HomeMy WebLinkAbout0421DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
13. -3 -81
BOX 5
111, IMES 0, s"l I
IN
IN
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,WET,,
IN '
IN
16 '
!F' L -ML- A.
00230
PUTNAM COUNTY DEPARTMENT OF HEAL 6il
DIVISION OF ENVIRONMENTAL HEALTH SERVICES`'
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION. PERMIT #.1-96
Located at 41 0 STA LAN4- Town or Village PANCASDO
A Ao A,SSbGAfT.s, C/o
Owner /Applicant Name Loos PEsc.A,ToaF ` ` ' °Tax Map 13 Block 3 Lot
Formerly
Subdivision Name AsfRD 4560CAA•E5
Subd. Lot # 11
Mailing Address $Z bObr ; HI u.. RD% H*4MCS , tNy 12531 Zip 1258
Date Construction Permit Issued by PCHD ZU Zo►3
45 &Arz 111 g,.v >
Separate Sewerage System built by CF2uGN Coi-i6mumor4, INC Address AUw�, N`i lo"
Consisting of 1 5o& Gallon Septic Tank and 5uo t.F of Q65oRPTwM 't2> tXJ- 6
Other Requirements: D� -O`' Tu Z - O" 2s�j. " C`I lt. o .6. • ' f,RAUF,�, f ��� '(P 167,
Water Supply: Public Supply From
Address ^�
or: ✓ Private Supply Drilled by A4t M. Mpvrt � 5orA6 Address ?0.6ox 7-1g. PAA(F. 01, y
Building Type 2,153 5F RE5060cti Has erosion control been completed? V0
Number of Bedrooms 5 Has garbage grinder been installed? lJ /iA
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: 1 14 'Certified by P.E. ✓ R.A.
.1 uw w _ Y Eaa� w� SAM10
_ Atp ycE k";j; 4,
4.
Address 3 6AR f( OL Aa osiz License - -4-160
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject to modification or change when, in the judgment of the Public Health Director, such
revoca=;Wg ce is necessary.
B �Title: � �- � Date:
Y•
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
o,
BRUCE R- FOLEY LORE'ITA MOLINARI RN., M.S.N.
Public ffedlth Director - Y O� Associate Public Health Director i
Director of Patiew Services 1
DEPARTMENT OF HEALTH
I Geneva Road'
Brewster, New York I0509
Environmental health (914)278.6130 Fax(914) 278 -7921
. t
Nursing Services (914)278 -6558 WIC(9L4)278-6679 Fix(914)278-6085
Esrly Intervention (914)Z78-6014 Preschool (914) 278.6082 Fax (914) 278 - 6648 '
E911 ADDRESS VERIFICATIM FORM
OWNERS NAM: �s�,ou�ATE.S G joISSt.,47ORE
TAX MAP NUMBER
-E911 ADDRESS: LANe
TOWN: �A?7�IGSot�1
•t.
AUTHORTLED TOWN OFFX C i.A:X,•
(Signature)
DATE: f O Z S 3
The Putnam County Department of Health will 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 Certificate of Construction Compliance.
(E91 I VEREWD
�3
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
40� WELL COMPLETION REPORT
Well Location
Street Address:
91 VISA i->A r-*
Town/Village:
r Q I,\
Tax Map #
Map 13 Block 3 Lot(s) $ I
Well Owner:
Name: Address: �71 WoT HIU- 1Loab
-o u 5® c/o Nuts P66CANOIE k ma N 12531
rimary
F2-Secondary e of Well:
Residential _Public Supply Air cond /heat pump _Irrigation
. Business Farm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equipment
_Rotary _Cable percussion Compressed air percussion —Other(specify)
Well Type
_Screened _Open end casing Open hole in bedrock _Other
Casing Details
Total Length f6&ft.
Length below gradtivft.
Diameter �7-in.
Weight per foot lb/ft
Materials: Steel Plastic Other
Joints: Welded Threaded Other
Seal: Cement grout Bentonite Other
Drive shoe: Yes _ No
Liner: _Yes No
Screen Details
Diameter in
Slot Size
Length ft
Depitto Screen ft
Develo ped?
First:
_Yes _No
Hours
Second'
I
Well Yield Test
_Bailed _Pumped Compressed Air
Hours
Yield 166 gpm
Depth Date
Measure from land su ace- static specify ft
16
unng yield test )
86AM I
ept o compete we in
a5-
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
If yield was tested
at different depths
during drilling
list:
Feet
Gallons Per Minute
Pump /Storage
Tank Information
Pump Type6jayUS 5U9 Capacity Al
Depth 001 ModeQ kJ6fel
VoltageZ. t!O V HP 3V
Tank Type (A0tI eK- Volume a
Date ell dopietea'
seX .f, C :, 8 i
Wel[ Duller PC Certificate # PNY,State # ��� l ' Date Re ort° ��! ,
+C .F£ ✓i. ' T K� b d O J 5.l. J»i vV S" 44 Phil Y f ✓ 2M ! KI �1
Y % iY R �
Pump Installer,, PCCertificate,# YI,
11,M1 Name `''8 Address 4
Y i .: R '£" £ J R Y.t %' Y . r1.i2•:''.ij. f
Si .
