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HomeMy WebLinkAbout0625DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -52 BOX 7 00625 l.� 00625 � PUTNAM COUNTY DEPARTMENT OF HEALTH \� DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE TREATMENT SYSTEM PCHD ONSTRUCTION PERMIT # P- 3 - q °1 lb �y L1,50 Locate at t�,�L�� f -��t.- _ -00 A7 Town or i age Owner /Applicant Name E3 e)( AM H YA -ff - Tax Map z3 Block ' Z. Lot t Formerly ` 64TH IWATC Subdivision Name Subd. Lot # Mailing Address !1EQ FUl L-ET J-DLE 14DAr7l) 281MR—SO"A QY- Zip 17-, Date Construction Permit Issued by PCHD 21--j t9`1 Separate Sewerage System built by B12 %A0tJ %bA --rr Address 4,5o &1Lo ,&rF L rV40 H- Consisting of Gallon Septic Tank and JA R8 L i OF 7' \A! 11;? 4Fr � QPQ Other Requirements: LLEAd- JVCAX5 ` , Qt.STeIZIATICK4 'R�r, *1205 04� CAAM B ER 'Water Supply: Public Supply From Address `x + or: is Private Supply Drilled by "&E lam, p2L(,e i,.lTr Address lolib P-C 311, PPrI't�it8cA3. Building Type 5 I Nle, 1-F TqW l L`( Has erosion control been completed? Yr--47 Number of Bedrooms 4 Has garbage grinder been installed? /\1n 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 epartment of Health. Date: 1011-1,100 Certified by P.E. 2 R.A. (Design ProfesNand�/ AddressR-+rvam FAakgLn MRi G. lo1 Am N.y, JoS 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 are subject to modification or change when, in the judgment of the Public Health Director, such revocation,,mn4ification,gl change is necessary. By: Title: �S�v Date: `� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 a UTNAM NGINEERINE PLLE. Engineers and Architects SEPTIC SUBMISSION FORM TO: Rc '�t�' i' I SS DATE: ©G i 13 a)o o PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: za yni��r2� P ZS6 j 7" 2;—Z--47 Z, ENCLOSED, PLEASE FIND: xCOPIES OF THE SSDS PLAN���� ❑ COPIES OF THE HOUSE PLANS ❑ CONSTRUCTION PERMIT APPLICATION (Revised) ❑ WELL PERMIT APPLICATION HEALTH DEPARTMENT FEE $KOO) (3 SHORT EAF ❑ DESIGN DATA FORM ❑ LETTER OF AUTHORIZATION ❑ APPLICATION FOR WASTEWATER TREATMENT (PC -97) ❑ LETTER OF EXPLANATION REMARKS: Ca nt s9W 691 cn-) ccn Pc.(r�+� c ��. - 6UWA�lf F1W5 WPI-6' Ay--" S l S COPIES TO: �i�(.� �., oil m - a 4 OLD RouTE 6, BREWSTER, NEW YORK 10509 (845) 279 -6789 • FAX (845) 279 -6769 • EMAIL: puteng @bestweb.net PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building y Buil ing Constructed by V,�- o &&l Ille RS, Location - Street Building Type �3 Z Tax Map Block Lot Town/Village Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the.date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month oy Day /y Year OD Signature: 31,ZekA 26 0� Title:. nLuner Generale ontractor wner) - Signature (50- Gle_ Cnfls.�Iucc ,C", Corporation Name (if corporation) Address: Jb Qox C79�1 Corporation Name (if corporation) Address: State di-A-i e / Y zip. ,105 ia' State Zip Form GS -97 it NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 LABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: MR. BRYAN HYATT 450 BULLET HOLE ROAD PATTERSON, N.Y. 12563 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) PHYSICALS: Color Odor CHEMISTRY: pH Turbidity Nitrite N Nitrate N Alkalinity Hardness Iron Manganese Sodium Lead AS ABOVE KITCHEN SINK WELL NONE RESULT: DATE SAMPLE COLLECTED: 4/11/200 TIME COLLECTED: 3:30 P.M. COLLECTED BY: BRYAN HYATT DATE RECEIVED @ LAB: 4/11/.2000 TESTED BY: LAB# 11471 REPORT DATE: 4/14/2000 per 100 ml 0 ND 6.82 0.15 NTUs <0.005 2.45 62.0 74.0 <0.03 <0.01 3.2 <0.001 ml = milliliter mg/L = milligrams per Liter * *Notification Level ** *Action Level MAXIMUM CONTAMINANT LEVEL 0 per 100 ml 15 3 Units no designated limit 5 NTUs mg/L as N 1 mg/L as N mg/L as N 10 mg/L as N mg/L no designated limits mg/L no designated