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HomeMy WebLinkAbout0628DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -57 BOX 7 ME in I 96 IN IN 6 No J Nir NO I N; AILI 11. ......... r . -,.r ,> ...., -- iN17 0 �3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO i ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P-46--'q.32 �_OJ ,553 Located at rAC4 -1 t'b I°l R lz k F✓7r77 Fp Np, Town or Village Owner /Applicant Name 'o'r j'-,q V LC) Tax Map Block - 2 Lot-,15.-7 Formerly KFLl6W411 Em,:H Subdivision Name Subd. Lot # Mailing Address f2 :3 969n To I . Date Construction Permit Issued by PCHD 'P-4 6-1 3 Separate Sewerage System built by A. TZLVdLPS $UPp1 K M Address ::IBdju t tila 115V Consisting of Gallon Septic Tank and = 5 L, V' c� ?� � VL/ t- G�1gE36 A>� Other Requirements: Water Sup&: Public Supply From. Address or: Private Supply Drilled b Address �„ 2 RA 050 RP. jzov�$u�p PP Y Y Building Type N-V-n L-r-- V::�AIt"Ibz,,Y Has erosion control been completed? Number of Bedrooms 15 Has garbage grinder been installed? N 0 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 regulati ounty tment of Health. �t Date: ZD�e O Certified by P.E. R.A. r4 E (21 K(C;(Design Professional) Address I U z rz_i t nt c-,A .Ag it . CA V_ vn et_ NJ-1Q5%-Z- License # 6G-7 9' -'i to 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 approv a subject to modification or change when, in the judgment of the Public Health Director, such revoc 1 n, odific or change is necessary. B Y / Till e:42,PVI)k 6 . Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 } �n: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 553 Farm to. Market .Rd. �atterson own/Village: Tax Grid # Map Block Lot(s) Well Owner: Name: Address: Stephen D'Octtavio Use of Well: 1- primary 2- secondary X 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 12 0 ft. . Length below grade fl Diameter 6 in. Weight per foot 17 lb /ft. Materials: X Steel Plastic _ Other Joints: _ Welded _ Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First NONE _ Yes No Hours Second Well Yield Test Bailed _ Pumped X Compressed Air Hours 6 Yield 1_ gpm Depth Data Mea§ure from land surface -stator specify ft) 40 During yield test(ft) 405 Depth of completed well in feet 405 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 105 6 soil 105 405 6 Limestone If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Competed 3/7/00 Putnam County Certification No. 10 Date of Report 5/22'/00 Well Driller (sign r Y� NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's N e Wragg Bros. Address:16 2 Baker Rd. Roxbury Signature: fir/' Date: Connecticut White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 FROM., : PUTNAM ENGINEERING PLLC PHONE NO. 9114; 225 2955 Ma -:j. 09 2000 01:44PM PI 9L j BRUCE R_ FOLEY LOR . E7TA MOLJXAIU XN. MAN Public Health Director Aisocwte hiblic Health Dkvctor r&rwtar of Patient Services DEPARTMENT 01F MEALTH I Geneva act, Brewster, New 9 EnAroulucatal Health (9l4)278-6IJ;--FhX 14) 278.7921 Nuriling9trvim(914)VO-6558 WIC (914)279-667it Fax(914)279-6085 Early Intervention (014)278-6014 Fruchool(914)278-6092 Fox(914)278-6649 E911 ADDRESS YE131EILATION-F)TINT OWNERS NANIE: TAX MAP NUMBER: E911 ADDRESS: TOWN: PA 01 AUTHORIZED TOWN OFFICIAL: (Signature) DATE: '2 41v 0 , The Putnam County Department of Healtb will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official - This form is to be submitted with the application for a Certificate of Construction Compliance. (E91 IvERPM • .