HomeMy WebLinkAbout0461�\ PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE THE EM
PCHD CONSTRUCTION PERMIT # P -3 — 0 I D
Located at 19 SC A CCA PLACE &wn or Village !A7 -Y6/Z 9c), -J
Owner /Applicant Name 3811 nJ SA lrvF ror, miss Tax Map I'S -'7 Block - f Lot s 3: o'--*,
Formerly
Subdivision Name '� C 14 f; C A
Subd. Lot # 3
Mailing Address .0 1 S sc N EC H f L A e C f'.AT"f e 2 S o n/ . Al Zip
Date Construction Permit Issued by PCHD ! n - 1 C o !
Separate Sewerage System built by &'L- 6A4K %5 &.- J5'f%VcTco.4 #xcfAddress ($35_ 127- SS 4Jr.14DAL.6-
Consisting of 000 Gallon Septic Tank and SOO L F z' wo vE 1���2c'To•� 1'�- Ewutc3
Other Requirements:
Water Suoaly:
Public Supply From
Address
or: x Private Supply Drilled by 0,01C> kV-TV;1A-f 1 Z.lCLL Address /054f X1' S"Z GA/LMEZ
Building Type P, E S l v6r -,,6 AL Has erosion control been completed? Y6 C
Number of Bedrooms 3 Has garbage grinder been installed? Nn
I c,rrtify 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: 1-3-07-
Certified by
P.E. x R-A.
Address <&f CAIN�, SUAV61 La!U,)SoAQG License# 6,431
3 GAPP,6 -r7 PLACE CA9m6L NYio;f -1ARC1{IT1rC790,6) F. 0.
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
revocatio mo ificatioR or change is necessary.
By: V "z Title: a::� Date: /,j 13 6 t_
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
Town/Village:
1. N
Tax Grid #
Block Lotfir. y
s)
Well Owner:
Name: Address: h5W-3
&�
Use of Well:
1- primary
2- secondary
,�C 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 __62Lft.
Length below grade eft.
Diameter min.
Weight per foot ��lb/ft.
Materials: Steel Plastic _ Other
Joints: _ Welded >< Threaded _ Other
Seal: Z( Cement grout _ 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 ,)Z Compressed Air
Hours
Yield 5 gpm
Depth Data
Measure from land surface - static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description,
ft.
ft.
Land Surface
/
f
/
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type jhyrl/J Capacity GZ &Afloms
Depth4]�S Model�7.a�iQ
Voltage Z 30 HP
Tank Type el •QiLa— Volume 6' Z Ea
l)
t
Date Well Completed
y -Aa
Putnam County Certification No.
o�-1y
Date of Report
Well Drier (signatur
Aj*
NOTE: Exact location of well with distances to at least two permanent landmarks to be provi pd on a s parat sheet/plan.
Well Driller's Name Address:
Signature: Date: �
White copy: HD Fife; Yellow copy - `Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
/NS/ TE
LEANGINEERING, SURVEYING &
NDSCAPEARCH/TECTURE, P.C.
1485 Route 22 (845) 278 -4990
Brewster, New York 10509 Fax: (845) 278 -6392
TO: Putnam County Health Department
1 Geneva Road
Brewster, New York 10509
LETTER OF TRANSMITTAL
Date: 9 -23 -02
Job No. 01160.300
Attn: Robert Morris, P.E.
Re: SSTS Compliance for Forbes
(Lot 3 - Schech Subdivision), 15 Schech PI.
(T) Patterson, TM #13.7 -1 -55.03
WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via
❑ Shop Drawings ❑ Prints ❑ Plans ❑ Samples.
❑ Copy of Letter ❑ Change Order ❑
the following items:
❑ Specifications
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598
(914) 245-2800
Albert H. Padovani, Director
LAB #: 93.202868 CLIENT #: 55833 NOW STAT PROC PAGE
FORBES, IRENE DATE/TIME TAKEN: 09/12/02 07:0OA
427 CORNWALL HILL RD. DATE/TIME REC'D: 09/12/02 11:45A
PATTERSON, NY 12563 REPORT DATE: 09/17/02
PHONE: (845)-878-7086
SAMPLING SITEg 427 CORNWALL HILL RD. PATTERSON SAMPLE TYPE..: POTABLE
: PRESERVATIVES: NONE
COL'D BY: IRENE FORBES TEMPERATURE..: < 4C
NOTES...: KITCHEN TAP COLlFORM METH: N/A
DATe FLAB PROCEDURE RESULT NORMAL - RANGE METHOD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
09/12/02 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 2037
COMMENTS:
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
SUBMITTED BY:
Albert
Directo
Padovani, M.T.(ASCP)
% .. ELAP# 10323
BRUCE R. FOLEY
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
Insite Engineering & Survey
3 Garrett Place
Carmel, NY 10512
Re: Proposed SSTS: Forbes .
15 Scheck Place
(T) Patterson, TM# 13.7 -1 -55.03
Dear Sir:
September 11, 2002
Review of plans and other supporting documents submitted at this time relative to the above -
regarded project has been completed. Comments are offered as follows:
1. Water analysis for iron exceeds State standards. It is advised that the system is flushed and
retested.