limits mg/L 0.30 mg/L mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] mg/L 20 mg/L ** mg/L 0:015 * ** ND = none detected NTU =Units RESULTS BASED ON SAMPLES SUBMITTEDA /11/2000 SAMPLE, AS TESTED ABOVE: M or AMNOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 * OUTSIDE CT: 800 - 654 -1230 BRUCE R. FOLEY Public ffeaith Dlrectcr DEPARTMENT OF HEALTH i Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., USX. Associata Public Health Dlractor Dtrgcrar of Pattant Servicas Environmental Health (914)278-6130 Fax (914) 278 - 7921 Nursing Service (914) 273 - 6558 WIC (914) 278.6678 Fax (914) 278.6085 Early Intervention (914)2",8-6014 Prticsool (914) 278 082 Fm(914)278-6648 -11i I DMITA DI I; 1\ 11310,1711 OWNERS NAME: all? r. e-) - /`/ y�l T T TAX MAPNUNIBER: � -z E911 ADDRESS: `ig LZ 157— A /oL TOWN: 40.4 rr15-4 s o ^� AUTHORIZED TOWN OFFICIAL: (Signature) DATE: The Putnam County Department of health will not issue a Certificate of Construction .Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 V�-RX4) �ee ->P. PUTNAM COUNTY DEPARTMENT OF HEALTH 1042 , /fig A DIVISION OF ENVIRONMENTAL HEALTH SERVICES 6 Q FINAL SITE INSPECTION Date: Inspecte by: Street Location T3� //e t- � /.v )�� Owner `!fie«. +e4 \ /-4an i Town Pa 75�etl' ao.-f Permit # -P— 3 -- g TM # 9- 3 _ ,22 - 5 2 Subdivision Lot # 1. Sewage Svstem Area a. STS area located as per approved plans ......................... b. Fill section - date of placement 3:1 barrier Lath. 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. Sewage System a. 6eptic tank size - 1,000 ....... ,250 .......other ............. b. Septic tank. installed level ............. ............................... c. 10' minimum from foundation ....... ............................... d. Distribution Box . All out le at same elevation -water tested........ 2. Protected below frost ............... ............................... 3. Minimum 2 ft.Original soil between box & trench e. Junction Box - properly set ......... ............................... f. Trenches Length required 900 Length installed 9O, 2. Distance to watercourse measured,/- 2,v o Ft....... J. Installed accordin to plan ...... ............................... 4. Slot§b#4encTi pta1R>l ltu'n'5. 10 ft. fro rty line - �0 fL- dati�r ..... 6. Depth of ttr 34hcY6fHj6Mrbce4;z;)..,V . 7. Room allowed for expansion, 100 % ...................... 8. Size of gravel 3/4 - 1' /z" diameter clean ................. 9. Depth of gravel in trench 12" minimum ................ 10. Pipe end5 capped ..................... ............................... g. PUMD o05o§6d)Svstems ize mp 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/Buildin ' a. House located per approved plans .............................. b. Number of bedrooms ................... ............................... IV. Well a. Well located as per approved plans ............................ b. Distance from STS area measured 21t /D 10 ft ....... c. Casing 18" above grade ............... ............................... d. Surface drainage around well acceptable ................... V. Overall Workmanship a. Boxes properly grouted ............... ............................... b. All pipes partially backfilled ....... .............................., c. All pipes flush with inside of box .............................. d. Backfill material contains stones <4" diameter......... e. Curtain drain & standpipes installed according to pl; f. Curtain drain outfall protected & dinto exist watercc g. Footing drains discharge away from STS area.......... h. Surface water protection adequate ............................. i. Erosion control provided ............ ............................... Rev_ 6197 FROM : PUTNAM ENGINEERING PLLC PHONE NO. : 914 225 2955 Oct. 01 1999 10:01AM P1 avl FROM: PUTNAM ENGINEERING, PLLC BATE: 1 o LO j i RE: REQUEST FOR SSDS AS BUILT INSPECTION PROJECT TITLE:` IW STREET ADDIRESS: Li X27 O tt b-L.L 1" l-{D ?-oAD TOWN: PA TT- 5 F—fms TAX MAP #: PERMIT #: PLEASE NOTIFY THIS OFFICE AFTER YOUR INSPECTION AT (914) 225 -3060, IN ORDER FOR US TO NOTIFY THE CONTRACTORIOWNER THAT BACKFILLING THE SYSTEM MAY BEGIN. AnT)Tz Fs s. Street Town State Zip PERSON IN CHARGE . % r I-- �-, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES pCONSTRUCTION PE AGE TREATMENT SYSTEM PERMIT # oZ /n- Located at b UA-_t. Sj— .6 byF F-OAja Town or Village VAIrC e-5C1k1 Subdivision name Date Subdivision Approved Subd. Lot # Tax Map X23 Block ;— Lot _S Renewal Revision Owner /Applicant Name D' bMt4 \ �AyAjj— Date of Previous Approval Mailing Address 2243 bLp 12:C ZZ Zip ! DSIa? Amount of Fee Enclosed Building Type S *i►t5►e Cztw 1 Lot Area3s '7 No. of Bedrooms 4 Design Flow GPD.SQQ Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of / ZS O gallon septic tank and Ge!q L.1=7 21 W IRE A 350"T 014 TPX--&C -H Other Requirements: DyFgjjoL_T l2�.SlolG ( AM1FF-j T)ttn- riTBtcr%o 4 bcj�. To be constructed by -ro 3 F_ . E D Address Water Sunuly: Public Supply From Address or: —y Private Supply Drilled by -rb -, e�- -pE-rj,=M I r g:D 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 theret Signed: * V P. E. >C R.A. Date '/7-0 �tt,Trla�Nol c zMt�, -F Address , n:)- ��, LF t F,,CLAtt r 1,1•4! o ,,Tj --- License # 0(,:;,7 4,q Ca APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when c sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit p oved fo harge of domestic sanitary sewage only. By: Title: d�Af- 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 n please print or type PC14D Permit # A - 10, r% Well Location: Street Address: TownNillage Tax Grid # IJU- L--LF—T- b-1V44�7 P A77—C q/V Map Block ;2 Lot(s) Well Owner: Name: Addre -� a Tri o 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 Soughthd J)V 5 gpm # People Served - AmtLyEst. of Daily Usage 860 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No X Name of subdivision Lot No. Water Well Contractor: �a2��_—(' Address: Is Public Water Supply available to site? .................................. ............................... Yes No ,X Name of Public Water Supply: P/A TownNillage 1A Distance to property from nearest water main: a .r t. Th" i Proposed well location & sources of contamin s arate sh lan. Date: Applicant Signature: -- PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water Al driller certified by Putnam County. Date of Issue?,/ 3 lqf Permit Issuing Date of Expiration 'L '].va i Title: CJ Permit is is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at ii.. hak _ice e r T/V 'F4jtZC.so/q Tax Map # 23 Block Z Lot _�_ Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize P &vt-Ai A m P_ cg:) , A4G F4_L -d_ . a duly licensed Professional Engineer ><,— 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 treatment and/or water supply systems inconformity with the provisions of " _. • le 1.45 and/or 147 of the Education Law, the Public Health Law, and the Putnam County,S 6ffd , -o Countersigned: P.E., R.A., # Very truly yours, Signed: (Own f Propem ) Mailing Address t� IF_4 �>A &tF Mailing Address: =,9 01d. State /q, V. Zip / o S 1 z Telephone:rc?l 4l 2ZS —3 ©(,o 1} 14So 1 State A 1. Zip las "6 3 Telephone: 0j `0 278 - 7A2,r Form LA -97 40'0" BREAKFAST BATH 3 FAMILY ROOM 9'6!,'2'-'X 12 i i 12.10' X 17`11' KITCHEN - tO'2" X 12'11" t• 16'9" .... _ ..... LIVING ROOM }^ OiNING ROOM 14'10" X 12`11' 12'3" X 12`•1" FOYER tog" X .?"I - PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR B7,FIMOMS OM COUNT ONLY; _ Sienature & Title Date l''�? 