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HomeMy WebLinkAbout0483DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.08 -1 -104 BOX 6 J 00292 � I EL m6 y I � � r } r r 00292 r 1v \� � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE F REATMENT SYSTEM PCHD CONSTRUCnTIION PERMIT # Located at Town or Village P A.� n �_Z <a)Q Owner /Applicant Namelbmsvl_� WL11W gWLi_(Z!fax Map Block Lot 1 Formerly Subdivision Name ri R N Subd. Lot # 12- Mailing Address 16 VEST 140110M (Z©Ab 0?J WST F_9-1 NY Zip i)s 01 Date Construction Permit Issued by PCHD �q ` �— IOU Separate Sewerage System built by Q ©�' SET V\(-)US)\PJ UlLb� ddress�' tNEST ST. Q Consisting of �'� Gallon Septic Tank and 4S O IJ Other Requirements: Water Supply: �_ Public Supply From M U N 1 C 1 E' 1 Address P A T T E P-M M N y or: Private Supply Drilled by Address Building Type ��� 1 N C_E Has erosion control been completed? ) �_:s Number of Bedrooms A-- Has garbage grinder been installed? NO 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 Deent of Health. Date: (' — 0� Certified by Address 20 S P.E. i , R.A. 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 ubject to modification or change: when, in the judgment of the Public Health Director, such revocationw m dificatioA or change is necessary. By: Title: /1-� _ Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 0 i - 45. 44, Ise 14 T m 4 _ 11 7 �S b!RNb P Ve 4 9(a US0(;ALLojy Serr%c TKIVk a DuNNIE. CO.0 COIL lw SITE PROPERTY! PROJECT: ppr R 'L ' A'T T M-5 GW CLIENT : DORSE DIMENSION CHAR' (in feet) Number . 43' 3 (00 qq' 4 COQ' 54,5' 5 ( S,5, ��•C, -12151 io 13 oz' C.o4,5' Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY t0509 99 Telephone (845) 2794003 Fax (845) 2794567 June 6, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, NY 10509 Re: Individual SSTS Compliance Van Cleef Subdivision Lot #12 2 Bonnie Court Patterson, NY 12563 T.M. #13.08 -1 -104 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing 5 -12, "As -Built Plan," dated 4/26/01. 2. "Certificate of Construction Compliance for Sewage Disposal System," dated 6/06/01 3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System," dated 4/06/01. 4. Laboratory , Report, dated 5/24/01. 5. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 6. "E -911 Address Verification Form," dated 4/20/01. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic is Jr., P.E. HWN: JM: jm 01- 026.12 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM VORSCr HoLLow jg\J1LAEiZ� l'3ed$ IOq' Owner or Purchaser of Building Tax Map Block Lot 'iJc9R4i_T HoLLoW RM)LDF-Qis Building Constructed by . Z '34NN )lam Coy RT Location - Street Zr.s,-aCr., C Building Type fi AT ?CRsoN TowrvNWW VAN C LEE.F Subdivision Name 1Z 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 oq�t of the building utilizing the system. Dat • Month Day 60 Year 0 Gen for (Owner) - Signa e i�o25�'T Ho i,Loyw ;aytL tD'BtS Corporation Name (if corporation) Address: ) s L jr-s -r Ho «o %,Q ptA , %jgQw s-C% a State ),J Zip ) o s o 9, Signature: Title: c, w N E D ®RS GT Ho L Lo u-N r3 L 1 L1�E R� Corporation Name (if corporation) Address: ,3 wciS ft, aQ &vrcMX State ,,,,, Zip ,aso Form GS -97 i S �rrx.:»n.s »n »»rassr. REPORT TO: 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 LABORATORY REPORT DORSET HOLLOW ESTATES DATE SAMPLE COLLECTED: 5/23/2001 Attn:ALLAN J. FINN TIME COLLECTED: 8:00 A.M. 15. WEST HOLLOW ROAD COLLECTED BY: A. FINN BREWSTER, N.Y. 10509 DATE RECEIVED @ LAB: 5/23/2001 TESTED BY: LAB #11471 LAB I.D. #: MAY -142 REPORT DATE: 5/24/2001 \11O �N ACC01044, fAO U � a x SAMPLE SITE: DORSET HOLLOW ESTATES, LOT #12 SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: -'METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) BACTERIAL: 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: DOTABLE or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS, FOR POTABLE WATER) OrAi4_q a �Mf " Laboratory Director -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 L-D 1, " 