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HomeMy WebLinkAbout0587DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -51 BOX 7 00587 PUTNAM COUNTY DEPAR'T'MENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE NT SYSTEM ff/ 7/0 Ij T PCHD CONSTRUCTION PERMIT # P 16 -0 0 T �, 11T^T 1 Located at i P C-1) Owner /Applicant Name d h (s- Formerly. Mailing Address Town or VM9g' e 4 ! 1 ipso L, Tax Map Block _ r Lot Subdivision Name Subd. Lot # zip / Q S/ Z Date Construction Permit Issued by PCHD 16-1,21-01 AIN Separate Sewerage System built by _ Address �' O , j3T� N lea v s l l Consisting of iZS`0+7M Gallon Septic Tank and 7 & 30 44 .A, 7, �cr Other Requirements: Water Suuuly: Public Supply From Address or: Y Private Supply Drilled by /U,,1�a� �1 Zft— Address 1 U 11� /g%, 31 t i� � °I Building Type d s r �,•,�i ' Ha$ erosion control been completed? ^ V� < Number of Bedrooms Has garbage grinder been installed? 1416 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 Countylpepartment of Health. Date: f i - al -0) Certified by P.E. !/ R.A. Professional) Address ;).6.1�v let- 2�i �ru,�sl'c� _ License # 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 ubject to modification or change when, in the judgment of the Public Health Director, such revocation, ification r change is necessary. By: Title: Date: White copy - HD File;'Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �L Received of The Sum �Of £ in_ a Doll r For 17' 3 ylo 4 �L� as ❑Check Q1 ISO j 0 Credit Card 1 0 K 0 42.75 I ST. WELD LL, r-X. 12*0 GAL. SEPTIC, rAt4K- 521 "750 GAL. 'r:,V-rr1C- TANK *twanalysis result / j �'✓ P'/ , �i i mOT WIter ning ng by PwPle of dAWd 0 0 more tharii 27o MA A sodium dic Ve OVA 00 'O'�. - �q6 OCT- 24-2001 01:07 PM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building � L& &�L Building Constructed by Location - Street 54It) / Building Type �3 �J / Tax Map Block Lot TowaNillage Subdivision Name �fl Subdivision Lot N I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatmcnt 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 pan 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 5vstem, The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Dcpartment of Health as to whether or not the'failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the s�Stem. Dated: Mon „�ci_�Day 29 Year Zool Signature. 301ral Contract r (Owner) - Signature _5ervice- Corporation Name (if corporation) Address: / A of / — State I'y Zip a " 6_? Corporation Name (if corporation) Address:�G' State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.102983 CLIENT #: 54848 NON STAT PROC PAGE 2 GAMBY, JOHN DATE/TIME TAKEN: 10/26/0 08:10 27SOMERSET DR DATE/TIME REC'D: 10/26/01 10:15 PATTERSON, NY 12563 REPORT DATE: 11/02/01 PHONE: (845)-878-9770 SAMPLING SITE: 27 SOMERSET DR, PATTERSON, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COL'D BY: JOHN GAMBY TEMPERATURE..: < 4C NOTES... COLIFORM METH: MF ~~~~~~=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1714. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USEDTESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE T8 METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE-AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L »iG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: W^'= 16.^W' ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.102983 CLIENT #:54848 NON STATPROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~°~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ GAMBY, JOHN 27 SQMERSETDR PATTERS8N, NY 12563 DATE/TIME TAKEN: 10/26/01 08:10 DATE/TIME REC'D: 10/26/01 10:15 REPORT DATE: 11/02/01 PHONE: (845)-878-9770' SAMPLING SITE: 27 SOMERSET DR, PATTERSON, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE CQL'D BY: JOHN GAMBY TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY 10/28/01 10/26/01 10/26/01 1O/26/01 10/26/01 10/26/O1 10/26/01 1O/26/01 10/26/01 1O/26/01 ` 10/26/01 PROFILE MF T. C8LIFORM LEAD (IMS) NITRATE NITROG NITRITE NITROG IRON (Fe) MANGANESE (Mn) SODIUM (Na) pH HARDNESS,TOTAL ALKALINITY (AS TURBIDITY (TUR RESULT NORMAL - RANGE METHOD ABSENT /100 ML ' ABSENT 1008 3.1 ppb 0-15 ppb 9101 1.28 MG/L 0 - 10 9139 <0.01 MG/L N/A 9146 <0"060 MG/L 0-0.3 mg/1 2037 <0.010 MG/L 0-0.3 mg/1 2037 46.3 MG/L N/4 7.0 UNITS 6.5-8.5 9043 464 MG/L N/A 306 MG/L N/A <1 NTU 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. iblic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium To- P Attention: Ah Harry W. Nichols Jr., P.E. pumm ptrk S!dtc 106 205ORMOn BMWOW. NY low TcUpbcm(&45)279-4003 Pax (945)M4567 Date: 17-- Job No.: Project A-c jo g s ed S5' TS - 6-? -�-- Gentlemen: We enclose (1�7) copies of /W Prints 0 Rgroducibles 0 RcR2rt3 Q Tracings 0 Specifications C3 M=2r8nd= Q'Copy Of letter 0 Dm.ripdoA:, 44s:—Bul-f PLAIN Revision/Date No. Sent Via: Our Messenger 0• Blueprinter 0 First glasi-MU O Special 'Delivery 0 Your Messenger 0- Hand Delivery 0 Copy to Very truly yours, -lam W. Kf OLS Jr.. rP.E. .. PUTNAM COUNTY DEPARTMEi DIVISION OF ENVIRONMENTAL H FINAL SITE MPEC Y Street Location So�vl�T15�T' br�iv Town __ P, TTETt sonl TMr_ 2.3— i — �/ 1. Sewage Svstein 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. SeN age System a. Septic tank size - 1,000 ........1,250 .......other ................ b. Septic tank: installed level ................ ............................... c. 10' minimum from foundation :. .... ............................... d. Distribution Box 1. A outlets at same elevation -water tested ................. 2. Protected below frost ................................................. 3. Minimum 2 ft.Original soil between box nches e. Junction Box - properly set..... .. .. f. 1 renc es T Zength required 6 "o C) en ed 5 2.- .Distance�to ��ratercourse�measured�-�- Ft_.. .;, Y- �S-lope�bf french- acceptat 5. 10 ft. from property line - 20 ft: foundations.......... 6. Depth of trench—<10-inches-from surface ........ :......... �/lid•F�x' Geacr�ldD/ =fi "a OIi CtS Ulf ' vT OF HEALTH EALTH SERVICES TION Date: 8 'f al Inspecte y: C, izefD Owner CAM &- Permit # 'P— / o —o o Subdivision Lot # _4'Z U. U14.- vl 6laYGl _W? - 1 /Z UICLL 1G1G1 WF.CUI ..................* 9. Depth of gravel in trench 12" minimum .................