40'0" is BATM 1 I BATH 2 ? FIR% DR00M 3 8b" X 11'31,1" X 97" " X 10`7' 97' j \\ ` -i j BEDROOM 1 7EDR00M 2 12'9:'X 16'6' I OPEN TO FOYER 9agr!� �w4 n�G N� Bee -)Pf r" "-4 0 Fn Q . I PUTNAf4 C7"::-,: E PLANS APPPOV;.) iJ7 '' # °° )Ott COUNT ONLY; Sig..... � ..;—'--�- -••mot, RFVAMNS OF ALL OEM MO LM HMO - AFE CWWMM WE WLL RFORCE ALL COPYFWfM TO PROTECT OUR CONSMIABLE INESUIENT H OEVELOPNO flf3E RAN AND B.EYATUa 1R HOME9 RE9L3iVE8 THE RMW TO MAKE KIMR CHANGES DI OWED IONS AS REOU FUM SV MODULAR COMSTMCTLON WMOD:1 TADDRESS. SITE LI]C.: -�- ISM ®� P6/aq z cl n SHEET p A -3a I pWN. BY: PV rn PROJ. ID a: C666 APP. BY: 06/07/96 MY SER IAL a_ - - -- ! PATE: rns •�� PLANS AND ARCHITECT'S STAMP VALID ONLY TOR NODULAR CONSTRUCTION BY CHELSEA MODULAR HONES.'INC. MANUFACTLOO i I FORMATMN CHELSEA MGVJLAR HONES INC. Pa BLOC 1108 ROUTE 9V NARLBORR NY. 12 542 914- 236 -3311 ®CpPRlIGNT 1996 QELSCA MODU{.AR Nt111ES - 4ll Y7GHTS ZrSCRVCO 11E ISI�IT[CiIAN. V� [flfT�IICO K�ar .e o-w�.• -- ._.•- � p iri Y 171V1r yr zn v munivmmAL REALM' bERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner N Y A 77— Address 2-,79 o/ ,Z% 2-2- 1 Located at (Street) f 1�4 ,�Rsf Tax Map Block 2-- Lot S.2- (indicate nearest cross street) Municipality PI�TT-Eg► Drainage Basin 6,-,--r Gib SOIL PERCOLATION TEST DATA Date of Pre- soaking >/Z A8 Date of Percolation Test ZZ lei- B NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (E e. < 1 min for 140 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 to Water Water rom Ground Level Percolation Hole No. Run No. Time Start Ela se Time Min.} Surface (Inches) Drop Indies Rate MitvTnch -Stop Start Stop 1- l 1"'60 - 2 : OS _313 2 , 3 �'.c� -z; O ' Z2- �� 1b 4 2:5'1 -7;z ► 5 2 -7 cr7 X3-7 2 2 3 % 2:3 ;O7 4 5 .gyp•; DEL iG C 2 4 p G74 �r ofis;�oNP` 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (E e. < 1 min for 140 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' t�- DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES HOLE NO. HOLE NO. ­2 Indicate level at which groundwater is encountered /V ,q Indicate level at which mottling is observed .'/N Indicate level to which water level rises after being encountered . /2 Deep hole observations made b` :'" ��'GH , �— Y !�► L KKK .r an/k1 ya-w.rea Date Design Professional Name: F � Address:lL� , C A Pmr L L S�ticHn�t � r� �T Signature: }... . Design Professional's Seal cPF.O 067446 �. pRQFESSiONP�" PROJECT I.D. NUMBER 617.21 SEOR ;1' Appendix C State Environmental Quality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM - For UNUSTED ACTIONS Only PART I ;~PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME. 3. PROJECT LOCATION: Municipality 50/St County e4 -t"1V A /-1 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SC s IT-F— /ATP rop- i_.acA7Pe4 5. IS PROPOSED ACTION: O New ❑ Expansion ❑ Modificationialteration 6. DESCRIBE PROJECT BRIEFLY: p iz.C5PU S E \i -J ) L<G PA 1 I—( 'per FLLI l-1 Cs O N -315.-7 -PAS QGE I- o F L-o N v, 7. AMOUNT OF LAND AFFECTED: Initially 515,1 acres Ultimately S� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? LL t� Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes IE�No If yes, list agency(s) and permiUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes No It yes, list agency name and permit/approval 12. AS A RESULT ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? rO�FYyPROPOSED Yes NO . Cl t� I. CE IFY THAT THE INF MATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE r 2 ( l ApplicanUspo e: Date: i Signature: If the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER I ..... ..