2. Please be advised that current codes require that the minimum scale of plans is to be 1 " =3 0'.
Please submit all future plans under these guidelines.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Very truly yours,
Robert Morris, P.E.
Senior Public Health Engineer
P" MU �1
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598
(914) 245-2800
Albert H. Padovani, Director
LAB #: 93.202405 CLIENT #: 55833
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
`RBES, IRENE
427 CORNWALL HILL RD.
PATTERSON, NY 12563
NON STAT PROC PAGE 1
~~~~~~~~~~~~~~~~~~~~~~~=~~~~~~~~~~~~~~~
DATE/TIME TAKEN: 08/13/02 07:45A
DATE/TIME REC'D: 08/13/02 11:30A
REPORT DATE: 08120/02
PHONE: (845)-878-7086
SAMPLING SITE: 427 CORNWALL HILL RD. PATTERSON N.Y SAMPLE :
E POTABLE
COL'D BY: IRENE FORBES
NOTES...: MASTER BATH
~~~~~~~~~~~~~~~~~~~~~~~~~~=~=~~~~~~~~"~
DATE FLAG PROCEDURE
PRESERVATIVES: NONE
TEMPERATURE..: < 4C
COLlFORM METH: Ml:''
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RESULT NORMAL - RANGE METHOD
PUTNAM CNTY PROFILE
08/13/02 MF T. COLIFORM ABSENT /100 ML ABSENT 1008
08/13/02 LEAD (IMS) <1 ppb 0-15 ppb 910).
08/13/02 NITRATE NITROG 1.10 MG/L 0 - 10 9139
08/13/02 NITRITE NITROG <0.01 MG/L N/A 9146
08/13/02 IRON (Fe) (D.330 MG/L 0-0.3 mg/l 2037
08/13/02 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037
08/13/02 SODIUM (Na) 4.86 MG/L N/A
08/13/02 pH 7.2 UNITS 6.5-8.5 9043
08/13/02 HARDNESS ,TOTAL 282 MG/L N/A
08/13/02 ALKALINITY (AS 226 MG/L N/A
08/13/02 TURBIDITY (TUR <1 NTU 0-5 NTU
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATER :;!)(WAS NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDIiif HE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR-THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION.
Pb/Cu LEAD limits for public schools are set at 15 ppb.
EPA Lead & Copper Rule for Public Systems requires that no more
than 10% of their distribution points have a LEAD value of more
than 15 ppb and a COPPER value of 1.3 mg/L, else water
treatment must be undertaken to reduce the waters corrosive
potential.
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
Na Na limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg/L of Sodium. For those on a
moderately.restricted diet, a maximum of 270 mg/L of Sodium
is suggested.
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heightg, N.Y. 1059E
(914) 245-2800
Albert H. Padovani, Director
LAB #: 93.202405 CLIENT #: 55833 NON STAT PROC PAGE 2
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
FORBES,. IRENE
427 CORNWALL HILL RD.
PATTERSON, NY 12563
DATE/TIME TAKEN: 08/13/02 07:45A
DATE/TIME REC'D: 08/13/02 11:3OA
REPORT DATE: 08/20/02
PHONE: (845)-878-7086
SAMPLING SITE: 427 CORNWALL HILL RD. PATTERSON N.Y SAMPLE TYPE..: POTABLE
:
COL'D BY: IRENE FORBES
NOTES.".: MASTER BATH
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAB PROCEDURE
PRESERVATIVES: NONE
TEMPERATURE..: < 4C
COLIFORM METH: Ml-.:'
~~~~~~~~~~~~~~~~~~~~~~~"~=°~~~~~~~~~~~''
RESULT NORMAL - RANGE METHOD
PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5.
Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE
HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 30O MG/L
MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER
HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L)
SUBMITTED BY:
Direct
M.T.(ASCP)
ELAP# 10323
/NS/ T
ENGINEERING, SURVEYING &
LA NDSCA PEA RCHITECTURE, P.C.
1485 Route 22 (845) 278 -4990
Brewster, New York 10509 Fax: (845) 278 -6392
TO: Putnam County Health Department
1 Geneva Road
Brewster, New York 10509
WE ARE SENDING YOU
❑ Shop Drawings
❑ Copy of Letter
LETTER OF TRANSMITTAL
Date: 9 -3 -02
Job No. 01160.300
Attn: Robert Morris, P.E.
Re: SSTS Compliance for Forbes
(Lot 3 - Schech Subdivision), 15 Schech PI.
(T) Patterson, TM #13.7 -1 -55.03
N Enclosed ❑ Under separate cover via
N Prints ❑ Plans
❑ Change Order ❑
the following items:
❑ Samples ❑ Specifications
COPIES DATE
❑ Approved as submitted
I NO.
DESCRIPTION
. ��._........_._._._.._....._...
y..__.. -. ........... ..,....._..._...__
❑ As requested
❑ Returned for corrections
❑ Return corrected prints
5
88- 13 -13 -02
AB -1
SSTS As -Built Drawing
19
3 -02 -
ZS sE �d £' d3S ZO
83040
$200.00 Fee _
1
3
..1
i 8 -6 -02
8 -30 -02 .-_
—
WC -97
GS -97
Well Completion Report
Guarantee
.<
8 -15 -02
-- - - - - - -
E -911 Form.