.:�.. / B .a' '. ,� ;(!✓ i z '
ell Dr(Iler ( gnat re)�• YY'
4' d �' k C'..t. a 1c,� }YY' X 1+M :+ �iVt y, �
. .:w s., i ..I�nCll�+r1�F"I'P"
Instr NamAress 4 f
Pum p alle
xd 4 d
+E Y": z�Y' L:.,� k 4 y`�i` i�T` u�' l%�
•{t ku pry, +r, *';^ '.c'nk �i' __{{ K= x' Y 4 enJ n/' `5, }'35''3b ..,.s"s�'�
�1� �,P k k�iV.: � � "•.yam } 1.. � � '��.. let. >n � � #a {'^��da�
y * Z qi� n 1 .� .t A. a. »Ya1". .6 '�. .y�� �w' Y x �� .:x "��{k�
n
PUmplstaller (sl f
S �3
{'. Cv A�'V�. F?,a °c ""i. , g "i�' III
fR � 1+*.1.. ".�+�1& ��N S �N.w�y 1. 41 y�µ+
1ivl.• 1 "" R N.i ia, +l ;Yn� �+�d+WLV;t�
NOTE: Exact Location of well with$iistances to at least two permanent landmarks to be provided on a separate shtset/plan.
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3106
/ `\
PHOENIAE!,".",
Environmental Laboratories, Inc.
587 East Middle Turnpike, P.O.Box 370, Manchester, CT 06045
Tel. (860) 645 -1102 Fax (860) 645 -0823
Analysis Report
May 22, 2014
Sample Information
Matrix: DRINKING WATER
Location Code: HYATT
Rush Request: Standard
P.O. #:
Project ID: 41 VISTA LANE
Client ID: PROFILE
FOR: Attn: Ms. Madelyne Hyatt
Hyatt Pump Service
229 South Road
Holmes, NY 12531
Custody Information
Collected by: JH
Received by: LK
Analyzed by: see "By" below
Laboratory Data
p Ae:;tiO.4
Q ti
NY 11301
Date
Time
05/19/14
16:00
05/19/14
16:36
SDG ID: GBG46252
Phoenix ID: BG46252
Page 1 of 2 Ver 1
RU
DW
Sec
Parameter
Result
PQL
Units
MCL
Goal
Date/Time
By Reference
Escherlchia Coll
Absent
0
/100 mis
0
05/19/1418:20
RS /KDB SM-9223B
Total COliforms
Absent
0
/100 mis
0
05/19114 18:20
RS /KDB 9223B
Hardness (CaCO3)
281
0.1
mg /L
05/21/14
E200.7
Alkalinity -CaCO3
246
20
mg /L
05/20/14
BS /KDB SM 2320B
Chloride
13.2
3.0
mg /L
250
05/19/14
BS /EG 300.0
Color
< 1
1
Color Units
15
05/19/14 18:30
DH /KDB SM 2120B
Nitrite as Nitrogen
0.02
0.01
mg /L
1
05/19/14 21:52
BS /EG 300.0
Nitrate as Nitrogen
0.09
0.05
mg /L
10
05/19/14 21:52
BS /EG 300.0
Odor at 60 Degrees C
< 1
1
T.O.N.
3
05/20/14 09:30
MA SM 2150B
pH
8.41
0.10
pH Units
6.5 -8.5
05/20/14 04:30
BS/KDB 4500 -H B
Sulfate
45.2
3.0
mg /L
250
05/19/14
BS /EG 300.0
Turbidity
0.524
0.20
NTU
5
05/20/1413:45
MA SM2130B
Calcium
17.3
0.005
mg /L
05/20/14
LK E200.7
Iron
0.021
0.002
mg /L
0.3
05/20/14
LK E200.7
Magnesium
57.8
0.05
mg /L
05/21/14
EK E200.7
Manganese
0.007
0.001
mg /L
0.05
05/20/14
LK E200.7
Sodium
3.86
0.05
mg /L
05/20/14
LK E200.7
Total Metal Digestion
Completed
05/19/14
AG E200.7
Page 1 of 2 Ver 1
IN ST ft"
ENGINEERING, SURVEYING &
LANDSCAPEARCHITECTURE, 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: 07 -18 -14
Job No. 98105.100
Attn: Joseph Paravati, P.E.
Re: SSTS for Astro Associates,
Lot 11
41 Vista Lane, Patterson
TM# 13 -3 -81
WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via
❑ Shop Drawings ® Prints ❑ Plans
❑ Copy of Letter ❑ Change Order ❑
the following items:
Samples ❑ Specifications -
COPIES j DATE
NO.
DESCRIPTION
.... ................ _..__ .......... ....... _ .......... ._...,...._.__ ...__.._..__._....._...._. ........._..__......._........_..._._........__._.._
1 07 =03 -14
.... .......... ...
CC -97
............ ........ .................. ._._..._........... ................_......._..... - _..._...._......_.__...._.._.._._._..........._............. _.. ....... ... ....... . _.._._.. ... ................ ....
Certificate of Construction Compliance
1 10 -25 -13
- --- - --
E911 Address Verification Form
_----- --._ ...._.___- .__---- ....._._� -__.. _— _�_.. - -__._
3 07 -03 -14
.. ..._..._._._._...._.___._....__
---- --
........... __.._ .___._..._.._.._....__._..._.._____.._......-_.__._.....__ ...... ............... ........ .. ....... .................. __ ... _ ......... _. .......... _..__.
Guarantee of Subsurface Sewage Treatment System
1 06-10 -14
WC -97
Well Completion Report
- - - -- __ ._ _ ..__��------ - - - - --
1 j 05 -28 -14
--- ._...---- ----------
- --
Sampling and Water Analysis
5 i 07 -03 -14
1_._...._.._.
Built Drawing-
......_.........__.__.__._ _._.._...__.... ._a_....___-.._— ___._...._._._. ...........__._.._.._.
1 106 -19 -14
-ABW .............._As
34916
..... -_. _.._.__.._...-.._._.__._............_....._...................____...._..........__.......__....._._.__ ... ............._........_.... -__.
$300.00 Certificate of Construction Compliance Fee
..... _.__......_._ .... _........_....--- .......... .......!....._..._._.. - - -. __........._ _
..._ _._...__._ ..............
