacent to protect site? ................................. ............................... 35. Are any sewage treatment areas in excess-of 15% slope? . :.......:....:..........::.::. �0 3 6. Tax Map ID Number ............................................... ............ Map i o Block Lot . Ce 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 ofa 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 21045 of the Penal Lo. A SIGNATURES & OFFICIAL TITLES: Mailing Address: .................................... .�Lo Iq PUTN.�,M..:C Y...DtPARTMENT OF -HEA IH DIVISION' 'OF ENVIRONMENTAL HE, ,NTH 'SERVICES DESIGN DATA . SHEET SUBSURFACE SEWAGE. TREATMENT SYSTEM Owner'-- 'Address' It ?M—NEf`f00 1%6` Located at (Street] Tax Map B lock ... . . ..... .... ..... (indicate nearest-cross street) -- Municipality Watershed WI b"-NCA� SOIL. P.ERCOLATIONTEST DATA Date of Pre-soaking• '410-f. 25 f b4 ...Date of- Percolation -* Test go 10 • -5��5 ME 1,11 W� D --t h Vf-V. Y3 h ..... A, 12:t3 -12 =23 Ip 2.4 Z% .3 31 A 21.3 S 12:45 +5 -2-4 Z-7 — 12:4p" f 2- -2-- J 24 ---Z6 3, 4 7 7 NUTEb:, I* UM 10'At same <6p t until: approxim6te Iy.qu4I pe o lation rates are obtined.at..e ch perroiatibn.test -,m 4gi n 2 be -h I (the; 1. i4f6e.*-I�I:Q: nhi 6h- 2 31! -2. pilim=imerten'ts-io,be: *4 VT Form DD-97 14.16.4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C State ,Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR ELIZ.ASI -M 6011LAO 2. PROJECT NAME I�10►d�9��1. �STy I" 6I" l , 3. PROJECT LOCATION:. �Nf`"" Municipality PAtq_tQSOL) County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Ao COS" VIALS QoAN_-,� Pa�ie itsoL) 0%1 1 256 3 5. IS PROPOSED ACTION: OR New ❑ Expansion ❑Modification /alteration 6. DESCRIBE PROJECT BRIEFLYp,�! 7. AMOUNT OF LAND, fF -CTED: 60% vjj Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? JAYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial Agriculture ❑ Park/Forest/Open space ❑ Other h❑ Describe: wad tv�lr 1 Pt Df,fnw' 111`I�i— �ri%ILT 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes _UNo If yes, list agency(s) and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes [RIo If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes 19LIN0. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE B g g r'�A��—y W ' �L�CQ � : ApplicanUsponsor ame: Date: Signature: If the. action is in the Coastal Area, and you are a. state agency, complete the Coastal Assessment Form before proceeding with. this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinaW the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH. THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C437$g4atiorfauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: comet nity'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. C*) ,-, 4v { . Gro %, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. P* C 31 C6. Long term, short term, cumulative, or other effects not Identified in C1-05? Explain briefly. t r3,lr�r C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. ••_; fry t;Xl " . ATh D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No' E. IS THERE; OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes ❑ No: If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is-substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting. (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude: if necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part 11 was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ 'Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a' positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any. significant adverse environmental impacts AND provide on attachments as necessary,'the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency. Title of Responsible Officer Signature of Responsible Of icer in Lead Agency Signature of Preparer (If different from responsible o icer) Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # G� - 04 Located at 110 LUIS HHAH PAC) Owner /Applicant Name �WWFT � RC` LAH Formerly Town or Village PACV 60H Tax Map I" _e Block 9- Lot Subdivision Name Subd. Lot # Mailing Address bu6 f WAd P- o 3 Zip `2'5t� Date Construction Permit Issued by PCHD Separate Sewerage System built by fL044CT)k io�it Address 90 C J O* 1V 4 Consisting of o o _ Gallon Septic Tank and LF A'65, r12-5H &t4 Other Requirements:_ Water Supply: Public Supply From Address or: X Private Supply Drilled by 4 Address Building Type �! fY Has erosion control been completed? Number of Bedrooms DE66t� F%— i Has garbage grinder been installed? p I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County) Dephrtment of Health. Date: 5 % n Certified by Address P.E. A. R.A. 0 5-M License # 66174 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^ subject to modification or change when, in the judgment of the Public Health Director, such revocatio i,,m dificati& or change is necessary. i By: �A-Ivtl Title: Date: .o ©J White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 SPLI RAIL See ZZ so r 1295. 3 is O ku U_ z z _j 140OZSE LEI ST Po 01- ,V 7 7 j;7— W S T-0 A(-& o 4 ,01— .. (A s6r-r,. '�izia� .1 . 4. A rw , . 4 4 " 4; 5 WALL 237.941 E N 78 °24 -S TO A t WALL 1. SITE LOCATION I SCALE: 1" 2000' PROPER Y SHOWN ON -DOWN Of: PAT*n TANMAV: 13.-7-64 PROJECT AS FYI ff,SSTS 90 CUSHMAN ROAD TOWN OF PAT'I'ERSON -ELIZABET.H. BOY.L. :90 CUSHMAN ROAD PATTERSON 13.17 �, N=.Harry. W;'Nich6 Suite 106, ?attc 2050 Rout Brewster. NY F 50 13 Z4 3 3 2l 32 30 29 5 6G G5 45 63 6B F October 14, 2005 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 279 -4567 Email:. hnengineer@aol.com Robert Morris P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance — Boylan 90 Cushman Road Town of Patterson, NY T.M. # 13. -2 -66 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As Built SSTS ", dated 08/31/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 08/31/05. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 08/31/05. If there are any questions concerning the enclosed, please call. Very truly. yours, Harry W. Nichols Jr., P.E. HWN:gav 04- 115.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot sen� P NjT-J�JL4 Building Constructed by TownNillage I0 .C,v54MP �KD �. Location - Street ,gr:;i —I 1-�6Lf Subdivision Name Building Type.' Stibdiv'ision Lot # I represent that I am wholly" and completely responsible for the. location, workmanship, material, construction and4&aimage of the sewagelreatment system serving the 'above- deseribed 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 parr-of said '-s-ystem cotis1ructed by me which fails-to operate fora 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 A 4 Day "?l Year TQC6" Signatur . Title: -� General Contractor'( Owner) signature . Corporation Name (if corporation) Corporation Name (if corporation) Address:' Address: Ala . �USI c Q �3 State zip 5� State NW —zip Form GS -97 -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by Location - Street -A 661 Tax Map Block Lot TownN,illage Subdivision Name Building Type."' - , .. Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and'dtaina'ge of the sewage Ireatment 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 parr —of said 18 -ystern constructed by me which fails- to operate fora 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 thefailure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month Au (,l Day Year Signatur . Title:- 1.. General Contractor (Owner) 8ignature7� . Corporation Name (if corporation) Address: 10 UU� State Zip Corporation Name (if corporation) Address: 90. State --Zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Arl Building Constructed by TownNillage Location - Street Subdivision Name �i A� Building Type." Subdivision Lot # I represent that I am wholly- and completely responsible for the location, workmanship, material, constrLxtiori and+draina'ge of the sewage#reatment system serving the 'above- descri bed 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 'Fart- -of said '-8-ystem cons`iructed by ' me which fails- to operate fora 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 thefailure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. x. . u .- M., ..1; .il , Dated: Month AU C Day ')) I Year 1-005" Signatur . 1 �+ Title: ­Gen 6—ral Contractor '(Owner) t �ignaturJ' . Corporation Name (if corporation) Address:( Uy�Ir� State Zip «S6 Corporation Name (if corporation) Address: Ala. State N� Zip I2,0 Form GS -97 90 Cushman Road Town of Patterson T.M., #13. -2 -66 Dear Mr. Hedges: Enclosed are the following: .1. Five (5) prints of SS -1 "Proposed SSTS ", dated 012/15/04. 