1
' 8 -20 -02
-
Water Test Results
1 i 9 -3 -02
1 CC -97
I Construction Compliance
__f......_.._._..
I
i
i
THESE ARE TRANSMITTED as checked below:
N For approval
❑ Approved as submitted
❑ Resubmit copies for approval
❑ For your use
❑ Approved as noted
❑ Submit copies for distribution
❑ As requested
❑ Returned for corrections
❑ Return corrected prints
❑ For review and comment
❑
REMARKS:
COPY TO:
ZS sE �d £' d3S ZO
SIGNED:
ANI
gohn M. Watson, P.E.
A.l,NQO "J irl� NIrld
.<
_ i1791w e
.
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
lot2000.dot
9148786343 P.01
AUG -15 -02 09:48 AM PATTERSON TOWN HALL J
96;'14!2002 10:35 845- 225 -9717 INSITE ENGI ER:NG PAGE 82' Y =:
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As .e
BRUCE R FOLEY * * >�7TA MOLIr1ARI -IM. M.S.N.
Aibuo Xeakhh rldsswim A+b& H"hb Dosdror
D(rwo of Pause SO VIOU
D' FPARTMIM 01+ MAI R .
I Geneva &Ad
Brewstey, Now York I0509
Egvl tlmetltri 8er1lh �Q14) 2]$ - 413D P� (4,lij 279.192 '
NurDiaj Beryl (914)271.039 WIC (M0278-4673 Fmi(pa4) 78-6M
Rsrly Jtlgrroetie (9!4) 278 -6014 I'rearhop► (914) 27$•60$3 Fac 0 ) a71. e6o1
OWNERS NAME:
TAX MAP NtMBERI
E911,A,DDfiESS: I C -redgeo
TOWN: F A I"Y 6R sr
AUTHOR= TOWN O 117 '1CM:
'(Signature)
DATE-. / f
The Putnam Coxmty DOaxtment of Health will not
Coustmedon Compliancy unless the above form is coml
address b assiped by= lauthorbedIm offieW: 'Y'his
with the application far al Certificate of Constracdoni C(
m 1mmw
vfl��
a Cer fixate of
ie., a legal E911
is to be subudtted
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
7 5-5,'c -3
Owner or Purchaser of Building Tax Map Block Lot
Building Constructed by Town/Village
Location - Street Subdivision Name
{2L°� I p eyJ°rz_
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 AvA,4 � Day ,3u Year hoc) a.1
General Contractor (Owner) - Signature
Corporation Name (if corporation)
Address: Zu-tt_ T6" wwul&k
t IJ
State Zip
Signature:
Title:
Corporation Name (if corporation)
Address:
State Zip
Form GS -97
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Lot 3 \ \
J. 3905 Acres
(14 7, 691 s. f. �)
Sl TE PL.AAI
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BOX (TYP.)
SEPTIC TANK f SCNECH PL�C
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1 ;THIS JS TO CERTIFY'THAT THl
°AS- :INDICATE!)'' ON THIS PLAN '
�` ,,-` �`
':;ENGINEERING, =' :SURVFYJNG �'3f
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WWRED OVER THE SYSTEM <:
4-F:,
ALL STANDARD RULES AND;' °RI
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OF HEALTH AND 7HE NEW YOI
2 :ALL FACILITIES- EXISTING, UNLE
3 ,.PR,0PERTY LINE DWELLING, DRI
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P.C. DATED JUNE 4, 2Q02
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PUTNAM COUNTY DEPARTMENT OF HEALTH
° DIVISION OF ENVIRONME\"TAL HEALTH SERVICES.
FINAL SITE INSPECTION
Date_.
Inspecte Ty.
Street Location �Sc,�,��G�/ t"�.trcce_ Owner Yorcaj;�s
Town PArrERSoN Permit #
TM # /3 7 — - 55. d3 Subdivision Lot # 3.,
1. Sewaae System Area
a. STS area located as per approved plans ...........................
b. Fill section - date of placement
3:1 barrier Lgth. Width Avg.Dpth
c. Natural soil not stripped ................... ...............................
d. Stone, brush, etc., greater than 15' from STS area.....::::.
e. 100' from water cour , tlands ...... ...............................
II. Sewage System
a. Septic tan, siz - 1,000 ........1, 250 ......... other ................
b. Septic tanl: insta eve] ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
1. All out ets at same elevation -water tested .................
2. Protected below frost .................. ...............................
3. Minimum 2 ft.Original soil between box & trenches
e. Junction Box - properly set ........... ...............................
f. 1 ren'T ches
T. Le -� required •3 oc:) Length installed : o3
2. Distance to watercourse measured+ 10 OFt..........
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 -1 %2" diameter clean ....................
9. Depth of gravel in trench 12" minimum ...................
10. Pipe ends capped .................................. :....................
g. Pump or Dosed Systems
Size ot pump c am er ................ ...............................
2. Overflow tank ............................. ...............................
3. Alarm, visual / audio........:: .......... ...............................
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ..............4................
6. Cycle witnessed by H.D.estnnated flow /cycle...........
III. House/Building
a. House ocated er approved plans ... ...............................