... _..__._..._._- ... _ .... ............................ _ .......... _ ......... ........ ......... - .............. ... _ ..... ...... _....... _ ... .. ._.._...............__ .... _....
i
E
i
i
i
THESE ARE TRANSMITTED as checked below:
®For 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: Louis Pescatore WkTM ErIU- oSt'Kg� SIGNED:
%105. luo FIL+ Jo atson, P.E.
Pngineer
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
Lot071514.doc
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Wc - -- .. -3 81
Owner or Purchaser of Building Tax Map Block Lot
c5 _ . :.SGi? _ —
P AIMSf)1tJ
Building Constructed by TownNillage
LAi
WAD
Location - Street Subdivision Name
Building Type Subdivision Lot #
l 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 ofHeatth, 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
10 operate was caused by the willful or negligent act of the occupant of the building utilizing the
system.
Dated: Month D(o Day 01 Year 2014
Genera Contract r (Owner) - Signature
AST o QsLb u A, Tfs
Corporation Name (if corporation)
Address: 8Z DEQOrj' H l Ll- PpAb , -lol ES
State NEw VDA)4 Zip S31
Signature-, _
Title: - --
Corporation Name (if c-o or�ti nQ )-
Address:
State 6 i% Zip��,i.
l=oan GS 9;:
. I
;
2' WIDE PRIMARY \ \ \
SSTS ABSORPTION 11 \ \
TRENCH (TrP.) \
2' WIDE EXPANSION SST5
\ ABSORPTION TRENCH (TYP.)
10
g
4 "0 PVC SDR -35 5
400 PVC SCH -40
4 \
3
0Eor 4pjl PVC
1,560 GALLON
SEP11C TANK
If If if if lf:lf li j. ' ��?
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25 50
EN
LA Go PLAN
SCALE! 1 SCALE IN FEET
SITE DATA:
Total Acreage., 1.502 Ac.
Tax Map Number, 13 -3 -81
APPLICANT/RECORD OWNER
Astro Associates
C/o Louis Pescatore
92 Depot Hill Road
Holmes, N.Y. 12531
NOTES,
1. This is to certify that the Sewage Treatment System was constructed
as indicated on this plan and that the system was observed by Insite
Engineering, Surveying, & Landscape Architecture, 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 facilities existing, 'unless noted otherwise.
J. Property line and house shown hereon are based on field survey by Terry
Bergendorff Coll/ns revised May 28, 2014.
NO,
A
CORNER OF
DWELLING
B
CORNER OF
DWELLING
REMARKS
1
31.5'
29.5'
1,500 GALLON SEP77C TANK COVE
2
34.0'
36.0'
1,500 GALLON SEP71C TANK COVE
3
23'
53'
JUNCTION BOX 1
4
30' ,
60'
JUNC770N BOX 2
5
35'.
65'
JUNCTION BOX 3
6
41'
69'
JUNCTION BOX 4 .
7
47'
75'
JUNCTION BOX 5
8
42'
98'
END. OF TRENCH
9
57'
110'
END OF TRENCH
10
71,
45'
END OF TRENCH
11
81'
67'
END OF TRENCH
PUTWA C'LiUI M DEPARTMENT OF HEALTH
DIVISION 'OF ENVIRONMENTAL HEALTH SERVICES,
APPROVED AS NOTED FOR CONFORMANCE WITH,
AP" ABLE RULES AND REGULATIC: S OF THE
ALLEN BEALS', M.D.; J.D.
Commissioner of Health
ROBERT MORRIS, P.E., MPH
Director of Environmental Health
September 25, 2013
Insite Engineering
John Watson, P.E.
3 Garrett Place
Carmel, NY 10512
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
. Phone # (845) 808 -1390 Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
Re: Field Inspection — Astro Assoc.
41 Vista Lane
(T) Patterson, TM 13. -3 -81
Dear Mr. Watson:
The above referenced separate sewage treatment system can be backfilled.
There are no open comments to be addressed at this time in reference to this Department's open
work inspection.
If you have any further questions, please contact me at (845) 808 -1390 ext. 43261.
Sincerely,
Gene D. Reed
Environmental Health Engineering Aide
GDR:cw
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date: 9 /2 l3
Inspected by: Ca �
Street Location V Vf s+i!>_ L_a,.n.e Owner &4-ro Assam,
Town e _542 � _ P.mmit # 2-07 , / A.. 16&) t3
TM # 13 . 3. — g I Subdivision Lot # >/
1: :Sewage System Area
a. STS area located as per approved plans ..........:................
b.. Fill section- date of placement
3:1 bamier Lgth. width . Avg.Dpth
c. Natural soil not stripped ...................................................
d. Stone, brush, etc., greater than 15' from STS area..........
e. 1 00' from water course/wetlands s ...... ...............................
II. Sewage SSystem
a: Septic tank size. -1,000 .... .... 1,250 .... :.... other ... .oa
b. • Septic• tankiristalledlevel ......... ...............................
c. 10' ffl1n='nTM from foundation ............................... .............
d. Distribution Box
1. Alt outlets at same elevation- water.tested ..................
2. Protected below frost ................... ...............................
3. . Nfinimum 2 ft-Original soil between box & trenches
e. Juuc ion Box properly set .......... ............... ..............:.:
6. Ten
1..Length required :5 00 Length installed oD
2. Distance to watercourse measured f rco Ft..........
3. Installed according to plan ...:. ...............................
4. Slope of trench acceptable 1116 - 1/32" /foot .............
5. 10 ft. from .property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ..................
7. f Room allowed for expansion, 10.0% ......... :...............
