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HomeMy WebLinkAbout0515DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 15. -1 -33 BOX 6 I 1 11 1!%"67 j J'Ar r , rA i r , 00515 SHERLITA AMLER, MD, MS, FAAP . Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Steven D'Ottavio 2400 Route 22 Patterson, NY 12563 Dear Mr. D'Ottavio: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health April 9, 2007 Re: Addition — Approval — A- 071 -07 No Increases in Number of Bedrooms 444 Haviland Hollow Road (T) Patterson, TM # 15.4-33 I have received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the addition. has been approved as per plans bearing the approval stamp from the Department dated April 9, 2007. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not obtained proper approvals. Any permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson If you have any questions, please contact me at your convenience. Sincerely, Gene D. Reed Senior Environmental Engineering Aide GDR:kly cc: BI (T) Patterson Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 =6648 a' SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH o 1 Geneva Road, Brewster, New York 10509 ADDITION APPLICATION RESIDENTIAL ONLY STREET `. i �.Ci TOWN TAX MAP# � NAMEPHONE � j 3 koi ' MAILING /l ADDRESS J ADDITION A '/Z NUMBER OF EXISTING BEDROO PROPOSED # OF BEDROOMS O (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 - 61.30. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all.living area including basement) 3. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #) *Non - professional sketches are acceptable 4. Copy of survey showing well and septic locations to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. �. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 r n f SHERLITA AMLER, MD, MS, FAAP . Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Town Leval Bedroom Count ROBERT J. BONDI County Executive Re: (Owner's Name) Tax Map #: Address:, Town: Year Built: 16�2 According to records maintained by the Town, the above noted dwelling, is in compliance with Town Code. is not in compliance with Town Code. The Legal Bedroom Count is This information has been obtained from: Certificate of Occupancy: Other: /le� S Building Spector Date Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services.(845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 2�.11 V MArf, ' '_:► :ISTING PLAN FOR FARCHITECT om`A u��,,�N,` K�1�M .cu,,.s, a.ewa..o .ot r,e.nw �e S. WEY. ?N D'OTTAVIO EXISTING PLAN o.� .o....�e M064v OM1 OYiOOt 1q N NEW YORK y 11 uis G,eUvoo ;2�. )S7 —j'33 Pc� 4- to r3o -, 1�41- / Xo � L ` its► . _ . . . . _ . . . . � - - -/- _ (j - - - - -- -- -- - - - - -- 14.-9„ -�- -- - O • ,� r 2 to .. I cm 1g - - -- -- - : t - -- - - -- -- —_. - -- . - — -PUfNAM COUNTY DEPART F liLOL111 7 _. _ - -- - - - -- -- — - -- -- — - - - - -- - - -- — - -- - - - -- e ,; t„ -- =� o t oo q 4 y la a �'� 1 ,� �{a ►10� , R, - - - -ALL _ �. + P r So-) Ott _._. _. _ ...... HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY -�— RE{ 30fiti�- 4--ow -o 7 rM �_ , - l - - - - SUBSEQUEPlT REVISIONIALTERATIO VNS-M TFIESERO-QH- - - - - -- PLANS POUSTBE -9176TUI Ole SIGNATURE & TITLE- - - - - - - - -- ..- t - - -- - -- - - -- - -- - - -- -- - - - - - _.... . . n -�-------- ------------------------ - - -- - --- - - -� -- - - - -... - - - -- - - -- - -- -- - Q -- -- - - -.. - -.. . - - -� - -- 0.