P PP P
COMMENTS
5:-0 " X 3' S � r„ ✓,
11 -,- i 1 F,.,20 5, 7 x 3,
m1w..2
sl��a
IV Well ----�-
.5a�We111ocated as per approved plans
........ ...... ..............
-- -
`b %Distanc
from rr m STS area measured ft...........
c. Casing 18" above grade .................. ...............................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box ... ...............................
d. Backfill material contains stones <4" diameter ..............
e. 'Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dir.to exist watercourse
g. Footing drains discharge away from STS area............ ....
h. Surface water protection adequate... .. ......................:.......
i. Erosion control provided ........... :.....................................
. E
_ Ali: .��C7K�� -•'rj--
- �•rw ---s —c --^•ems
11/12/2001 10:39 845- 278 -6392 1NSITE ENGINEERING PAGE 01
PU'XNAM COUNTY DEPARTMENT OF HEALTH
DMSION OF ENVIRONUMNTAL HEALTH SERVICES
ATTENTION . L3 ADAM
All information must be Fully completed prior to any
inspections being made.
PCI D Construction Permit #
Located: If '2 K6CK
Owner/Applicant Name: dog'
Formerly:
Is system fill corrmleted?
�GENF
For: Pill
Trenches
J4rtCt-5 (T) (V) rjklm tso^)
a ICE S TI 172 Block I Lot 55-.o
Subdivision Name; _151-'061W
Subdivision Lot # `a
•� /- Date:
Is system complete? �r�" Date: 11- 9 —o
Is system constructed as per plans? _
Is well drilled? "i o Date:
Is well Located as per plans? .- hh
Are erosion control measures in place? _
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_ (- / Z a r Certified by:
Insite Engineering, Surveying 0_ � Pro&Wnai
Address: Landscape Architecture, P.C. 19 -S r
Brewster, New York 10509
Comments:
Form FIR-99
Nnnj- 1a -pmj MnN 191:43 TEL:845 -278 -7921 NAME :PUTNAM COUNTY DEPARTMENT OF P. 1
O
BRUCE R. FOLEY
Public Health Director
LORETTA MOLINARI R.N., M.S.N.
�
[V_, (5, Associate Public Health Director'
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113 .
November 16, 2001
Jeffrey Contelmo, PE
Insite Engineering
Route 22
Brewster, New York 10509
Re: Field Inspection -Forbes
Schech Place, (T) Patterson
Lot # 3, TM# 13.7 -1 -55.03
Dear Mr. Contelmo:
The above referenced separate sewage treatment system can be backfilled. The following
comments must be corrected in the field:
1. An inspection of the well and a bedroom count need to be performed by this Department
upon completion.
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
Very truly yours,
Gene D. Reed
GDR:cj Environmental Health Engineering Aide
/ c•
/J
f '
r DATE :
NAME :
J. TEL -
1
t
PHONE
PAGES
START TIME
ELAPSED TIME
MODE
RESULTS
SENDING CONFIRMATION
NOV -20 -2001 TUE 11:04
PUTNAM COUNTY DEPARTMENT OF HEALTH
845 -278 -7921
92786392
: 1/1
NOV -20 11:03
0012011
ECM
OK
FIRST PAGE OF RECENT DOCUMENT TRANSMITTED...
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HR= R FOLEY LORBITA MOLR" 0.N., M.S.N.
Nuk Aid* Dbe Armcroax Paaar AaaM D&wtar
Doww 1 Pmtav snkri
DEPARTMENTT OF HEALTH
1 Ganova Road
BM%Vft, New York 10509
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November 16.1001
Jeffrey Contelmo, PE
Incite Engineering
Route 22
Brewster, New York 10509
Re: Field Inspection - Porbes
Schech Place, (T) Patterson
Lot # 3, TMN 13.7 -1 -55.03
Dcar Mr. Conwlmo:
The above referenced separate sewage treatment system can be bzckiilled. The following
comments must be corrected in the field:
1. An inspection of the well and a bedroom count teed to be performed by this Depattmeat
upon completion.
If you have any further questions, please contact me at (845) 278.6130 ext. 2261.
Very truly yours,
0
Gene D. Reed
QDR:cj Environmental Health Engineering Aide
BRUCE R. FOLEY
Public Health Director
DEPARTMENT 'OF HEALTH
1 Geneva Road, Brewster, New York 10509
LORETTA MOLINARI R.N,, M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
August 28, 2002
Jeffrey Contelmo, PE
Insite Engineering
3 Garrett Place
Carmel, New York 10512
Re: Field Inspection - Forbes
Schech Place, (T) Patterson
Lot # 3, TM# 13.7 -1 -55.03
Dear Mr. Contelmo:
A re- inspection at the above referenced lot has been completed.
There are no further comments.
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
Sincerely,
Gene D. Reed
GDR:cj Environmental Health Engineering Aide
l
08/13/2002 09:57
is
�l
845 - 225 -9717
1NSITE ENGINEERING
M COUNTY DEPARTMENT OF HEALTH
OF EN'VMONMENTAL HEALTH SERVICES
ATTENTION ❑ ADAM eGENE
vPAGE d 01-
1.7
REPIMS1 FOR FINAL PECTI For: Fill 4,11A
All information must be fidly completed prior to any Trenches. tJ1A
inspections being made.