19_ 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 (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Iitervenhon_(914) 278.6014 Preschool (914) 278 -6082 Fax (914) 278-- 6648 I 001F.11 110 1110CISAWSU-101.111 OWNERS NAME: Ijsj,ot,JJIt1Q�u7 TAX MAP NUMBER: j E911 ADDRESS: co ua TOWN: 15G1� AUTHORIZED TOWN OFFICIAi,: v (Signature) DATE: 'Z I 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 VERFRK PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Inspecte d by-' �� �E�, Street Location f✓�5T S i Owner ��r��T ,�� . To«n Permit # P— ;t, 7 - oy TM 7.1 _ 3_ t ©� I — /� Subdivision Lot # 1. Sewage Systein 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 course/wetlands.. .............................. II. Seilage System a. eptic tank size -1,000 ..... .. 1, 250.. ..... other ................ 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 ........... ............................... f. Trenches Leniffi required _ zf Length installed 2. Distance to watercourse measured + i C­)0_ 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 -1 %:" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ................................... :.................... g �I size of pump chamber ................ 2. Overflow tank ....................... .............................. 3. Alarm, visuaVaudio ................ :.................................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ......................................... ........ ::..... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. HouseBuildin a. House located per approved plans.... ............................... b. Number of bedrooms ....................... :.:............................ IV. Well a. Well located as per approved plans . ............................... b. Distance from 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 watercour g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .. ............................... i. Erosion control provided ................ ............................... BRUCE R FOLEY Public Health Director April 27, 2001 LORETTA MOLINARI R.N., M.S.N. 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 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Dorset Hollow Builders West Street, (T) Patterson TM# 13.08 -1 -104, Lot 12 Dear Mr. Nichols: The separate sewage treatment system on the above referenced project can be backfilled. The following comments must be corrected in the field: • No comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed �l GDR:cj Environmental Health Engineering Aide Q BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. 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 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date: /A/ To: &A1zn 5 From: Gene D. _Reed Putnam County Department of Health __z For your information Fag #: No. Pages (Including cover sheet) Please respond For your review Attached as requested As discussed Please call Notes/Messages In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. PiJTNAM COUNTY DEPARTMENT OF HEALTH _ DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM'` Se PERMIT # Located at 2 Bonnie Court Town or Village Patterson Subdivision name D o r s e t H o 11 o w E Etbd. Lot # 12 Date Subdivision Approved Tax Map 1 3 0 8Block '1 Lot 104 Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road, Brewster, NY Amount of Fee Enclosed $300.00 Building Type Res i d e n c e Zip 10509 Lot Area 9 2 No. of Bedrooms 4 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 gallon septic tank and yyLl LF o; wiJe— 4re,,,r-h &5 (10 ro,j5 Q L15 L rz) on f7, reserve Other Requirements: To be constructed by Dorset Hollow Builders Address 15 Water Supply: X Public Supply From water °Districtson or: Private Supply Drilled by West Hollow Rd., 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 treatmentsystem 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 as 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: P.E. X R.A. Date LI-M-00 Address 3871 Route 6, Brewster, NY 10509 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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy, - Design Professional Form CP -97 ' MIMIMILV11MiMlAY. UMIMYl Y/_ �IMIM1/. 