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HomeMy WebLinkAbout0425DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -93 BOX 5 00234 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1,4x Ac, c> Of 013 WELL COMPLETION REPORT Well Location Street Address: 14),V 7 Town/Village: To tllage: �� �d Grid # Map 13 Block 5. Lot(s) q Well Owner: Name: Address: A/4 r) L & - r al 7 ) Use of Well: 1- primary 2- secondary Residential. Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) 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 ft. Length below grade. Eft. Diameter `Z in. Weight.per foot _L`_lb /ft. Materials: Steel Plastic _ Other Joints: Welded _ Threaded —Other Seal: _ Cement grout X Bentonite Other Drive shoe: 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 Y Compressed Air Hours Yield ; gpm Depth Data Measure from land surface - static (specify ft) T- -`e, e,� During yield test(ft) / & d M wkk Depth of completed well in feet 3f0� i Well Log If more detailed information descriptions or sieve analyses are available, please attach.pa Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface S f r✓ If yield was tested at different'depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 5�26 Capacity Depth &12:2 Model,2 Voltage s HP 2 Tank Type�r7 Volume Date Well Complete Putnam County Certification No. 607 Date of Report L63 Well Driller( si nature) *4t NOTE• x ct location of well with distances to at least two pernianeat lautimarks to be provided on a separate eet/plan. Well Driller's Nam C C � , f ve�� Address: jl% v�� ��g�ci�' a � D� / v • Signature: Date: d White copy: HD File; ;Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Nu -Craft Builders, Inc. P.O. Box 528 Bedford, NY 10506 Dear Sirs July 1, 2004 Re: Addition- Nu -Craft Builders, 42 Vista Lane No Increases in Number of Bedrooms (T) Patterson, TM #13 -3 -39 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated July 1, 2004. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at five without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Very truly yours, William Hedges WH: lm Senior Public Health Sanitarian cc:BI (T) Patterson AS - - ••1 � / ' X99 S i ; dVR msoearad Jorra Ns" KUVD vnv c / � \ Fi•d - / �J \�` /� ,� .,�•�_ (; fir/ �f y ♦ ',JABl00! aw Jow i ../ /•' /// / b /Cry ~ .� ILA wo b y � e Opp -- - � f f. % �; • -� ! _ 'else : s - !, sla \�ra°7Ya�a>ad 41, r 1' -6" a �m 0 X m rS�OQ lU k N r iQ I I --------=------------------------ -- __ - -_— __ _____ _____ _____ _____ _____ _- -- - - - - - - - - - - - - ' - - - - - - - -- - - - - -- iR— 1-6 2 -6L I STA I TO I -- I o 0 I D _ • yA I I m° S ti V` Vf op N � W 4 I_ - -____ — — _ — r' Z a 2 (TYP) I: iT�i 'a yop$ I o m - -- -I 1 I- -- - --1 I I _ • iR— 1-6 2 -6L I 4 16" STA I -- - --J _ 97.2v ti I I �----- Y4 0 r.I �< S 99991 r ----' —`—,,� 0P I I _ • iR— 3 Z x 12 R r• _ 97.2v ti I s°. I- — Iv I I 1 I. I I I I I I i I I i I 1 SIR I ' 1 I I. I N I, I � I I � _ I I i I i I ' I I I ' L_♦ ----- -- ----' I— —= ---- - -= —1. �� nr _ I 23• -r• 2• -6.. I _ _ • yA 1 S ti V` � W 4 I: I s°. I- — Iv I I 1 I. I I I I I I i I I i I 1 SIR I ' 1 I I. I N I, I � I I � _ I I i I i I ' I I I ' L_♦ ----- -- ----' I— —= ---- - -= —1. �� nr _ I 23• -r• 2• -6.. ,f 44 �r1 Cp BRUCE R._FOLEY, P c Aeting PUhlla Mealch Oi.-e:t.�r DEPARTMENT OF HEALTH Division . Of Environmental health Services Ceneva' Road, Brewster, New York 10509 (914) 278 -6130 Puts.: -.. County Dept. of Heait , 4 Geneva Rvad B:ewstrr, NY 10 C9 I Re: Residences Taff Map Town � 8J1ii%m�i1: . According i.o records maintaired by the To%�—n, the above noted dv elling .S NOT in (=piianc�',y,ith code and the total number of bedrooms on record This information ,ia5 been obtained from CERTIFICATE O.F OCCUPANCY: ASSESSORS RECORD-. Building Inscector Ale 'EPAR1MIv 1 OF I-MALT.H DfvWon of Environmental Health Serykes 4 Geaava Road BTeWster, New Yorir 10sa9 Tel. X914) 278.6130 Fax (9I 4) 278 - 7421 L . 