�ec� -- -- -- �- -.._.. .. -.. _. �� - - - - -- - -= - - -1 -� - -�- -- �1_------ - - - - -- _- - ----------- - - - - -- -----------_------ - - -- -- - — — . .. -- . ��� -- �ImS�i- __ --- - - - - -- ---- - - - - -- - — - - -- 6 D -._ -_ - ___. LORETTA MOLINARI Public Health Director 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 InterventiowTreschool (845) 278 - 6014 Fax (845) 278 - 6648 January 28, 2004 Harry Nichols, PE 205 Old Route 22 Patterson Park Suite 106 Patterson, NY 12563 Re: Addition- Steve D'Ottavio No Increases in Number of Bedrooms (T)Patterson, TM #15 -1 -31 Dear Mr. Nichols, PE: ROBERT J. BONDI County Executive I have received and reviewed the plans for the replacement to the above - mentioned residence. The proposal for the replacement has been approved as per plans bearing the approval stamp from this Department dated January 27, 2004. The replacement is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson If you have any questions, please contact me at your convenience. WH:lm cc:BI (T)Patterson Very truly yours -- William Hedges Senior Public Health Sanitarian :ISTING PLAN FOR ?N D'OTTAVIO N, NEW YORK Jac bey �ti ✓�)a+, ►,o�lvW 2j 2� :2iZ rd V its '..► "CHI,:IM WTERIWOLV(E ,AAL P(AI1],E sere. .a rc.. K iR \dT O EEfNCt' AND Mf ESE RICHARD S. WEY. 'EXISTING PLAN ARCHITECT ��T � f GFMW- 'a=/AAL \71 AA.Cf.00144 n10�Cts MUalE DOE TLI: W 1b11E]S {lS i}E 3011 �b+l/p K GOi 11MClW ItP AW E«Ep /S7 -)-33, F R5i FI.00k PLAN 5CAU 1/ 4' - I'-O" PDF created with pdfFactory Pro trial version www.pdffactory.com V- - - -- -------------------------------------------- - - - - -- 2j 5CON19 MOOV PLAN SCALE 1/9" - 1'-01 PDF aeeted with PEIFeaory Pro trill version PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �2 QZ:7A_-7K/0 Address &4VU Located at (Street) Tax Map 16-, Block Lot 33 (indicate nearest cross street) Municipality Watershed 0_4:5 7— ?9�A � SOIL PERCOLATION TEST DATA Date of Pre-soaking ti �910:K Date of Percolation Test / / / / a f o j X.: X ....... . . .. ..... ..... ... ........ ............. ...... ......... .......... .................. .. ............................ ........... .. ... .......... ........ .. ............ .. . . e ... 1. pthlb, .......... .... ... .... ............................ "From:G" . .. ......... . ....... " Time , ... ... . T * **' In N N Start.:,. .... ....... ... ... Sa 1 t .. ......... nee i; .. .... MinlInch /0,100 - 1011/7 t 7 7 2 :z 5 i7 1 3 7 � 2- -!L& 7 4 5 JL- 6 2 1,111'3 ll,'Oq 1 3 11t,0,8 -/ ; ?,,0 3 �-7 4 /J(j P 3 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30,min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 PUTNAM COUNTY DEPARTMENT OF HEALTH y DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL. INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project J) `p E7 �I n �) .�A A) County _ t/ r –A) Site Location- 114VL4- ,dAZD I G , l' 3 Building' construction begun — Extent Is property within NYC Watershed ? ................. Yes ❑ No SECTION B. TOPOGRAPHY (Please heck all appropriate boxes) � 1- Hilly * : � Rolling Steep slope Gentle ,slope ❑ Flat 2. Evidence of wetlands a Low area subject to flooding a Bodies of water F7 Drainage ditches Rock outcrops 3. Property lines or corners evident ....................... ............................:.. ❑ 'des No 4. Do water courses exist on or adjoin the property? ............................ s No 5. Will these affect the design of the sewage system facilities? ... 6e.4f e —ks Yes F7. No 6. Do watershed regulations apply in this development ?....................... es No 7 Will.extensive grading be necessary? ...............:.. ............................ .... Yes No 8. Will extensive fill be necessary for SST S? :........ ............................... Yes o 9. Do filled areas exist within the SSTS area? ........ ......................:........ F7 Yes No, If yes, what is the condition of the fill? SECTION C: SOIL OBSERVATIONS ( '` ° 1 G5 l'V'f Nole-s h .ca/ylwm I oc� jo►z 10. Appearance of soil: ❑ Sand ❑ Gravel a Loam Clay Hardpan Mixture 11. Observed from: ❑ Borings Q Bank cut ❑ Back-hoe excavations 12. Soil borings /excavations observed by on 13. Depth to groundwater on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas ...... ................ ......:......... ❑ Yes No 16. Soil percolation tests made by on 17. Soil percolation tests witnessed by on , SECTION D (on back) Form ST -1 4 Q BRUCE R. FOLEY Public Health... Director - LORETTA MOLMARI R.N., M.S.N. Associate Public Health Director Director of .Patient Services DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 REQUEST FOR FIELD T SE TIN G - MENTIO\ s: ❑ ADAM STIEBELING GENE REED All information below must be LL4 completed prior to any scheduling. ENGINEER OR FIRM: REASON: DEEPS: ` 1. PERCSY ROAD /STREET: 'A41-1 Ld fieda� Re TOWN: 's DATE: PHONE #: 3-7 9-1003 PUMP TEST: ❑ TAX MAP #: / 3", — / —3 3 SUBDIVISION:. LOT #: OWNER: S�Lcl �o y l� YES NO 0 J-- Proposed SSTS - within the drainage basin of `Vest Branch or B.oyds Corner Reservoirs. 0 Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 0 Proposed S-STS design flow greater than 1000 gallons /day-or SPDES Permit required. 0 Proposed SSTS for a Commerical Project. I I is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered y-a to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COU \-IY USE OSLY DATE: � _ — t [ ®® MNIME TS: GAP °S IC (FTE L D TEST) TIME: % j l 10 (off/, / ®i ® 0 -P 4 A�l and 31w N w� oa c z� �P .Putnar Lake �f �m cc lu z zol PO x LA FID 3 637.44 N i 5.0.87 (L 22 7 12 °LLleenc° 25 try .78AO � 11 , ° 1. - \ -• .. L84 z48.99 z9z4 2.73 AC �0 i 20.4810 1167 �3 655,AS 1.70 AC'. 9� ti 430 304.74 26 I 670 m� 9 53.73 AC. CAL., • �B 30 AG (DEED) 34 N , `o° = 33 25.56 AC. CAL. l= 9`ti °� s ti ,phb o 32 14.70 AC. 10 31 • CAL. lCL 25.50 AC. CAL. ` I U 18.26 AC. �,`a \ /• 3TL99 'O� \� \B 29 s+ \5 R / 20.0 AC. $ 30 o S, �$ ' 8 &d 204 Ac 1 j / - I,�A1 21B.zL. 246 ry age o` - .�f •. 1 26.09 AC. CAL. i `S� 1n. '"H L --� I SsyAVILAND a "WAXER I zot � � 29 x �•• � 3s 7 z l o Ac. 2 / f . cAL. o' 16.14 AC. CAL sa97 I � X794 r, SM90 PN 4 6 IQ 7�9� i pfl4 ` �d�a 5 3T611� 4 .� Ci _ 0 37 W 8.03 AC. CAL. 57� 4.55 AC. 1 16.88 AC. 46 60.1 IAC. 312002 StA7t Lltff 49 46AC.CAL. r• 1 - - EAS__.. 6 P CAL. I 601 - �5. Co /. i OA 1 39fi38 , 1 i AL N AL N ss ° 8.34 AC. W 39.1 / i AL \ 3 2.02AC. e . ° •, - � I !N 399 I 8 /- 325.17 AC. CAL. m R 4049" 41. a, a / ffi 1.93 AC ~ �~, 429 / 3S�• yp 4.06 AC A3ti� 3.42 AC. :r •1 \67 t� 1 43 I \ i. 2.14 AC �I W 2.01 AC' 13� i a 6 445 155.95. 92 - row 4. ---------------- n 968m - - - - -- - - -- -� 2.00 AC. FOR ASSESSMENT PURPOSES ONLY REVISIONS SPECIAL DISTRICT INFORMA aL�- s•a.ar u.[.°a • ♦r:4sa► vwmus NOT TO BE USED FOR CONVEYANCES SDM •SDI• Can Cfm& S0A70L Din = I,u__,.ssu.sat rrs4a yNn1 "a 46 60.1 IAC. 312002 StA7t Lltff 49 46AC.CAL. r• 1 - - EAS__.. a 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 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date: /Z Zg- /® e From: Gene D. Reed P tnam County Department of Health For your information For your review As discussed Notes/Messages Fax #: 77 3 ' D 3 �,� No. Pages !Z (Including cover sheet) Please respond Attached as requested Please call 49 V1 /I z/0 (0 /D;oe) In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. Jz � i. _``__ 3 -- 620 -- - -- -- 600 o�. / \ \`,\ \ I, 590 -- __ - \� • . --- 600 . � • Y - / r e � ' ,cam- •—�.C�...J L1� m � _ --' " " , F-V� OL" In / _. ---j� �.. -• / A X xIT �C �C A to 530 ,! 510 N/ --74 1.� i �6,�� W Nun� i l : - 14.16.4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant or Protect saonsor) SEAR 1. APPLICANT /SPONSOR �7 V DI arrmjO 2. PROJECT NAME SETS pLEQA(IR -/ PEFTL_ GEwt;�qr . 3. PROJECT LOCATION: r59 GH P^r N rM HM Municipality County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) I- �VtL- AEI -�t7 l+OtLN- P-OAQ 5. IS PROPOSED ACTION: ❑ New ❑ Expansion RModlfication /alteration 6. DESCRIBE PR JECT BRIEFLY: Expc�t -�y to� o F I✓k�tiT . t ��• �S►pErLE To '� P�►2 . 7: AMOUNT OF LAND FFtCTED: + �' S Initially acres Ultimately acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS ?. &es ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? &Residential ❑ Industrlal ❑ 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 It yes, list agency(s) and permitlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes V,No• It yes, list agency name and permitlapproval 12. AS A RESULT OOF1 PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? El Yes X1 No. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor n �' r Ml 1 �7 'V`G name: Date: Signature: I/ 4 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 617.4? If yes, coordinatvthe review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART. 617.6? If No; a negative declaration may be superseded by another involved agency. ❑ Yes. ' ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community-or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb 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 matWi'als. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately, addressed. If question D of Part If was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Preparer (It different from responsible officer) Harry. W.. Nichols Jr.; P.E. Patterson Park, -Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 To: f &k 9 Attention: JOE ?h'Rf,\INf) Date: 0,. I I(1 ,') Job No.: Project l7�VL ©1 Gfr�� I 0 Gentlemen: We enclose ( ) copies of B/W Prints Reproducibles Reports Tracings Specifications Memorandum Copy of letter Description: ( Revision/Date No. S Sen Via: Our Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to . Very truly yos, s Jr., P.E. 7 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING All information below must be fully completed prior to any scheduling. ROBERT J. BONDI County Executive DATE: 0'Ji -�I Q ENGINEERING FIRM: NPSG �S * I��U�Oi.S� Q�G PHONE #: PERSON TO CONTACT: NkW NEW CONSTRUCTION ❑ REPAIR PROGRAM El ADDITION' PROGRAM REASON: DEEPS:„ PERCS: I PUMP TEST: ❑ ROAD /STREET: '44 IAMkLAN� M w�J Vow TOWN: ��01J.. TAX MAP #: �� • '' ' SUBDIVISION: OWNER: LOT #: . NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING 'OF SOIL TESTING YES NO ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner & Croton Falls Reservoirs. ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYCDEP-project status (Joint or Delegated) based on the response. If you answered eyes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYDCEP. If a' project has been,determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: COMMENTS: TIME: REQ. FOR FIELD TESTINQUY . Environmental Health (845)'278-6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (843) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845).278-6014 Fax (845) 278 -6648 UCE R. FOLEY lie Health Director LORETTA 'MOLINARI R.N.; M.S.N. Associate Public Hetslth Director . Director of Patient Services b EP.ARTNMNT' OF. HEALTH ' 1 Geneva Road { Brewster,. New .. York 10509 • . 'Environmental Health, (845) 278 .*6130 ,Fax (845) 278 - 7921 s 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• ADDITION APPLICATION _ STREET rev �(> � 9•���.° goner NgMESf _ i9 .ESIDENTIAL;ONLYI " / .. ;: TX MAP# / S �� - Pi�D� - d • ' DES CRIPTION OF ADDITION ' .. e �,,5, NUNIBER OF-EXISTING BEDROOMS_;_3-,PROPOSED # OYBEDROOMS- (FROM CERT. OF OCCUPANCY OR ���, : • '_`� ;' CERTIFICATION lads t BMDIN.G'•WPECTOR) �. *4y addition which is:considered 16droom re uires form z. vat' :£ fans Construction Petnut prepared by a Professional Engineer nr„Registered Architect uI accordance tivifh applicable sections of the _ .. .. Putnam County Saiii e. Please submit this form and the folMving to Putnam County Health Dept:, 4 Geneva Road, Brewster, NY 10509, Phone 278 -6130: ` • : 1. Certified check of money oider-for'$100.00.. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) *Nonpiofessional sketches-are acceptable, 3. Two sets of proposed floor plan (drawn lo'scale, with name, street, and tax map 9) *Non- professional sketches are acceptable. 4:. Copy of survey. showing well and septic location, to the best of your knowledge.' Include date of installation if known..Labet all wells and septic systems within 200 feet of the property.line. Contact this office with.any- questions. S. -Copy- of Cert. Of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling... OFFICE USE . ' Comments . PFhouseguidelines YU.IINAM U-0UIN I X VhrAtUIVI 'XI Uk+' DIVISION: -OF-- ENVIRONMENTAL - HEAA.LTH,.SERV!0ES-' -` - ... s. - APPLICATION FOR APPROVAL OF PLANS..FOR •A WASTEWATER TREATMENT' SYSTEM;: - �.... - -TT- A-41 Name and address of applicant: • � Viµ • �� 0�:�1 I 0­.' .. 