-A U1ra� rotAr3 Ul/eCC eUriCCin� 162 BAKER ROAD, ROXBURY, CONNECTICUT 06763 (660) 354 -1969 FAx (660) 355 -2665 May 22, 2000 Putnam County Dept. Of Health Div. Of Env. Health Services Gentlemen: We are enclosing a'well completion report dated today to replace one dated 4/4/00 covering the well at 553 Farm to Market.Rd. The owner of.the well is Stephen D'Octtavio. This revised copy is necessary due to an error in reporting the results of the well yield test. The first report reflects, a typing error. We changed the amount from 31, to 5Z GPM. David Wragg Owner I TS Tri j� 1 PUTNAM ENGINEERING, PLLC 102 Glenelda Avenue Carmel, New York 10512 Phone: 914 - 225 -3060 Fax: 914 -225 -2955 . -� LETTER OF TRANSMITTAL Date: A'so ` D c) RE: ,p IOT -AVID 5155 I;i4f-wi nRtrE=e4oVr4 rte" 23- z -s'7 P/E Job # We are sending you attached X_ under separate cover, the following items via 1st Class Mail, Overnight, Hand Delivery, Pick Up: Originals Prints Colored Prints Copies Date Reports Plans Photographic Exhibit Specifications Other: Dwg. No. p - cam, f 1. aF_ ?00� AG o F A1-F e At4AL -Y5, 5 Description 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: SlGNED:,AajM du'eta If enclosures are not as noted, kindly notify this o ce. (LtrTransnutmps.Tl �tiw-- sv►.. PUTNAM ENGINEERING, PLLC 102 Glenelda Avenue Carmel, New York 10512 Phone: 914 -225 -3060 Fax: 914 - 225 -2955 LETTER OF TRANSMITTAL Date: Sl0 Q /o RE: �D VT. 7mwi 23. 2 -5r7 P/E Job # We are sending you . attached _�< under separate cover, the following items via 1st Class Mail, Overnight, Hand Delivery, Pick Up: Originals Prints Colored Prints Copies Date Reports Plans Photographic Exhibit Specifications Other: Dwg. No. Description 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 If enclosures are not as noted, kindly notify this ufframmdmps.2) MAY %09 -00 O4:01 PM TOWN-OF PATTERSON M14 ! P"4 "I P%ER I NG PLO pro; 10. ` 919 /U A s I BRUCE IL F=Y lar , Md& &.Mwr A :' LORBlTA 1 iMWARL RN.. MAX .Wood�a Ai6N .961kh Dltat& �(� d taArart �+�aFi DUAFtT'Mh'NT TH is rWould KWA MAIM• 14� Z71.79dt wd�a.r t.r,�lr.. morn -ups wa �� »t•eatt ra�u�:s»•tots a.rhr satervauoe (Al�)2:�•101� r�eneol dt417ld0ea heO14�3u•M+t 1 91t -ADDR yC TERIE CAlMO FORM. Tax scar wmimR: " 5 77' - E9 te ADDREM S^S• 3 C *lam r t: j*Pg�T' rzArD TOWN; VA TM MS0 AUTn4MUD TCMN 01TICIALI (Si�nllture) DATE: The Putnam County Department, of Health will vat issue a- Certificate of Construliwa Cumpliuuce unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town of dal. This form is to be submitted with the application for s Certificate of Construction Compliance Xt>>VUUM A ICHA(e-l> VI I JAMS BRUCE R. FOLEY Public Health Director' LORETTA MOLINARI- R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (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 (9 14) 278 - 6648 May 1, 2000 Putnam Engineering 102 Gleneida Avenue Carmel NY 10512- Re: D' Ottavio Farm to Market Road (T) Patterson, TM# 23 -2 -57 Dear Sir: The above regarded application is incomplete and cannot be processed. This means the project cannot be forwarded to a Putnam County Department of Health reviewer for comments.or approval until the following has been received: 1) Standard E911 Address Form. 2) Construction Permit Application. 