1L1/ MEMII UIMIMIMIMIMIMIMIMIMEMIMIMJRGHMtMIRMM1Rtl IMIMIMIfl /1F1V111.11UMI1V11MIMIMVSLYIMIN �111�IM r � y i y Eal CyY/Y(1l WYE/ iY7lliliNlllll l% 11l 1/ IWEV1l71/ y! 11 1if11 11IHYiri/ lillYI YAYYi7/ 1/ ?1rVlWif/YINM(JVIH11fi/1A1/tie V�Y1/y9�Y7' v: W71/ VYi/ YI�l v7�l 1i1i1�71 /NlN'vfi/VI1lM"7KN71lGi7ilY 7H1i71 /N7ilVIKVIifiVIV toio wD -5 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # (-C) %— y Located at 2 Bonnie Court Town or Village Patterson Subdivision name Dorset Hollow E Oubd. Lot # 12 Date Subdivision Approved EM Tax Map 1 3 • 0 8Block 1 Lot 1 0 4 Renewal Revision Owner /Applicant Name Dorset Hollow Builders Date of Previous Approval Mailing Address 15 West Hollow Road,.Brewster, NY Amount of Fee Enclosed . $300.00 Building Type Res i d e n c e Zip 10509 Lot Area • 9 2 No. of Bedrooms 4 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 gallon septic tank and ijgtj LF of wide. 4re,., P.5 10 rows 45 L c» !�26 re-se,-ye- Other Requirements: To be constructed by Dorset Hollow Builders Address 15 West Hollow Rd., Brewster, NY °te° Patterson Water Suppy W a r District 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 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: QV�5 P.E. x r� R.A. Date L4-9) -Oo Address 3871 Route 6, Brewster, NY 10509 License# 059346 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh n c ns'dered nec ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe proved fo harge of domestic sanitary sewag B ✓ Title: �Yrv�xt lleaz<— Date: 6 Y• White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 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 (9.14) 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 OWNERS NAME: E911 ADDRESS VERIFICATION FORM Dorset Hollow Builders Lot 12 TAX MAP NUMBER: 13.08 -1 -104 2 Bonnie Court E911 ADDRESS: Patterson TOWN: AUTHORIZE TOWN OFFICIAL: FFICIAL. (Signature) DATE: t L Go 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 VERF'Rlvi) .s 14.16.4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 'SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UN LISTED. 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 Put n a m 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Lot # jd — Dorset Hollow Estates (formally Van Cleef Estates) ;l 13onja; e aor it, Pcjfers,o" , �J y 5. IS PROPOSED ACTION: El New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Construction of subsurface sewage treatment system — •for.singie- family resid'emce and connection to public water sgpply. 7. AMOUNT OF LAND AFFECTED: Initially 015 acres Ultimately 0•S • acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Li 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 permitlapproval Subdivision.approval from Town of Patterson Planning Board /PCDOH 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 Applicant /sponsor na P.W. Scott , P . E . , R.A. Date: 1V 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 11— 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, of 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-Cl-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 and /or prepare a positive declaration. ❑ Check. this box* if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency N3 Signature of Prep a (I i`e tro"rgsjojs`1¢ e officer) � r ) e i I Date 2 Dom: -,-.., ..,.., 'y ^_�....- �u.=:.��. 1'�rL- =: D��'..�x..�i+ � �.`-.�: �T.c. i�7'••_ 3. z a r -r St=a `� �31 / c /�W VL,v, -44 416W, •Pa Se'r_ /3. y =lcc. 7 `ct / DAM ? C-ri=, J, "C , �`�- *'r'_y� . W_'I:? -op � C:"qS LOT /2 ..Gt--. cf Pre - ;Staking Bat a of Per=laticn 1GSt /11 17 / / d Z _2 Iz- 5 2 3 1. '!pest; to be repeater• at sarm depth untL'-r a =rcc:mate' y eqLm1 soil mts . are ' obtained .at each re=laticn tast hole. • 'Ail data to' be stab t`t d for reviema. 