Loading...
HomeMy WebLinkAbout0479DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.08 -1 -100 BOX 6 L No , �� -� , F,, 11 :: \ r�' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR ) V.AGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 1�1 —00 ! Located at Q�� C�U�� Town or Village ` Q�-_`C) Owner /Applicant Name W -9E W )U-D W QXWWC&Tax Map V2) �06 Block Lot 10Q Formerly Subdivision Namev� N cl_z_E Subd. Lot # V6 Mailing Address M6 �('���1�1 E& N Zip 100 Date Construction Permit Issued by PCHD �; WESrt Hot,ww �A� Separate Sewerage System built by �Q(Z 'SEA �U.OW RIMAddress f.3C`C�,J S i EC'�� PJ `j \0509 Consisting of Gallon Septic Tank and nGS Other Requirements: T ©W N OF Water Sup"I : Public Supply From W A N Et.& Address or: Private Supply Drilled by Address Building Type N C V,� Has erosion control been completed? GS Number of Bedrooms Has garbage grinder been installed? NO O I certify that the system(s), as listed, serving the above premises were. constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: 10� Certified by Address '�O 5o q:� P.E. X R.A. License # J� to � 2 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 bject to modification or change when, in the judgment of the Public Health Director, such revocatio , o ficatio change is necessary. By: Title: (%j /° `' Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 I r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM �n CzSF_Y Owner or Purchaser of Building Tax Map Block Lot ZN Building Constructed by TownNillage Location - Street Subdivision Name . x'15 NCC (9 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 wh the or not the failure of the system to re-m- 11ateerate was caused by the willful or negligent act of the o upan of the building utilizing the Sys : Q ;� _ Day Year 1 Signature Title: C� \i4 A( General 66ntr c o neh - Si �o Q� Corporation Name (if corporation) Corporation Name (if corporation) Address: \\1Dj WA State N Zip \Q 313 State N 7 Zip !Q�OQ Form GS -97 l �i.. .. YYhY /Y NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 REPORT TO: DORSET HOLLOW ESTATES Attn:ALLAN J. FINN 15 WEST HOLLOW ROAD BREWSTER, N.Y. 10509 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: LABORATORY REPORT DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: LAB LD. #: REPORT DATE: 5/23/2001 8:00 A.M. A. FINN 5/23/2001 LAB #11471 MAY -143 5/24/2001 0 \N ACCOgQ��c` e v a =_• x DORSET HOLLOW ESTATES, LOT #16 KITCHEN TAP WELL NONE RESULT: METHOD # - MAXIMIUM .CONTAMINANT LEVEL (MCL) Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/L - - - - -- ml = milliliter mg/L = milligrams per Liter ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met RESULTS BASED ON SAMPLES SUBMITTED: 5/23/2001 SAMPLE, AS TESTED ABOVE: 0 OTABLE or OT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 BRUCE R FOLEY LORETTA MOLMARi RN., M.S.N. Public Health Director ��t+w 0�� Ar:ociate Public Health Director Director Q/ Patient Servleer DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914)278.6110 Fax (914) 278.7921 Nursing Services (914) 278.6558 WIC (914) 278.6678 . Fax (914) 278.6085 -' Eariy'Tote6iod6o'(914) 278'• 6014 Preseb6ol (914)27W92 082 Fax (914) 279'. 6648 OWNERS NAME: 7) 0 CZS E. T "O.LL-O W G U )1_b E_. - TAX MAP NUMBER: V; QS- \_ W 4 E911 ADDRESS: \ 93oN N VE- - CO UQA CLOT -* 16) TOWN: 9 NI-A F._C2--SON — - AUTHORIZED TOWN OFFICIAL: (Signature) DATE: The Putnam County _Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E91 I VERFRM) Lo Ni v O O N• 0 � � e 3 o 0 "o 0 0 t DIMENSION- CHART, (in feet) Number g /.A � X4,5' 3►' � � 52:,5 :... - ... .. 41► 10 52;5.` .....:.:.... .......... � _ $3'. 11 5 2,5 %2' 12 525 1' 13 53' 14 55' Sot 1 C� 56.. 5k 77 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM 0 PERMIT # ^ °e j �- 00 g . Located at 1 1 Bonnie Court Town or Village P a t t e r s o n Subdivision name nor set Hollow E E%bd. Lot # 16 Date Subdivision Approved Owner /Applicant Name Dorset Hollow Builders Tax Map 13.-0 8 Block 1 Lot 1 0 0 Renewal Revision Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, NY Amount of Fee Enclosed $ 3 0 0.0 0 Building Type Residence_ Lot Area . 