3:6410-:0 BRUCE R. FoLzy Public Hecith Dir:c .,c,. STREET Zo,� d,,e,-- TOWN X ivL Y 1 3, 3 NAME f�U'- 3 ' �G : PHOI, 9 PCHD r INI Ai1.LNC ADD S3 CUMBER OF EMSTITING BEI)ROONAS -4 PROPOSED # OF BEDROMMS - � (FROM CERT. OF GC;: ??, \Cf OR CERTIFICATION FROM BUILD24 G INSPECTOR) 5/ � �✓ *Any addition «-loch is com tiered a bedroom requi res formal approval of plans (Coastraction Permit) prepa:ed by a = refessior,al Engineer or Registered Architect in accordance with applicable sections -cf the PuLum Co=ty Saz itezy Code. z:holoing U F am County Health Dot.; 4 Greva Rd., Please submit this for= ,e N rer�st : *, NY 10509, Phone ?', -F :30. nified check or mor_ey order for SI00.00 ske -tches of existing floor p;asi (drawn to ses?e,. all living area including basement) * Non - professional sketc =s arc accept =oIe 3. Two sets o: proposed floor plan (drawn to scale, with name, stree'., a :d 'x,. r.,,.,-,p 4) *No n­pro cssionai sketches are acceptable 4. Copy of saryq s owir:; well and septic location, to the best of your k a ledge. Inclolde date of installation if kno--.;Vn: Label all tireLls and sepdc.systems within 200 feet of the p ;open lire. Contact this office with any questions. 5. Copy of Cen. of Occupancy from Town or Certification tom Buildin Dept. ,Mth legal bedroom count of dwelling. 1OFFiCE UHF Cornmer,:s 'rob 93 AM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVIC RTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT PCHD CONSTRUCTION PERMIT # Located at 44 V%S A LAnJr, CofwnrVillage `( AT .TE R (5O'J Owner /Applicant Name t4Q- CRAfl, Tax Map 13. Block 3 Lot 93 Formerly ASt�L o W o C k AT O Subdivision Name Subd. Lot # (R 3 Mailing Address C/o E,D V>,)6 T1 g Ea�AD 0 Y , - Ea_z*a 4 Zip 10506 Date Construction Permit Issued by PCHD � -au -o3 Separate Sewerage System built by NV --d1zA -fit• 0L1(L tXnS, 11X, Address f o T, -V�K 5'z-(� I&0 Fart.0 . ' IV Lf 10 5-06 Consisting of Gallon Septic Tank and 556 LF p f a` \,J,DG AU. ?trod R(nlcltES Other Requirements: 0(o Water Sunnly: ' Public Supply From or: Private Supply Drilled by NL%EIS K• IPX 6"As Address Address 101% R"f • Sit IWOLSoa r 4- Building Type RV5 `1) L^t l I R l Has erosion control been completed? Number of Bedrooms ' Has garbage grinder been installed? ,'t° ,A) D 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: 9 J 5 (-01- Address tas%jE P.E. X R.A. G 1 I 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 a subject to modification or change when, in the judgment of the Public Health Director, such_ revocati odifica or change is necessary. By: /WL! Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 N Aug 30 04 02:55,p .TOWN OF PATTERSO 845 - 878 -2019 p.1 BRUCE R. FOLEY Public Keclth Diractor LORMA MOLINARI• RN., M.SN. A- voclate Public Health Dimtor Directo of Patiant Servlee t DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10�U9 Eavlroomcata Health (914) 213.6130 !cox (9,14) 278 -7921 Nanlag Servkei (914) 178 - Oi8 WIC (914) 273 -6678, Fox (410) 278.6085 Early Iatcrvendon (914) 275 •.6014. Preschool (914)278.6052 FAi (914) 278 -6648 E911. A DDRE T V�'.RiFI('ATI Ft)Ry� OWNERSNAME c TAX MAP NUMBER: E911 ADDRESS: 4a y+SrA I-PoJ6 TOWN; A>1t'itOMED TOWN OlFFIC.CAE: (Signature) DATE: 3° D The )Putnam County Department of Health will not issiae a Certificate of Construction Compliance waless 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. (E911 VERFW 2 ,,2:d 6T0Z8Z8:01 LT-L6922Sb8 SNI833NISN3 31ISNI:WOU OS :TT b002- 0£-gflti t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �o-fol3WELL COMPLETION REPORT Well Location Street Address: � To illage: � c , d 1� Tax Grid # Map 3 Block 5 Lot( -) Well Owner: Name- Address: A14,cr e, Use of Well: 1- primary 2- secondary Residential, Business Industrial Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details. Total length ft. Length below grade 6 ft. Diameter `Z in. Weight per foot 17—lb/ft. Materials: Steel _ Plastic _ Other Joints: _ Welded X Threaded —Other Seal: _ Cement grout wf< Bentonite Other Drive shoe: 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,` Q 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 th From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface S° ,S e If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth • l SZ 0 Model% Voltage ? BF Z Tank Type Js r7 Volume' GAP f i Date Well Completey io l o� Putnam County Certification No. d o 7 11,016,163 Date of Report Well Driller (,signature) o}., ly4,4' NOTEVExi(tt location of well with distances to at least two petmaneat lattmarks to be provided on a separateoiieet/plan. Well Driller's Nam 41&C om Signature: Address:IO v� Aareo!o / a I . Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 /NS/ T ENGINEERING, SURVEYING & LANDSCA PEA RCHITECTURE, 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 LETTER OF TRANSMITTAL Date: 8 -31 -04 Job No. 98105.100 Attn: Robert Morris, P.E. Re: SSTS for Nu -Craft Builders, Inc. Lot 23 42 Vista Lane, Town of Patterson TM# 13 -3 -93 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via the following items: ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of Letter ❑ Change Order ❑ COPIES I DATE j NO. DESCRIPTION ._5__. ,- 9- 1- �04_ ..__._.___.._._.._..`- AB- 1__.._ .._.._.._.....__.___...._.. ___.._........._..___......_._.___...... w......_._..._..,..._.......__. ~As-Built SSTSN Drawing 1 8-30-04 i CC -97 i Construction Compliance 3 8 -31 -04 j GS -97 Guarantee 1 18 -30 -04 - - - - - - -- E911 Address Verification 1 7 -30 -04 - - --- - - - - -- �._._..__._. --- _._W..__.___.___ _ .__._._...__.. ..._.__.. _. __._ Water Test Results 1 10 -04 -03 i WC -97 Well Completion Report 1 8 -25 -04 , 2777 $300.00 Fee ._._..._...__,. _.__._....__.._____..__ 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 T0: lot2002.dot SIGNED: f �- J hn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building 0 'J'i (�- Building Constructed by LA'JE Location - Street Tax Map Block Lot To illage 0 -CRR% ba+LDERS 'Tric. (G1sf(,o ASSos�,g;tsl Subdivision Name A� a 3 Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material; construction and drainage of the sewage treatment system serving the above- described property, and that is has 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: Month Day Year 104- Signature:4J General Contractor (Owner) - Signature Corp oration.Name (if corporation) Address: State Zip Title: eclv/✓ef'L, N (/— c:n. -,- F. d u! c. a !L5S i 4j C_ Corporation Name (if corporation) Address: State Zip Form GS -97 JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET STAMFORD, CONNECTICUT o6905 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Name: Hyatt Pump Service Address: 229 South Rd City: Holmes State: NY Telephone: 845 - 855 -5136 Sample's. Information: Site: Kitchen Tap Preservative: HNO3 Temperature: <4C Client: Nu- Craft/Ed Buetti Zip: 12531 Fax: 845 - 855 -5136 Collector's Information: Name: M.H. Address of site: Lot #23, Rte. 311 City: Patterson State: N.Y. Zip: Telephone: Date Collected: 7/29/04 Date Received: Time Collected: 4:30pm Time Received: 7/30/04 4:30pm Lab No.: J047960 Date Analyzed Test Name Result MCL Method 7/30/04 16:00 Total Coliform Absent Absent SMWW 9222B 7/30/04 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 7/30/04 Color ND 15 Units SMWW.2120 B 7/30/04 Odor ND 3 TONs SMWW 2150 B 8/2/04 Iron <0.050 mg /L 0.3 mg /L SMWW 3111B 8/2/04 Manganese <0.050 mg /L 0.3 mg /L SMWW 3111 B 8/2/04 Sodium 10.1 mg /L N/A SMWW 3111 B 8/2/04 Chloride 22 mg /L 250 mg /L SMWW 4500 Cl C 8/2/04 Hardness 292 mg /L N/A SMWW 2340 C 8/2/04 Nitrate 1.44 mg /L 10 mg /L SMWW 4500 NO3E 8/2/04 10:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 7/30/04 pH 7.09 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 8/2/04 Sulfate 23.8 mg /L 250 mg /L SMWW 4500 SO4F 7/30/04 Turbidity 0.61 NTU 5 NTUs SMWW 2130 B 8/2/04 Lead <1.0 ug /L 15 ug /L SMWW 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Reviewed by:. Sharon Houlahan, Director Signature: State #: PH -0218 Michael Lapman ELAP #: 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES » FINAL SITE INSPECTION a Date: Inspected by: e:�; �BGP Street Location V;5±]== !a„� e Owner _/�5 Town tPe,_ fern o K Permit # — - — c� TM # 13 , — 3 9 3 Subdivision Lot # Z 3 1. Sewage System Area a. STS area.located as per approved plans ..................... I...... b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc.; greater than 15 from STS area...,...... e., 100' from water course / wetlands ....... .......................:,.....: II. Sewage System r a. Septic tank size - i,000 ...: .E 5 .....1,250.........other Q_. b. ' Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ..........:...... 2. Protected below frost .................. ............................... 3... Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6, T renc Fe s 1. Length required 5-5-6 Length installed ,-,'�_ 2. Distance to watercourse measured -�- lDo Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... '10. Pipe ends ca pped ........................ ......:........................ g. Pump or Dosed Systems 1. Size of um pump chamber ................. ............................... 2. Overflow tank . ........................... ..............:................ . 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildhiz a. house located per approved plans.... . b. ' Number of bedrooms........... g .j.. � .................. IV. Well r*/ Well located as per, approved pl s .......:.......s. %.�..' b. Distance from STS area measured 4-_) 3eft........... c. Casing-18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ...................... . ............................ b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box.:. ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.: f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate..'.......*... ................ i. Erosion control provided ................. ............................... Rev. E402 APR -20 -2004 X0:15 ,FROM:INSITE ENGINEERING 8452259717 TO:2787921 P:1/1 e PU'1( NAM COC]N'1'X DEPARTMENT OF HFALTH DWISION OF ENVIRONMENTAL, HEAL'T.H SERVICES A'TI'EENTION Q ADAM ?(GENE L�STOR��p�'IO For: Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit # Located: 4a. J's-, n L��E �rT�, $AT i ER 5,V Ovmer /Appli,cant Name: ""- "nR` g, "`' y��,p a�Ert� TIVI ! Block 3� Lot 13 Formerly: P+Sr?,a assnc_+a"cs Subdivision Name: Ai%1- A55,11 „►ifs Q0 1-,•s V0, -f-k ff Subdivision Lot a2 3 Is system fill completed? Is system conaplete? YaS Is system constructed as per plans? 1,fo Is well drilled? . Yes Is well located as per plans? Vt Are erosion control measures in place? _ X( 5 Date: --`� Date: 4- 1"—” Date: 4-161-o7 I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: Certified by: _ pR Z , Insite Engineering, Surveying esi Prof ' nal Landscape Architecture, RC. Address: 3 Garrett Place Lie. # Carmel, Now York 10512 Comments aGO "A ,v[L ot 1Z6 p6--ot.ATt" flZd- 1KC, Afif totAe^v G.�a � 41>0It'roriM- qA,,W 10.27c G✓kS o-C-"D ig 77x6 it 5T SGT d Tl-r►c�G>r .,k Form FIR-99 L$ *-;OV a LA" "L- ��-� APR -20 -2004 TUE 13:18 TEL:845 -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 a LORETTA MOLINARI Public Health Director; DEPARTMENT OF HEALTH 1 Geneva Road, Brewsier, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 ROBERT J. BONDI County Executive April 26, 2004 Jeffrey Contelmo, PE Insite Engineering 3 Garrett Place Carmel, New York 10512 Re: Field Inspection — Astro Associates 42 Vista Lane, (T) Patterson Lot # 23, TM# 11-3 -93 Dear Mr. Contelmo: The above referenced separate sewage treatment system can be backfilled. There are no open comments to be addressed at this time. If you have.any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj -3. RY ' i � �PUTNAAA COUNTYHE�lLTH DEPT f ` O'2 4.715 t,Geneva Road (845) 278 -6130 J Brewster, NY 10509a Received of t t'The s0M. ` ollars $ z C k/I O ❑ Cr dit 'Card B /�QA'D�¢ '� � .. ❑.Cash � 1 ' ❑ hec 1 A l A A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # f-!;-01 Eq L ocated at ►� ►t vesTA LaNi or Village PA- r-rEit3vd Subdivision name AORo As5oclATC Subd. Lot # Z,� Tax Map 1-3 Block 3 Lot 9 3 Date Subdivision Approved 10-9-00 Renewal Revision /i19-Ow . "e>oc;A -Tf_5 Owner /Applicant Name eln L vu t.,> /' E Date of Previous Approval y -11 •-o 0 Mailing Address a Z S 0 6? vel-1 5 owe V D. R6&G PAV?-6zi P Zip Amount of Fee Enclosed 0 d. �a Building Type Rfs1 6,Vj' /AL Lot Area I- 07 % No. of Bedrooms 9' Design Flow GPD / XjJ AcROs Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage -System to consist of /, Soo gallon septic tank and -r.5C L o6 If Z' ,,,�r�� AQSoRPt�On! T�EA►ckE� Other Requirements: n/ /A To be constructed by V A/ &Jy D jj n/ Address Water Suouly: Public Supply From Address or: �_ Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the -Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years inimediately 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. it-A. .c. License # Date 0-if -03 61931 c,AatAet, n!Y 10912 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh nsidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm t. prove r discharg of domestic sanitary sewage ony. By: Title: 0"", Date: zv White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design rofessional Form CP -97 /NS/TE. ENGINEERING, SURVEYING & LANDSCAPEARCHITECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam County Health Department i 1 Geneva Road Brewster, Ny 10509 WE ARE SENDING YOU ❑ Shop Drawings; ❑ Copy of Letter LETTER OF TRANSMITTAL Date: 8 -14 -03 Job No. 98105.323 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates Lot 23 a ane, wn of Patterson TM# 13 -3 -93 ® Enclosed ❑ Under separate cc ® Prints ® Plans ❑ Change Order ❑ U the following items: ❑ Specifications COPIES j DATE i NO DESCR TION 5 1 8-14-03 CD -1 Construction Drawing 1 8 -14 -03 ( CP -97 j Construction Permit 1 i 8-14-03 1 WP -97 ! Well Permit 1 1 3 -18 -03 27777 ? $300.00 Fee y i .