— �41 .1n%0"MCnI04. A00=00 eons do ce compierea oy Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6 ?. If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly. C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: i 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 C5. Growth, subsequent development, or related activities likely to be induced..tiy the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C tSC Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. 0. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it Is substantial, large, important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural);_ (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts, which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this box If you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lea Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency Date Title of Responsible Officer Signature of Preparer (if different from responsible o icer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION ��X.0 ilO�� . l�'`� ' NAME OF OWNER f LTTZ &/. rojj) REVIEWED BY RNI, GR, AS, NIB, BH 2 / DATE 0 / TAX MAP Y DOCUMENTS. R1�IIT APPLICATION PC -I L PERMIT _ PWS LETTER TTER OF AUTHORIZATION DES GN DATA SHEET (DDS) CORPORATE RESOLUTION FtT EAF ANS - THREE SETS HODS LANS - TWO SETS RIANCE REQUEST Y 20JO FOUNDATION WALLS _15'WEL 200' N DLOD, 150' PITS 00' TO STREAM WATERCOURSE LAKE (ir 50' TO CATCH BASIN, 35' STORMDRAN, P] •''TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEI 15'MN to CDS= >5 %,10'- 4 %,25'- 3 %,30' -2 %,35 20' IN "to CD discharge /100'with 182 cons da} i 7 Az ,� i F��M►W =� MINA AL CHECKED FILL DEPTH TAN DRAIN 1 $ED STANDPIPES GENERAL ATED N NYC WATERSHED VS SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED M- TO BE WITNESSED Ad oOVAL SSDS ADJ. LOTS LANDS (TOWN/DEC PERMIT REQ'D ?) AA 01,1 DDS PLANS & PERMIT SAME I969'RVEIGHBOR NOTIFICATION FLOOD ELEVATION REQ'D PERMIT(S) ;WAGE SYSTEM PLAN - (NORTH ARROW) ADS HYDRAULIC PROFILE CAVITY FLOW )NSTRUCTION NOTES ?SIGN DATA: PERC & DEEP RESULTS CONTOURS EXISTING & PROPOSED ;OSION CONTROL:HOUSE,WELL, SSDS .RC & DEEP HOLES LOCATED ;PRESENTATIVE OF PRIMARY & EXPANSION )CATION MAP _ M. AREA; SHOWN; GIPn � �W, SUFF.SIZE PUMPED, PIT & D BOX SHOWN & DETAILED )USE - NO.OF BEDROOMS ELLS & SSDS'S WAN 200' OF PROPOSED SYS. ',OPERTY METES & BOUNDS )USE SETBACK NECESSARY (TIGHT LOT) )USE SEWER - 1/4" FT. 4 "0; TYPE PIPE ) BENDS; . MAX.BENDS 45° W /CLWOUT- FILL SYSTEMS .AY BARRIER T. HORIZONT ;SLOPE 3:1 TO GRADE LL SPF.CS FILL NOTES LL CERTIRCATION NOTE PROFILE & FILL -N EXPANSION AREA � TRENCH ( RENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED - : • . �� SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL G /GUTTER/CURTAIN DRAINS WFL.L OIL.TYPE BOUNDARIES 0'-6----.-06NaOFSERVICECO�EC�nON T TI BLOCK; OWNERS NAME,ADDRESS #,PE/RA; NAME,ADDRESS,PHONE# DRAWING/REVISION OF DRAWG/REVISION M REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET COMMENTS: ic. expan) PED WATER SYSTEMS - 1°/0100' - <1% discharge P`L ;DRI1/)�WA4Y, -E .:. ;Ill 20JO FOUNDATION WALLS _15'WEL 200' N DLOD, 150' PITS 00' TO STREAM WATERCOURSE LAKE (ir 50' TO CATCH BASIN, 35' STORMDRAN, P] •''TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEI 15'MN to CDS= >5 %,10'- 4 %,25'- 3 %,30' -2 %,35 20' IN "to CD discharge /100'with 182 cons da} SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL G /GUTTER/CURTAIN DRAINS WFL.L OIL.TYPE BOUNDARIES 0'-6----.-06NaOFSERVICECO�EC�nON T TI BLOCK; OWNERS NAME,ADDRESS #,PE/RA; NAME,ADDRESS,PHONE# DRAWING/REVISION OF DRAWG/REVISION M REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET COMMENTS: ic. expan) PED WATER SYSTEMS - 1°/0100' - <1% discharge PUTNAM ENGINEERING, PLLC 102 Gleneida Avenue Carmel, NY 10512 914- 225 -3060 Fax: 914 - 225 -2955 TO: 12D 8 C7 fl?