2. Name of project: IPPI410 fl1—. 3. Location T/V 4..Design Professional: WNW TJ, 0` U Q5 5. • Address: S0• • . - �. 6. Drainage Basin:�� 7. Type of Project:. - 1.8. Js project located near-a public water supply system? ...................:..... p 19.' If yes, name of Neater supply:. Distance to wr: supply r A -. _. ..... -2-0. Is,project site near a public sewage collection or. treatment system? NQ Name of sewage-system _.: :A Distanceto _sewage sysfem • -- 22. Date test--holes-observed �12�d� 23, Name of Health Inspectdr $11; 24. Froj:�ct* design flow (gallbris,per day) .....:...............: .....:.... ......... ..... ............... -... 25. Is State Pollutant Discharge Elimination :System. ( SPDES)- Permit .required? 26. Has SPDES Application been submitted to local DEC office? :.......... I.: ........... l`t Form PC -97 Private/Residential Food Service Commercial , 'Apartments'-: - Institutional T Mobile Heme- Park•. -• _ .. _ . Office Building Realty Subdivision __ . Other (specify) ` 8. Is this project subject.to State Environmental Quality Review (SEQR) ?' :. Ty e•-Status ( check - one): ..::...:.............. ..........I......:............. Type I :Exempt° Type II ` Urilisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... �Q 10. Has DEIS been completed and found acceptable. by Lead Agency?...,,'...,. N A 11. ..-Name of Lead Agency : Ja* ,Is this project in an -area under the control of local planning, zoning,.or other :;; ;; .• ::; , .•:;. __ officials, ordinances? ..................... ........................:.•.`.. ............ - ......" ..... �?.; -.: .. 13. -If so, have plans.been submitted to.such authorities? ........ ............................:.. N .. . 14. Has preliminary.approval been'grarited by such authorities? 0 Date granted:T 15: `type of Sewage. Treatment- System Discharge-.*..;; ............. surfce water­ u er ?n 16. __7`1­ :If surface water discharge;-what is the stream class'designation? :,' 17. Waters index number (surface). ............................ ....................:.......... . (' (::. 1.8. Js project located near-a public water supply system? ...................:..... p 19.' If yes, name of Neater supply:. Distance to wr: supply r A -. _. ..... -2-0. Is,project site near a public sewage collection or. treatment system? NQ Name of sewage-system _.: :A Distanceto _sewage sysfem • -- 22. Date test--holes-observed �12�d� 23, Name of Health Inspectdr $11; 24. Froj:�ct* design flow (gallbris,per day) .....:...............: .....:.... ......... ..... ............... -... 25. Is State Pollutant Discharge Elimination :System. ( SPDES)- Permit .required? 26. Has SPDES Application been submitted to local DEC office? :.......... I.: ........... l`t Form PC -97 29'. --Is Wetlands Perm-it required? � �.� Has application been made'to Town or Local DEC office? ............................... N 30. Does project require a DEC Stream- Disturbance._Perini.t? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to .orchards or other crops, solid ox hazardous waste disposal, Ian dfilling,�sludge application-or in activity? ............................ Ye's/No U 32. Is project located within 1,000 feet-.of existing or abandoned landfill, -aste site, salt stockpile, landfill, sludge disposal- hazardous.- site or any Other potentially known source of contamination? ..................... ........... Yes/No Iv 9 DESCRIBE: 33. Is there a local master plan on.file with the Town or Village? ........................ 34.. Are community water and/or sewer faciIiti es. planned to be developd.Within 15 years in or adjacent to project site? tJ0 35. Are any sewage treatment areas in excess of 15% slope? .........................:.... 