HomeMy WebLinkAbout0416DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
13. -3 -73
BOX 5
1 1 INNS
11 1
I
1
S' !J
=,A
t
I
.,
�N,
, .
IN
V-6
: r
NJ
y
I ,
�I '
00225
Y,
JTNAM COUNTY DEPARTMENT OF HEALTH
SION OF ENVIRONMENTAL HEALTH SERVICES
TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREAT T SYSTEM
PCHD CONSTRUCTION PERMIT # Q- (0- O a
o
i Q
Located at YS '3�� / Lo,4 G y , EvJ -� Rl v f (9or Village ` ATf� K So r�
RStRu ASSoC►gtFS '73
Owner /Applicant Name c-/o Loj % 5 4 J s c ATo Q F Tax Map 13 Block 3 Lot
Formerly Subdivision Name AST ?,o ASS oc 1 A-f t S
Subd. Lot # 3
Mailing Address 9 " S o boo f LE VA RD , RE G o QAQY- rJy Zip 11 3 ,
Date Construction Permit Issued by PCHD
Separate Sewer — built b Y Nv -c f TS v u-0 Address Oo CV 6co �! /Jy to 5w, Consisting
of (, Soo Gallon Septic Tank and
of a' W%09 AbS-,�RQT►--3nl -rRE4c.HtiS
Other Requirements: N ° �► E
Water Supply: Public Supply From Address-
or: Ex s
X Priva te Supply Drilled by MIL-ro J N yA T �
Address
Building Type h'5' 0 f r►'r `A L'
Number of Bedrooms'
5
Has erosion control been completed?
�A•rl E 0.S-W
P0
Has garbage grinder been installed? N o
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: Certified by P.E. X R.A.
Address 'iasvrt &4,,AEa,arj SuR -iy,N LAaoS aacN,TEcT„2E�License# �o g31
Q.C. Ny 1051.
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 ubject to modification or change when, in the judgment of the Public Health Director, such
revocatio mo ificat' or change 's necessary.
By: Title: P::—_ Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
j Form CC -97
/"
May 28 04Q,08:13a TOWN OF PATTERSO 845 - 878 -2019 p.3
4
BRUCE R. FOLEY
Pnblle Health Diruator
LORETTA MOLINAX. RN„ KS-N.
Aaaactate Public fleatt>< Director
Director of Patient Services
DEPART ENT OF HEALTH
1 Geneva Road
Brewster, New 'York I O
Eavlronwentol Kcalth (913)218.6190 Pax C9.14) 272.7921
Nurslug Services (914) 278 - 6558 WIC (914) 278 - 6678 Fvx (914) 213 - 6085
Eady law- ventloo (914)Z76 -6014 Yrvadool (914)2186082 Fax(914)278.6640
E911. A.1 URESS V• P'�RIFICATIf1N iti+'OR I
OWNERS NAME;
TAX MAP NUMBER
E911 ADDRESS:
TOWN:
�T({ -� gSS�C�ATt<,j yo• �,pJrs Q�Si,gTO�.L
4 I�a6U�E•.l a�t1��
i All C(LSo�l
AUTHORIZED TOWN OFFICIAL:
. '(Signature)
DATE:
The Putnam County Department of Health trill not issue a Certificate of
Construction Compliance unless the above form is completed, i.e., a legal E911
address is assigned by an authorized town official. This form is to be submitted)
with the application for a CelrtAficate of Construction Compliance.
CC-91I VERFRM)
£i£:d 6TO2818:01 LTL6922SbB 9NIa33141%a 31IS'NI:WO8-4 2E:r0 V002- 52 -AUW
-PIJTN COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purehasei of Building Tax Map Block Lot
Building Constructed by T
S9 Boa
fsy�t,�f ��iui
Location - Street
ow illage
ns�tL� - f�SSoc�A't�S
Subdivision Name
�f5�9tin►Y►A� 3
Building Type Subdivision Lot #
i represent that T am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above- described property, and
that is has been constructed. as shown on the approved plan or apprarred amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Flealrth, 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.