S. Size of gravel 3/4 -1 'h" diameter clean ..............'.:..:
9. Depth of gravel in-trench 12" minimum......:,...........
10. Pipe ends ed Sed ..................... ...............................
g. Pumo or.Dos vstems
1. Size of pump c}> amber ................ ...............................
2. Over$ow tack ..................... .............. .................. .
3. Alarm, visu8l/ audio ...:............... ...............................
4.. Pinup easily accessible, manhole to grade .................
5. First bona baffled ........................... .......... ........... ............
G. C cle witnessed by H.D.estimated -flow /cycle...........
III. Hous aildi
a. douse located . er approved plans........ .. ...........
b. Number of bedPooms ....... .. ................... 3 .. ............
IV. well
Well located as per approved plans . ......:...............I........
b. Distance from STS area measured l / ' • ft ...........
c. Casing. 18" above grade ................ ...............................
d. Surface drainage around well . acceptable .....:................
V. Overall Worlomanshio
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfilted ...........................................
c. All pipes flush with inside of box ... ...............................
d. Backfill material contains stones <4" diameter ..............
e. Curtain drain & standpipes it s -ed 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.......
i. Erosion control provided ................. .....:.........................
Rev. 2ro2
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
ATTENTION JOSEPH GENE
OMT FOR FiNAi. INSPECTION For: rill
Ail information must be fully completed prior to any Trenches
inspections being made.
PCHD Construction Permit #
Located:
Owner/Applicant Name: A-,Tao Ascot Am s coo ,s,,,,« TM 13 Block 3_ Lot fs�
Formerly: Subdivision Name: fAs ,rk.o
Subdivision Lot # 1
Is system 0 completed? _ `�' E 5 �G�p �` ,� s o truer) Date:
Is system complete? `�' F S Date: `� �� ►3
Is system constructed as per plans?
Is well drilled? '?F-5 Date: of z3 f c .3
Is well located as per plans? Y F- s
Are erosion control measures in place? E 5
I certify ti& the systems), as listed, at the above premises has been constructed and I have inspected
and verified their completion in accor+da= with the issued PCHD Construction Permit and
approved plans and-the Standards, Rules and Regulations of the Putnam County Department of
Health.
Date. q ( Certified b : $ _ PE RA
- .
esign Professional
John M. Watson, PE
Insb Englneedng, Surveying & Landscape Architecture, P.C.
AddMSS: s tGanvit Place, Carmel, New York 10512 Lie.
77950
Comments: - 1400sE ir-"v-k N?i'QtoJEz> PC,At i , D,-? i7--0rr -ANC
oN ef'VtDsrTE SIDE , {A try CRrTCCOL- 5-Q- T43Ac.KS CoMPt -t`cA wrrH
Lot3r2Ar -'To a- To "r4f -aVr-c sLOPE 5.9:.LO�P ExPRa4'Sw,J p,CL-ed� F U— '4�
3 0 t T'4r2 AYP2,wCA> T-tAN
_jZt>>O`F �R c N O u r l-ET
Form FIR -99
1
PUTNAM COUNTY DEPARTMENT OF EA ,
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #� � ��r i � 5 . „J —0 t _ 1_,J
Located at Town or Village 4-4,-r, on
Subdivision name 4 4,. Subd. Lot # i I Tax Map 13 Block 3 Lot _
Date Subdivision Approved AA 10 1 'r / O v
A,4ra /¢Uot i < Fc)
Owner /Applicant Name % Lov:� P e_l C'40ie'-
Renewal Revision
Date of Previous Approval
Mailing Address J 2 - S-o Q,-,A, Q jam,(. 14$16 pn,, k Zip 11
Amount of Fee Enclosed Z"00, a0
Building Type Lot Area 1 ,Sk ,-'7 -No. of Bedrooms S_ Design Flow GPD 4_006
Fill Section Only Depth Volume
PCIID NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED'
Separate Sewerage ))System] to consist of I_ ► �� o gallon septic tank and 9'0 L F of
2 W KL Gt b orp +;an J-nemf,
Other Requirements: 'p'.. 0 F' 7, 2' -O'' 2,T0 I cy F-11 To I S 2.
To be constructed by 7o bt a��errh�nc Address
Water Supply: I Public Supply From
Address
or: _( Private Supply Drilled by lb L �� ua, ,,L 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 treatments stem 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 Dimtor /Commissioner will be submitted to the
Department, and a written4.uagtee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in gdcjopetiaatNii ondition any part of said sewage treatment system during the period of two (2) years
immediately folloy�ing,the dard;oftheissuance of the approval of the Certificate of Construction Compliance of the original
system or any re airs- tn'ereto. �(, 7
Signed: r
Address `I n
�7—
P.E.
-e.c krz—" P. c..
�-R Date
10 -Z3 -1 Z
License # -" q50
APPROVED FOR CONST1t1CTCTION: 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 Director /Commissioner. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
gy, Title: M44= Date: c /13
W 'te opy - HD File; Yellow copy - Bui ding Inspector; Pink copy -Owner; Orange copy -Design Professio Form CP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL _
�CRe� : l P lease not or type
a 7.7tra
Well Location
Street Address: Town/Village: Tax Map #
V; sk ,q. La h P" �efJ o n Map (3 Block _ 3 Lot(s) 8 I
Well Owner:
Name: 4.,4,,, G.
-
J?ll.
Phone #:
(b oo , Pesan4ofe-
11317¢
(iefo ark r /V v
Use of Well:
_Residential _Public Supply Air /cond /heat pump _Irrigation
1- Primary
Business Farm Test/monitoring —Other(specify)
2- Secondary
Industrial Institutional Standby .
Amount of Use
Yield Sought S gpm # People Served S Est. of Daily usage 36 o gal..