2. Dept: = sare ants w be rz f-= top or hole. : rev. s /as NHOLv R�Tl , •l a=se Dept<Z to .wate_'� 'C:1 Yiate= Love: No. TiMp- Gr=d Surface. Lm .:.- -.ches ' Re SCL at start SLOP Droc In Y-Ln/I..'1 Dro-p _ Incnes I -nches ili^.G.eS 2 17 Z _2 Iz- 5 2 3 1. '!pest; to be repeater• at sarm depth untL'-r a =rcc:mate' y eqLm1 soil mts . are ' obtained .at each re=laticn tast hole. • 'Ail data to' be stab t`t d for reviema. 2. Dept: = sare ants w be rz f-= top or hole. : rev. s /as TT�ST PIT DAB? re ?SD 710 HE SuP1�(.I'I'I'T� —LTA 1PPLI TICIN G4T D.?S =TION v" SOILS lawJN 1=1 IN TEST HOL—) D HCL% ISO. HOZZ M. G.L. Rc 4' �y ` 51 PO 71 Y 8t 9t 10' 11' . 12' 14' INDIC,za-Z LES,IE`, AT INMIC7 GRCUNI7C IS E \ =U�1T�.� ^Jm - INDIC.� LEES , TO WHIM wATE.''� Lr vm RISES A=1 M=G E.N =GIM= DES HOLE OBSr:.4VATIONS M�E BY: D=—: ' Dr^SMN Soil bate Used �- /�� Min /1" Drop: S.D. Usable Pse Provided Nc� of u3rocns Septic Tank Cap,aci_t;T Type /c , Absorpticn Area Provided Ev yZ1 q L.F. x 24" width trencz 1 Other �' Name W. SC d� LNG/ NEED /NG�.JQG.S�iTrat�/tFlg� -attt� Address MIS SPA= -- FOR USE UY iM— UTH M- F- UM4ENT ONLY: :'� '�ESS10 Soil Rate Approved sq:ft /gs:.. L.,ecked by Date 0 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 drawings • Copy of letter CXAttached ❑ Under separate cover via ❑ Prints ❑ Plans ❑ Change order ❑ INTTME @LF U � ° H@NOcTUL%1 DATE r� 1 _ 00 roe NO. 99— 1 5 9 ATTENTION RE: Dorset Hollow Estates — L04 8 (formally Van Cleef Estates) Subsurface Sewage Treatment System (SSTS) Application for Approval of Plans (PC -97) I ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION 1 Application for Approval of Plans (PC -97) I 1 Construction Permit for Sewage Treatment System (CP -97) I 1 Letter of Authorization (LA -97) 1 2 Design Data Sheet (DD -97) 1 House Plans (2 sets) 2 1 Letter from G & E Development,LLC, Re: Public Water 1 1 Check #335- 11d -3-7do for the amount of $:3po,op 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 • Approved as noted ❑ Returned for corrections ❑ Resubmit copies for approval • Submit copies for distribution • Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS List Continued: 4 1 Septic Site Plan Drawings I 1 E911 Address Verification Form (E911 Verfrm) COPY TO SIGNED: ../jr If enclosures are not as noted. kindly notify us at once. 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: Dorset Hollow Builders Lot 4�, 1 °�. 15 West Hollow R6ad Brewster, New York 10509 Dorset Hollow Estates Patterson 2. Name. of project: (formally V anC 1 e e f Est 3. Location TN: 4. Design Professional: Peder W. Scott, P.E., R.5k.. Address:3871 Route 6 6. Drainage Basin: East Branch Reservoir Brewster, NY 10509 7. TyDe, 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) ....................... ............................... Type I Exempt Type II Unlisted X 9.. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 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- Subdivision 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 erviced 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 ! o 16 - `I(,, 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 GPD 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 F] 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number .......................................................... ............................... N/A 29. Is Wetlands Permit required? Individual Lo.t 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 DESCRIBE: 0 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_11o& Block t Lot to 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 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... Peder W. Scott Agent for Applicant 3871 Route 6 . --6 JAI Brewster, New York 10509 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Dorset Hollow Builders Located at 2 Bonnie Court T/V Patterson Tax Map # 13.08 Block 1 Lot 104 Subdivision of Dorset Hollow Estates (formally Van C lee f Estates) Subdivision Lot # Gentlemen: 12 Filed Map # 2 7 7 1 Date Filed 