Date Month Day Year
General Contractor (Owner) - Signature
0s7
Corporation Name (if corporation)
Address:
State D Zip
Signature:
Title:
Corporation Name (if corporation)
Address:
State
Lip
Foim GS•41
2�a:6 ti6tt85b8LLti Ol 4L16S28Sb8 8NI833NIDN3 31ISNI:1W0183 82:20 17002-52 -,�
/NS /TE
' ENG /VEER /NG, SURVEY /NG &
LANOSCAPEARCH /TECTURE, P.C.
June 10, 2004
Mr. Robert Morris, P.E.
Director of Engineering
Putnam County Health Department
Division of Environmental Health Services
1 Geneva Road
Brewster, New York 10509
RE: SSTS for Astro Associates lot 3.
34 Longview Drive
Town of Patterson
Tax Map No. 11-3 -73
Dear Mr. Budzinski:
The enclosed information is submitted in support of construction compliance for the subject project:
• Five (5) copies of SSTS As -Built drawing dated May 27, 2004.
• Construction Compliance for Sewage Treatment System.
• Copy of Well Completion Report. (Previously submitted)
• Three (3) copies of a Guarantee.
• E 911 Address Verification Form.
• Acceptable Water Test Results dated June 7, 2004.
• Three Hundred Dollar Fee.
Should you have any questions or comments regarding this information, please feel free to
contact our office.
Very truly yours,
INSITE ENGINEERING, SURVEYING & LANDSCAPE ARCHITECTURE, P.C.
By: e.1'
Joh _M Watson, P.E.
ciate
JMW /plo
Enclosures
Insite File No. 98105.300
051204mb.doc
3 Garrett Place, Carmel, New York 10512 (845) 225 -9690 Fax (845) 225 -9717
www.insite- eng.com
I
JMS 'ENVIRONMENTAL SERVICES, INC.
1500; SUMMER STREET
STAMFORD, CONNECTICUT o6905 NEL AC, CT and NY State Certified Environmental Laboratory
Mailing Information: Collector's Information:
Name: Hyatt Pump Service Client: Astro ReaTy Name: MH
Address: 229 South Rd Address of site: Lot #3
City: Holmes City:
State: NY Zip: 12531 State: Zip:
Telephone: 845-855-5136 , Fax: 845-855-5136 Telephone:
Sample's Information:
Site:
Date Collected:
6/3/04
Date Received:
6/4/04
Preservative: HNO3
Time Collected:
16:00
Time Received:
14:00
Temperature: <4C
Lab No.: J045828
Date Analyzed
Test Name
Result
MCL
Method
6/4104 16:00
". Total Coliform
Absent
Absent
SMWW 9222B
6/4/04
Chlorine Free Residual .:::
<0.1 mg /L
N/A
SMWW 4500CIG
6/4/04
Color '`
ND
15 Units
SMWW 2120 B
6/4/04
Odor
ND
3 TONs
SMWW 2150 B
6/7/04
'Iron
<0.050 mg /L
0:3 mg /L .::.
SMWW 3111 B
6/7/04
Manganese
<0.050 mg /L
0.3 mg /L
SMWW 3111B
6/7/04
Sodium
13.8 mg /L
N/A
SMWW 3111B
6/7/04
Chloride
22 mg /L
250 mg /L
SMWW 4500 Cl C
6/7/04
Hardness
336 mg /L
N/A
SMWW 2340 C
6/7/04
Nitrate
1.38 mg /L
10 mg /L
SMWW 4500 NO3E
6/7/04 10:00
Nitrite
<0.1 mg /L
1.0 mg /L
SMWW 4500 NO3E
6/4/04
pH
7.19 S.U.
6.5 -8.5 S.U.
SMWW 4500 H B
6/7/04
Sulfate
33.8 mg /L
250 mg /L
SMWW 4500 SO4F
6/4/04
Turbidity
0:42 NTU
5 NTUs
SMWW 2130 B
6/7/04
Lead
<1.0 ug /L
15 ug /L
SMWW 3113 B
At the time of analysis the sample was acceptable for total Coliform
N/A = Not Applicable
S.U.= Standard Unit
MCL- Max. Contaminant Level
ug /L- micrograms per Liter
Signature.
Michael Lapman
President
mg /L- milligrams per Liter ND- None Detected
NTU- Nephelometric Turbidity Unit
TON- Threshold Odor Number
Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com
C ,.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date: i3 5 p 3
Inspected by: -4, - n
Street Location i V6 4311 /Go VIAW a7?