Replace Existing Supply Test/Observation Additional Supply
Reason for Drillin
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 io
Is well located in a realty subdivision? ........................................... ............................... Yes No
Name of subdivision A-%4ra Asp oc-; Qf es Lot No.�_
Water Well Contractor:. To 6e. '&f ("ilL'a Address:
Is Public Water Supply available on site? ............. ...........................�� .... Yes _ Nom_
Public Water Supply: i
Name of
Distance to property from nearest water main: t' A,,`�'P�
Proposed well location & sources of contamination to be r V' off1; arate s t/plan.
gip- 23.171 � y
Signature: {
Date: Applicant
(113 Nnacf, "Af
rt� o ct 2-
PERMIT TO COS RUCTaAJW IK
This permit to construct one water well as set forth above, is granted and &-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 Departmel
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 approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam County.
Date of Issue Permit Issuing Offici -
Date -of Expiration 6 Title:
Permit is Non- Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06
JUN -25 -2000 OT:26AM : FROM-- ENVIROMENTAL HEALTH
DEPARTMENT OF REAi,TH
Bueau oaf wafer Supply, Protection
Name ofAppticsnt
Address
Contort Information
Site Location
s 9L-5o Qv.ens !l
o 919-96 -6s67
8452TO7021 T -930 P.001 /001 F -T66
arrxat+tt; WAM&R APPLICATION
Request for Approval of Noncomplinace with
the Standards of IONYCRR Appendix 75-A
Wastewater Treatment Standards— ludividuttl Household SMews
Bits[ O U 1
NJ
om Pe o Pam s-ft Al Y I zip 113 74
FAX: CM[h
The following iofonaadvll Is being submitted in wppon ofmY application for a Specific weer from compliance NWO one or more
standards of l d1VYCR.IR Appendix 75-,4, "Wastewater Treatmext S1r�ldat"ds:- Ihdividaal A'o�eJioid Systepts':
1. The wastewater treatment system cannot nutet the following standards of 10NYCRR Appendix 75-A:
C1 Separation distances cannot be achieved (75- AA(b), Table 2, Separation Regnirwoents)
Excessive Slope (7S- A.4(1), Soil and Site Appraisal
D Design is not addressed In Appendix 75-A
Q Technology is not addressed in Appendix 75-A
0 Other:
2. The
3. Supporting information provided:
Detaned Site Plan
Detailed Design
O Sail and Site Evaluation
C3 Neighboring conditions of eancern (at.. weft, watarbodies, wetlands, eta)
0 other:
Explain:
I, (applicant) L o v is ' Pei c . +re— (type or print) admawledge that tbis waiver request b necessary because h
is not pradical for an onsite wastewater treatment system to the referee standards of 1ONYCM4 dine 75-A on
tl�pro- X I I
Signature Date
I, (engineer) J A n W, + a on- P. 9. (type or print) aelmowledge that ft waiver request is necessary because It is
not practical for an onsite wastewater treatment system to meet the referenced standards of IONYCRR Appendix 7S-A on this
property. In my professional opinion, the proposed design described la this application will. provide a degree of protection
equivalent to the onsite wastewater treatment standards) that be met iopp# prow- ly and will not in to
increased risk to public health or the enviro� "Zn0f 7_
In�'Ie. C70j,- "',") JorveJ;!%J ..Leal, e P.c. k
7 GaN— P%, caIA•tl i ar! 2 `Sign tare PE License
*For
Based upon the ubrmatioiXovided in this application to waive the referenced standards of Appendix '75-A and In
accordance with IONYCRR§§ 713 and 78.6 (b), the waiver requested is hereby:
Approved as proposed.
Approved, with following conditions:
❑ Not acted on, because additional information is required:
❑ Denied, because:
Norw This waiver may be revoked should eondMons con before approving this waiver chaiwe otter approvaL
Health Aepartw t Representative Signature Date
hr
REBECCA WITTENBERG, RN, BSN
Public Health Director
ROBERT MORRIS, PE
Director of Environmental Health
MAP- YELLEN ODEL.L,
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390'
Fax # (845) 278 -7921
PUTNAM COUNTY DEPARTMENT OF HEALTH
SPECIFIC WAIVER
NAME: °SOCr� Y� j
ADDRESS:
SITE LOCATION: L% V l,S)'�'
TOWN: �d 7r�`S�� TM # % �j•� 3 ._ �' l
PERMIT # ,CI v lam_ DATE(S): `��° a-
STAFF PRESENT: Michael Budzinski P.E. Robert Morris P.E. Joe Paravati P.E. Gene Reed
SPECIFIC WAIVER(S)
REQUESTED : � r� cC2 f7 r�rt -i A "7- {� l
DOES THE PROPOSED VARIANCE REQUEST POSE A HEALTH HAZARD OR
ENVIRONMENTAL CONTAMINATION PROBLEM? /
YES ❑ NO [�
WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP?
YES qX NO ❑
DISCUSSION
SPECIFICWAIVER DETERMINATION ' /
APPROVED [� DENIED ❑
REAS OR DENIAL
3�
ch
D CTO NME G� )frAL HEALTH
PUBLIC HEAL'
)L 1 I ti
D TE
1
/DNS /TE
ENGINEERING, SURVEYING &
LANDSCAPEARCH/TECTURE, 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: 1 -21 -13
Job No. 98105.100
Attn: Joe Paravati, P.E.