__ THESE ARE TRANSMITTED as checked below: m ® For approval ❑ Approved as submitted ❑ Resubmit copies f r apprayal) ❑ For your use ❑ Approved as noted ❑ Submit copies for n ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: Rob, This approved 5 bedroom SSTS, permit # P -5 -01, is up for renewal. If you have any questions, please contact me. John' COPY TO: lot2002.dot SIGNED: [� JJ h n M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # P _ 67" Well Location: Street Address: To ge Tax Grid # VIS-rA 1AIyr< PAffCR ;OA/ Map 13 Block 3 Lot(s) Well Owner: Name: 6-mo Asf CC, Address: c,j�s �Z -say LVP (-,e o Fay,, W 1 1(3'7+ Use Well; Residential Public Supply Air /Cond/Heat Pump Irrigation 1- rima Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5' gpm # People Served �- Est. of Daily Usage 300 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling 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 Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision A S fR D A Lot No. -3.3 Water Well Contractor: 1/ i,l A101,1 Al Address: A04 Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: .v /A Town/Village _ TA Distance to property from nearest water main: 6 Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: "1�'� 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. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a watvV411 driller ceArtified by Putnam County. I A Date of Issue � � 3 Permit Iss 0�9cial: . &"/ Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 l u XPUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PER1Vt AGE TREATMENT SYSTEM PERMIT # Located at UYS - EE I H /W51A 4 A j1 f own r Village Subdivision name Asi go 4SSOj /A -r6 Subd. Lot #23 Tax Map 13 Block 3 Lot Date Subdivision Approved %Q °,S - X Renewal Revision -- SAO ASSOC1 fEs Owner /Applicant Name C1 LO v;5 &S -tA foO,C Date of Previous Approval Mailing Address V - 50 (aU>;NS 9c7 ()LE9 a ir'(7 PAP 61, 3 Zip" Amount of Fee Enclosed Polio Building Type RESIQ� Lot Area .0 No. of Bedrooms 5' Design Flow GPD� Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of j '00 gallon septic tank and ����6 L 0 r 2' wive Absok Prim IRE "CUES Other Requirements: To be constructed by omiuyowd Address IVIA Water Sunoly: Public Supply From Address or: X Private Supply Drilled by UNKKVc?W'N Address IVA I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed Addres P.E. y R 4 . Date 3-20-01 . Si�rS ��Es r W iaraj License # 0131 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permi . pprove r discharge of domestic sanitary sewage only. By: Title: V ®�' Date: 11L10 / White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 COUNTY DEPARTMMNT OF HEALTH D ,` SZO R N ELI_H ICES N V V+ � k.., DESIGN DA'T'A: SHEET- SUBSURFACE SEWAGE TREATMENT SYSTEM ; Owner s lL 12 5 ©G ` ��� Located at (Street) ,v Y-5 Ri _3/� �V 15.rA- cAArTax Map • -13 Block 3. Lot 53-.'Z'-3 (indicate nearest cross street) Municipality ?o �,v . 9,x: 0 5� Drainage Basin �f1sr ,g <1,;41 ;/ w�T�R sy�42 SOIL PERCOLATION TEST DATA Date of Pre- soaking /2 f � L10 Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time Min.) De_ppth to Water k'rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 23.E 1 5 -2=1 30 L2. tf, -.26 t 3 Z- 96- -34 )5' �23 " 3`� 4 .5 .233 1 3`r 3 3 2:Ir - 23''Y�6`` 3 ' 4 V 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. :5 1 min for 1 -30 min/inch, s 2 rein for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 10.0' TrEST PTT DATA DESCRI TION Op- SAILS, ENCOUNTERED IN TEST HOLES .... _ ...._ _v.. _. HOLE TIO. .2 3 A HOLE NO 3 HOLE N0. Indicate level at which groundwater is encountered1 Indicate level at which mottling is observed NIA Indicate level to which water level rises