Town p i-nje x ,y
TM# /3- � - 5�,3
1. Sewage System Area
a. STS area located as per approved plans .......... .. ................
b.. Fill section - date of placement
3:1 barrier Lgth. Width . Avg.Dpth
c. Natural soil not stripped .....................
.............................
d. Stone, brush, etc., greater than 15' from STS area..........
e. 100' from water course / wetlands ...... ...............................
H. Sewage System
a. Septic tank size - 1,000 ...:.....1,250 ......... other. �. }. o� .
b. 'Septic* tank installed level ................ .......I........................
c. 10' minimum from foundation .......... ........................4......
d. Distribution Box
1. All outlets at same elevation -water tested ..............:..
2. Protected below frost .................. ...............................
3. .. Minimum 2 ft. Original soil between box & trenches
e. Junction Box - properly set .......... ...............................
6. T renc es
1. Length required ,� ',� % Length installed ��
2. Distance to watercourse measured + 1 p0 Ft..........
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1/16 - 1/32'.' /f6ot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ..................
7. Room allowed for expansion, 100 % .........................
8. Size of gravel 3/4 - 11/2" diameter clean ...................:
9. Depth of gravel in trench 12" minimum .......:...........
10. Pipe ends capped ........................ ...............................
g. Pump or Dose(f Systems
1. Size of pump chamber ...................................... *.........
2. Overflow tank ............................. ...............................
3. Alarm, visual/ audio........:........: .. ...............................
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ...............................
6. Cycle witnessed by H.D.estimated flow /cycle...........
III. House/Buildhig
a. House located per approved plans ... ....................:..........
b. Number of bedrooms ....................... ...............................
IV.. Well
Well located as per approved plans . ......:............4...........
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 & dir.to exist watercourse
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate... ...................................
i. Erosion control provided ................. ...............................
Rev. 12/02
Owner -,4 4rK,o AsgoG
Permit # 9--16 - o;
Subdivision Lot # 3
AUG -11 -2003 13:06 FROM:INSITE ENGINEERING 8452259717 TO:2787921 P:1/2
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AT'T'ENTION' Q ADAM W GENE
EQT JEST FOR FINAL INMMTION For: Fill
All informations must be fully completed prior to any Treaches
inspections being made.
PCHD Construction Permit
Located: NyS! -Au llorA64%�+w! (V) 7A TTER otJ
Owner /Appli.cant Name: P6T°`'° Rio Lai �s Q9r' (-*fnQt TM 13 Block 3 Lot SS• 3
Formerly: Subdivision Name: 20 f�ssoc.� q't 5
Subdivision Lot #
Is system, fill completed? Date:
Is system complete? AV) Date: 0 "1f -0
Is system constructed as per plans? Y f 5
Is well drilled? , -1 4�; Date: it o3
�
Is well located a' s per plans? YES
Are erosion control measures in place? , qC5_
I certify that the system (s), as listed, at the above premises has boon constructed and I have inspected
and verified their completion in accordance with the issued PCHD Construction Permit and
approved plans ,and the Standards, Rules and Regulations of the Putnam County Department of
Health.
Date; 0- t { Certified by: PE RA
Inaite Engineering, Surveying $ Design rofes i al
l.andscape Architecture, P.C.
Address: 3 Glerrett Place Lic. # 19 I
e, Now York
Comments:
C7�ryE - 'ri-� Pwr" 5 -C« J�ChS Tv bvr Tom- rKC-
el," C 1[oasC 7-1!> -TWO -'5rr7 C- TK%.--dr
Form FM-99
ofit- ii- ac,A-� mnw 1 -1:1R TFI:R45- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1
n
LORETTA MOLINARI R.N., M.S.N.
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845)278-6130 Fax(845)278-7921
Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085
Early Intervention/Preschool (845)278-6014 Fax(845)278-6648
August 18, 2003
Jeffrey Contelmo, PE
Insite Engineering
3 Garrett Place
Carmel, New York 10512
Dear Mr. Contelmo:
ROBERT J. BONDI
County Executive
Re: Astro Associates, c/o Louis Pescatore
Route 311/Longview Drive, (T) Patterson
Lot # 3, TM# 13. -3 -55.3
The above referenced separate sewage treatment system can be backfilled. The following
comments must be corrected in the field:
1. A bedroom count must be performed by this Department upon completion of
the dwelling.