PCHD Construction Permit
Located: 1 !� UACU P1-4cC PA7*T rA-rbry _
Owner /Applicant Name: 5 Al 8646 4-66-$ TM 1!1-7 Block. I _ Lot ��•�
Formerly: N Subdivision Name: C
Subdivision Lot 9 '
Is system fill completed? 44 JA Date:
Is system complete? J Date:
Is system constructed as per laps? yFr
Is well drilled? r Date: "(tlK'
Is well located as per plans?
Are erosion control weasure� in place? AJIA .,
I certify that the system(s), as h sted, at the above premises has been constnucted and I have inspected
and verified their completion in accordance with the issued PCHD Construction Permit and
approved plans and the Stan arils, Rules and Regulations of the Putnam County Department of
Health.
Date: �r '� z" Certified by: PE _-
rlsi a Erq iffi-eering, SurveN Desi Profes 'on
Landca a Architecture, P.C.
3 Garrett Place
Address: Lic.
Comments: -f-A 1 S
Form FIR-99
7;,m
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08/13/2002 10:25 845 - 225 -9717 1NSITE ENGINEERING PAGE 02
0
PUTNA 4 COUNTY DEPARTMENT OF HEALTH
DIVISION bF EN'VIRONMMNTAL HEALTH SERVICES
ATTENTION 13 ADAM GENE
U=ST, FOR EMAL 212ECEON )~or: Fin %A
All information must be fully Completed prior to any Trenches
inspections being made. p
PCHD Construction Permit
Located: 1 - _r e N F C N
Pb q e� (V(V) (' A r"7 i<R 4'.AN
Owner /Applicant Name: bi
�RgNE FoU36.5 TM i 3.7 Block i Lot
Formerly: •= N
Subdivision Name. S CVF. cd
n
Subdivision Lot #
Is system fill completed?
nI /A
Is system complete? ••
Date:
Is system constructed as per
Tans? his
10A
Is well drilled?
Date:
Is well located as per plans?•
YES' .
Are erosion control measures in
place?
I certify that the system(s), as fifted,
at the above premises has been constructed and I have inspected
and verified their completioia
iu accordauce with the issued PCBD . Construction Permit and
approved plans and the Stan ands; Rules and Regulations of the Putnam County Department of
Health.
Date: l� �' �'
Certified by:
PE -\C- —fir
nsr e
n
nearing, Surveys & Desi
Profes 'on
Lands
Architecture, C.
3 Gamett
Address:
Place
VeFk
Lic. #
/ q
F 406i 2.
Comments: I � S
G 1J - S PJ aeSPbAIX15
rug YOUR
N D � 1
Zbnr L i5771ER
Al's j a -fWA-r Ani
1,vs ?Ec7'1o.v
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03
oan B45' - 137S- log
Form FIR -99
AUG- 13-2002 TUE 16:23 TEL:845- 278 -7921
L
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0
NAME:PUTNAM COUNTY DEPARTMENT OF P. 2
A'
0B/13/2002 10:25 845 - 225 -9717 1NSITE ENGINEERING
J
ENGINEERING, ,SURVEYING �
I LAIVDSCAPEARCNITECTURE, P.C.
Facsimile Cover Sh et
Company: r° riVA,4 CvuO -Y HtLA '4 veow -rAeA -
Phone:
Fax g r 2�6,-'1a7 !
From:
Company:
Phone:
Fax:
Date:
Pages
(lndudingihis coverpage):
RE.,
-V
Awe/
InsIts,
Engineering, Surveying & Landscape Architecture, P.C.
(845)
225^9690
WAS
225 -9797
PAGE 01
AUG -13 -2002 TUE 16:23 TEL:845 -278 -7921
NAME : PUTNAM COUNTY UEF'HK I MLN i Ur t-1. 1
0
K.
;J e v r ,;
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f % PL, COUNTY HEALTH DEPT 022419:.
1 'Geneva 8oad (845) 278 =8130
`
Brewsbar, NY +10508 ti ' � 0 2 6' %
y Date `J
Received of 1
.
SV/ a
The Sum Of �/(/s- /, --�c.�
Dollars $
s
TH IVK YOU►
` ■Cash V'Cfieck M O' Q Credit Card
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # - 500_ 4 '`
15 s H EC*k (y(ACE / 01
Located at Town or Village P* ttn�c,^)
Subdivision name S GK ezK
Subd. Lot # '3� Tax Map 13 ,1 Block t Lot 5;57,0 3
Date Subdivision Approved F(L-w g 17-01C14 Renewal — Revision
Owner /Applicant Name -A o N d � t K"ew c- Fm tz b !-5 Date of Previous Approval
Mailing Address -tZ3 Cc 4-1 wAs t, K c w /moo, 19A1rL>rUS�, Al y Zip " i Z 543
Amount of Fee Enclosed 4300-00
Building Type R�uTcor(�
Lot Area 3.31 AG No. of Bedrooms 3 Design Flow GPD (PpO
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of t 1 000 gallon septic tank and
Other Requirements:
To be constructed by 1-0 8E p EWK-- fP 9P Address
Water Supply: Public Supply From
Address
or: _�_ Private Supply Drilled by To 6E 0e7MA,,,,Mo Address
Soo LF aF
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 s, sy tem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed:
Address
Date
License # & 1`l 3k
J J J.