after being encountered T Deep hole observations made by: Date 1.2 95 Design Professional Name: Jeffrey J. Contelmo, P.E. Address: Lnsite Fhginrering, surveying & Landscape Arci�iteeture, P.C. CF W 1485•Route 22' Brewster, New York 10509 Signature: Design P.rofessional's Seal: Fo�: �6193+ s' I i i z4ii /N-S/ T JT�7­ENGINEERING, SURVEYING & LANDSCAPEARCHITECTURE, P.C. 1485 Route 22 1 (845) 278 -4990 Brewster, New York 10509 Fax: (845) 278 -6392 T0: Putnam County Health Department 1 Geneva Road Brewster, New.York 10509 LETTER OF TRANSMITTAL Date: 3 -21 -0 1 Job No. 98105.323 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates - Lot 23 CD-1 Vista Lane, Town of Patterson _ 1 TM# 13 -3 -55.23 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. I DESCRIPTION _ 5 3 -13 -01 CD-1 Construction Drawing _ 1 3 -20 -01 CP -97 ' Construction Permit 1 3 -20 -01 WP -97 Well Permit 1 ---=------- - - - - -- LA -97 Letter of Authorization _ 12 -27 -00 CA -97 Corporate Affadavit 1 I -------=------- - - - - -- PC -97. Application for Approval of Plans 1 2 -12 -01 -- - - - - -- Short EAF 12 -22 -98 DD -97 De " sign Data Sheet (previously submitted with subdivision application) 2 - - -- -- Modular 5 Bedroom House Plans 1 ! . ° _�_. _.__,__241047 '1 Y$300.00 Fee .._.. .._..____.._______.....__...__. ___. .. _ .. .... ... -------- .--------- _ _.. __.__ - A__...........................«.... ..._- .._...._ ......... ......Y_. __... u..__.._._.....».._.._......_....._...:......_......._,..._..,........___._.._....__.._.._.._..._.._., .._...._...._...._......... «_.. THESE ARE TRANSMITTED as checked below: ® For approval ❑ Approved as submitted ❑ Resubmit copies for approval For your use ❑ Approved as noted ❑ Submit copies'for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: i I I COPY TO: i SIGNED: John M. Watson,-P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE M2000.dot PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit Well Location: Street Address: (1,0wriPiliftge Tax Grid # VISA UVEANS 90 PTE 3 11 PA 0 Map ' 3 Block 3 Lot(s)5y' Well Owner: Name: g57Ro gS$c&AZ Address: a0fM5 gnANA0 o Louts Pescore- 1 060 f RK,1,'f 1137q Use of Well: Public Supply Air /Cond/Heat Pump Irrigation - rimary Business . Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional, Standby Amount of Use Yield Sought ,S gpm # People Served _,� _ Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling 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 Is well located in a realty subdivision? ...................................... ............................... Yes—k, No Name of subdivision AWO ASSOCIATES Lot No. 2- Water Well Contractor: Vga Ua�J/ Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: A/ /A Town/Village W/A Distance to property from nearest water main: A A Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: J 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. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water w driller certified by Putnam County. Date of Issue 1,10,1011 i Permit Issuing cial: Date of Expiration Title: Permit is Non - Transfer a e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 MA PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION Property of AsfRo AssociA E(; Located at 1 � T LA-/J f�V i Ta $0 Tax Map # 13 Block. LLot S�0. 23 Subdivision of AS-69p A SSOCAfES Subdivision Lot # 23 Filed Map # 28% Date Filed / e !?() Gentlemen: This letter is to authorize Insite Fhgineering, Surveying & Landscape Architecture, P.C. (Jeffrey J. Contelmo a duly licensed Professional Engineer x oc�=d)0xxbd=xxxxxto apply for the required wastewater. treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: P.E., X x' # _619 f: Mailing Address >nsite':06�n�; nay .shed ng & Landsc .trArel� ;te�ctizre' P.C. Route 22 °roatetr" Nsw e 10509 State t-.w York Zip 10509 Telephone: (914) 278 -4990 Very truly yours, Signed: I (Owner of Property) qSfRo ASW I,� %ES Mailing Address: ,C/o LOu1 S PESCA- kE q2--50 CLOEE�5 50YL5VARPD� 2;0 %RK State . MEW ft K Zip 113` q Telephone: I -'716- �18 -2600 Form LA -97 PUTNAIVI 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�'fR0 ASSOC 1A rCS _ LC-M I, Lou15 Pf5CA I' AE represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: A590 AS OCI ES Having offices at: q2-50 6(Jf NS RLE\1ae � a Pair tjr-� C1371 