36. Tax Map ID Number .......: 5 .................. ............................... Map �, Block Lot 3) 37. Approved plans are to be returned to ..... . Applicant X Design Professional NOTE: All applications for review and approval of new SSTSto be located within the NYC Watershed shall he.serit to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP' approval of the,7SSTS prior'to final :approval by the Department. Projects within...the watershed may also require DEP review. and:approval. of other aspects of a project, *su-ch as stormwater. plm.5..or the creation' of impervious.sEarfaces, 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.affi'rm; .under penalty of perjury, drat 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 210.95 of the'Penal•Law. SIGNATURES -& - OFFICIAL TITLES.: Mailing Address: ......... ..................... DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. I HOLE NO. 2- HOLE NO. Indicate level at which groundwater is encountered NON Indicate level at which mottling is observed N A Indicate level to which water level rises after being encountered N A Deep hole observations made by: V- A� w fgkGmts J(- ., M- Date 10�104 Design Professional Name: MtIE- dN, EVtm ,1 P6 Address: So r`� qj- , Signature: Design Professional's Seal OF NEW. r09 4L W w 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 6Tr='JIEr o-TTA,4 l t Address 1A BMD� �V- Located at (Street) 41N�14�4 Tax Map IC-1, Block Lot (indicate nearest cross street) Municipality.­..._ 0 Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking OLA Date of Percolation Test .. . . . . .... . . . . . . . . . .. . .. . ....... :.*.:.:: .. : : ." : .. *.: ........... 2 )_Q 3 4 5 oil 2 3 10 110 4 5 2 3 . 4 5 NOTES: "' 1. Tests to be re'neated at same death until ant)roximateiv equal nercolation rates are obtained at each .1 - - - - - percoi�tion�test hole. .(i.e. _-� I min for 1-3-0- min/inch, :g 2 min for 31-60 min/inch) All data to be submitted for review. 2., Depth measurements to be made from top of hole. Form DD-97 JLJL PUTNAM -COUNTY DEPARTMENT OF HEALT1EY.;, DIVISION ..OF. ENVIRONMENTAL HEALTH -SERVIC LETTER OF AUTHORIZATION, RE: Property of 0 Located at T/V Tax Map # Block Lot Subdivision of 8ubdivision'Lot# Filed Map # Date Filed­. Gentlemen: This letter is to authorize a duly licensed Professional Engineer or Registered Architect to pl .y for thuequired wastewater treatment and/or water supply permit(s) to serve the above- noted - property :in with the standards, rules or regulations.as promulgated by the Public 14'ealth Director of.tliewPui am County Health Department. and to sign all necessary- papers on my behalf in connection ' mith . il s' matter and to supervise the construction ofsaid'wastewater tretment and/or water supply systeftis in - conformity with the provisions. of Article 145 and/or. 147 of the Education- Law. tht Public Health- - Law, and the Putnam County Sanitary Code. -Countersign*e P.8., R.A., # Mailing Adcb State Zip I D's- cj,� Telephone: (��s�. 2� _ ,�- Oo�j Very truly youms ed: (Owner of Property) Mailing Address: �j State Tele ��y �� ?. - �_� i d:... plfbne: .. FornVLA-97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 2794567 January 19, 2004 Mr. William Hedges Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Repair /Addition D' Ottavio Town of Patterson Dear Bill: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSDS ", dated 01/19/04. 2. "Short EAF ", dated 01/19/04. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System ", dated 01/19/04. 5. "Design Data Sheet." 6. "Letter of Authorization." 7. Two (2) copies of Residence Floor Plan. 8. Review Fee in the amount of $100.00. We would appreciate your review, approval and issuance of the Permit at your earliest convenience. Very truly yours, Harry W. Nic s Jr., P.E. 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