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HomeMy WebLinkAbout0417DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -74 BOX 5 00226 'L IL 00226 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES bT* T WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Grid # Map Block 3 Lots) 7(/ Well Owner: Name, Address: Po koc).4�t,� z - S' 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 __K Compressed air percussion Other (specify) Well Type Screened Open end casing _k Open hole in bedrock _ Other Casing Details Total! length ft. Length below grade ft. Diameter _�in. Weight per foot lb /ft. Materials: _ Steel Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _Cement grout -4 Bentonite _ Other Drive shoe: K 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 ompressed Air Hours 6 Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed; information descriptions or ' sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 30 - D <<j YI s If yield was tested at different depths during drilling, ' list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type t rS Capacity Depth 3f4 Model 4 Voltage 3a HP 3 Tank Type! Volume 6� Date Well om eted 0 Putnam County Certification No. Dd 7 Date of Report M Q a,3 Well Driller (signature) N07E: Pxact location of well with distances to at least two permanent lancltnarxs to be provided on a separapneeupian. Well Driller's Na r me G ► t S0� S Address: l ll// 6 h /U► Signature: Date: i White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 _T.:' PUTNA COUNTY kEALTH DEPT. .. 026426, 1 Geneva Road ; (845) 278 -6130 u star 10509 e� Date_ 7 ` LT 5�9��= o�55�4h9 i�� y Received Of Thetum Of D b� V� ollars $ For , THA Nk YOU! ❑ Cash ❑ Check M.O. ❑Credit Card By l l l l i l l 1 1 1 1 1 1 1 1 1 1 l 1 1 1 1 1 1 7 -s. 4� r I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # a -.; Located at LorJ (T o r_, A J Q\A � own r Village Q ATi o srj Subdivision name AST0.-o �5sof_% Rc(_,5 Subd. Lot # Tax Map t3 Block 3 Lot `1 y Date Subdivision Approved Renewal Revision E1STQo, t {sS� c.► AT l;S Owner /Applicant Name C,/o Loy �� Q ESc gTo �e Date of Previous Approval Mailing Address ��T `JO raoaAs %04agg(W , �t Mb Ny Zip 113r1 Amount of Fee Enclosed t y00. 0. Building Type WOb4l ►RL Lot Area Los tqc No. of Bedrooms rJ Design Flow GPD 1^ Fill Section Only Depth Volume Separate Sewerage System to consist of I,Soo gallon septic tank and 6dS Other Requirements: To be constructed by Iri E 0 CT E (kM%N Q Address NIA Water Supply: Public Supply From Address or: X Private Supply Drilled by To IbC 1 �'TQ M%40 Address NIA I repre�;,Alt 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 P.E. R.A. �Q4, ARc �� cG «��F; Q�License # Date GyI ll t vm&i.m yLR(.f) CA(kMe1L Ny IvSi�. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment s stem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified whe cons dered nece sary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. ove or barge of domestic sanitary sew e� nly. vs Z, By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design irofessional . Form CP -97 0 /NS/ TE ENGINEERING, SURVEYING & LANDSCAPEARCHITECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam Countv Health Department 1 Geneva Road Brewster, NY 10509 WE ARE SENDING YOU ❑ Shop Drawings ❑ Copy of Letter LETTER OF TRANSMITTAL Date: 1 -12 -08 Job No. 98105.304 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates - Lot 4 46 Longview Drive, Town of Patterson TM# 13. -3 -74 ® Enclosed ❑ Under separate cover via ® Prints ❑ Plans ❑ Change Order ❑ ❑ Samples the following items: ❑ Specifications COPIES DATE NO. — — DESCRIPTION 5 1 -08 -04 I CD -1 Construction Drawing 1 -- 1- 12 -08� i CP -97 ' Construction Permit 1 --------------------- LA -97 I Letter of Authorization 1 12 -27 -00 CA -97 1 PC -97 Corporate Affidavit Application for Approval of Plans -12 -08 1 1 -12 -08 --- - - ---- j Short EAF 1 112 -29 -98 i DD -97 Design Data Sheet (previously submitted with subdivision application) 1 f 12 -30 -03 i 86367 $A60.00 Fee 1 2 1 2498 ` --------------------- i --- - - - - -- 1 -12 -08 j WP -97 5 Bedroom Modular House Plans Well Permit i THESE ARE TRANSMITTED as checked below: ®For approval ❑Approved as submitted ❑ Resubmit ❑ For your use ❑ Approved as noted ❑ Submit ❑ As requested []Returned for corrections ❑ Return ❑ For review and comment ❑ REMARKS: � g oo vo %�.-, w•r� K �N� r� � �-w � �/ � 0 a . do �lLew, uses rn a�✓e7 �''�- vc-� -/ .7P � COPY T0: copies for approval copies for distribution corrected prints ,K # IV fS gq & 9 Z 08 SIGNEDjJo M . Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE lot2002.dot PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL ,� 1 please print or type PCHD Permit # / 'o' ' 0 7 Well Location: Street Address: o illage Tax Grid # 46 4or 41W '99\,E l- VOLSo,. Map IS Block S Lot(s) '14 Well Owner: Name: AS-r o Address: ASS0C_%ATt5 Use of Well: _\ Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) ?_ -Cp nr 1dAq Industrial Institutional Standby Amount of Use Yield Sought . _- gpm # People Served ! Est. of Daily Usage Soo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision' AST q_ o �5S OC l tA1 E S Lot No. 4 Water Well Contractor:-�o dr Address: w IA Is Public Water Supply available to site? .................................: ............................... Yes No Name of Public Water Supply: 0 lec Town/Village Distance to property from nearest water main: N IN Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty.(30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take ,appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water we 1 iller cent' ied by Putnam County. i- Date of Issue ® Permit Issui >.cial: Date of Expiration Title: —s Permit is Non-Trinsfefrifilk, White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 14.164 (2187) —Text 12 PROJECT I.D. NUMBER 61T.21 SEOR Appendix C State Environmental Quality Review SHORT. ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART [—PROJECT INFORMATION (To be completed by Appkant•or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME.SSTS ASTRO ASSOCIATES ASTRO ASSOCIATES (ASTRO LOT# 4) 3. PROJECT LOCATION: Municipality P=ERSON County PUTNAM 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) SEE LOCATION MAP ON CONSTRUCTION DRAWING 5. IS PROPOSED ACTION: 10 New ❑ Expansion ❑ Modifleationlaiteratlon 6. DESCRIBE PROJECT BRIEFLY: CONSTRUCTION OF A SINGLE FAMILY RESIDENCE, DRIVEWAY, SSTS,WELL, AND APPURTENANCES 7. AMOUNT OF LAND AFFECTED: Initially 1.05 +/- acres Ultimately 1.05 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ®yes 13 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Q Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/For"LlOpen space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ® Yes ❑ No It yes, list agency(@) and permltlapprovals DRIVEWAY PERMIT - TOWN OF PATTERSON SSTS & WELL - PUTNAM COUNTY HEALTH DEPARTMENT BUILDING PERMIT - TOWN OF PATTERSON 1111. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes RNo It yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes 5 No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE INSITE ENGINEERING, SURVEYING & LANDSCAPE ARCHITECTURE, P.C. MC4— ADPlicantlsponsor name: JOHN M. WATSON. P.E. 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 PART II-- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 817.12? 