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems Size ot pump c am er ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ........:................. ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Building a ouse 'orated pe oo ed;plans b, ?lumbe =of bedrom os: IV. Well .. a. Well located as per approved plans . ............................... b. Distance from STS area.measured-1_- 1. V ft...........J. `-d — Surfac ifrainage 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 matenal contains stones <4" diameter .LL.. . __IQlA= u1Q1'IYW= JIQIIU�l1ll5..J 111JKi11GLL GiVGVI\llil��v y'�� -7 -. . Curtain drain outfall protected & dir.to exist watercourse ;. Footing drains discharge away from STS area......... i.—Surface water protection adequate Erosion control nrnvided- ' -• ....... ... COMMENTS .x - Z 'd d0 lN3Wl8Ud3Q AlNnoo WUNind :3WUN T26L- 8L2-St,8 :131 TS :ST mi Tow- c2-9nu MTNAN MUM OF NZAL= nrY1�9ION 0111 Q�AI� 1.?8 CIGS A,ITW ION 13 ADAM GENE . ..., • YNAL 9dPZ=Mj For:, FM All iaib=tb M MOUt bti;O ll gomplatd prior to ow Tremba ' „- iaspecemas befog redo. OwmedAp*"N= ..GAWA TIA '33 BIocY.�_Trot 1 • Subdivt�n Lot � 1s qua= 511 MIPWO rim: is syataa oomw - 13 "am CODU cted as vat ph”? JgA Is well dr2W? Date: is well located u pat PlM? y, Are erosion word In PW ... 1 cc* dus the iysaa4 a used„ udis ttbmmmisa bu been coosweted end thm iaspmed and verified tb$Lr vomVW= in smolaw with the issued P= Coa tt Won Permit and approved pleas nod the StW&* IWW and Regulations of the Pump County Department of _ Health Due: - ,o . �wir+w�.r ■� ca" br • P9 M • Da profasatot+al Addfm.. &G124 Cam , wq r Form 1899 Z0 'd L9Sb 6LZ bib SlOHOIN M ANNUH Wd Zb:£0 S00Z -£Z -9nu t BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 . Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 August 24, 2001 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Gambi Somerset Drive, (T) Patterson Lot # 41, TM# 23 -1 -51 Dear Mr. Nichols: The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: 1. The silt fence has not been installed. All silt fence must be properly installed prior to the start of any construction. A formal notice of hearing may be issued if the violation is not corrected within 5 days. It is truly hoped that the above violations are corrected without having to take legal action. Very truly yours, Gene D. Reed Environmental Health Engineering Aide GDR:cj 61 Vj6�iv 7-0 #W7ZTZ % 1/✓ -P,6�72Z50 Av A,) g19- S/01 P• BRUCE R. FOLEY Public Health Director August 24, 2001 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Gambi Somerset Drive, (T) Patterson Lot # 41, TM# 23 -1 -51 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled staking all corners. The following comments must be corrected in the field: 1. The dwelling at the above mentioned lot has a bedroom count of five (5). 2. The well casing needs to be 18 inches above grade. 3. Stand pipes need to be installed. 4. Silt fence needs to be installed. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide C BRUCE R. FOLEY Public Health Director November 2, 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 Fax (845) 278. - 6648 - Preschool (845) 228 - 5912 Fax (845) 228 - 6113 . Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Gambi Somerset Drive, (T) Patterson Lot # 41, TM# 23 -1 -51 Dear Mr. Nichols: The above referenced separate sewage treatment system can be :backfilled staking all corners. The following comments must be corrected in the field: 1. The well casing needs to be 18 inches above grade If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:cj Very truly yours, Gene D. Reed Environmental Health Engineering Aide SENDING CONFIRMATION DATE NOV -2 -2001 FRI 17:51 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE PAGES START TIME ELAPSED TIME MODE RESULTS : 2794567 : 0/1 : NOV- 0217:51 : 00' 0011 : ECM- : NO ANSWER FIRST PAGE OF RECENT DOCUMENT FAILED TO SEND FULLY... 0. BRUCE R. FOLEY LORE=A MOLINARI R.N., V.S.N. P.6fM ffcdrA D69etar A—MM P.W t/ fa dtienv D,— of P"- Srr DEPARTMENT OF HEALTH 1 Geneva Rod Brewster, Now Yak 10509 rmnlemnNl R6.tn (ws)rn -61w rapls)rn -mt !l..Wt a-"- (145)275.6936 wle WMM -6679 ►.(619)279 -6ole C.rlr aw,.maw (NS)275 -66N i.a(945)37B-6615 h16ra6d(14912y•3912 P.c(945)121 -e11r November 2, 2001 Harry Nichols. PE Patterson Park, Suite 106 2050 Route 22 Brewster, New Yak 10509 Re: Field Inspection - Gambi Somerset Drive, M Patterson Lot k 41, TMP 23 -1 -51 Dear W. Nichols: The above referenced separate sewage treatment system can be.backflled staking all comers. The following comments must be centered in the field 1. The well casing needs to be 18 inches above grade. If you have any further questions, please contact roe at (845) 278 -6130 ext. 2261. vevery Udy yours. 4o- A&P Gene D. Reed GDR:cj Environmental Health Engineering Aide Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 November 30, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance Cornwall Ridge - Lot #41 Somerset Drive Patterson, NY T.M. #23. -1 -51 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -41, "As Built SSTS," dated 10- 17 -01. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 11- 29 -01. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 10- 29 -01. 4. "Well Completion Report," dated 7- 18 -01. 5. Laboratory Reports dated 11- 02 -01. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. "E-91 I Address Verification Form," dated 11- 29 -01. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HWN: imm OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: C;2 Se v"+ cv bi° t v TOWN: AUTHORIZED TOWN OMCIA-L: (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 bg.subnpii�ted with the application for a Certificate of Construction Compliance. (E91 I VERFRM) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 0 r4 e. C ri V e, I Town/Village: P"t-MiA lMapa Tax Grid # 3Block Lot(s),F Well Owner: Name: Address: GL Use of Well: 1- primary 2- secondary _ � Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _X Compressed air percussion Other (specify) Well Type Screened Open end casing _X Open hole in bedrock Other Casing Details Total length ft. Length below grade _ft. Diameter _in. Weight per foot -,L7 -lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _Other Seal: _ Cement grout Bentonite Other Drive shoe: Yes No Liner: Yes _X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped Compressed Air Hours _j< Yield ja gpm Depth Data Measure from land surface- static (specify ft) � ee During yield test(ft) a Depth of completed well in feet P. T - � Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Typ� Capacity Depth ; ^cam Model Z&4',4 Voltages U HP Tank Type , e— Volume e!i�- Date Well Comple ed 7�'7! Putnam County Certification No. 007 Date of Re ort �/� Ql Well Driller (signature) &, NO `E: Fact location of well with distances to at least two permanetyf landn?