2. "Short EAF dated 012115//04. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System "., dated 12/15/04. 5. "Design Data Sheet ". 6. "Letter of Authorization ". 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". We would. appreciate your review, approval and issuance of the Construction Permit at your, earliest convenience. Very truly yours, Harry W. Nict �h Jr., 'P.E. HWN:gav 04- 115.00 1. PPELIIC.tAzNT 1 OR... . 2.; R OJT NME.' E 1 ti9v�.: i i�'R== .:..:.419h BSPOTNtSa A 60 1AkS 3. PROJECT LOCATION: -CiSOv Municipality PA'N County 4. PRECISE LOCATION (Street address and, toad Intersections, prominent landmarks, etc., or. provide map),;;:. . ... QO G.y5N1'tA►S Q,pAD QAwEg-so0 N `/ l Z56 3 5. IS PROPOSED ACTION: ENew ❑ Expansion ❑ Modiflcationialteratior '6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: �� Initially acres' Ultimately acres a. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? 0Yes ❑ No If No, descrilpe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT7 IN Residential ❑ Industrial ❑ Commercial ❑ Agriculture O Park/Forest/Open space ❑ Other ... Describe:- f 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes M—INJo it yes, list agency(s) and permitlapprovals 14. DOES ANY ASPECT .OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes Xlo If yes, list agency name and permittapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes RNO . 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ✓� ' Applicantlsponsor name*' - Date: Signature— r If the action is in the Coastal Area, and you are a. state agency, *.complete the Coastal Assessment Form before proceeding with. this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by.Agency) . A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR; PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR'UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No; a negative declaration may be superseded by another.Involved agency: . ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE.EFFECTS ASSOCIATED WITH .THE FOLLOWING: (Answers may be handwritten, if legible) Ct. Existing air quality, surface or groundwater quality or quantity, nolse.levels, existing traffic patterns, solid,waste: production or disposal, ,:.;. pote,.n.lial,fo( erosioin, 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, fish, shellfish or wildlife species; significant habitats, or threatened or endangered species? Explain briefly: . C4.,_A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short terra, cumulative, or other effects not Identified In C1-05? Explain briefly. C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No ..0 Yes, explain briefly b PART III — DETERMINATION OF SIGNIFICANCE (To be completed `by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect, should be assessed in connection with its (a) setting :(i.e. urban or rural); (b) probability of occurring; (c) duratioh; (d) irreversibility ;;je) 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. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this -box if you have determined, based .on the information and analysis above. and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: 'Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Date 2... . . 13. If so, have,plans been submitted-to such authorities?.. , ................ ................... .. Or 14. Has preliminary approval been granted by such authorities? NO Date.granted:. NR 15. Type of Sewage Treatment System Discharge ...........:..... _ surface water X 'groundwater 16. If surface water discharge -what is the stream, class designation? ...........,............ 17. Waters index number.(surface) :..... . ..... .......................... ....................... N;f 1S. Is project located near a public water supply system? ......... I ............................. 19. If yes, name.of water supply Distance to water supply` 20. Js project-site near a public sewage collection or treatment system? ...............:.. �0 21. Name of sewage system. Distance to sewage, system 22. Date test holes observed 2.3.. Name of Health Inspector 24. Project design flow (gallons per day) .......................... : ............................... .... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... NO 26. Has SPDES Application been submitted to local DEC office? ............ (� Form PC -97 27. 28. 29. 36. 31. 32. 1 r 2 OV'' Is any portion 6: fthis project located within a desigiiafed.Town or State wetland? NO Wetlands ID Number. : ::: Is Wetlands Permit required?-.. ................. . ................................................ Hasa .plication:b.een:made.to...Town orLocal`DEC'o fide? ..................... �A Does project require a..DEC Stream*, Disturbance° Pernnit` .:. ....:.......................... Is or -was project. siteusetl'yfor agrieu`ltural actiVityr ' 'involving application of pesticides to orchards.,.or .other crops, solid or hazardous-waste disposal landfilling; Sludge application or industrial activity Yes/No (�;A Is project located within :1,000 ; feet of existing or abandoned landfill ~' hazardous waste site, salt stockpile, landfill, sludge disposal site or any other otentially known source of contamination? :...:......:....:.:.......... Y's/No f Q CIL 33. Is.there a local .master plan. on file with theTown or Village? 34. Are community water and/or sewer facilities planned to be developed within 15 years da or adjacent to project site? ............... :..::....,...: :...'...:............................ .. ' _ "No 35. Are any sewage treatment areas in excess-6f 15 %o slope? .................... .. �0 36. Tax Map ID Number ....... ............. ............. Map )$ 4 Block Lot .14 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.aspec'ts ofa 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, underpena4 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 Lo. n SIGNATURES & OFFICIAL TITLES. Mailing Address: ... ............ 05 (� r PUTNAM CnNTY DEPARTMENT :'� HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at .90 C J 6p okN RoA9 Town or Village Subdivision name Subd. Lot # - Tax Map Block Lot Date Subdivision Approved Owner /Applicant Name Mailing Address 9 (;4 61-t lA/S1H Amount of Fee Enclosed Renewal Revision �niL P" Date of Previous Approval Zip, I�y6� Building Type Lot Area 416- No. of Bedrooms NA Desig{� Flow GPD 1Qc) i ;bra R4 04 1 6►�1 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To; be constructed by Water Supply: Public Supply From or: 2. Private Supply Drilled by L op0 gallon septic tank and Ill Lf Pr&j . -r4rJW 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: �Q/V Address e2v P.E. X R.A. Date I'm 15 pIF IJ i 10s01 License # 5612¢ 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 permit. Approved for discharge of domestic sanitary sewage only. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNA'* THR DMSION 'OF ENa_ RONMFNTA- L HEAL 'SERVICES DESIGN ,' TH: DATA 'SHEET. --�,*.SUBSURFACE SEWAGE-TREAT -S MENT YSTEM: IJO N Address . Located at (Street) AP —.1 3...,.B I '�k Q. 2 Lb (indicate nearest'cross street) Municipality. - A' Wate.rsb ed VEST DATA SOM-PERCOLAT JON - Date of Pre - soaking' Date of-Peicqjajjon� PY*'.�i K14 C-J�11: � + - 7 24 Z 3::: 3.3 -2- 2.7 3* 213 S 1.2 Z4 Z-7 �>-a -IS 12! 0 Z6. T 3- 3 TZ, A I tI ::!;,C>, ----------- 4 T Nons TES eS� . 7— , repeated at seine d*'ep.th.--.un-til.*�.-,app-.rdXima'tel.y..equ "I -' . 'fation -rates ateobta .-per & Irv,;. or: .. 0 C. (ize-; S 3Q in%iiicti 'S Z` ..Sub rnift, d'fl t!a vd, .2. m ents -to be': FT TIP .Form DD-97'. :......... TEST PIT DATA..., :... 2, DESCRrPTI�01`IiO ENCOUNTERED XN TL�HOLES: .. ,. HQL`NO` zz DEPTH : Y t X - V L r: ... 0.5' � ..,. 2.0' zsw. As. -; .;t ;. 2.5' 3.0' 3.5' n .,..... 4.0' x i S n •+ � , 5.01 : � t�4 r r � f.' t � i 6.5 � r , � � �� �. fr ; • � �,� • • t 8.0.. F • - - Jo 10.0 E t E• Ac -D e4gtt Pr: jrlth PUTNA M- .1 J.UNTY. DEPAR. TMEN".X%­0F REALT DIVISION .-OKENVIRONMENTAL HEALTH -SERVICES.-: LETTER;OF AUTHORIZATION RE: Property�of . Ek I ZA S E-TH* a0'/LA0 Located at CIO COS"Hk$3 ROAD PATVfP500 12563 TN. PAwr_ p_& 0 Block 2 0 Tax Map # 13. _Lot 66 Subdivision of 8'u'bdivision'Lot # Filed Map # Date Filed.• -. Gentlemen: This letter is to authorize AA92Y Q. P%r_%AoLt-, Ta a duly licensed Professional Engineer ✓ or Registered Architect tcrmplly for the• req'viired wastewater treatment and/or water supply permit(s) to serve the above-noted -property ".*in a'*'c*co*ro'a*'n"'ce":',!'*:,l'.,,*:' with the standards, rules or regulations,as promulgated by the Public 14'ealt1i Director of the.