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) 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 Ilk-Sly to be Induce0.4y the proposed action? Explain briefly. C6. Long term, short term, cumulative, or'other effects not Identified In C1-05? Explain briefly.. I 07. 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, 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. ❑ 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: 1. Print or Type Name of esponsi e Officer in Lead Agency Signature of Respon sible Officer in Lead Agency Name of ea Agency Date Title of Responsigle Officer Signature of reparer different from responsible officer) EAS Fotm 14 -16-4 (Page 2 oil) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM Name and address of applicant: ASTRO ASSOCIATES C/O LOUIS PESCATORE REGO PARK, NY 11374 SSTS FOR 2. Name of Project: ASOCIATES LOT 4 4. Design Professional: JEFFREY J. CONTELMO P.E. 6. Drainage Basin: EAST BRANCH 7. Type of Project: 3. Location: ;T. . : PATTERSON INSITE ENGINEERING, SURVEYING & 5. Address: LANDSCAPE ,AP ARCHITECTURE ,�. 3 GARRETT PLACE CARMEL, NY 10512 X Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR) ? .............. Yes/No YES Type Status (check one) ...................................... ............................... Type I Exempt Type II Unlisted x 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/No NO 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes/No NO 11. Name of Lead Agency N/A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............................................................. ............................... Yes/No YES 13. If so, have plans been submitted to such authorities? .. ............................... Yes/No NO 14. Has preliminary approval been granted by such authorities? NO Date granted: NO 15. Type of sewage treatment system discharge ........................ surface water X groundwater 16. If surface water discharge, what is the stream'class designation? .......................... N/A 17. Waters index number (surface) N/A 18. Is project located near a public water supply system? . ............................... Yes/No NO 19. If yes, name of water supply N/A Distance to water supply N/A 20. Is project site near a public sewage collection or treatment system? .......... Yes/No NO 21. Name of sewage system N/A Distance to sewage system N/A 22. Date test holes observed 2-10-99 23. Name of Health Inspector ADAM STIEBELING 24. Project design flow (gallons per day) ............................. ............................... 1,000 25. Is State Pollutant Discharge Elimination system ( SPDES) Permit required? ... Yes/No NO 26. Has SPDES Application been submitted to local DEC office? ......................... Yes/No N/A Rev. 11 /02 Form PC -97 Pg. 1 of 2 27. Is any portion of this project located within a designated Town or State wetland ?... Yes/No NO 28. Wetlands 11) n umber .................................................................. ............................... N/A 29. Is Wetlands Permit required? ...................................... ............................... Yes/No NO Has application been made to Town or Local DEC ........................... Yes/No N/A 30. Does project: require a'DEC Stream Disturbance Permit. Yes/No NO 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? .......................................... .........................Yes/No 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/No NO DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .........................Yes/No UNKNOWN 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? .................................. .........................Yes/No UNKNOWN 35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No NO 36. Tax Map ID'Number .............. ............................... Map 13 Block 3 Lot 74 37. Approved plans are to be returned to ................ Applicant x Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 1, 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: 1 SITE EN NEERI SURVEYING & LANDSCAPE Mailing Address:.......: AR TECT RE, P. 3 GARRETT PLACE CARMEL. NEW YORK 10512 Form PC -97 r PUTN.AM COUN'T'Y DEPARTMENT OF HEALTH (DIVISION OF ENVIRONMENTAL IElEAL SERVICES . . , �'H DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner s Ro /�SS�c Tr'..5 �G, Address RiG o P Al y y6 _��wE Located at (Street) -:.; :.: Tax Map .13 Block 3 . Lot 71 (indicate nearest cross street) Municipality �,,.�,v . �� oy7)25o,.5a7, Drainage Basin PX/M/C# T` 9- SOIL PERCOLATION TEST DATA Date of Pre - soaking /y /a g fq g Date of Percolation Test /2Zg -, j 9 v 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 2 2-;a y 2- yo z� %" 3 '1'H 3 z�zs" -zoo .2- 4 5 8 1 Im+fis -yo/5 3D �1" .23X Z3`1+ !l 2 �e r 6 -- za �� 3 i �O 3lµ'' .- y3• z ,��r �� / 3 2oLl p -3c /$ 3Q 21 — 23�g�� 4 5 1 2 3 4 5 ivv i P,a: i. 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. 1 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA _1�ESCI2iPT'ZON.O `S07 ,S.ENCOUNTERED IN TEST HOLES HOLE 140. HOLE NO. �8 HOLE N0. Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: T©yt; ,,,i ,,,, JSD.c> Date ,z4 3 Design Professional Name: Jef f rey J • Conte] �ey� Address: insite Ehg'- n�ering S1�rue}'ir� & P.C. ._.... _ ..:- . 3 �A(ttt tiii' cp Q C. �CLrv.tl Ny ► 10 S +2 =�- a��r�NT ^ Signature: Design PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of A s o 'ocjgE5 Located at N Y.51. 60V r E S I � f V _ $© Tax Map # 3 Block Lot 1�1 Subdivision of— $ M A ( SSocIA-r6 Subdivision Lot # `i: Filed Map # Date Filed 8 00 Gentlemen: This letter is to authorize Lnsite Engineering, Surveying & Landscape Architecture, P.C. (Jeffrey J. CantelTro, a duly licensed Professional Engineer x aRugi�md )4Kbitoaxxxxxto 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 Sary Code.. Countersigned: P.E., X.A., # E Mailing Address OF NEIV 3''oo 0 co w � o rc Q� \D,o^ 61931 1s & Lands P.C. cape��i, >.i;"jzeT -' PJAC CARr»(%.ANy jos)z State New York Zip Telephone: ( 914) 278 -4990 10509 Very truly yours, Signed: (Owner of Property) WO ASW Mailing. Address: CLo L 0 u j 5 LES bU-c q2 j5 Q 6MEE �5 8OUL VA.9e ) AEGV CAIRK State NEV ft K Zip ) i3` q Telephone: 1 - `718 -- �28 -2600 Form LA -97 PUTNAM ;COUNTY .DEPARTMENT OF HEALTH DIVISION 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: AS``RO A S SO C 1 -6ES t-°? y I, Lvvl 5 ff5CkM L represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: ASfA0 A5506 1ES Having offices at: 9Z- 50 QUEENS ROOLEVARo UP PARK i N,Y 1J37� Whose Officer's Are: President - Name: t,005 PESC T� £ Address:. $qM 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 to before' me this day of month) 'jpo_ (year) Notary Public CARL M. CE'.-,AR V-410 (:o1ary Pubic, Si::�e o r:aw York r�fl. bc;oloa3 C�unl {f {s >. <t iil i,;iir:er,:; Count/ r be. 29� Y " Form CA -97 A r, Signed: v��- -- Title: C Corporate Seal PUTNAM.COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: TAX MAP #: (CONFIRMED) Y DOCUMENTS PERMIT APPLICATION *xHlPC-97 ELL PERMIT OR PWS LETTER ER OF AUTHORIZATION ',N DATA SHEET (DDS) ORATE RESOLUTION T EAF 3-THREE SETS HOUSE PLANS - TWO SETS ( )VARIANCE REQUEST lT SUBDIVISION LEGAL SUBDIVISION USUBDIVISION APP OV CHECKED C_)PERC RATE / C_)(_)FILL REQUIRED . DEPTH C__)C__)CURTAIN DRAIN REQUIRED - d v GENERAL LOCATED IN NYC WATERSHED (_) PLANS SUBMITTED TO DEP (�DELEGATED TO PCHD C�DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED � PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION W/I200' ((_)SOIL TESTING LOTS >10 YEARS OLD )SEWAGE SYSTEM PLAN - (NORTH ARROW) )SSDS HYDRAULIC PROFILE )GRAVITY FLOW )CONSTRUCTION NOTES 1 -15 )DESIGN DATA: PERC & DEEP RESULTS )2' CONTOURS EXISTING & PROPOSED )DRIVEWAY & SLOPES, CUT )FOOTING /GUTTER/CURTAIN DRAINS )USDA SOIL TYPE BOUNDARIES . )TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# )DATE OF DRAWING/REVISION )DATUM REFERENCE )LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS )WELLS & SSDS'S W/IN 200' OF SSTS )PROPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01 /00 Y /9- (REQUIRED DETAILS ON PLANS CONT'D) (L )HOUSE SEWER - %" FT. 4 "0'; TYPE PIPE CAST IRON (! )C_)NO BENDS; MAX BENDS 450 W /CLEANOUT RENEWALS (— ( SITE NOTE (NO CHANGE) FILL SYSTEMS 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS/ FILL NOTES 1 -5 (_) FILL PROFILE & DIMENSIONS (FILL IN EXPANSION AREA FILL GREATER THAN2 FEET CLAY BARRIER FILL CERTIFICATION NOTE DEPTH GAUGES i VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS SEPARATION DISTANCE FROM TOE OF SLOPE E C �LF TRENCH PROVIDED 60FT MAX. C_) PARALLEL TO CONTOURS 100% EXPANSION PROVIDED (� DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL _)GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS ' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (6 1020' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS TTT 100' TO STREAM, WATERCOURSE, LAKE (inc. espan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATERLINE (pits - 20') (__)50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS E�C__)10' MIN TO LEDGE OUTCROP SEPTIC TANK (� 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES (� OCATION OF SERVICE CONNECTION MIN 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA 520 %) REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED (_)I DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL j15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %, 100 % - <1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge Cq—)l0'MlIN to NON - PERFORATED PIPE i TNAM COUNTY DEPARTMENT OF HEALTH ION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT.SYSTEM PCHD CONSTRUCTION PERMIT # Located at � L � f,•`y L&2 j7�, ,� ' CTO OPA4W Owner /Applicant Name_C &, LC�r , r 5 ?�.s :.l 7•e _ Tax Map 13 Block Z_ Lot Formerly Subdivision Name h bro A_, .ss cn e .,, a fr S Subd. Lot # --r Mailing Address q5= c> Q e_� rn S cy< < .l r ►rr, re(' eN Park- ,_ Zip 11 37 Date Construction Permit Issued by PCHD Separate Sewerage System built by Cew.L, c�,fj C,:-J ;,- Address k;2e`ws%ZN, Consisting of 1.5nn. Gallon Septic Tank and 62s F. 2, Other Requirements: — Water Sunnly: or: Private Supply Drilled by A\ $ rt- m a. A zc,,s Address )om P-T3 i I Building Type R ej ,,q-IL, e J Has erosion control been completed? L Number of Bedrooms i 5 Has garbage grinder been installed? Ny 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.. R.A. e4 VJrn�, R1✓; esi Profess al) Address — ".. ;, d-VhQE License # / 93 / 3C�i�mer ,Al��.c 1- 4-"pi, ofv �oSIZ Any'person occupying p remises �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 ub'ect to modification or change when, in the judgment of the Public Health Director, such revocati0 , M0 ification hange is necessary. By: Title: Date: 4, 3 J White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 o Nov 24 04 12:32p BRUCE A. FOLEY Public Health Dtroc�a l 1 TOWN OF PRTTERSO 845-878 -2018 U&w', DEPARTMENT OF HEALTH 1 Creneve Road &ewstor, New York 10509 p.2 LOR=A MOLINARI- R-N., M.S.N. AasaadW Public ,Yeakh Dlrectar Dirueror Of Patient Services Eariroumeatal Health (434)278.6130 Fax(9,14) 279.7921 Nurslur Serrica (914)218 -6SS8 W[C (914)278 -6678 Fmc(914) 278.668S Eady Intervention (914)278-6014 Pruchoal (914) Z73t. M pax (734) 278.6641 Ow�RsxAn�aE: A�r¢.