<arks to be provided on a sepa13,1 sheet/plan. Well Driller's Name , . Signature: Address: 161Z , i A y Date: 71LO White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 OCT -31 -2001 06:25 PM HARRY W NICHOLS 914 279 4567 P.03 x —DOG. o o PUTNAM COUNTY DEFARDUIC OF BEALTR DrMION OV INYUOMYOMAL BEALTZ SERVICES ATTENTION ADAM GEl'tE • cvnrl�4T AENAL31SAL____IQ.N_ For:. Fill All information Haut ba fW y4ompleted prior to soy Trenches ..Wpacdow be'ins Made. POW Coastmodoa Permit # � t G —16 C""�1 ��7arsd h' Located; a --�—� OwaeriApplicant Nea;to: e � 71tii �,�... Rloclt _.,,�,. Lot_�.L �, 9 Fot�Derly: Subdivis Name: ►' ►, rrj ri ' SubAtvisica Lot is cyst= au campleted? Date; Is sysuW compiote? Date. _.-- 0,_ I —01 _ .�d !3 eys:em con vated,a; per pleas? '6 f. / Is weu c!:11dd7 Is we:; loL,zted as par plans? u An erosion control pssa=*$ in phce? I cart�,y ti:.± the sypm(s), as list as the above primlues hes boon coosc.wcd &nd I have inspected sad their completion in aecordoce with tha issued PCHD Coostruetioa Permit sad approv.-a piaos and tha Standards, Rules sad RCSWI O' of the'Putnam County L?epairtmant of Health. , r h . Certified by: ' Addler5; Gn M ! 5-0 _ t+Om�tll�: PE A RA Profcssioc$l L,ic. # i� I - Form FIR -99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SE. E TREATMENT SYSTEM 0 PERMIT # Located at i v Town or V' ge ",qiew fy Subdivision name Subd. Lot # _ Tax Map Z3: Block �_ Lot V Date Subdivision Approved 9(� Renewal Revision Owner /Applicant Name Td J +� a. � � Date of Previous Approval kqjoc Mailing Address i hE[ c4 & i1! z;(j J) P i v e- � v-„ ke j . hk I , Zip -/ 0 fi 17 Amount of Fee Enclosed / S f1 Building Type &Je�tq. I Lot Area /, .7-3 No. of Bedrooms Design Flow GPD 1 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WIZEN FILL IS COMPLETED Separate Sewerage System to consist of 1 zS- 7 gallon septic tank and Other Requirements: To be constructed by Address Water Supply: Public Supply From Address or: Private Supply Drilled by l ►� �.� 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 R.A. Date `j -,�� -01 License # S ce 121 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh c Sider necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe 1 • A prov or discharge of domestic sanitary sewage only. By: Title: P-L— Date: o /2_ o White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 *V A v 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 September 24, 2001 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Individual SSTS Revision Cornwall Ridge Estates Lot #41, Gambi Somerset Drive Patterson, NY T.M. #23. -1 -51 Permit # P 10 -10 Dear Robert: It has been determined that the residence under construction at the above noted location has the potential for five (5) bedrooms. Accordingly, we are enclosing the following for a revised Construction Permit. 1. Five (5) prints of Drawing SS -41, "Proposed SSTS," revised 8- 28 -01. 2. "Short EAF," dated 9- 17 -01. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 9- 24 -01. 5. "Design Data Sheet." 6. "Letter of Authorization." 7. Two (2) copies of Residence Floor Plan(s), for Bedroom Count Only. 8. Review Fee in the amount of $150.00 We would appreciate your review, approval and issuance of the revised Construction Permit at your earliest convenience. Very truly yours, Harry W. ' hols Jr., P.E. HWN: JM: his 00- 006.00 P U _k1tiAI�2 COUNT X DEPA.RTiNIEi:�T O HEALTH DI -MION OF ENS ONI MI .ENT.A.L, HEA.IJ-' H SERVICES LETTER OF AUTHORIZATION Located at _- S�red5 ��1 Drt vC- T/ ash o+-. %�• Tax Map r �� Subdivision of wCi I/ Block Lot Subdivision Lot '¢ Filed Map ('47A. Dace Filed Gentlemen: This letter is to authorize P f C/ d a duly licensed Professional Engineer V &,,--o c Registered Architect to apply for the required wastewater treatment and/or `eater supply permit(s) to serve the above -noted pcoper►y in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and'to sign all necessary papers on my behalf in connection Nvith this mater and to supervise the construction of said wastewater treatment and/or water supply systems in conformity Nvith the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersio ed P. E., R. A., _ Mailin; Addcess State /r/ zip 10S—c? Telephone: a.-ib – Ce_ 108 - Very truly routs, Sided- Mailing'Address: 1 i y I � r� v D_C__ State %� % Zip Telephone: 2�2_f1 --Lja — Fo^ LA.9 14.16.4 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR- ] 2. PROJECT NAME. �- a 3. PROJECT LOCATION: Municipality QfiY$ dH County 4. PRECISE LOCATION (Street address and road. Intersections, prominent landmarks, etc., or provide map) I � 5. IS PROPOSED ACTION: aw ❑ Expansion ❑ Modiflcatlon /alteration 6. DESCRIBE PROJECT BRIEFLY: G 2. 7. AMOUNT OF LAND AFFECTED: 3 Initially 11 2-2 acres Ultimately 1 2 3 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 'IIYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? { ( Resldentlal ❑ 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)? M Yes ❑ No If yes, list agency(s) and permit/approvals {J c HD i r- n 101 0 r 1'; J W rdr 1 811 /0 r� ✓lv9 rwr C.- w 1. 11. DOES ANY ASIDE CZ OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes o If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes Z3<0 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE `t Date: l 7 �o ApplicanUsponsor name: Signature: . Y 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 PART II— ENVIRONMENTAL ASSEENT (To be completed by Agency) Y A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? 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, 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 Cl-C.5? 