12/24/88 This letter is to authorize P e d e r W. s. c o t t, 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. - - -- ��� Countersigned: J " P.E., R.A., # 59346 Mailing Address 3 8 7 1 R o u t e 6 Brewster State New York Zip 10509 Telephone: ( 9 14 ) 2 7 8 - 2 1 10 Mailing Address: Dorset Hollow Builders 15 West Hollow Road, Brewster State New York Zip 10509 Telephone: ( 9 1 4 ) 2 7 9 - 1 3 3 9 Form LA -97 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 # 12 (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. G &E Development PO BOX 352 BEDFORD, NY 10506 aeMay 31, 2000 rork bepartment of Robert Morris, RE Environmental' nvironmental Putnam Co. Health Dept. Protection 4 Geneva Road Brewster, NY 10509 Re: Dorset Hollow. Lot 12 West Street Joel A: Miele Sr:, P.E. Patterson, Putnam Commissioner East Branch Reservoir DEP Log # 10227 (Joint Review) Dear Mr. Morris: This letter is to inform you that the New York City Department of Environmental Protection (Department) has determined that the above - referenced application is complete. In addition, the Department has no objection to the approval of the above- referenced regulated activity. This determination is based on the review of submitted documents including the plan .titled "Septic Site Plan Lot 12 prepared for Dorset Hollow Estates ", dated 04/19/00. The applicant must contact Sissy De La Ossa of my staff at (914) 773 -4416 at least 2 days prior to the start of construction of the SSTS so that a Department representative may inspect and monitor the installation. Sincerely, Margaret Lloyd, P.E. Supervisor Engineering Design & Review ��ADAK CITY DEAAq f N z dap FryyRD'VMENTAL PROS�'�`D� . wwww. cT nyc. ny. us /d 2 p (718) DEP - HELP xc: James Covey, P.E., NYSDOH 465 Columbus Avenue, Valhalla, New York 10595 -1336 BRUCE R. FOLEY Public Health Director May 15, 2000 DEPARTMENT OF. HEALTH 1 Geneva Road Brewster, New York 10509 V1_- LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of . Patient Services Environmental Health (914) 278 - 6130 Fax (914) 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 PW Scott Engineering 3871 Route 6 Brewster, New York 10509 Re: Dorset Hollow Builders, 2 Bonnie Court, Lot # 12 (T) Patterson, TM# 13.08 -1 -104 Reservoir Basin Dear Mr. Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on April 25, 2000 is complete. The Department will notify you by June 5, 2000 of its determination. ❑ The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ® Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by CertifiedMail, Return Receipt Requested. The notice would be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with Section 18 -23 (d) (6) of the New York City Department of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if DEP review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2166. Very truly yours, Robert Morris, PE Public Health Engineer RM:cj iv 1J Hill HHKKY W N.ICHOLS 914 279 4567 P.02 of — OZb.az PUTNAM COUNTY DLrPAATM W 01 =ALTO DMIONOP ZRVMNMWAL STS UR CZ8 A7lT OTION Q ADAM ®GENE • • For: , pill All Wfo=tloo muet bo illy C=pkted prior to any . Trenehes inspections Wa Mwe, PCHD Coamr melon Permit # , P - t: -1 - o 0 Lowed: 2 goy N 4I C. �s''Giw•ii1:�.ws.+sM (vt G��N•I� N'r Owner/Applicant Name: TM 15,0% block I Lot 1„ o+ Pormvly Subdlv15100 Name: VAN c. Lr.E F �„ �g Subdivision Lott # W Z 9yat= SY completed r �.•. �aarwis Date: .. _ . Is sysiem complete? Date: 11 "am co stnimd a pea Pl uss? ;*AS Is wl11 drWed? ®r. o ' M o-w s e fig: Date. Is W90 located as pot ph=? �. . Are erosion 40iWol oseestteaa in P I certify tint the syseoa(SI a ht4 at the above prvtobas bas been cooatatcted and Y Gave inspected and verified theft complodoa is aceor6we with the issued PCHD Coamoction Fermit and approved plans and the Standards. Hulas and Aeplatloas of the Putnam County Department of Health Due-, 4.- Ql_ CaMad by: kj oZ %v W U �s t pg ..Z.a. RA Design Professioaal Address:.r.6 4n = 7q w.3�3+,.w�.ti�.101+s3B.t,..�l�r i— °Lie.O form M99