Re: SSTS Renewal for Astro Associates,
Lot 11
49 Vista Lane, Patterson
TM# 13 3 -80
WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via
❑ Shop Drawings ® Prints ❑ Plans
❑ Copy of Letter ❑ Change Order ❑
the following items:
❑ Samples ❑ Specifications
COPIES DATE NO. DESCRIPTION
5 1- 14-13 CD -1 Construction Drawing
2 10 -19 -12 Al. A2, & A3 Architectural Drawings
THESE ARE TRANSMITTED as checked below:
®For approval
[]Approved as submitted ❑ Resubmit copies for approval
❑ For your use
❑ Approved as noted ❑ Submit copies for distribution
❑ As requested
❑Retumed for corrections ❑ Return corrected prints
❑ For review and comment
❑
REMARKS:
Joe,
The Construction Drawing enclosed herewith has been updated to match the new Architectural Drawings. If you have any
questions or comments regarding this information, please do not hesitate to contact our office.
pPresident
COPY TO: Louis.Pescatore�(w /..`enclosures)_; SIGNED:
, P. E.
Senior Project Manager
IF ENCLOSUR ES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
L0012113jp.dot
10/03/2012 WED 9:22 FAX INSITE ENG.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of c;
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner A., 1r, Address &t. P,,.1<. A
Located at (Street) ✓vas ReA, 31( Tax Map 1 3 Block 3 Lot g
(indicate nearest cross street)
Municipality pow, Watershed E4,� Qn2,,A
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Z ft I '2 Date of Percolation Test �/ ZS`/ I -Z
NO. Hole
Run No.
Stint _�
F.Lapse Time
t;Min.)
Depth to,SYzter
From Ground
Surface (Inches)
Start Stop
tauter
Level
prop In
Inches
Percolation
Rate
Min/Inch
G
1
l : V V . to 11:1.2-
.3
2
2:0 7D 12.3
. �.
2:34 7b WTI
1 P'
22 2�`
3
4,T7
4
5
.
2z- 2 s`
3
T 2;3L
22 7-5-
3
3
3
2:s� ;�. z:a�
9
2.1- 2 f
.
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, 5 2 min for 31-60 min/inch). All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Focm DD-97
Pg. l of 2
Y-
TEST PTT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. 11 L HOLE NO.�_
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'
HOLE NO.
Indicate level at which groundwater is encountered Lv /�
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by. Soo- Pcra y'U; ko ) 14. L 1 _,, �?kT Date 22212
Design Professional Name: Jchn -M. Watson, P.E. Address:
& Landscape Architecture, P.C.
3 Garrett Phase, Cmmel, NY 10512
Signature:
C ®UNTO
Design Professional =s Seal
OCT 2 2 2012
DEPARTMENT OF HEAD
(3 MNE14i
CO
PUTNAM COUNTY.DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner A ,!r4 L Pe, a �,/',-Address q Z -.S i, j
Located at (Street) ,,1y s 2 , V( Tax Map 13 Block 3 Lot Q i
(indicate nearest cross street)
Municipality P{ far" ., Watershed
SOIL PERCOLATION TEST DATA
Date of Pre - soaking _ 9_ / &/ i 1- Date of Percolation Test
Hole
Run�No.
rime
Elapse Tae
M
Depth to Water
From Ground
Surface (Inches)
Start Stop
Start
water
Level
prop In
lathes
Percolation
Rate
Mintlach
P
•L3' 2 e
3
2y 3
. 2; 1 7
Il
2'� 20
.4
�5
P.il (3
1
6 0 :s1
"7
2
L;o2
21 29'
3
3bo
3
3
4
5
�1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolanon
rates are obtained at each percolation test hole. (i.e. S 1 min for 1 -30
min/inch, 5 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
Pg. l of 2
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. 1 I Q
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'
HOLE NO.
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 hole observations made by: (,`j�,� (cpanl Date I�'9
Design Professional Name: Jahn M. Watson, P.E. Address:
Tns53WD= M. SurveyLm & T.mxbcape Architecture, P.C.
3 Garrett Place. Cpl, NY 10512
Signature: "
Design Professionals Seal
PUTNAM COUNT'
OCT 2 2 2012
DEPARTMENT OF HEALTH
NEW
CO-
'� °+ Al's, •C7
3
C
)1.
�A
r Z-0 T
P[JTNAM CO0 DEPA IE�iT OF HEALTH
DIVISION OF ENVIRONINIENTAL. =HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATN[ENT SYSTF-M
owner:
Located at (street):: LOCI (y�����°i✓/k!t)
Municipality: �(l. �i��DP,
Address:
TIVI 4 Section: — Block _ Lot
Watershed:S'��Ji2�✓+c�
SOIL PERCOLATION TEST DATA
a Witnessed by:
Date of Pre - soaking: Date of Percolation Test: d�TIL 3
Notes:
I. Tests'to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < l min For 1-30 min/inch, < 2 min for 31 -60 miniinch).
All data to be submitted for review.
2. Depth measurements to be made from top ofhole.
Forst fin -97 �o i ,
Time
Stop
Elapse
Time-___
(min.)
Depth to
water from
ground
..- ._..._ _— - - ........
surface
(inches)
Start - Stop
Water
in inches
Percolation
min /inch
Pal A
IL4.3 11'S2
S-- g
3
2
3--7
3
jt::06- 0:17
11
as- dq,
�.
4
s
Eli J
I.
I :4 :53
01 — Z2 q
I. 3
l'.
11:53- ixoj
I -
3'
4
�W j q
ae� -
4.7
2
1 ,2.*d3 * a, 37
- a 5
{ '7
I'. 4�
I
I
3
I
a.l1P
"'
1 Ca�C
3
3
3
3
30 -Q: 39
-
4
5:
1
f
I
I
I I
Notes:
I. Tests'to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < l min For 1-30 min/inch, < 2 min for 31 -60 miniinch).
All data to be submitted for review.