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 en c nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new pe t. pprove r discharge of domestic sanitary sewage only.
By: 14 z Title: Date: t" 0 U
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
C1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print or type PCHD Permit # - 39-
Well Location:
Street Address: is 5"0" Town/Village Tax Grid #
I" &Aegc1. Map 13.-1 Block Lot(s)9,;.0';
Well Owner:
Im
n�n
Address:
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 5 gpm # People Serve 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 S c Lot No.
Water Well Contractor: -to 6e d - K Address:
Is Public Water Supply available to site? ........ ........... ............................................... Yes No
N A
Name of Public Water Supply: A _ Town/Village F
Distance to property from nearest water main: ZVIA
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date: Applicant Signature:
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. vision or alteration
of the approved plan requires a new permit. Well to be constructed by a water 7wedril er certi ied by Putnam
County. /
Date of Issue Permit Issuin p cial:
Date of Expiration G Title: �/
Permit is Non-Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
PUTNANI COUNTY DEPARTNIE \T OF HEALTH
- DMSION OF ENVIRONMENTAL HEALTH
LN-DIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
p REVIEW SHEET FOR CONSTRUCTION PERMIT
NAME OF OWNER: 7� �O STREET LOCATION:
REVIEWED BY: RNL OR, .5, SRDATE: �� / TAX NIAPr: (CONi IIt D) �3 S• 63
Y, N DOCUNI EN ?S ��// -Y Ni (REQUIRED DETAILS ON PLANS CONT'Dl
(/�UPER.ti1TT APPLICATION (�UHOUSE SEWER -' /�" FT. 4 "0; TYPE PIPE CAST IRON
f -')(_JtitiELL PER�IIT ORPWS LETTER (UC__)NO BENDS; bLAX BENDS 45° W /CLEANOUT
C!UUPC -97 RENEWALS
(A/JC__)LETTER OF AUTHORIZATION E NOTE (NO CHANGE)
(,::!�)C_)DESIGN DATA SHEET (DDS) FILL SYSTENIS
C-J(Z)CORPORATE RESOLUTION (___)L_)10' HO Oi AL; PAST TRENCH SLOPES 3:1 TO GRADE
UUSHORT EAF C_)UFILL SPE I L NOTES 1 -5
(it- -THREE SETS, (�C�FILL PRO •DIMENSIONS
(ZC�HOUSE PLANS - TWO SETS
UUVARlk\CE REQUEST UUFU.L Di ANSION AREA
SUBDNISION ILL GREATER 77T 2 FEET
�CJLEGAL SUBDIVISION UU CLA R _ .
USUBDIVISION APPROVAL CHECKED C-- )FILL C I ATION NOTE
C ZUPERC RATE _9 _ � UUDEPTH G G S
C _
__)VOL. ON Y FOR RO.B., UNCLASSIFIED & IMPERVIOUS
_)(� F
UUSEPAR�. ON DISTANCE FROM TOE OF SLOPE
ENERAL U
TRENCH
-.. __ .: :... ..... . .:. _ E
C (___)LOCATED L`i NYC WATERSHED P
PARA,LELTO CONTOURS
_TO. D
(�U100 %EXPANSIONPROVIDED; -
. -
C/)UDETAIIJDUST FREE CRUSHED STONE OR WASHED GRAVEL
C .
(UUGEOTEXTILE COVER
. )
SEPARATION DISTANCES ON PLAN - FROM SSTS
CSC )EX- APPROVAL SSDS ADJ, LOTS C
C/)U20' TO FOUNDATION WALLS
C—)( (TOW '/DEC PERMIT REQ'D ?) _ .._ _
(J�U100' TO WELL, 200' ICI DLOD,150' TO PITS
(f)C _)DATA ON DDS PLANS &. PERMIT SAME U
UU100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan)
C_J(•,6PRE 1969 NEIGHBOR NOTIFICATION (
(_/JC-__)50' TO CATCH BASIN, 35' STORNIDRAIN, PIPE_ D WATER
C_)CZ)LETTER BUZBA (
(A, U10' TO WATER LIME (pits - 20')
C�(�100 YR FLOOD ELEVATION W/I200' 5
50' hNTERbIITTENT DRAINAGE COURSE
C__)C /,SOIL TESTING LOTS >10 YEARS OLD 2
200' /500' RESERVOIR, ETC. _
REQUIRED DETAILS ON PLANS O
_ 1
.. S
SEPTIC TA _
UUGRAVTTY FLOW _
_.
(/J(-JCONSTRUCTION NOTES 1 -15 _ _ (
(._ -.- DItilENSIONS TO PROPERTY -LINES = - ---- ----
'�"
(�C�DATE OF DRAWINGIREVISION UUP .. NO'
(Zj( _JDATUM REFERENCE UC__)DOSE -°/
(U(_JLOCATION OF. WATERCOURSES, PONDS U(__)DETAIL IP
LAXES,WETLANDS WITHIN 200' OF P.L. UUPIT AND
UUPROPOSED FINISH FLOOR AND UU1 DAY
BASEMENT ELEVATIONS
UC jWELLS & SSDS'S WAIN 200' OF SSTS C-- )(-JST P
Cam(_JPROPERTY METES & BOUNDS UU15' MhN to
UU20' MN to
UUIO' MIN ty
COMMENTS: (}�I� ( _/v N��C -7/s�'
OF )6E V LUMEADOSE VOLUME NOTED
ORC IN, (PIPE TYPE, ETC.)