Whose Officers Are: President - Name: t.OU) S i ESCA _rOP £ Address: SAid 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) (year) Notary Public I 'CAitL of Now York Notary Pub ic., 00 No. u+,�lOG3 �uo,li Ccuni/ Comm s ;i „n .xpires December 29, a O�, Form CA -97 Signed: — Title: PUTNAM COUNTY DEPAR'T'MENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES i - APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Lab PA k K; AJ, V i139 2. Name of project: SSI S. � ' � (Xt 'Va,!33.. Locatiorl�yv: incite Engineering, surveying & Landscape 4. Design Professional: Jeffrey J. Contelmo, P.E. 5. Address: Architecture, P.C. 6. Drainage Basin: c rJ 6J(/{Ft W, –� Brewster-, r �' 10509 7. Type of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Horne Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type. Status check one .... Type I Exempt Type II Unlisted K 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... A/0 10. Has DEIS been completed and found acceptable by Lead Agency? ......:........ 11. Name of Lead Agency 12. Is this project in an:area under the control of local planning, zoning, or other officials, ordinances? ....................................................:.... ............................... been submitted to such authorities? ........ ............................... 13. If so, have plans be 14. Has preliminary approval been granted by such authorities? /,gyp 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? ........................ I............. K0 19. If es name of water supply ' Y PP Y % Distance to water supply i 20. Is project site near a public sewage collection or treatment system? ................ V0 21. Name of sewage system %% Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector c - fk3> =Li�1G 24. Project design flow (gallons P er day) ................................. :............................... /000 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... VD 26. Has SPDES Application been submitted to local DEC office? ......................... W Form PC -97 2 27. Is any portion of this project located within a designated 'i ow,u or State wetland ?�Ci 28. Wetlands ID Number ........................................................... ............................... - - -�--� 29. Is Wetlands Permit required? ...................................... :...................................... A/C Has application been made to Town or Local DEC office? .. .............................�_ 30. Does project require a DEC Stream Disturbance Permit? 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes E U 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? ............................... Yesc. I�C DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... UN dVo,'✓d 34. Are conununity water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ...............:................ ............................... wKiyowd 35. Are any sewage treatment areas in excess of 15% slope? . ............................... A/c 36. Tax Map ID Number .......................... ............................... Map 3 Lot�o Z3 37. Approved plans are to be returned to ..... Applicant % Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. Iliereby affirm, underpenalry, ofperjury, that information provided on thisform is true to the best of my knowledge and belief. False statements made herein are punishable as a Class misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES. msite Engineering, Surveying Mailing Address: ................................ Landscape Arnhitscture, g & 1485 Rodte 22 Ikewster, New Ye, k V509 14 -16.4 (2/,87) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C State Environmental Ouality Review SWO_ RT .ENVIRONMENTAL ASSESSMENT. FORM. . For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant.or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME. 3. PRO ECT LOCATION: P .Municipality r r�J1� County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SCE L 00ATION/ r^'1 / O i4 C- 0AJ 5.r'VCT)eW p4lf wl w 5. IS PROPOSED ACTION: �ew - ❑ Expansion ❑ Modificationlalteration 6. DESCRIBE PROJECT BRIEFLY: �ESfd�CI�lGr'� PAV-w , coos m/Cilt d or 0IJ J% AM I Y AtjO A PP4'T NA In'r- 7. AMOUNT OF LAND AFFECTED: / /�r� AG I Initially -07AL acres Ultimately 1 •V / acres 8. I LL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? �s ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE.OR LOCAL) ?. V�Yes ❑ No If yes, list agency(s) and permlVapprovals PP;viFi,ily fErAj r— l ej%,JV Or.. /'�it�kSaal 55 sLAwE1L P1'T1V M CWvrv, IIE1 i1 A lY 311 LOInx' f : 'LO tA T tE 0< 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes `&'o if yes, list agency name and. permitlapproval 12. AS A RESULT OF PROPOSED ACTION.WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? b` ❑ Yes o ; I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE INs ITY ��rIL,� N tEisN.