If you have any further questions, please contact me at 845- 278 -6130, ext. 2261.
Sincerely,
Gene D. Reed
Environmental Health Engineering Aide
GDR: cj
PUTNAM COUNTY DEPARTMENT OF� HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMI E TREATMENT SYSTEM
PERMIT # l� 0
Located at A/ i s 1LoVCVji5W'D81V6 0)wn or Village PA —ITCR s o j
Subdivision name A.2KRo AQ4C /A125SSubd. Lot # 3 Tax Map (3 Block 3 Lot
Date Subdivision Approved /0-9-00
A $f:E o A SSOC l .AT EJ
Owner /Applicant Name C4 Lav1r PE5cAroA5-'-
Mailing Address 11- 70 0061
Amount of Fee Enclosed W-300 00
Renewal Revision
Date of Previous Approval
Y
Zip 1/3.7'1
Building Type R ES /) N
�/AL Lot Area • at % No. of Bedrooms Design Flow GPD jOJC�
40CS
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of . IVJ gallon septic tank and Cloy.. L
F
Other Requirements: AlOA16
To be constructed by IrO 66 DETOR/+ IA/C - -D Address AIIA
Water Supply: Public Supply From Address
X i STt �C� � � ,J k'�'SZS �,•.I
or: x Private Supply Drilled by )A K'I A Tr Address
I represent that I am who and`completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the.-Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed:
P.E. %� " 1. Date `' 3 o (ez—
L Ad DSM-0E A C91 cTvA =C.
Address 3 C -AR.¢ ,*LACE. CAILM6 , Ny ;01-1a License # C 1 1 31
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 whenNnsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new pe i . prove r discharge f domestic sanitary sewage
� only.
By: �— Title: U ®� Date: S Z—
`. White copy - HD File; Yellow copy.- Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
'3
PUTNADI COUNTY DEPARTMENT OF HEALTH ..
DMSION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SENVAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERMIT
NAME OF OWNER: STREET LOCATION:
REVIEWED BY: RM, GR, AS, SRDATE: TAX MAP=: (CO\L TM%fED)
4NN"D06Ud1E`iTS l' IREOUTRED DETAILS ON PLANS CO\'T'Dl -
PERMIT APPLICATION (� HOUSE SEWER -'/1' FT. 4 "0'; TYPE PIPE CAST IRON.
E LL PERMIT OR PWS LETTER (NO BENDS; bIA\ BENDS 45° 1YlCLEAN OUT
(PC -97 RENEWALS
LETTER OF AUTHORIZATION SITE NOTE (NO CHANGE)
DESIGN DATA SHEET (DDS) FILL SYSTEMS
CORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
I -
SHORT EAT FILL SPECS! FILL NOTES 1 -5
C� PLANS -THREE SETS FILL PROFILE 8 DIMENSIONS
PLANS - T�VO SETS )FILL Di EXPANSION AREA
U VARLANCE REQUEST " FILL GREATER M S 2 FEET
SUBDIVISION ,U cL4Y BARRIER
LEGAL SUBDIVISION &JFILL CERTIFICATION NOTE.
SUBDIVISION APPROVAL CIOrD C.2L DEPTH GAUGES
(�IJPERC RATE �l V OL. ON PLAN FOR RO.B., UNCLASSIFIED & IDIPERVIO US
UUFILL REQUIRED DEPTH (__)USEPARATION DISTANCE FROM TOE OF SLOPE
UUCURTAIN DRAIN REQUIRED TRENCH
GENERAL LF TREN CH PROVIDED GOFT MAX.
LOCATED IN NYC WATERSHED L3
PAPALLEL TO CONTOURS
Cfi PLANS SUBMITTED TO DEP - - ;- ,
(� 10� /° EXPA-\SION PROVIDED
DELEGATED TO PCHD ( DETAIIJDUJST FREE CRUSHED STONE OR WASHED GRAVEL .
(DEP APPROVAL, IFtEQ'D ( GEOTEXTILE COVER
( TEST HOLES 'OBSERVED SEPAR�TiON DIS?AN CES 0 \PLAN = Oir1 SSi S PERCS TO BE WITNESSED X10' TO P.L. DRIVEWAY, LARGE TREES,TOP OF FILL .