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 It 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. If question D of Part II 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 fi Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer ,. Signature of Responsible Officer in Lead Agency Signature of Preparer (Ii ifferent:,t m responsib e� officer) Date 'S° PUTNAM Cr"�UNTY DEPARTMENT OF�IEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Jolh J 2. Name of project: ira go s 4. Design Professional: 6. Drainage Basin: 30A 7. Tyne of Project: I/ Private/Residential Apartments Office Building SS TS 3. Location TX: A #',O-so', / 4 va• Address: Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted L,- 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... ZVO 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency AZ /A 12. 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? ........ ............................... //a 14. Has preliminary approval been granted by such authorities? Date granted: 4N ,4 15. Type of Sewage Treatment System Discharge ................. surface water 1/ groundwater 16. If surface water discharge, what is the stream class designation? .................... /)/,A 17. Waters index number (surface) ........................................... ............................... N 18. Is project located near a public water supply system? ....... ............................... a 19. If yes, name of water supply 4 Distance to water supply — 20. Is project site near a public sewage collection or treatment system? ................ Cr 21. Name of sewage system LA- Distance to sewage system 22. Date test holes observed ?--10 -00 23. Name of Health Inspector C"" A-�") 24. Project design flow (gallons per day) ................................. ............................... - I A0 00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... /v O 26. Has SPDES Application been submitted to local DEC office? ......................... Iq I. orm PC -97 8/99 q 2 27. Is any portion of this project located within a designated Town or State wetland? ./V4 28. Wetlands ID Number ........................................................... ...................:........... 29. Is Wetlands Permit required? .............................................. ............................... o Has application been made to Town or Local DEC .office? ............................... IV IA 30. Does project require a DEC Stream Di sturbance'Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, �p landfilling, sludge application or industrial activity? ............................ Yes/No /4 .0 32. Is project.located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any , 1� other potentially known source of contamination? ............................... YeslNo DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... CJ( 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? ly 36. Tax Map ID Number .......................... ............................... Map 23 Block % Lot 37. Approved plans are to be returned to ..... Applicant 1/ 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 DER 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 Lgw. „ _ SIGNATURES & OFFICIAL TITLES: M Mailing Address: ................................... �C fY \V �. PUTNAM C( JNTY DEPARTMENY -OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES t DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ;lc��a [t -a,w, 1 Address I Located at (Street) s�o ors ire „� Tax Map 2-3 Block % Lot 5 (indicate nearest cross street) Municipality_ P'1 �6'Lj Drainace Basin o Urad L SOIL PERCOLATION TEST DATA Date of Pre - soaking 2_-"1- d 0 Date of Percolation Test Hole No. Run No. Time Start - Stop Vag Time 1in.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 4 2_02, 2-2 y 3 /Z 3, 3 2 10;s'4 _ ti! 0-t 10 2- z /4s /eI 3 I), off- i i : i S 16 Z�,'' �.�it � d� '3.3 4 5 2 1t}:0 — t0"t7 30 � �, Zit 4 5 1 2 3 4 5 _J .l NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obMined -<< percolation test hold. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to b-: submitted for review. 2. Depth measurements to be made from top of hole. Fo„n DD -91 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 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 DESCRItfION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. 1 HOLE NO. '2 HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is obsen•ed 3 �-0 -1 Indicate level to which . water level rises after being encountered Deep hole observations made by: Uesign rrotessional Name: rr� LU., hl,C.Ltiv is Address: qg-4 m', Signature: Design Professional's Seal Date 2.40 -0'6 A KITCHEN la,-e* x 13--o- 234 Sr GARAGE 23' 5'31X Sr T A OC-"-U— 91 BUILDCQ 1 V " 3,0• C.<P 801. SIDES DINING ROOM 15'-4• X 13:-C* 199 Sr Ll B-1 19 Sr - — 12-1 112— NOOK 12--2- � FAMILY ROOM 157 Sr 18'-6• x 13• -0• 240 Sr WING ROOM 16' -6• x 13-0' 240 Sr CPT C)PT T COUNTY DEPARTMENT F 111EA141kE IL IN(GS FIRST FL00R 23• -:" 15-4 3/9* 1 1 . . - I 16'-6• a4'- t-9EeR - eC75! ef)tfNT Ofity, + 248 3/4, 74• 1 11204,� D r.: r" -, c il s ALL PLANS T"HESE HOUSE A T P. A P. �L- i .Eb TO PC13 D) PPROVAL §'1�GN,VFLJRE -&,-T-ITLE DATE A� AN:) FtCVATV)-4S CIF kt! C)fj Sr,,k U':o I Lj 301,VS VVT W21 [MCX'�f:f A' I Uill io Pn w r, i oji coo,-AX P-k.3�E ►4vTsrLc-x'. P4 x y-II( 4' ,, r,,[. SE PLANS A.� LIEVATIW, N PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERM GE TREATMENT SYSTEM C° PERMIT # /` 0 Located at Ar1 ve, Town or Village A 4-.r 0+, Subdivision name CG r wa I e Subd. Lot # Date Subdivision Approved S' - ZS'`- tlCF Owner /Applicant Name Mailing Address e-r- Amount of Fee Enclosed '-700 Tax Map z3 ,, Block / Lot s l Renewal Revision Date of Previous Approval Y Zip 0S`I " Building Type Lot Area ),23 Ac-No. of Bedrooms Design Flow GPD BUG Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12-q-0 gallon septic tank and Other Requirements: To be constructed by ) 13 0 Address Water Supply: Public Supply From Address or: _� Private Supply Drilled by 13 b Address ltd .torf T)- 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 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 R.A. Date 3 --�210 .