2. Depth measurements to be made from top ofhole.
Forst fin -97 �o i ,
D I Ic. 0,.-. �. 73
till
r J
M.S
q,2- riple- 14
b., l a OF
6q �,�, fe J�vo" -5�Oa
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: 141 qo Pc...f
0-.: le-vc -t
Re c . 00- A r /V y 11
2. Name of Project:.Isrj P, Aa,W 1,l 1*11 3. Location: T/V:
INSITE ENGINEERING, SURVEYING &
4.. Design Professional: 5�1,� �, W�,}.,;,, r P, 5. Address: LANDSCAPE ARCHITECTURE P c.
a Basin: F,� 0r,� 3 RMEL, T PLACE
6. Drainage CAMEL NY 10512
7. Tvne of Proiect:
-- 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
Type Status (check one) ...................................... ............................... Type I Exempt
Type II Unlisted V
9. Is a Draft Environmental Impact Statement (DEIS) required ? ...:................ Yes/No /V o
10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes/No
11. Name of Lead Agency
12. Is Is this project in an area under the control of local planning, zoning, or other officials,
ordinances? .. .. ..............
13. If so, have plans been submitted to such authorities? .. ............................... Yes/No X1/0
14. Has preliminary approval been granted by such authorities? 1110 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? . ............................... Yes/No ,vd
19. If yes, name of water supply /IZA Distance to water supply
20. Is project site near a public sewage collection or treatment system? .......... Yes/No,
21. Name of sewage system .✓ A Distance to sewage system A!:1- �
T
22. Date test holes observed R 2,�J 23. Name of Health Inspector :3,) VC-4i PE-
24. Project design flow (gallons per day) ............................. ...............................
25. Is State Pollutant Discharge Elimination system (SPDES) Permit required? ... Yes/No /yv
26. Has SPDES Application been submitted to local DEC office? ......................... Yes/No /U
Rev. 11/02 Form PC -97
Pg. I of 2
27. Is any portion of this project located within a designated Town or tate etland ?... Yes/No of
28. Wetlands ID number .................................................................. ............................... 2, 2
29. Is Wetlands Permit required? ...................................... ............................... Yes/No /L 4
Has application been made to Town or Local DEC ........................... Yes/No
30. Does project require a DEC Stream Disturbance Permit? .... .........................Yes/No /c/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/No le"o
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 /-"a
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? .........................Yes/No ui%ko own
34. Are community water and/or sewer facilities planned to be developed within
35
36'.
37.
15 years in or adjacent to project site? .................................. .........................Yes/No un kn-un
Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No �i- F`« T°
�LeAy 7c
Tax Map ID Number .............. ............................... Map 13 Block 3 Lot rL ( (S"�
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 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 herd a�e� hable as a Class A misdemeanor
pursuant to Section 210.45 of the Penal Law. NE1
SIGNATURES & OFFICIAL TITLES.
INSITE
Mailing Address: .............. ............. i15ARI
NY, 105�X " \\
A- r >1V
E ARCHITECTURE, P.C.
PUTNAM COUW
For,947 < 2 291
14 -16.4 (11/95) —Text 12
PROJECT I.D. NUMBER 617.20 SEOR
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-- PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR
2. PROJECT NAME
A r, 4.aj0 Gi'C 'e-1
SSTs F; -r
3. PROJECT LOCATION:
Municipality 19 krl0A County Boy 4k)4.{)1
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map)
SCG IOCtiIlO� /Y1oi0 G�` CO:,J� ✓vudn �iQk�i.�J
5. IS PROPOSED ACTION:
hi yy New ❑ Expansion ❑ Modification /alteratlon
6. DESCRIBE PROJECT BRIEFLY:
Con.4rur, klo o4 one_ 4�4►e,, J fea.:fen� r 6(r; ✓u4,7 r Ss.f� r .i„e l! 4a1 gPPV 2tic'el .
7. AMOUNT OF LAND AFFECTED:
` 3' 4-r_
'
Initially, acres Ultimates acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Yes ❑ No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF -PROJECT?
PKIResidentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest /Open space CI 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 If yes, list agency(s) and permit/approvals
'j-oUN
��ivu.• ^`� /�BIA.#' 0� Pm}'j'Cd��r J
s'�r� y M.�tl — P�,�;nar, . Cn�.� pbpn�i-n�.F- v!- Iia��fl•
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
13'Yes %No If yes, list agency name and permlUapproval
12. A$ A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION ?.
❑ Yes No
I CERTIFY THAT) ORMIA'tIQQr' OVIDED ABOVE IS TRUE TQ THE BEST OF MY KNOWLEDGE
4,4 4" �cc�ie.. �•
n J: e Sc� i'j h- .4 G
v ' ��-� a 34-1 L._
P
A.ppllctin.tlsponsor name: - . Date:
Signature: tY°
. X793 •�,
1 0hection inn, �th,eOC�oa�s,a Ia, and you are a state agency, complete the
Coastal ASS@TSrinent :Form before proceeding with this assessment.
OVER
1
PART 11— 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)
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, 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 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
Print or Type Name of Responsible Officer in Lead Agency
Signature of Responsible Officer in Lead Agency.
Name of Lead Agency
Date
Title of Responsible Olf icer
ignature of reparer (If ditferent from r 6 rN,Y
DEPARTMENT OF HEALTH
10/03/2012 WED 9:22 FAX INSITE ENG. 0005/005
'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: 4-5.4a A-5-so, coisr
represent that I am an officer or employee of the corporation and am authorized to act for:
Name of Corporation: - s ��o ,��, , C TO- 4 ns
Having offices at: q? - 3-0 Q. ,ee "s Q ou l e va raQ � art c 3
� � e� o _ /f/• � 1 I %5�
i
Whose Off Csja
President - Name;
Address:
Vice President - I
Address:
Secretary -Name:
Address:
Treasurer -Name:
Address:
and that 1 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.