)EX-APPROVAL SSDS AD7, LOTS �0' TO FOUNDATION WALLS
(
WETLANDS (TOWN/DEC.FERNIIT.REQ'D ?)
( I _ 100' TO'WELL, 200' IN DLOD,150' TO PITS
( f E DATA ON DDS:FLANS. &: PERil1IT SA1tiZE U(�100' TO STREA-M, WATERCOURSE, LAKE (iuc ex id)
( -( )PRE 1969 NEIGHBOR-NOTIFICATION (( ss1l )50' TO CATCH BASIN, 3T STOR:`IDJtALN, PIPED WATER
(Z) LETTERBI/ZBA C-2 LJIO' TO WATERLINE (pits -20')
100 YR. FLOOD ELEVATION W/I200'
((�50,1\'TERbITITENT DRAINAGE COURSE .
( SOILTESTIiiG L6TS >10 YEARS OLD UD26' /500' RESERVOIR, ETC. 150' GALLEY SYSTEMS.
O REOUiRED DETAILS ON PLANS (��10'.LNINTO LEDGE OUTCROP -.
-.. f/ (SEWAGE SYSTEM PLAN- (NORTHARROW), SEPTICTANK
(� SSDS HYDRAULIC PROFILE (__)10' FROb1 FOUNDATION; 50' TO WELL
",Kr, FLOW WELL
DESIGN DATA: p` NO .TES_1- 15.._— .--- .-- .---- . - - - -- . _ __.. -::..
— — — -- jDf�fENSIONS TOPROPERTY LL`IES - - ________•�T.
ERC &DEEP RESULTS (JCJLOCATION OF SERVICE CONNECTION LZ2'CONTOURS S EXISTING & PROPOSED U °U }IL�I 15' TO PROPERTY LINE
U DRIVEWAY &SLOPES;, CUT '� SLOP
FOOTI9G /GUTTER/CURTAhN DRAINS 0 °!°
((SLOPE IN SSTS AREA ) S
(USDA SOIL TYPE BOUNDARIES}REGRADED TO 15 %, IF REQUIRED
( /i �T1TLE BLOCK; OWNERS NAME ADDRESS �r DOSE/PUhiP SYSTEMS
TN&" PE/RA; NAME, ADDRESS, PHONE
DATE OF DRAWING/REVLSIQN PUMP 5% O
L DATUM REFERENCE ( DOSE 75% OF PIPE VOLUbIE/DOSE VOLUtrIE NOTED
(LOCATION OF WATERCOURSES, PONDS DETAIL FOR FORCE MAIN, (PIPE TYPX, ETC.)
LAKES ET WITHIN 200' OF P.L. ' PIT AND D -BOX SHOWN &DETAILED
( PROPOSED FINISH FLQOR AND f DAY STORAGE ABOVE ALARb1
BASEMENT ELEVATIONS CURIATNDRA'iN _
WELLS & SSDS'S WAN 200' OF SSTS L020'blIN STANDPIPES, 5' BOTH SIDES, DETAIL
(`(PROPERTY METES & BOUNDS
IS' bIL` ItoCDS=> 5%, 20'- 4 %;25'- 3 %,35'- 1 %o,1bU %-<1% •
to CD DISCHARGE /100' with 182 cons day discharge
(_.),(JEROSION CONTROL FORHOUSE, WELL & `(�10, MIN to NON - PERFORATED PIPE
SSTS, EROSION CONTROL NOTE .
COMMENTS:
(Itusif EET)09101100
BRUCE R. FOLEY
Public Health Director
TO:
PROJECT:
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Assoc(ate Public Health Director
Director of Patient Services
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
TOWN: C S + P K
DELEGA TED
m p y") 64 f
PV DATE SUB'D APPROVAL: 4d'h k A 2=
NOTICE OF COMPLETE APPLICATION DATE:
0
T E
ENGINEERING, SURVEYING &
LL,
ANDSCAPEARCHIrECrURE, P.C.
3 Garrett Place (845) 225-9690
Carmel, New York 10512 Fax: (845) 225-9717
TO: Putnam County Health Department
1 Geneva Road
Brewster, NY 10509
LETTER OF TRANSMITTAL
Date:
4-30-02
Job No. 98105.303
Attn:
Robert Morris, P.E.