-0 O License # S� 12-f 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p it Appr d for discharge of domestic sanitary sewalze only. By: Title V `` Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # - 0�3 Well Location: Street Address: Tow ge Tax Grid # Sa W- terse- f I v e— A ft-��04, Map 2-3, Block i Lot(s) � 1 Well Owner: Name�:- ] Address: • / /�% Use of Well: /Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought ,r- gpm # People Served fo Est. of Daily Usage go D gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _k/ New Supply (new dwelling) Deepen Existing Well Detailed Reason z t for Drilling Well Type _� Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realy subdivision? ...................................... ............................... Yes !i- No Name of subdivision Lot No. T Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No d/ Name of Public Water Supply: W4 1 Town/Village --_. Distance to property from nearest water main: 41-A Proposed well location & sources of contamination to be provided on separate s eet/plan. Date: ; -2-U - 40 Applicant Signature: M PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not io degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed bAwaell rille r certified by Putnam County. Date of Issue T [ d Permitui ic Date of Expiratio 0 Title: L f / Permit is Non -Trans rrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 .'I '.Y '� ••J: r. -`tt :•: J :i . : : 11 1 :: .\ I YI ti IJ: ........ :: �i :.•::�'.A'�•r :. . BATH` BEDROOM 4 12'•0" DRESSING, BEDROOM,. WALK' 13' -0" x 10'•0' } — IN ` CLOSET Fl I � t 1 � k ! J•' — -- 1r - - r MASTER BEDROOM BEDROOM 2 = OPEN N 17' -0+c 16'•8' 1 HOB zum APr- D FOR RLDR00,1'al G+Dm p 9 l pCT TT Y�L rh 'j LL 1711: lil T7 taL'JL' 1a,1�,0�UJ��P•••'� SECOND F L 0.0 R PLAT S T iiE " ail' " t' 'iii 1' �E ,92S I GR 4ASI� . jA t GIG ' ATURE & TITLE, DATIt KITCHEN N DINING ROOM MORNING A0,0164 r 13' 0' w 12'•0' L. -t IN —L: OPEN i ABOVE LIVING ROOM i v' FAMILY ROOM 17.•x.. r 1•. 0.. 13' 0" 17' 0•• FOYEM �. • l FIRST FLOOR . � - 4828 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAL'T'H SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATIMENT SYSTEM Owner 144, 70L Address 1 14, Ca-r-,-al , Kq 9 Located at (Street) S G +�, �,. _� 7 �;.� v e_ Tax Map 23, Block j_ Lot (indicate nearest cross street) J Municipality' 1pw r5oti Drainage Basin East- 13ina!, 6 C, SOIL PERCOLATION TEST DATA Date of Pre - soaking 2 -Ol d0 Date of Percolation Test �L-i © -0 G Hole No. Run No. Time ..Start - Stop Eta se Time (p1i'Iin.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 10542 -WS3 1 i 2-2. 2-6' Lg 3S 1,1 4 5 2 10'17- 10.'x#7 30 �r 2LoY 2_i0 3 10 30 2.�r�� 7-�Yi 4 5 1 2 I 3 4 5 __ ,.t,• �„�,� �r Path NOTES: 1. Tests to be repeated at same depth until approximately equal percuia:wil raLCS a« vv,u,..-, — __ percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to b? submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' . 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. .4. 2- HOLE NO. - -I TO I L- FAMW Mr �� C9 r-y Q -n � � G O ti Ch-4 cn Indicate level at which.grbundwater is encountered Indicate level at which mottling is obsen•ed -3,-0 Indicate level to which water level rises after being encountered Co —d Deep hole observations made by: C'.. JZ j Date 2, W -00 Design Professional Name: Address: --;?/, r�n,,—I, Signature: /i f- ;/ Design Professional's Seal 14.164 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 SEQR 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 /SPONSO 2. PROJECT NAME 1rCG C G S I 3. PROJECT LOCATION: -y Municipality L, county l�// 1 a 4. PRECISE LOCATION (Street address and,road Intersections, prominent landmarks, etc., or provide map) svCi(J'! sY C/L, 5. IS PROPOSED ACTION: G9 ew ❑ Expansion ❑ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: / 7. AMOUNT OF LAND AFFECTED: Initially :2-3 acres Ultimately 1 �3 acres 8. WILL 125 POSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? 911,03 ❑ No - If No, describe briefly 9. WHAT 1 .PRESENT LAND USE IN VICINITY OF PROJECT? e31dentlal ❑ 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)? PXes ❑ No It yes, list agency(a) and permlu'approvals CC ' r-V t C':, %C'O'I'' p' lG 0-P �c?i sow ACJ6 u'\ �Yiv�+, 1 j 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes o If Y03, 113t agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes 9?-No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ApplicanU3ponsor name: �` " " t" �`"� Date: —3—:20-06 Signature: If the action is in the Coastal Area, and you area 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 yea, 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) Ci. 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: C2 �G 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 resou �? Exi ia•bwy to T' C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. p rn c,`) �C3 C) 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 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. If question D of Part II 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 potentlally 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 ea Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature. o Preparer (if different from responsible officer) Date 2 Harry W. Nichols Jr., P.E. 311 Clock Tower Commons . Route 22 Brewster, NY 10509 Telephone (914) 279 -4003 Fax (914) 279 -4567 March 20, 2000 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Cornwall Ridge Estates Lot #41, Gambi Somerset Drive Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -41, "Proposed SSTS," dated 3- 20 -00. 2. "Short EAF," dated 3- 20 -00. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 3- 20 -00. 5. "Application to construct a Water Well," dated 3- 20 -00. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Two (2) copies of Residence Floor Plan(s), for Bedroom Count Only. 9. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nichols Jr., P.E. 60-00(,.00 .0® PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at 15 a L_" r, e 5-.m D -I v -e— Tpt Tax Map # L-3• Block / Lot 11 Subdivision of Ca V w�l (' ► )q e '/tz'r let, k Subdivision Lot # -" i Gentlemen: Filed Map # 2-1 I.7 A Date Filed This letter is to authorize r IV, _Ntclkoly I& a duly licensed Professional Enginee° r,- 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 s of Article 145 and/or 147 of the Education Law, the Public Health Law, and the P @o utt; r��itary Code. dRJ `ti . S lJVU11LGlJ1�11GU.