Signed:
Title:
Sworn to before me this day of
(onth) (yam)
Corporate Seal
Form CA -97'
AG ,dIS Yor{
Notary Public, -
r, !�w
No.
Qualified 'P county
Commission ExPirE's Apr. 14, 20
1,�
/NS/ T
7R7—ENGINEERING, SURVEYING &
LANatSCAPEARCHITECTURE, 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
COPIES
DATE
10 -23 -12
10 -23-12
10 -23 -12
9 -25-12
10 -23 -12
10 -23-12
10 -03 -12
LETTER OF TRANSMITTAL
Date: 10 -23 -12
Job No. 98105.100
Attn: Joe Paravati, P.E.
Re: SSTS for Astro Associates,
Lot 11
41 Vista Lane, Patterson
TM# 13 -3 -81
® Enclosed ❑ Under separate cover via
® Prints ❑ Plans
❑ Change Order ❑
NO.
j CD-1
f WP -97
LA -97
—97-
DD-97
�A
DD -97
PC -97
EAF
#42471
THESE ARE TRANSMITTED as checked below:
the following items:
❑ Samples ❑ Specifications
DESCRIPTION
Construction Drawing
Well Permit
t on Permi
Construction
..___._.ructi
Letter of Authorization`
Affidavit
Design Data Sheet
Application for Approval of Plans for a Wastewater Treatment System
Short Environmental Assessment Form
Modular 5 Bedroom House Plans
_.._.- .- .._._..
$500.00 Fee
®For 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:
1
COPY TO: Louis Pescatore SIGNED:
(M. Watson, P.E.
President IF Senior Project Manager
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
Lot101212.dot
/NS/ T
ENGINEERING, SURVEYING &
LANQSCAPEARCH/TECTURE, 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: 12 -14 -12
Job No. 98105.100
Attn: Joe Paravati, P.E.
Re: SSTS for Astro Associates,.
Lot 11
41 Vista Lane, Patterson
TM# 13 -3 -81
WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via the following items:
❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Copy of Letter ❑ Change Order ❑
THESE ARE TRANSMITTED as checked below:
®For 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:
As requested, the PCDOH notes has been revised for this submission. We trust you will find the enclosed information in order,
and sufficient for the construction permit to be approved.
COPY TO: Louis Pescatore (w /out enclosures) SIGNED:
0021412.dot
Watson, P.E.
sident / Senior Project Manager
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
J
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
November 30, 2012
Insite Engineering
John Watson, P.E.
3 Garrett Place
Carmel, NY 10512
Dear Mr. Watson:
DEPARTMENT OF HEALTH
1, Geneva Road, Brewster, New York 10509
Telephone: (845) 808 -1390; Fax: (845) 278 -7921
MARYELLEN WELL.
County Executive
Re: Proposed SSTS - Astro Associates
Vista Lane
(T) Patterson, TM.13.3 -81
This office has received and reviewed the most recent set of plans for the above- mentioned
project. We would like to offer the following comments for your review and consideration.
• The proposed SSTS is on a natural slope of 18% which is greater than the maximum
allowable slope of 15 %. The application is denied. However, since the lot was part of
an approved subdivision, a waiver from the current code can be requested. Please submit
the latest waiver form.
This office will continue its review upon consideration of the above - mentioned comments.
Please feel free to contact me at (845) 808 -1390 ext. 43157 if any questions arise.
JSP:cw
Sincerely,
e� /7GLc�
CJoseph S. Paravati, Jr., P.E.
Assistant Public Health Engineer
t k?
AI.I.EN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director ofEavironmentd Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Telephone: (845) 808 -1390, Fax: (845) 278 -7921
November 13, 2012
Insite Engineering
John Watson, P.E.
53 Garrett Place
Carmel, NY 10512
MARYF:i. XN OD1kLL
CountyExeLVtive
Re: Complete Application Determination for
41 Vista Lane
(T) Patterson, TM 13 -3 -81
East Branch Reservoir Basin
Dear Mi. Watson:
The Putnam County Department of Health.(Department) has determined that the above
referenced application, including fee, and revisions received by this Department on
October 24, 2012 is complete. The Department will notify you by of its determination
November 28, 2012.
M. The Project has been delegated to the Putnam County Health Department for
review pursuant to the guidelines set forth in the Watershed Agreement.
❑ Joint review with. the NYCDEP will commence pursuant to the guidelines set
forth in the Watershed Agreement.
If the Department fails to notify you within the above referenced time frame, you may notify the
Department of its failure by certified mail, return receipt requested. The notice should be sent to
my attention at the above address. This notice must include your name, the location of the
project, the office With which you filed the application originally, and a statement that a decision
is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection
Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the
receipt of the notice, your application will be deemed approved, subject to standard terms and
conditions as set forth in the regulations.
Please be advised that projects within the NYC Watershed may also require Department of
Environmental Protection review and approval of other aspects of a project, such as stormwater
plans or the: creation of impervious surfaces, and the project applicant should contact the
Department of Environmental Protection regarding such activities to see if Department of
Environmental Protection- review and approval is required.
If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43157.
Respectfully,
(Joseph S. Paravati Jr., P.E.
Assistant Public Health Engineer
JSP:cw
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
DEPARTMENT, OF HEALTH
1 Geneva Road; Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARY1ELLEN ODELL
County Executive
TO: 1VCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN: 16 /),/Ivl d k1d e #e,'s; a
FROM: :!
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE'TREATMENT SYSTEM PROGRAM
DELEGATED
New Application 2- Renewal ❑
PROJECT: S'7rc A� So <('C -- �e s
LOCATION: Z/(
TOWN: Pk.,4z C) '0 DATE SUB'D APPROVAL �� r
TM#
NOTICE OF COMPLETE APPLICATION DATE: Xf 12-
DELEGATED