Re:
SSTS for Astro Associates - Lot 3
CA-97
Longview Drive, Town of Kent
i ----------------
TM# 13.-3-55.3
WE ARE SENDING YOU Z Enclosed ❑ Under separate cover via
❑ Shop Drawings Z Prints ❑ Plans
F-1 Copy of Letter ❑ Change Order ❑
the following Items:
❑ Samples ❑ Specifications
COPIES I DATE
5 4-12-02
N0.
CD-1
DESCRIPTION
Construction Drawing
1 4-30-02
1 ---------------------
I CP-97
I LA-97
I Construction Permit
I Letter of Authorization
1 12-27-00
CA-97
Corporate Affidavit
i ----------------
PC-97
Application for Approval of Plans
1 4-36-02
---------
Short EAF
12-23-98
DD-97
Design Data Sheet (previously submitted with subdivision application)
1 2-1-01
$300.00 Fee
2 ------ ---------------
---------
5 Bedroom Modular House Plans
THESE ARE TRANSMITTED as checked below:
NFor approval ❑Approved as submitted
❑ For your use ❑ Approved as noted
F-1 As requested ❑Returned for corrections
❑ For review and comment ❑
REMARKS:
❑ Resubmit
copies for approval
F71 Submit
copies for distribution
❑ Return
corrected prints
COPY TO: SIGNED:
hn
M. Watson, P.E.
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
lo=02.dot
. PU TNAM COUNTY DEPAR'TMEN'T OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant:
RE60 PUK v 1I19y
2. Name of project: !;c'Tr�7�� ��'' °` A � .�S tTdk -�3. Locatior0rv:
incite Engineering, surveying & Landscape
4. Design Professional. Jeffrey J. Contelrm, P.E. 5. Address: Architecture, P.C.
6. Drainage Basin: ad W >�('SI�tD 4tou — � 3 Gar�ent Place
� n1Y10Sl7.
—� aas� Iei�Yar�c.m.Qkw
7. Type of Project:
_ Private/Residential Food Service. Commercial
Apartments Institutional Mobile Horne 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 K_
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... wo
10. Has DEIS been completed and found acceptable by Lead Agency? ............... Jb�
11. Name of Lead Agency /VIA
12. Is this project in an area under the control of local planning, zoning, or other
officials, ordinances? ......................................................... ...............................
YE
13. If so, have plans been submitted to such authorities? ........ ............................... A/d
14. Has preliminary approval been granted by such authorities? V0 Date granted:
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? ....... ............................... NO
19. If yes, name of water supply // Distance to water supply Vr�
20. Is project site near a public sewage collection or treatment system? ................ V0
21. Name of sewage system g Y N IA Distance to Y
sewage system �I
22. Date test holes observed iz "..zg y8 23. Name of Health Inspector44 S�F��t1nJC
24. Project design flow (gallons per day) l .
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... V0
26. Has SPDES Application been submitted to local DEC office? ......................... 1l1
Form PC -97
2
27. Is any portion of this project located within a designated 'i owu.. or State wetland?� Arm
28. Wetlands ID Number .......................................................... ............................... /J
29. Is Wetlands Permit required? ..... ..................... .....:....................................... �/c
Has application been made to Town or Local DEC office? ............................... +N�
30. Does project require a DEC Stream Disturbance Permit? ... ..............................O
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 Co' NO
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste; site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes k4
DESCRIBE: ,
33. Is there a local master plan on file with the Town or Village? ......................... QA1L\A Lv
34. Are cornrnunity water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ...............:................ ............................... I)L Alow /
35. Are any sewage treatment areas in excess of 15% slope? . ............................... IiQ
36. , Tax Map ID Number ....................................... a................. Mapes Block Lot
o
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.
1 hereby affrrm, 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 misdemeanor pursuant to Section 210.45 of the Penal Law.
SIGNATURES & OFFICIAL TITLES:
Mailing Address: ............ I .......................