9 2 a c No. of Bedrooms 4 Zip Design Flow GPD 8 0 0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1250 24" wide trenches and 100% reserve. Other Requirements: gallon septic tank and To be constructed by D or set H Q 11 o w Builders Address 15 Water Suoal t e ° s t i c t s o n 4 � r Patterson or: Private Supply Drilled by 400 LF of 10509 West Hollow Road. Brewster. NY Address 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 immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address P.E. X R.A. Date q-g A000 My 1, ,Tocj License # 059346 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 onsidere ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pprove f discharge of domestic sanitary sewage B Title: Sr V /. Date: o) By: �� s White copy - HD File; Yellow copy.- Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 ' MIMIMIMIMIAAFMIMF!1AIAPIMIMIAI. BUJ. II MIMI MIM iM_ AFAA VRAIMIMFAM"YONME"IMI"TAMMIMIMIM IMFM IMFAMI MIMIMFAAIMIA AIR AXON AIMIMIA A1�1A f c i f I t C Yiil 111 V1" IilyiVtil�Yl�l Vlyp[ Vriy' J7171YIK�FNVIV�I V1l1YViV' v7WNiYVlillii� lYiil�I�lyL�lNi�'H11/L' S1lNFNtiIIi!Li1l11FyylYN11f 11111 MI11Ylil 11AWIIIVIiIVIil NIB1iIV�V. y1 :'11iti11lGIIifV"11fVIillAi/ll4i PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHAT FOR CONSTRUCTION PERMIT NAME OF OWNER: 5 �1 /,STREET LOCATION: ,�" L REVIEWED BY/ �R, AS, SRDATE: 4 Al 01) TAX MAP #: (CONFIRMED) 0 I 'r' I O0 Y DOCUMENTS Y/�� (REOUIItED DETAILS ON PLANS CONT'Dl (-!6 PERMIT APPLICATI )e- OUSE SEWER -1 /d' FT. 4 "0'; TYPE PIPE CAST IRON WELL PERMIT OR P ETTE O BENDS; MAX BENDS 450 W /CLEANOUT (PC -97 RENEWALS VELETTER OF AUTHORIZATION ,� �STTI�NOT NGE) DESIGN DATA SHEET (DDS) FILL SYSTEMS C--) CORPORATE RESOLUTION ()(�10' AST TRENCH SLOPES 3:1 TO GRADE SHORT EAF FILL SPECS/ FIL S 1 -5 PLANS -THREE SETS ILL ILE &DIMENSIONS HOUSE PLANS - TWO SETS EXPAIV A (_)V )VARIANCE REQUEST G SUBDMSION C—) tLAY BARRIER LEGAL SUBDIVISION (_) FILL CERTIFICATION NOTE U(vSUBDTVISION APPROV CHECKED (_) DEPTH GAUGES ,)PERC RATE (�' L. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS FILL REQUIRED DEPTH (_)SEPARATION DISTANCE FROM TOE OF SLOPE CURTAIN DRAIN REQUIRED TRENCH GENERAL )� )LF TRENCH PROVIDED 60FT MAX. (. , )LOCATED IN NYC WATERSHED PARALLEL TO CON 4S SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED CS TO BE WITNESSED APPROVAL SSDS ADJ, LOTS 'LANDS C PERMIT REQ'D ?) A O DS PLANS --& PERMIT SAME PRE 1969 -DiE6R NOTIFICATION LETTER BI/ZBA ��ROIL 00 YR FLOOD ELEVATION W/I200' TESTING LOTS >10 YEARS OLD WAGE SYSTEM PLAN - (NORTH ARROW) DS HYD_ RAJULIC PROFILE "OTES 1 -15 PERC & DEEP RESULTS 'CONTOURS EXISTING & PROPOSED },DRIVEWAY & SLOPES, CUT (�FOOTING /GUTTER/CURTAIN DRAINS E��USDA SOIL TYPE BOUNDARIES �•TITLE BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# IDATE OF DRAWING/REVISION TUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. rPROPOSED FINISH FLOOR AND ,BASEMENT ELEVATIONS iWELLS & SSDS'S W/IN 200' OF SSTS TROPERTY METES & BOUNDS COMMENTS: (REVSHEET) TOURS 100% EXPANSION PROVIDED DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL U/ (__)GEOTEXTILE COVER (!CSEPARATION DISTANCES ON PLAN - FROM SSTS — 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL L�J 00' TO WELL, 200' IN DLOD, 150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits - 201) 0' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (p(_)10' MIN TO LEDGE OUTCROP SEPTIC TANK FROM FOUNDATION; 50' TO WELL WELL (DIMENSIONS TO PROPERTY LINES OCATION OF SERVICE CONNECTION UMIN 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA 520 %) UREGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) IT AND D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN ( STANDPIPES, 5' BOTH SIDES, DETAIL ( 1..�15'MIN to CDS = >5 %, 20' -0 %, 25' -3 %, 35' -1 %, 100 % - <1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge (___)C__)10' MIN to NON - PERFORATED PIPE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of norset Hollow Builders Located at 11 Bonnie Court T/V Patterson Tax Map # 13.08 Block 1 Lot 100 Subdivisionof Dorset Hollow Estates (formally Van Cleef Estates) Subdivision Lot # 16 Gentlemen: Filed Map # 2 7 71 Date Filed 12/24/88 This letter is to authorize P e d e r W. Scott , P. E., R. A. a duly licensed Professional Engineer X or Registered Architect to 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 tretment 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. Countersign P.E., R.A., Mailing Address 3 8 7 1 R o u t e 6 Brewster State New York Zip 10509 Telephone: (9 14) 278-2110 c Mailing Address: norset Hollow. Builders 15 West Hollow Road, Brewster State New York Telephone: Zip 10509 (914) 279 -1339 Form LA -97 PUTNAIN /1 COUNTY DEPARTMENT OF HEALTH DIVISION5 OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Dorset Hollow Builders Lot # 1Co 15 West Hollow Road Brewster, New York 10509 Dorset Hollow Estates 2. Name of project: (formally V anC 1 e e f Est 3. Location T/V: Patterson 4. Design Professional: Peder W. Scott, P.E. , R.