� p1S�r,��gYES �� Laves Q�s���.�, TAX MAP NUMBER: 3 - I - "11 ADD$LSS: TOWN: VA-T (. Sod r AUTHORIZED TOWN OMCL41: grz"& DATE: The Putnam County Department of He%16 will not issue a Certificate of Coustmction 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 Certificate of Construction Compliance. (E9I I V6IiFitbl) 2 /2 :d 6T028L8 :01 LTL6 22Sb8 EN12133NI9N3 311SNI :W083 e2 :TT bt302-t72 -i10N i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # f -L–U J Located at Lr,n ir,"9 LJ--) 17 ,.le. J A 5 it o ,4-3 s c9 Owner /Applicant Name _dc, LLz ; S 'Ppz 1- ti.-1le _ Tax Map I— Block _ Lot 7 Formerly Subdivision Name 85h: , A _ss c� e°L' c lr_ s Subd. Lot # z% Mailing Address q6-6 c-9 Q o ns _._e n S "Re,, , j e t,��, rcf��cu� 'far �/y �/ Zip I I 67 Date Construction Permit Issued by PCHD Separate Sewerage System built by ck-2uttq r- C/rJSir e-OCe, Address Consisting of 1.5o c) Gallon Septic Tank and 625 C.F. n -� 2' w,itp Other Requirements: — Water SupDIV: _ or: Private Supply Drilled by AVM ± m , ctid- A Scns Address /oiB grj i l �a- -e-e ,Dn. N y Building Type - ,R ej zc -eA-h ed Has erosion control been completed? LeS Number of Bedrooms ; 5 Has garbage grinder been installed? Nd 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. R.A. .Ire !f►-e y fon -1m o, R 6: ---4pesigh ProfessWal) Address ���v : 'cLihve.•r,nol �clfye (nr, 1p��1 n� hcLer. k,rP: P(License # /93 / 3 67 ; IA le z -e Currr,e i, ivy /05-1z 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 ubiect ' to modification or change when, in the judgment of the Public Health Director, such revocatio , o ification hange is necessary. Title: By: 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: L ` Town/Village: Tax Grid # Map Block 3 Lots) 7y Well Owner: Name- Address: A& k- 0 2-5 7VL'.n 5 BA, i ua v 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 _K Compressed air percussion Other (specify) Well Type Screened Open end casing Y, Open hole in bedrock Other Casing Details Total length Y ft. Length below grade • ft. Diameter 7 in. Weight per foot lb /ft. Materials: & Steel Plastic Other Joints: _Welded Threaded _ Other Seal: Cement grout Bentonite _ Other Drive shoe: X Yes No Liner: Yes &No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield 3 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface Q P� U V n If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type T, X t o °Capacity Depth 1 'fo Model ,S Voltage 36 HP 3 Tank Type, Volume Sd Date Well Complete d Xk1U Putnam County Certification No. 007 Date of Report k;�LO3 Well Driller (signature) I 1#.7P NO E: JRxact location of well with distances to at least two permaneo landinarks to be provided on a separa a eet/plan. Well Driller's Name C� ► IlLbIl t 7' SOA5 Address: / P c ,ol/ Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 11375 PUTNAM COUNTY DEP'A fMENT OF HEALTH XVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSLWACE SEWAGE TREATMENT SYSTEM A Owner or Purchaser of Building Tax Map Block Lot Dw,�X a _ Building Constructed by o illage Location - Street ! Subdivision Name Ll Building Type Subdivision Lot # 1 represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment ;system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: M th D Year General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State Zip Signature: Title: ,�/u C 4 Form GS -97 Z:d ZZZ6S22Sb8 9NIN22NI9N3 31ISNI:WONJ b£ :bZ S002- 9T -:AUW Page 1 of 1 Environmental Servlcei, -lnc. 41 Kenosia Avenue WATEA, SOIL AND AIA ANALYSIS Danbury. Connecticut