Insite Engineering, Surveying &
3 Garrett Place
Carmel, New York 10512
PUTNA.M COUNTY DEPARTMENT OF HEALTH
DIVISION� OF. ENN71R.O NTA HEALTH SEIZ CES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM ;
Owner 5 /Zo . , 113 �
-Address AfZ-0 04
Located at (Street) ,y YS /,1i 3,11 - - Tax Map, - 13 Block 3 . , Lot 53 �. 10
(indicate nearest cross street)
Municipality ;�,;.•,� of o,�,• �5�� Drainage Basin jests; .Bx1m1Gi# w�rERs�lE�
SOIL PERCOLATION TEST DATA
Date of Pre - soaking ! 2 (ZS /?,a Date of Percolation Test Iz Izri I9C5
Hole No.
Run No.
Time
Start - Stop
Ela se Time
Min.)
Depth to Water
From Ground
Surface (Inches)
Start Stop
Water
Level
Drop In
Inches
Percolation
Rate
Min/Inch
j%}
1
iioai- / /o�S
lQ
Zi,i — �-U''
3 ,
3
2
11414 — /lam
12
3
3
5
36
1
101, -716 1/aco
32—
0 _ az' /u°
31114
10
2
op
i
3.44
Z11i
3
i1acF�- -iZ�i6
3`'i
/�I'� — It
3
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
DEPTH
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
9.5'
10.0'
i
TEST PIT DATA
IXTr+llrrxrrr
2
i lNTEST. HOLES - - -- ._ —_
HOLE N0. 34 HOLE NO. 3 6
HOLE NO.
Indicate level at which groundwater is encountered -7
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered -7'- 0%1%
Deep hole observations made by:
Design Professional Name: Jeffrey J. Contelmo, P.E. .a A
Address: Incite F21CJ]SSing, surveying & Landscape Arcniteclure, P.C.
A
t- 4-8�.r ntt�2 '3
Signature:
Design Professional's Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of AsrRo AS.SQQA'TEl;
Located at
&V _eAf-r So Tax Map # (2 Block 3 Lot
Subdivision of $TRQ As ociArtFS
Subdivision Lot # Filed Map # Date Filed B-00
Gentlemen:
This letter 1S t0 authorize Incite Firiineering, Surveying & Landscape Architecture, P.C. (Jeffrey J. contPairo
a duly licensed Professional Engineer x 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
P.E.,1K.A., #
Mailing Address" I
State New York
Telephone
Signed: `
-,; (Owner of Property)
& Iaridscape ~Architecture, P.C.
Zip 10509
(914) 278 -4990
ASiRo ASW'Al -ES
Mailing Address: 2 L oU1 S PESCAfb RE
92.50 61vEE�5 boUl.Cti%gRQ, �00 _ARK
State j IFV `OAK Zip 113'7q
Telephone: -2640
Form LA -97
PUTNAM'COUNTY DEPARTMENT OF: HEALTH
DTVMSION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT
To: Public Health Director
In the matter of application for: �S�R A S 5Q C 1 A 'r6
I, Louj S E�5CAuAf-
represent that I am an officer or employee of the corporation and am authorized to act for:
Name of Corporation: �IASTR�,D QSSQCIf� rE5
Having offices at: 92 -50 QUEENS
Whose Officers Are:
President -.Name: tQU1 S PESCW E
Address:
Vice President Name:
Address:
Secretary -Name:
Address:
Treasurer -Name:
Address:
and that I am and, will be individually responsible for any and all acts of the corporation with respect
to the approval requested and all subsequent acts relating thereto.
!