�,1'w; 0.A P.E., R.A., Mailing Address 3 f 1 `d Very truly yours, Signed: 14.,d (Owner of Prop ) r 4OVs``a�', z,- Mailing Address: ecG -Vs re- wll e,,- State Zip 16 M! State Zip to 5-1 2 Telephone: Telephone: Form LA -97 BRUCE R. FOLEY Public Health Director LORETTA- MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 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 March 31, 2000 Harry W. Nichols, P.E. 311 Clocktower Commons Brewster NY 10509 Re: Proposed SSTS: Gambi Somerset Drive, Lot 441 (T) Patterson, TM# 23 -1 -51 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) Correct filed map number is to be provided. 2) Revise note #4 to 200 feet from 20 feet. 3) No cuts are to.be within 10 feet of a trench, maximum slope of cut is 3:1. 4) Mottling is noted at 3 feet, therefore, the minimum of 3 feet of fill is required. 5) Minimum distance from the solid curtain drain discharge line to the SSTS is 10 feet. This should be clearly dimensioned on the plan. 6) Test pit description on plan is to note any mottling. 7) Minimum slope of house sewer is to be noted. 8) _ G4; lis to note °dust feet,- washed crushed stone or washed gravel. 9) n standpipe d etail is to be shown `° Upon receipt of a submission, revised to reflect the above comments, this application will-be consider further. RM:tn V ly yo s, Robert Morris, P.E. Senior Public Health Engineer BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI. RN.; 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 Harry W. Nichols, P.E. 311 Clocktower Commons Brewster NY 10509 RE: Gambi Somerset Drive, Lot #41 (T) Patterson, TM# 23 -1 -51 Reservoir Basin Dear Mr. Nichols: March 31, 2000 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 22, 2000 is complete. The Department will notify you by April 20, 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 certified mail, return receipt requested. The notice should 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 NYC Dept. 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 Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation o.- --v Letter to: Harry W. Nichols, P.E. - March 31, 2000 .2 of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2166. Ve ly your Robert Morris, PE RM:tn Senior Public Health Engineer 44 G w/ 14 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C7A/+j F31 Address Som 00!5, -7— X 7R, Located at (Street) T» V©,6/ 7z OA D Tax Map ;L3 Block _� Lot 15l (indicate nearest cross street) Municipality -F>1?T7 6g5c;e,/ Watershed 15,45 T 73 ,$ SOIL PERCOLATION TEST DATA Date of Pre - soaking Z2 /a a Date of Percolation Test ' az/ 6Z9 O percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 24 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. a. HOLE NO. Indicate level at which groundwater is encountered ( /— O " Indicate level at which mottling is observed 39_010 Indicate level to which water level rises after being encountered O '' Deep hole observations made by: Ki�6 p / H� N,� No�S Date o0 P : G� V. /—/. Lcaurert �rry Design Professional Name: Address: Signature: Design Professional's Seal RECORD OF PHONE CONVERSATION DATE: / / 2 % ®O TIME: PERSON CALLING: PHONE #: REASON ( ) Inspection: N & and /o eres: SCHEDULED FIELD MEETING �fc - Sank DATE: CD TIME: tl rrc-s -* p,CrS miler /"";7 ROAD /STREET: Al 45- R S L: T P 7? Al— 4/ TOWN: PA �" T TAX MAP #: SUBDIVISION: LOT #: YZ 1 COMMENTS: Denton Lake 29 (Solomon Lake 12531 G) 0 84 est �l 164 t. In Ail. ESjj s 31 1 64 6-4 12563 22 Ala, c c f ;Mendel Pond 164 65- aines g v9 311 Corners 62 Come -, (f;p in - 1141 n". 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CALI 42.0 AC. �AL a r I Ar- CAL ,• 6' 3 % � 1 NI- s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: 6����'(, STREET LOCATION: ��1}7�IZPP/�f,� bkl-[ REVIEWED BY: .6�R, AS, SRDATE: 313-d/0-0---TAX MAP #: (CONFIRMED) YVN DOCUMENTS ✓ PERMIT APPLICATION (WELL PERMIT OR PWS LETTER UUPC -97 (_))LETTER OF AUTHORIZATION (j/ C)DESIGN DATA SHEET (DDS) AP 'I (C�7 CORPORATE RESOLUTION �� SHORT EAF C_)PLANS -THREE SETS C !.'�)(_JHOUSE PLANS - TWO SETS C__)C_)VARIANCE REQUEST Y ' (REQUIRED DETAILS ON PLANS CONT'D) HOUSE SEWER - %" FT. 4 "0'; TYPE PIPE CAST IRON (_)NO BENDS; MAX BENDS 450 W /CLEANOUT RENEWALS C_)STTE NOTE (NO CHANGE) Z FILL SYSTEMS �j 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE �) FILL SPECS/ FILL NOTES 1 -5 C-) FILL PROFILE & DIMENSIONS (___)C-)FILL IN EXPANSION AREA SUBDIVISION j�)LEGAL SUBDIVISION (_)(__)SUBDIVISION APPROVAL C C (_)(_)PERC RATE �j L�C_)FILL REQUIRED DEP / Z CURTAIN DRAIN REQUIRED GEAR L LOCATED IN NYC WATERSHED CZ PLANS SUBMITTED TO DEP DELEGATED TO PCHD UUDEP APPROVAL, IF REQ'D ( ) DEEP TEST HOLES OBSERVED ( C, ) PERCS TO BE WITNESSED - APPROVAL SSDS ADJ, LOTS ;TLANDS (TOWN/DEC PERMIT REQ'D ?) TA ON DDS PLANS & PERMIT SAME E 1969 NEIGHBOR NOTIFICATION )LETTER BI/ZBA )100 YR. FLOOD ELEVATION W/I 200' )SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS )SEWAGE SYSTEM PLAN - (NORTH ARROW) )SSDS HYDRAULIC PROFILE )GRAVITY FLOW )CONSTRUCTION NOTES 1 -15 )DESIGN DATA: PERC & DEEP RESULTS )2' CONTOURS EXISTING & PROPOSED )DRIVEWAY & SLOPES, CUT )FOOTING /GUTTER/CURTAIN DRAINS )USDA SOIL TYPE BOUNDARIES )TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# )DATE OF DRAWING/REVISION DATUM REFERENCE )LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. FINISH FLOOR AND BASEMENT ELEVATIONS �) WELLS & SSDS'S WAIN 200' OF SSTS (_)PROPERTY METES & BOUNDS COMMENTS: (REVSHEET) FILL GREATER THAN 2 FEET �) d�AY BARRIER FILL CERTIFICATION NOTE L� DEPTH GAUGES VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS (_)C�SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH LF TRENCH PROVIDED 60FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ( DETAILMUST FREE CRUSHED STONE OR WASHED GRAVEL (_JGEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS �10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD, 150' TO PITS rl,60'INTERMITTENT 100' TO STREAM, WATERCOURSE, LAKE (inc. espan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits - 20') DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS 10' MIN TO LEDGE OUTCROP SEPTIC TANK T(--)IO'FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION (MIN 15' TO PROPERTY LINE f/ SLOPE � JSLOPE IN SSTS AREA (520 %) (_)(_)REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS )PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PTT AND D -BOX SHOWN & DETAILED DAY STORAGE ABOVE ALARM Y Z CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL �U�15to CDS = >5 %, 20'-4 %, 25' -3 %, 35' -1 %,100 % - <1% 'MIN 20' MIN to CD DISCHARGE /100' with 182 cons day discharge (_)(_)10' MIN to NON - PERFORATED PIPE 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: ,lug, T 4, / , r 2. Name of project: S t S 3. Location T e 4. Design Professional: ,,f, 13 5. 