—T-- t✓10re- P—(5 QE-1 l'GIi`Np CS>tAIIIII 'y HP-AVTH V'GPT. We are sending you >C attached Shop drawings Specifications Plans No. of Copies LETTER OF TRANSMITTAL Date: RE: DMA Ta/q — PYATr Iu t-(-- FT JI 6: RoAFP (-Q TWTt -4.I e50n1 under separate cover, the following items: i� Prints Copy of letter Other: Descrintion FU72WAIIIIII I WA A W!, ! WMA 21- These are transmitted: _ For approval _ Approved as submitted _ For your use _ Approved as noted As requested _ Returned for corrections _ For review /comment _ Resubmit copies for approval _ Submit _ copies for distribution REMARKS: Copies to: SIGNED: 4Z6�n dv If enclosures are not as noted, kindly notify this office. r u i n Ain k u U 1N * t' Y DEPARTMENT OF. HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS-FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 1JeA'01,,L " \/+Q-rt- 2. Name of project: DEA-mrA\, "YA-rT 3. Location TN: ^I 4. Design Professional: :Purg&M iF4ICa t►.tgNE: 5. Address: ► o .1 L- F.4\M1Psa. Aq 6. Drainage Basin: EA-C' -5 2 f e---H 7. Type of Project: _ Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision 'ATLI 2 1 t1 14 q N I ZYNI • Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Exempt >c Unlisted n/O 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... A/O 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities? Date granted: 111A 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... IN/%;'q 17. Waters index number (surface) ............................................. ............................. %9 18. Is project located near a public water supply system? ....... ............................... 19. If yes, name of water supply Distance to water supplyi 20. Is project site near a public sewage collection or treatment system? ................ O 21. Name of sewage system Distance to sewage systemG- -07� 22. Date test holes observed 23. Name of Health Inspector AAr--L. Kelm 24. Project design flow (gallons per day) ................................. ............................... Doc) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... ,a 26. Has SPDES Application been submitted to local DEC office? ......................... ���} U 27. Is any portion of this project located within a designated Town or State wetland? N 0 ., 28. Wetlands ID Number .............................................:............. ............................... 14 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? . .....................:....:..`. 30. Does project require a DEC Stream Disturbance Permit? .. ............................... /y O 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? 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 7� O DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... A10 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? . ............................... 1\4D. 36. Tax Map ID Number .......................... ............................... Map Z-_ Block 2__ Lot 2 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 m e here' rarrm ' able as a Class A misdemeanor pursuant t ec r SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... c o a— _CAi?vnoL_ Al-4 lob"t.'2- 24• PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGjE TREATMENT SYSTEM Owner A U Address A/ Located at (Street) T A9 1F Tax Map Block Lot, (indicate nearest cros street) Municipality 0 A1Y Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test Depth to Water From Ground Water Ley e' l Percolatrot�. Hole No Run No. Tiirne Mart Sto . pLn) .......... . lta se Time .......... .. ..... . Surface (Inches) : Start Stogy propp In Inches :. . Rate MznfInch ::" 2 2 .' o � �.: y - 3 -'17 a-49 -SO '9- S` 3 10 5 2 2,'a7 ;3� -3O'�' 2 ( 30 3 r 3 �1 3,, c)j 3o- 4 3; D� 33�' �o �' 9 .. Y,;�' 61/0 5 1 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 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 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. 