Sworn o before me this k I day of
' (month) r 1/00 0 (year)
Notary Public
1
1
�i�•.f:l 71'1.:. t.�;' \:: '.1.1. -1
"doiaiy Public, Sic. G'' , + Y;;;!:
No: �'1
Form CA -97
Signed: %�--
Title:
Corporate Seal
o
14 -16-4 (2187) —Text 12
PROJECT I.D. NUMBER 617,21 SEAR
T Appendix C
State Environmental Quality Review
SHO_ RT .ENVIRONMENTAL ASSESSMENT, FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Appiicant.or Project sponsor)
1. APPLICANT /SPONSOR
. s j 0 AMc , - '
2. PROJECT NAME •
SS -rS —b L7• L o 7-.4E 3
3. PRO ECT LOCATION: _ A/
Municipality P r�1V County
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)
SG;� L �C/�T� c�•J r11 /� � O,� C ��1 S J �t,�GTia�/ ..1%��w'17�iG�
5. IS PROPOSED ACTION:
19,New . ❑ Expansion ❑ Modification /alteration
6. DESCRIBE PROJECT BRIEFLY:
l2c"usi val6d or AF510a/C(-
Ak/O q vk-f6 N Oc G S
7. AMOUNT OF LAND AFFECTED:
Initially 1, CS +— acres Ultimately �. �S }- acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
7° es ❑ No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/ForesUOpen space ❑ Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATEE.�q.OR LOCAL) ?,
PYes ❑ No if
yes, list agency(s) and permitlapprovals
jbUtL-0lnk- E/,<
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑ Yes (&o if yes, list agency name and permit/approval
12. AS A RESULT 0, F PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes ovo
I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Try ►i � ��G��J�E��N.C; S�'�'Ji:�ii , LAO&I rc Art 41 r,50-04f, f C,
Applicant/sponsor name: •,)Cfb M " VA%eN P L' . Date
Signature:
If the action is in the Coastal Area, and you are a state agency, complete'the l
Coastal Assessment Form before proceeding with this assessment
OVER
1
v
PART II— EIYVIRONMENTAL'ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.121 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 617.61 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:
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 term, cum i ulative, or other effects not identified in C1-05? Explain briefly.
C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly.
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes ❑ No If Yes,iexplaln briefly
PART III — DETERMINATION OF SIGNIFICANCE (ro be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it Is substantial, large, Important orotherwise significant.
Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural);. (b) probability of occurring; (c) duration; (d)
Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.
❑ Check this box if you,have Identified one or more potentially large or significant adverse Impacts which MAY
occur. Then proceed directly to the FULL 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:
Print or Type Name o Responsi le Of icer in Lead Agency
Signature of Responsible Officer in Lead Agency
Name of Lead Agency
Date
2
Title of Responsible Officer
Signature of Preparer (If different from responsible officer)
0�.
IV .0
au
40¢0
2
i I
PROPOSM KU
MR RLM MAP
03
IiII
I
A
o
12, 11 10 g 8 7 6' 5'._ 4 3 2
15 . 13
14 ryD�
`Sst PROPa= SSTs
LOT a
pm hL o MAP T846
AS INDICATED ON THIS PLAN AND THA T THE SYSTEk4 WAS OBSERVED ' BY /NS/TE
ENGINEERING, . SURVEYING, & LANDSCAPE ARCHITECTURE, P.C. BEFORE IT WAS
COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN GENERAL ACCORDANCE w7H
ALL STANDARD RULES AND REGULATIONS OF THE PU77VAM COUNTY DEPARTMENT
OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH..
2. ALL 'FACIU7IES EXIS77NG, UNLESS N07ED 07HERWSE.
.3. PROPERTY LINE AND FOUNDA71ON LOCA RON ' TAKEN FROM. SURVEY OF PROPERTY
PREPARED BY • TERRY BERGENDORFF COLUNS� DATED_ APRIL 22, 2004.
AS -®UIL T MEASUREMEN TS
NO.
PR�TY
cavaR
of
8U1[MG
GOER pF
PROPERTY
REMARKS
1
23'
46'
=
1.800 caupav SEM Tama
2
45'
.48.5,'
-
aw Box
3
51:5'
48:5'
—
DROP BOX
4
57'
49'
_
DROP' SOX
5
64' ,
49.5'
=
CROP WX "
6
71'
51'
—
DROP BOX
7
77'
54 p
_
DROP BOX
8
84'
57'
—
oROP MX
9
90.5.'.
.60'
—
aW BOX
16
.97'
63.5'
—
DROP BOX
11
:104 "' _
` 69..'
—
CROP BOX .
12
1'10'
73'
83'
DRW BOX
13
90 5'
107'
154'
90 OF'nauxH
14
116'
112'.
116'
E OF MCH
15
1475'
127
71.5'
&W or nowH =
Butnam County Department of Health
Division Of Environmental Health Servioee
110ro is noted for conform
anoe with
9101 o b Ru #8, Regulations of the
Co h D tment.
Signature & Title D e
NO. DA 7E REVISION BY
�wY
i Af 3 Garrett Place
ci [J Carmel. NY 10512