TW,OOWN & DETAILED
RAGE ABOVE ALARM
)ES, DETAIL
25'-3%,35'-l%, 100%-<I%
E /100' with 182 cons day discharge
TED PIPE
(REVSHEET) _ _
iki INS/ TE
ENGINEERING, SURVEYING*$
LA NDSCA PEA RCHITECTURE, P.C.
1485 Route 22 (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: 10 -3 -01
Job No. 01160.300
Attn: Robert Morris, P.E.
Re: SSTS for Forbes ( Schech Sub. - Lot 3)
15 Schech Place, Town of Patterson
TM# 13.7 -1 -55.03
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
10 -3 -01
CD -1
Construction Drawing
1
10 -3 -01
CP -97
Construction Permit
1
10 -3 -01
WP -97
Well Permit
1
--------------- - - - - --
LA -97
Letter of Authorization
1
75628
75628
$300.00 fee VZ
1
--------------- - - - - --
PC -97
Application for Approval of Plans
1
10 -2 -01
----- --
Short EAF
1
1 -8 -98
DD -97
Design Data Sheet (previously submitted with subdivision application)
2
--------------- - - - - --
-- - - - - --
3 Bedroom House Plans
THESE ARE TRANSMITTED as checked below:
® For approval
❑ Approved as submitted ❑ Resubmit
❑ For your use
❑ Approved as noted ❑ Submit
❑ As requested
❑ Returned for corrections ❑ Return
❑ For review and comment
❑
REMARKS:
COPY TO:
copies for approval
copies for distribution
corrected prints
SIGNED: '4!�& a
J hn M. Watson, P.E.
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
Iot2000.dot
PUTNAM COUNTY DEPARTMENT rte? HEALTH
±a DIVISION OF AVIRONMENTAL HEA H SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
,SoKa i,cc�+e Fo�s� ' 1,
Owner _ Address
(� 5cK6Ctf Pt4GE eFF c9F .. .
Located at (Street) 100 4*4evi4l tll Kew Apf�> Tax Map 13,V'7Block l Lot SSD 3
(indicate nearest cross street)
Municipality oahfralvhel_yj Drainage Basin
GJG(,(LG(-( 5 i3 pl dlSt o n�
SOIL PERCOLATION TEST DATA
Date of Pre-soaking. l 71q!�' Date of Percolation Test
Hole No.
Run No.
Time
Start - Stop
Ela se Time
(pMin.)
Depth to Water
From Ground
Surface (Inches)
Start Stop
Water
Level
Drop In
Inches
Percolation
Rate
Min/Inch
�3
1
12;,¢- l; /¢
Z
l b 13
3
`7
2
!: /5 -1:37
-Z"Z—
10 13
3
7.
3
!; 39 - to S9
Z' 1
/0 13
3
7
4
)f F3A VW
A 10' 0157Q` l
7Z7Tfi- t- H1 o c6
lv'f
Z61
5
C?
2
/; w:!�7— 1;
14—
! Z
3
3
J;3
13
i 1z
3
4
1:46
13
1Z
` -3
5
F3 5 H
A- ! 2u 6
7TT7f-(— K of 6
PO"
Z7
1
2
3
4
5
i ests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All• data to be
submitted for review.
2. D6pth measurements to be: made from top of hole.
Forrn DD -97
DEPTH
G.L.
6.51
1.01
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'
8.01
8.5.'
9.01
9.5'
.5
10.01
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. P 3 HOLE NO. V 5 13 HOLE NO.
-31
W 1-4 t5 --'5A-AV 1--arar Sip
-TV &41
I
Indicate level at which groundwater is encountered loor-79
Indicate level at which mottling is observed laoxic-
Indicate level to which water level rises after being encountered
Deep . hole observations made by: Date
Design Professional Name: Jeffrey jg�-,*Vreqho, P. E.
Address:Insite Engineerin . g & S in
Rout-p- 2 2
Brewster, New York 10509
Signature•:
11 1 1
Desi s s i o n a* I's Seal
r)F NE t
0. fi
I
08/29/2001 14:27 845 - 278 -6392 1NSITE ENGINEERING PAGE 02
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of
!S SGKCCK P1 4C-6' -FA of
Located at GB'&"'wAtf- H cu- A41A
T c070YKe 'C Tax Map # t3 •? Block . Lot �� 3
Subdivision of y 60 VCK
Subdivision Lot # Filed Map 4 7.805' Date Filed
Gentlemen:
This letter is to authorize insite t2gin ,,g, SurW5§pq & rand=M Architecture. P.C. (Jeft're9' J. CCntelmo,
a duly licensed Professional Engineer �_ cxr4qg=-am4*jWrh=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., l� �• # _ E
Mailing Address
& 16PA ca-pe= Atchi tecWte T.C.