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' CTO 8.0' 8.5' 9.0' 9.5' 10.0' v HOLE NO. HOLE NO. I w1m 0 1 OE .I 1 � 2 ,9/py Indicate level at which groundwater is encountered oe Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: �, Date Design Professional Name: Address: Signature: Design Professional's Seal Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT PERSON IN CHARGE -,-)e9,e)) BA 1- 0 Name and Title l TYPE OF FACILITY: /07- � �%J%? A 1 I // <'in A l FINDINGS: 1,4,e )G ,ero L A r/0Al I/lgL Es / /V Co Mr.. r-ss /1E TNSPFC'TOR , TFT Signature and Title RF.PCIRT RFC- RTVF.T) BY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: I / i I FROM RJTNAM ENGINEERING PLLC PHONE NO. 914 225 2955 2531 311 Dec..21 1998 01:24PM P2 #0 T et ft?d 10509 12563 IT Ow 'P t PA ERSON't �45 tein 60 Comers Mors 84 1 / ' 62 FROM : PUTNAM ENGINEERING PLLC DATE: FAX NO.: PAGES: 2- including this cover sheet. Dec. 21 1998 01:24PM PI -FH 6c%A-le-1 From the desk of- 102 MzialDA AVENUE, CARPEL. NEW YORK 10512 0 PHONE (914)225 - 3060 -FAX (914)225 -2 55 Lake i I ✓eSt�a � 8 w •� 1 Briyr on 2 �s ES { '� A. 1 \ Laic et,�fi � 1 ,m •�� nr�,11 `•� \j ' x12531 6., r. s I '00k o 12563 Ma a 52 I ^` kum � ' �.� • ,� e � ` rya I p own 1 + t a 164 Ul .o :rr Ea �H / q, w i� i8 g Corn I F 1 to iMrndel Pond 8 164 Town H $ 311 ( �ialrif Come Co.a�i � � 4 r,a �t teinback Corners 60 1 f s i y.' JC_ i '✓ e 1 •� ��� � 1 \ I ° � i I i mers t84 aa HS \i F m 3-Dele -- Pa 1 I a Brewster ,. 5 b ` q�d ernan � Pond MS ` �tT r el Aso � _ •,b` Z J * CARMEL HS I County Courthouse °s :ounty Office Build/ng 1 312 U `, y ' rbll Ludington I OR D. woo monument e 312 1 RECORD OF PHONE CONVERSATION Time: ► D® Date: %/ S Person calling: ��nj f f [L Phone #: Reason (} Inspection: 04-Deeps and /o eres: Scheduled Field Meeting `Pry Perc 5 Time: 5c7 A�nr ken (- Date: I JAZ I dL Y N Tentative /to be confirmed () ( ) Town: Road /Street: B UI 1 a z Ha4, W, Tax Map #: 13 — 9, — Comments: .�� 363 Lt. RU 12 13 14 PRELIM 1 NARY w °con ,w' ..... mum+ u� w a� s( . 4 -- -" .fma °a. G. onaai a,wE�v of mmi'ut a eu °®0a°01° , I °"° 22 24 OF PATTERSON u«< ____ iilFla/,A IIK y, ffa ►•° nraw,a►�K scam,naniw iaaa 6 TOWN wn r c'R frmlK,nnlCl f0P0. 011"'n cY1 WIL mmn uN �r cuum W INK m 33 34 35 PUTNAM COUNTY, NEW YORK ° °n B, MI. r ur _ _ _ rurt v rum'. - fxa,m,m ur im s rum var°n — — nfaa mmau wrfa ar�u n 363 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location I Street Address: & Ile- t Ildle Town/Village: Alfemoj_% Tax Grid # Map Block 2_ Lot(s) §1_'2,` Well Owner: Name: 14 Address: Use of Well: 1-primary 2-secondary ResidentiaC/ Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(speci6)`!` Industrial Institutional Standby Drilling Equipment Rotary _ Cable percussion —k— Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter Tin. Weight per foot lb/ft. Materials: Steel Plastic Other Joints: Welded Shreaded Other Seal: Cement grout Bentonite Other -:"i Drive shoe: Yes No Liner:_ Yes oi Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed?, First Yes—No' Hours Second 4 Well Yield Test Bailed Pumped It Compressed Air Hours 6l Yield _,5_ gpm Depth Data Measure from land surface-static (specify ft) 97/ During yield test(ft) AA,;In Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 3 5FS V de If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Type Capacity Depth Model Voltage BP Tank Type Volume Date Well mnleted ,3 7t Putnam County Certification No. 007 Date of Report � Well Driller (signature) I INUTJK: E*ct location of well with distances to at least two permaneift landTnarkS to be provided on a separate spet/plan. Well Driller's Name Z1177Ae Signature: 94&9 L5�1 Address: /,()/?r Date: 71-1 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 I . if 10! " "55 Y. too 1 �.. x'