-�•. Address: 3871 Route 6 6. Drainage Basin: East Branch Reservoir Brewster, NY 10509 7. Type of Project: X . Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... I Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Exempt _ Unlisted X No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N/A 11. Name of Lead Agency Town of Patterson Planning Board 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .......................................................... ............................... Yes.- 13. If so, have plans been submitted to such authorities? ........ ............................... Yes— Subdivis ion 14. Has preliminary approval been granted by such authorities? Yes Date granted: 1998 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... N/A 17. Waters index number (surface) ........................................... ............................... N/A 18. Is project located near a public water supply system? ....... ............................... Yes +servi.ced 19. If yes, name of water supply Town of Patterson Distance to water supply by system 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system Individual Lots Distance to sewage system 22. Date test holes observed v- 6- 9 23. Name of Health Inspector M. B u d z i n s k i P. E. 24. Project design flow (gallons per day) ................................. ............................... 800 cPD 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? N/A Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? No 36. Tax Map ID Number ............................................ Map i3.cB Block i Lot `oo 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 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. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section,1.0.0 of the Penal Law. SIGNATURES & OFFICL4L TITLES: Mailing Address: ................................... Pe'e . Scott Agent for Applicant 3871 Route 6 Brewster, New York 10509 WetlandsID Number ............................................I ............... ............................... N/A 29. Is Wetlands Permit required? ............... ....... Individual Lat ............ .. .......... ............................... No Has application been made to Town or Local DEC office? ............................... N/A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... No 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No No DESCRIBE: 33. Is there a local master plan on file with the. Town or Village? Yes 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ........................................................... . Water-.Only 35. Are any sewage treatment areas in excess of 15% slope? . ............................... No 36. Tax Map ID Number ............................................ Map i3.cB Block i Lot `oo 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 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. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section,1.0.0 of the Penal Law. SIGNATURES & OFFICL4L TITLES: Mailing Address: ................................... Pe'e . Scott Agent for Applicant 3871 Route 6 Brewster, New York 10509 ." • , �{. J'T`1I7U _ �....G.71"_' 'JJr✓= M�.tF'�`i^.^ �'i� �:::�i�. ..r....Me- r..'.zu .IlI s , {/N,r off, .Ac vy 3. �:� 2 10645 ZD at (.��a__} ;R�� // r C7�ry�: ✓.sG.. •f�,.� P� .Set.. /3. y .lc::c / / 1) 3 DIGT�S: 1. +'es -,s ��.7 �e --ecea:a::� at sam de=-.h =t l aCti.i=C.*'1ately eCt:2.1 so =-z-°s are obtainea .at eac:. pe= wlat =cn mast hole. �L? cat : t^' i� s.::--:L'c`er fcr review. Z. recth mzaz � remp-nt5 to he race ``- trc cf hole. ' `rr- Late cf =r.:.? et:c : m2st 3AM/91 EOLZ- watez :.zVell lic. GlV'L:G ..1.��.. .� �.. e5 '. !f� nches r-' 1;091. y l9 ,, ZZII 13 1) 3 DIGT�S: 1. +'es -,s ��.7 �e --ecea:a::� at sam de=-.h =t l aCti.i=C.*'1ately eCt:2.1 so =-z-°s are obtainea .at eac:. pe= wlat =cn mast hole. �L? cat : t^' i� s.::--:L'c`er fcr review. Z. recth mzaz � remp-nt5 to he race ``- trc cf hole. rG.o7' i6 G.L. 2` ` 3' 4'.. 5' 7 6' 7' 8' SST PIT DATA RD. RID TO BE SMMI= TN= tAPPL7 TION DFSC:=IGN OF SORTS Ems' C'yT7IMM IN TEST BOLL,-.) HCE M. I EOLE NO" HOLE NO. / __....._.._._......... _ ............. _..