'Address: ?)I 6. Drainage Basin: as Src4,,L� 7. Type of Project: c.,-Private/Residential Food Service Commercial Apartments Institutional Office Building Realty Subdivision Mobile Home Park 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? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Exempt Unlisted t/ /y_ 12. 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? ........ ............................... No 14. Has preliminary approval been granted by such authorities ?,g% Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... k4 18. Is project located near a public water supply system? ....... ............................... _ Ah 19. If yes, name of water supply a ��-- Distance to water supply 20. Is project site near a public sewage collectiio/n or treatment system? ................ NO 21. Name of sewage system /v Distance to sewage system 22. Date test holes observed 2- -10 -Do 23. Name of Health Inspector o. I <-ci 24. Project design flow (gallons per day) ................................. ............................... goo 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? ......................... V /_1 form PC -97 8/99 01 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number .............................. ............................... �J 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? ................... :............. A 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 /% 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 , C/ DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... AAff 35. Are any sewage treatment areas in excess of 15% slope? . ......:........................ 1V� 36. Tax Map ID Number .......................... ............................... Map 2.3, Block ( Lot GJ 37. Approved plans are to be returned to ..... Applicant __Design Professional NOTE:.All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application.is signed by a person other than the applicant shown in Item l.,the application must. be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. 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 PenalL4w. SIGNATURES & ®FFICM6 jf ' � E ;:U I r, �,! ryry A `! I i I.d. 'T� 4' , A 1 C J i' �! 1�dn;U� Mailing Address: ....................... wvNi lc � (�0 "48 0 \Ni \ \\ N MOPE TAX M,, sal. i 4 SEOf, l N SOIL R. `\ � ABSOR. Pi701/ O TM pow ' J i 41 ,' jG SY1'� ,k2L . P�yj j- /1y1 5� 1YJ i X S. F O � aav /X PROJEL TO�NN OVEN7 PA7r =_ ti:� o o Million- Date 41 Peevlow Togne patg Subdivision S'_. Fee= - Enclosed j, 1i61 Y, C'i im Ames Pm $OCI)00 Vab Dej t6 sma Nt�ber. a[aDeioas .. _ Des k*,Flow G " P D _ (e Q"!S PCHD Is Repa red wbafi Ply b oaespktesl `. Sa�eaNe Siwoe�e SyM� 1006 Galm � S L o V� ✓� d ewalat 1, f s.pue T..t taaa T� be eNaQ�aled by �% C� D Addreer Wadrr Sss ¢: n a.e.. Ihe� Addreaa eel S*O.1eMd by OIYr 1 representt"! 1, am wholly one eon►pNtily rtfpoMibN forth* dasilln and location of the, proposed systerrim 1) that the - separate aw ' `ell or: slam avow described will!" constructed as horn on the app► amairdment there to and in accordance with the standards, rules a rpu nee ham Comity. Depart"Mit of "It ►. !k that on "eolllplet" theroof a:. "e"ficate. of Construction Compliance' satisfactory to the Colllmissioner of.Healthwill be subs tad to the t)epertinant _and. it. written, guarantee wi11, -0a furnished the owner. his sucpaois.:MNsbt assigns by the builder, thet. said builder will place N pod, opsntaq osnditlon,.any part, of` said "swap disposal. systim during the peria0 of two (2) yews Immediately folbwina'thidati of t6o isau- illlte of, the approi!al of the Certificate W �COhstrudkM_ ComplNr±ei of tM ortyitiel system or any repairs thareto.,Z/ that the drilled welt A 66lbed a6me will. loeaied.as shawrt ori,tM �pprewd plan enel that tiIII f_p will,tio instal_` in scoordan6s .with the. `go S; rulms'an* rpu , onf of the ' putMm County Dep"= of NealEh i P. A.A. _ Date , i<—� — D 1. S Adaoss License .. No, SGT f z.4 APPROVED FOR CONSTRUCTION:. This approwl axpiristwo years_ hem tM date issuo0 ur less const►uctiom of tM buildirq has been undertaken "and Is revocable for caves or may do `amarlslid or moelifkl0 wheel considiied;neeeaory by :the Commissioner of- Health. Any change of alteration of, construction ""Ulf" a per it. :Approved for disposal 'of domedlC y siwige, a prtvate,'water supply only. vO. a�. y' e 'a v AP l0/ °8 -T 1Y �khJY. .. Title a Patnan..._ounty Department of Health Division of Environmental Sanitation. Notary' Pul;lic BONNIE J. OAVIS kouq ouMic. gulf d Nrw yoft oukhm cw* W Commission Qspins AO 03,1q.71 - q7 . Corparate Seal N=: 1. Tests to be repeate6 at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to* be suhmittbd for review. 2. Depth measurements to be made •fran top of hole. 3 .. 0:221 lo;S 3�e 2Z • �S 3 ` Z . 9 .. 5 _ 4z 3 - lo; r s- . 32- - 22 3. ro ��— S 21 Z2. 2.5 3 ... 10 s .. J O 2 3 a . f. N=: 1. Tests to be repeate6 at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to* be suhmittbd for review. 2. Depth measurements to be made •fran top of hole. 131 14 .. INDICATE LEVEL AT WHICH GROUNDWATER IS ENQOUN�EtFD - INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING �7170UNTERID DEEP HOLE OBSERVATIONS MADE j BY l� k �� + �l/ L Dom: S DESIGN Soil Rate Used 1Z Min,l Drop: S.D. Usable Area Provided SdJ 0 No. of Bedrooms 3 Septic Tank Capacity 1600 gals. Type C oic , ..Absorption Area Provided By 3`7S L.P. x 24" width trench Other pF NEVI y`0. Name L vv Signature? • :h�i d��'r'v i Address 3 ... �� ► 'i`� ��1 � 2_ SEAL.J_,�. ff No. 66124 opROFESS%Z' Y THIS SPACE FOR USE BY HEALTH DEPAMEM ONLY: Soil Rate Approved sq.ftlgal. Checked by Date TAT PIT DATA 'RDOnTitID ,: TO .; APPLICATION DESCRIPTION •:OR: SOILS iEN00Mn M ':MTEST;.HOLES DEP1 i HOLE NO. H LE NO. + �` � 1. �; N t �.;C 'C,e L ? s�� .