�: Applicant/sponsor name: ° I •- \A) 13c Date: _ Signature: - If the action is in the Coastal Area, and you are a state agency, complete'the .Coastal Assessment Form before proceeding with this assessment OVER C 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? 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 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. 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 andlor prepare a•positive declaration. ❑ Check this box if you have determined, based on the In and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on* attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible O ficer Signature of Responsible Officer in Lead Agency Signature of Preparer (It different from responsible officer) Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONIMEN-TAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: ?E4e.A , STREET LOCATION: REVIEWED BY: �4, R, AS, SRDATE: 12, 1 Q% TAX 1,L4P0: (CONFIRNIED) Y/ DOCUiti 'L TS ) PERMIT- APPLICATION 4WELL PERMIT OR PWS LETTER PC -97 LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) X)CORPORATE RESOLUTION (_ _ � (SHORT E:�F L PLANS -THREE SETS (__)HOUSE PLANS - TWO SETS C__)LJVARIANCE REQUEST / SUBDIVISION U LEGAL SUBDMSION L _6�SUBDIVISION APPROVAL CHECKED L6 ERC RATE LL REQUIRED DEPTH CURTAIN DRAIN REQUIRED GENERAL CLk—JLOCATED IN NYC WATERSHED ;PLANS SUBMITTED TO DEP DELEGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED CS TO BE WITNESSED LPROVAL SSDS ADJ, LOTS L/X_ )WETLANDS (TOWN/DEC PERMIT REQ'D?) DATA ON DDS PLANS & PERMIT SAME (PRE 1969 NEIGHBOR NOTIFICATION (LLETTER BI/ZBA �� 100 YR. FLOOD ELBVATION W/I 200' SOIL TESTING LOTS >10 YEARS OLD REOUTRED DETAILS ON PLANS (SEWAGE SYSTEM PLAN - (NORTH ARROW) (SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS )T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT (� (__)FOOTING /GUTTER/CURTAIN DRAINS (__)USDA SOIL TYPE BOUNDARIES LJTITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVLSION (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 `�JWPROPERTY METES & BOUNDS EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (ItEVSIiEET) 09/01/00 (� Y N (REQUIRED DETAILS ON PLANS CONT'D) �HOUSE SEWER -'/4" FT. 4 "0'; TYPE PIPE CAST IRON NO BENDS; MAX BENDS 451 W7CLEAN6UT RENEWALS (—�SITE NOTE (NO CHANGE) FILL SYSTEMS (ILv10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE SPECS' FILL NOTES 1 -5 PROFILE & DIMENSIONS IN EXPANSION AREA FILL GREATER TH_•IN'2 FEET Y BARRIER CERTIFICATION NOTE CH GAUGES .. ON PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS ARATION DISTANCE FROM TOE OF SLOPE TREINCH X TRENCH PROVIDED LOFT MAX. 'AR4L.LEL TO CONTOURS 00% EXPANSION PROVIDED TAIUDUST FREE CRUSHED STONE OR WASHED GRAVEL UUGEOTEXTILE COVER / SEPARATION DISTANCES ON PLAN - FROM SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 4 20' TO FOUNDATION WALLS X100' TO WELL, 260' IN DLOD,150' TO PITS �100' TO STREAM, WATERCOURSE, LAKE (inc. espaur) 50; TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10 TO WATER LINE (pits - 20') 50' L\TERti1IITENT DRAINAGE COURSE �')00'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS 10'MIIN TO LEDGE OUTCROP SEPTIC TANK (—)(___)10' FROM FOUNDATION; 50' TO WELL / WELL ( DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION L�U�II`i 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA (S20 %) UUREGRADED TO 15 %, IF REQUIRED . DOSE/PUN1P SYSTEMS PUMP NOTES U DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED U DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN ' STANDPIPES, 5' BOTH SIDES, DETAIL (� 15' MIN to CDS= >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % -<1% (_ _) 20' MIN to CD DISCHARGE /100' ivith 182 cons day discharge X10' bIPi1 to NON- PERFORATED PIPE