-Nffi'a­m`*'!;;..:' County Health Department. and to sign all necessary•papers on my behalf in connection.-with--this matter and to supervise the construction of said wastewater tretment and/or water supply systoffis, in conformity with the provisions. of Article 145 and/or. 147 of the Education. Law; -the Public Health.•- Law, and the P61,nam unitary Code. -0,ountersia P.E., R.A., # 124 I Mailing Address State WLJ_qqq_i< Zip. josoct Telephone: Fos _-z-rq;,4po3- Very truly yours, Signed: (Owncr of Proper.ty) Mailing Address: 91D 00614 1Aj 940,04b -7 ------- ' State 0 P_ Y_ 4 Telephone:. 1'45- 916 66'6-r-'.. Form'LA-97 - 283.1 Putnam County Npartment of HatAth Division'of Enviranrne-mital He- dth Se: lice no'led for cor fori'd'Iarice tit ill i ,, l rf ��? pilc-.i ,'Q Rules and Fii f. i.}i2,.i a'iL nature Title %OIZ PGHD APPiKOVAL_ STAMP . ---s PROPERTY LINE EDGE OF PAVEMENT/ROAD _L _ . , EXISTING BUILDING EXISTING-GRADE PROPOSED GRADE +v2.so PROPOSED SPOT GRADE R° Fv PROPOSED ROOF & FOOTING •DRAIN; Pr. PERCOLATION TEST LOCATION TP TEST PIT LOCATION Q EXISTING WELL PROPOSED WELL. EXISTING SSDS . PROPOSED SSDS EXISTING TREE LINE EXISTING STONE WALL T -45• T • PROPOSED SILT FENCE. J =�- ---- PROPOSED STRAW BALE DIKE EXIST. STONE WALL TO BE REMOVI.1_ PROPOSED SSTS 90 CUSHMAN ROAD TOWN OF PATTERSON. NEW YORK ELIZABETH[ BOYLAN 90 CUSHMAN ROAD PATTERSON NEW YORK Harry W. Nichols Jr., RE, Suite 106, Pat ierson Bork 2050 Route 22 Brewster, NY 10509 (89.5) 279 -4003, Fax 279 -4567 CONSULTING SITE ENGINEER; PROPOSED SSTS 1" = 3.0 ` New . `ks 12- 14- oa M G r ' tWCI o�-- I15 -oI �. Nv 124 por It- S �! . SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Boyd Artesian Well Co., Inc. c/o Henry Boyd 1054 Route 52 Carmel, NY 10512 July 26, 2007 Dear Mr. Boyd: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed Well Boyland 90 Cushman Rd (T) Patterson A field inspection was conducted on the above referenced lot by Mitchell Lee, Public Health Technician. The application to drill a new well is approved with the following stipulation: 1. A Well Completion Report (WC -97) shall be submitted no later than 30 days after the well completion by the permittee. Please contact me at (845) 225 -5186 ext.2233 if you have any questions. ccMile Sincerely, �j," t L Mitchell D. Lee Public Health Technician Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool(845)278 -6014 Fax(845)278 =6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type Well Location Street Address: Town/Village: Tax Map # Map / Block ,;2 Lot(s) Well Owner: Name: A dress: �v��3 Phone #: Use of Well: Residential _Public Supply Air /cond /heat pump rrigation 1- Primary Business Farm Test/monitoring _Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason ! / , 77 for Drilling Well Tye Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ NoX Is well located in a realty subdivision? ........................................... ............................... Yes _ No X Name of subdivision Lot No. ' Water Well Contractor: s �` Address f0�� /e-X,6�z -�10 �_� Is Public Water Supply available on site? �esI o ......................... ....................TownNillage Name of Public Water Supply: Ade ..' Distance to property from nearest water main:�j%,�/� Proposed well ocaf n & sources of contamination to be provid d on separate s etlplan. Date: Applicant Signature: ZZZZ PERMIT TO CONSTRUCT A WATER ER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that'within thirty (30) days of the completion of water well construction, the applicant or their designated 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. 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 Commissioner of Health. Any revision or alteration of the app rov d plan requires a new permit. Well to be constructed by a water well driller certified by Putnam Co�ftnty. n �. Date of Issue 7 — Z4 -01 Permit lssuin fficial: Date of Expiration _Z4 _011,21 Title: Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; nge copy - Well driller Form WP -97 Rev. 3/06 F1 Boyd Artesia'n Well Co., Inc. 1054 Rte. 52 Carmel, N.Y. 10512 (845) 225-3196 Fax (845) 225 -8420 C � , ,,4 Al 1 Z ?1 'A(J000 "v duip1; L ilq 7Z, I 4N ITD Boyd Artesian Well Co., Inc. 1054 Rte. 52 ��� Carmel, N.Y. 10512 (845) 225 -3196 r Fax (845) 225 -8420 ABILITY �; 1 u• Vii: } r ._ /1 � t ! 4 t � r r • A •i ti_7 � . {i