+�Y�1:: L .L a A } i �,1.�� S •18W+ 4'� !r �{..:_ � G.L. T�psoiv ti � s a _ hN t S 4f :..i 2• v' r( l.(..r;'..'^ 7 j �` <� ".- ii•,�h•.h.. . i a 12 . 131 14 .. INDICATE LEVEL AT WHICH GROUNDWATER IS ENQOUN�EtFD - INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING �7170UNTERID DEEP HOLE OBSERVATIONS MADE j BY l� k �� + �l/ L Dom: S DESIGN Soil Rate Used 1Z Min,l Drop: S.D. Usable Area Provided SdJ 0 No. of Bedrooms 3 Septic Tank Capacity 1600 gals. Type C oic , ..Absorption Area Provided By 3`7S L.P. x 24" width trench Other pF NEVI y`0. Name L vv Signature? • :h�i d��'r'v i Address 3 ... �� ► 'i`� ��1 � 2_ SEAL.J_,�. ff No. 66124 opROFESS%Z' Y THIS SPACE FOR USE BY HEALTH DEPAMEM ONLY: Soil Rate Approved sq.ftlgal. Checked by Date 4 s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES. Date• Re: Property of: (',d QA)U�J4'LL T�Q%EL��/i1 �i�P� Located at t*',Oje/ )L )41L� (T)_ IATmese Section Block Lot OZ. Subdivision. of 019dGt 4t_ 6-6 Subdv. Lot #.._ Y Filed Map # o�J !'7 k Date jp�r`aA,57-j Gentlemen This letter is to authorize /l)/C 40L,6- a duly licensed profess i onal—engineer or registered architect (Indicate - to apply for a Construction Permit for a separate sewage-system, to... serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health,. and to sign all necessary papers on my. behalf iu connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code �l Count P.E., Address ATTUfS-00. Nx /a � r9 /4f��f�'- (oio Telephone Very truly yours, Signed O AVENUE Address NEW ROCHELLE Town (914) 654 -2611 Telephone n LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 RANDOLPH W. LAURENT, PE. (914) 278-6108-(FAX) 278.2658 HARRY W.NICHOLS, JR., PE. CONSULTING SITE ENGINEERS December 27, 1989 Putnam County Department of Health 110 Old Route Six Center Carmel, NY 10512 Att: John Karell, Jr., P.E. RE: Cornwall Ridge - Lot #41 Somerset Drive Patterson, NY Dear John: 1. Four (4) prints of Drawing SS -41, "Proposed SSDS ", Lot #41, dated 12- 26 -89. 2. "Construction Permit for Sewage Disposal System ", dated 12- 27 -89. 1 3. "Design Data Sheet ". 4. "Letter of Authorization ", dated 8 -4 -89. 5. Two copies (2) of Residence Floor Plan(s), for "Bedroom Count Only ". 6. "Application to.Construct a Water Well ". 7. "Application - Corporate Owner Application ", dated 8 -4 -89. 8. $150.00 Money Order for review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly, yours, LAUR NT �`E'NGI�NEERING ASSOCIATES, P.C. Harry W. kdichols, Jr., P.E. 89067/map cc: Mr. J. Shapses w/ encl. APPENDIX 3 fumI c--m cawrm- OF E;-r'.r TH: - Dr7T-S!C-N OF EN-V ==N.Mam-L SEAL S- W--Af—r-i SUPPLL & SiBSURFAC-2. SE-1-Fil =-- DISPIMAL Rp N P V=- MM RE" of Cwner) rc=. i- ca No I Dcq:-A—rNqr-q Ps t A--Z)l i Ca t.;-cn ccnr�:Craatz Re-solut-C.11 Plans - 7:ree sa,=* sis l00% D cr J =rv; PI--mo c 77777777t7 s 7 we D�+ 41 _4 s c 1= cvar lc-�I ati N10tas SZ-L ,4- 1 DEZ -777777��. ic�: t Contcux-m ExistLric I I jF^OL :LAC 1 _� � C —1-ta Dra (dis ax-g= CM, Per=' & Deeo Holes -r,-=- T Reprasentatir.7—e of or' Lizary and e��slc,'I cllavh-E-=- ler raVi tv f: Lawsuff. s-*=e -cr, Ap=rra . . . . . Pi & D Bcx sac.-Li f i -1 11 n &L. .. . . .... A na; S=ec Wells & $ "s -S-t 's Win 2000 Lt. L. CL n--- ---c s --Z (T& A T R D Prc:certy -Metas & Ec-:a Se k Necassazy (T i e, i lc t) Dc Ca LC- Plar.- & ps= EMISS6 Sewer - 1/4"/ft. A"O; T a oi- L'O v--. fIccd e-Ler. 457 w/(:Iea=ut+ D'EIT-L =-I --c CN SEPAREMCCIN D M 1 -21 z NCE 5 S C rz=. c"I Fie-Ids C= Svstan� P lan. P.L. Drivewc%jj Top or z ,A VG ia VS! :a7!1 7- 10'0!x' t:6 1 200!., im D r 0 D--'-' _ =7 F Prof l00% D cr J =rv; PI--mo s 7 we D�+ 41 _4 s c 1= cvar lc-�I ati N10tas SZ-L ,4- 1 DEZ ic�: t Contcux-m ExistLric I I jF^OL :LAC 1 _� � C —1-ta Dra (dis ax-g= CM, Per=' & Deeo Holes -r,-=- Reprasentatir.7—e of or' Lizary and e��slc,'I cllavh-E-=- ler raVi tv f: Lawsuff. s-*=e 10 Pi & D Bcx sac.-Li f i -1 11 n &L. Hcu-Sa - 1,110. of na; S=ec Wells & $ "s -S-t 's Win 2000 Lt. L. CL n--- ---c s --Z dez-L-i CaUces Prc:certy -Metas & Ec-:a Se k Necassazy (T i e, i lc t) EMISS6 Sewer - 1/4"/ft. A"O; T a oi- L'O v--. fIccd e-Ler. 457 w/(:Iea=ut+ SEPAREMCCIN D M 1 -21 z NCE 5 S C rz=. c"I Fie-Ids P.L. Drivewc%jj Top or z 20." t6 ccr1d- =ticn 0: res-ex-mi--i:.. et=. L 10'0!x' t:6 1 200!., im D r 0 D--'-' . c 150. f t ri-gall, / Cal Ljj*� L -�:.td D�a ri -CS Lead S 101: to Wa":m- LLie (-i t --201 IC 1% 1 101 5 to ueil J;Z I 'jell pr 9 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER9 CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL C *`J/ PCHD PERMIT .# WELL . LOCATION Street Address . own Tax Grid Number WELL OWNER Name r .�,� a Maili g AddresJ� /) 0" N�r �+u CeGl, rivate Public USE OF WELL 1 - primary 2 - secondary SIDENTIAL ® BUSINESS 13 INDUSTRIAL OPUBLIC SUPPLY O FARM U INSTITUTIONAL ❑AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY ®ABANDONED 0 OTHER (specify El AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST . OF DAILY USAGE � % tDg al O REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY d-NEW SUPPLY NEW DWE LING ) ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG []GRAVEL 0 OTHER 'S IS WELL SITE SUBJECT TO FLOODING? YES _�NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME.OF SUBDIVISION: CGY Lot No. WATER WELL CONTRACTOR: Name % y Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: A/ �/� TOWN /VIL /CITY Jl j DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED &N SEPARATE SHEET %w (date) ( gnature) .:i PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted ini er the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and; provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1.. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. .j 3. Submit a Well Completion Report on a form provided by the Putnam County Health De artment. Date of Issue: _19A 0 Date of Expiration: Permit Is-suing official 4fti Permit is Non - Transferrable t.e copy: H.D. File Yellow copy: Building Inspector Rev. 10/88 Pink Copy: Owner Orange oopy: Well Driller II ( A i i Ii 5� i i • i� / all G / MIN. � -may F -'' ,�•,• � �� K / / / 1 p � ;o `\ VIP / % 4 5� i i • i� / all G / MIN. � -may F -'' ,�•,• � �� K / / / 1 p � ;o `\ VIP /