o6810 I Telephone 203 -798 -2229 Mailing, Information: Name: Hyatt Pump Service Address: 229 South Rd City: Holmes State: NY Phone: (845) 855 -5136 Sample's Information: Site: Tank Test Name Preservative: HNO3 Temperature: <4 Matrix: Water Hyatt Pump Service Collector's Information: Name: Madelyne Hyatt Address of site: Lot #4 Astro Realty City: Zip: 12531 State: NY Fax: (845) 855 -5136 Phone: Date Collected: 8/16/2005 Time Collected: 12:00:00 PM Zip: JMS ID: 005198 Date Received: 8/17/2005 Time Received: 3:00:00 PM Lab No.: J0608818 u CONNECTICUT. NEW YORK AND NELAC CERTIFIED. Toll Fre Date Analyzed Test Name Result MCL Method 08/17/05 Color ND 15 Units SMWW 2120 B 08/17/05 Turbidity 0.15 ntu 5 ntu SMWW 2130 B 08/19/05 Hardness 152 mg /L N/A SMWW 2340 C) 08/17/05 Odor ND N/A SMWW 2340 C 08/19/05 Manganese <0.05 mg /L 0.3 mg /L SMWW 3111 B (NY) 08/19/05 Sodium 5.88 mg /L N/A SMWW 3111 B (NY) 08/19/05 Iron 0.051 ppm 0.3 ppm SMWW 3111 B 08/19/05 Chloride 6 mg /L 250 mg /L SMWW 4500 Cl C 08/17/05 pH 7.18 S.U. 6.5 -8.5 S.U. SMWW 4500 H B -NY 08/19/05 Nitrate 1.19 mg /L 10 mg /L SMWW 4500 NO3E 08/19/05 Nitrite <0.1 mg /L 1 mg /L SMWW 4500 NO3E 08/19/05 Sulfate 28.5 mg /L 250 mg /L SMWW 4500 SO4F 08/17/05 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 08/17/05 4:00 PM Total Coliform Absent Absent SMWW 9222B Comments: At the time of the analysis the sample was Acceptable for Total Coliform CFU = Coliform Forming Units MCL = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable ND = None Detected ntu = Nephelopmetric Turbidity Unit ppm = parts per million S.U. = Standard Unit Units = Units Signature: _ Reviewed By: Michael Lapman Sharon Houlahan, Director President State #: PH -0218 ELAP #: 11715 e 866 - JMS -5097 I Corporate Fax 203x98 -2408 I Lab Fax 203 -798 -2107 I www.jmsenvironmental.00m /NS/ T r ENGINEERING, SURVEYING & LANDSCA PEA RCHITECTURE, 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: 8 -29 -05 Job No. 98105.100 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates Lot 4 46 Longview Drive, Town of Patterson TM# 13 -3 -74 THESE ARE TRANSMITTED as checked below: the following items: ❑ Specifications NFor approval ❑Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: COPY TO: lot2002.dot . 1 e SIGNED: • 'P"^ J hn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE .a EXISTING WELL 21 n4 A o v o 2 9 0 11 2 19 4 / 18 5 / 17 f 0 ® 57' 6 165 8 20 14 (7 O an') i 1: THIS IS TO CER77FY THAT THE SEWAGE TREATMENT SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS OBSERVED BY /NSITE ENGINEERING, SURVEYING, & LANDSCAPE ARCHlTEC7URE, P.C. BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN GENERAL ACCORDANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH, 2. ALL FACILI RES EXlS77NG, UNLESS N67ED OTHERWSE. J. PROPERTY LINE AND HOUSE SHOWN HEREON ARE BASED ON FIELD SURVEY BY TERRY BERGENDORFF COLLINS COMPLETED ON JULY 1ST 2005. N0. CORER Or D*UUNG CORNER OF DOELUNG D COR ER OF DNEWNG REMARKS 1 55' 25' — SEP77C TANK MANHOLE 1 2 56' 29.' — SEP77C TANK MANHOLE 2 3 80' 74 ' — DROP Box 4 85' 76' — DROP BOX 5- 91 ' 78' — DROP BOX 6 96' 80' — DROP BOX 7 101' 82' — DROP BOX 8 107' 85' — DROP BOX 9 66' 23' — END OF TRENCH 10 73' 22' — END OF TRENCH 11 79' 26' — END OF IRENC+ 12 85' 11, — END OF TRENCH 13 91, 36' — END OF TRENCH 14 128' 133' — END OF TRENCH 15 124' 132' — END OF TRENCH 16 120' 111, — END OF TRENCH 17 117' 130' — END OF TRENCH 18 113' 130' — END OF TRENCH 19 110' 130' — END OF TRENCH 20 104' 78' — END OF TRENCH 39' ftu R N0. 1 DATE I REVISION { BY f 3 Coyle t t P/ fJ ,. U J Garr N Y 10 10512 (845) 225 -9 ENG //VEER /NG, SURVEYING & (845) 225 -9717 717 fax �I �I .�t is ;.f r L . -:J yi �f i, ,T >>s