- _...... INDICATE LL""S7EI, AT WaICH GRMJNU1r—=_ IS F.i=UNTF' M IWI= LF.UEL TO WHIGci WATER LEVEL RISES AFTER BEING k�TO tE = DEEP HOLE OBSERVATIONS MADE BY: DATE: �1A a /9�, DESIGN -Soil Rate Used Min/l" Drop: S.D. Usable Area Provided No- of Bedroam Septic Tani: Capacity gals. Type Absorption Area Provided By L.E. x 24" width trench Other R MA,11,E. r WA MIS S1?AC.11 FOR USE BY EMUTH DUAMIUM ONLY: Soil Rate Approved s . q.*ft/gal.* C%eak=- by Date 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 (914)278-6130 Fax (Q14) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 -.6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: Dorset Hollow Builders Lot 16 TAX MAP NUMBER: 13.08 -1 -100 11 Bonnie Court E911 ADDRESS: Patterson TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) i DATE: 1/2 J The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFW G &E DEVELOPMENT, LLC Gregg Macaluso 914 - 878 -4355 March 17, 2000 Robert Morris P.E. Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow Estates Lot # 16 (formally Van Cleef Estates) Edward Bloes 914- 234 -2281 This letter is to serve as a notice that I as the contractor for the Dorset Hollow Water District, currently under construction, can provide adequate pressure to serve the proposed lots. - This water plant shall be inspected and approved by PCDOH for use to meet the demand requirements for the subdivision. Very EdwardE oes G &E Development PO BOX 352 BEDFORD, NY 10506 P. W. SCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (914) 278 -2110 FAX (914) 278 -2166 TO Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 WE ARE SENDING YOU ❑ Shop drawing ❑ Copy of letter 1.,12"T "T[E l OLP � ° LIVUW0CTVZ1! L'� DATE 3-31 - StOO l . JOB NO. 99- 159 ATTENTION � _ j1,. �/y� , �obel -t, / � i r i s RE: Dorset Hollow. Estates - Lot '*16 (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) Application for Approval of Plans (PC -97) I C(Attached ❑ Under separate cover via the following items: s ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 1 Application for Approval of Plans (PC -97) I 1 Construction Permit for Sewage Treatment System (CP -97) 1 1 Letter of Authorization (LA -97) 1 2 Design Data Sheet (DD -97) I House Plans (2 sets) 2 1 Letter from G & E Development,LLC, Re: Public Water 1 1 Check #g6(j_2850o38 for the amount of $ 3oo.00 1 1 Short Form EAF THESE ARE TRANSMITTED as checked below: • For approval • For your use • As requested X1 For review and comment ❑ FORBIDS DUE • Approved as submitted ❑ Resubmit copies for approval • Approved as noted ❑ Submit copies for distribution • Returned for corrections ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS List Continued: 4 1 Septic Site Plan Drawings 1 1 E911 Address Verification Form (E911 Verfrm) COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. 14.16 -4 (2/67) —Text 12 PROJECT I.D. NUMBER 617.21 'SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME Dorset Hollow Builders Dorset Hollow Estates 3. PROJECT LOCATION: (formally Van Cleef Estates) Municipality Patterson County Putnam 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Lot Wi6 - Dorset Hollow Estates (formally Van Cleef Estates) ij .QoNN ;e Covrt, Pa.�erso•� . 5. IS PROPOSED ACTION: El New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of subsurface sewage treatment system -for single- family resid'emce and connection to public water syipply. 7. AMOUNT OF LAND AFFECTED: Initially O.5 acres Ultimately P1.5' 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? ® 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)? ❑ Yes ® No If yes, list agency(s) and-permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yes, list agency name and permit /approval Subdivision approval from Town of Patterson Planning Board /PCDOH 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes ® No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name :..' 7P . W . Scott , P.E. , R.A. Date: i 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) Ct. 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, of other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation of 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 (aj setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check. this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsi e Officer in Lead Agency Name of Lead Agency Date 2 Title of Responsib e O icer Signature o Preparer (i if erent rom responsi le officer)