Route .22 . .
State New York Zip 10509
Telephone: (914) 278 -4990
Very truly yours,
Signed:.. Gc�
/ caner of Prop )
Mailing Address: ��_ ( oariwa // A/W
State �Je_'j o 2I(
Telephone: ?-7;R- (e�5_ (n
Form LA -97
14- 16.4 (2187) —Text 12
PROJECT I.D. NUMBER 61711 SEAR
4 Appendix C .
State Environmental Quality Review
SHO_ RT .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,
3. PROJECT LOCATION'
Municipality P/�'���`J�� County
4. PRECISE LOCATION (Street address and road interseea�lions, prominent landmarks, etc., or provide map)
-y
AMWOL /5- r4~0 v.°!- c9f--
Cb/L�vr,✓h�.ti (�( w— 120vrD C 5g;g- (�GhTiv� H�A� Off'✓ C� S'�/L./cr't..�% D�.k
5. IS PR POSED ACTION:
New ❑ Expansion ❑ Modification /alteration
6. DESCRIBE PROJECT BRIEFLY:
Cd►.. V m - crz.Pj 13 co 4,vc— >rj f ..J(= c9, rel— lAe5, eu,•jq
()(�1 ✓E+✓ (,tiE2L :55�i �j A P�l�T6nl.:4 -NC C3 i
7. AMOUNT OF LAND AFFECTED:
Initially 'y �9 acres Ultimately • 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?
11 ED
Residential Industrial Commercial ❑ Agriculture pJ Park/Forest/Open space Other
scribe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM. ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)? •
C6Yes ❑ No If
yes, list agency(s) and permiUapprovals
�.vs fe/9-M
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
El rvtNo If yes, list agency name and permiUapproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑ Yes No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
�! °tom �h
ApplicraUsponsor name: I Date:
Signature:
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? 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 resourc e ? Explain briefly
.y MO
C5. Growth, subsequent development, or:reiated activities likely to be induced -by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not identified In C1-c5? Explain briefly.
c,: j ` 'S
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 and/or prepare a' positive declaration.
❑ Check this box if you have determined, based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts
AND provide on'attachments as necessary, the reasons supporting this determination:
Name of lead Agency
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible o icer)
Date
2
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: JoKa ca�wE ��e.�
2. Name of project: y513
4. Design Professional
4T3 con'd" « L (-c c w pow
PA-Cxsed 4 N y T 5'
�zo�t 3. Location T/V: PAV-MgIJ
Insite Engineering, Surveying & Landscape
Jeffrey J. Contelm, P.E. 5. Address: Architecture, P.c.
6. Drainage Basin: 0451' ( AA Ct i ate 22
New Y=, 1.050Q
7. Type of Project:
_ X Private/Residential Food Service Commercial.
Apartments Institutional Mobile Home Park
Office Building Realtv Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................... ................ ................ Type I Exempt
Type II Unlisted
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... tJO
10. Has DEIS been, ,completed and found acceptable by Lead Agency? ............... A)
11. Name of Lead Agency A
12. Is this project in an area under the control of local planning, zoning, or other
officials, ordinances? .................... ............................... Y
. ...... ...............................
13. If so, have plans been submitted to such authorities tj 0
14. Has preliminary approval been granted by such authorities? OkDate granted: 0 1k
15. Type of Sewage Treatment System Discharge ................. surface water iC groundwater
16. If surface water discharge, what is the stream class designation? ............. ........
17. Waters index number (surface) ........................................... ............................... P�
18. Is project located near a public water supply system? ....... ............. ................... 00
19. If yes, name of water supply (k Distance to water supply �� h
20. Is project site near a public sewage collection or treatment system? ............... IV 0
21. Name of sewage system (� Distance to sewage system (A
22. Date test holes -observed' 23: Name of Health Inspector Amm. t�f(0066A
24. Project design flow (gallons per day)............... .................. ............................... ADO 6f V
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?...
26. Has SPDES Application been submitted to local DEC office? ......................... (A
Form PC -97
27.
2
Is any portion of this1project located within a1designated Tamar. State wetland ?_:
Wetlands 'ID Number .....:.:.............:..:.................................. ............................... D r- Zz
29. Is Wetlands Permit required? ..... ... .. ................ .......:....: ............................... N o
Has application been made to Town or Local DEC office? ............................... N R
30. Does project require a DEC Stream Disturbance Permit? .. ............................... A)O
31. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid"O' r hazardous waste disposal,
landfilling, sludge application or industrial activity Yes/No
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or, any
other potentially known source of contamination? ............................... Yes/No
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? ......................... q 65
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ................................ ...............................
35. Are any sewage treatment areas in excess of 15% slope? . ............................... PO
36. Tax Map ID Number .......................... ............................... Map VVI Block I Lot 5S03
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 formsfor 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 mU-s"i -
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 irm under penalty o er'u that information provided on this form is irue
Y .lf � P t3' .fP I rY,
to the best of my knowledge and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
SIGNATURES & OFFICIAL TITLES.
Mailing Address ............................
-
In ' gineer , Surveying &
Landscape Architecture, PC.
1485 Route 22
"Brewster, New York 10509