3) Certificate of Construction Compliance Application. 4) A certified check or money order in the amount. of- ❑ $300 for a Construction Permit. ❑ $300 for a renewal of a Construction Permit. ❑ $150 for a revision of an approved Construction Permit. ❑ $200 for a Certificate of Compliance. ❑ $100 for a Well Permit. ® Other: Standard E911 Address Form is missia -e If you have any question regarding this matter, please call me at (914) 278 -6130 ext. 2152. Very truly yours, Theresa Nemeth Senior Typist e N. E.. NORTHEAST. LABORATORY of 'DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert , -PH -0404 L"S (203) 748 -7903 - FAX-(203) 748-06521 NY Cert. 11471 LAP, -ORATORY REPORT.-- WATER SUPPLY TESTING REPORT TO: 14OR-TBERIDGE BUILDERS DATE SAMPLE COLLECTED:'4 /13/2000 Attn:STEVE DOTTAVIO TIlVIE COLLECTED:3 30 P.M. 5 PROGRESS STREET COLLECTED BY: STEVE D. ,BREWSTER, N.Y.. 10509 DATE RECEIVED @ LAB: 4/13%2000. TESTED BY: LAB #11471 REPORT DATE:4AO /2000 SAMPLE SITE. T0_MkRKET.RD ;.BREWSTER, N.Y. SAMTLING POINT: OUTSIDE HOSE fil1TTR!`F • I 1r .T _NTW: . CHL1VllS "17ZY Nitrite N <0.005 " mg/L as N 1 mg/L as N Nitrate N _0.24 mg/L as N l0 mg/L as N Alkalinity. 82.0 mg/L . -no designated limits Hardness 68.0 - mg/L no designated limits Iron 0.282 mg/L ` 0.30 mg/L Manganese X0.01 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus 'Manganese `= 0.50 mg/L] Sodium 12.1 in . 20 mg/L ** Lead 0.014 mg/L 0.015 * * *. m1= milliliter mg/L = milligrams per Liter ND .= none detected NTU =Units *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTEDA1 /13/2000 SAMPLE; AS TESTED ABOVE: O.TABLE MIP . or OT POTABLE . (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory. Director -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037di (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 * OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM l IeF 'D'o2ZZ VIQ 23 Z 5.7 Owner or Purchaser of Building Tax Map Block Lot -P6U --ex L*ks - SU.epic < ;f , Building Constructed by :r_ ZZy✓L t-01 Location - Street i K& G-E CA r-Gt i Building Type Town/ illage 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 �_ Day 1 —1 Year Zo -00 d General C tractor (Owner) - Sign e Signature: Title: Corporation Name (if corporation) Corporation Name (if rporation) Address: 7 Qom,; e!j La, -xe l3 rows *el- Address: /) f 160X �3 7 ' State Zip d S o State /� � Zip d Sa 9 Form GS -97 PUTNAM E`TGINEERING, PL LC 102 Gleneida Avenue Carmel, New York 10512 914 -225 -3060 Fax: 914. 225 -2955 To: F&ffeK-.t Mc,�S, Ft, Letter of Transmittal Date: V I 1-1 `7 RE: NI<- LV n( FAgM To films WE ARE SENDING YOU _�_ Attached _ Under separate cover via the following items: — Shop drawings Copy of letter _ Prints % Plans Change order Conies Date No. Samples ® Specifications Deserintion # ►► tg�ti -7 SSf�S R��risEV iii^► S7A� ors Lis�l l �Lm-�VTZIzb cu' 1 j A C) 4�t5c- ( * 30,�> �,) THESE ARE TRANSMITTED as checked below. For approval Approved as submitted — Resubmit _ copies for approval For your use _ Approved as noted — Submit _ copies for distribution As requested _ Returned for corrections _ Return _ corrected prints .For review and comment — Other FORBIDS DUE , 19_ PRINTS RETURNED AFTER LOAN TO US REMARKS emGI.OsSt> vJA41— X1(,1✓ D COPY TO SIGNED: "00 _ � Dw yr � 1 rY C Dr-r � � `oosv�w� � r I I MB i 43 Sr BEDR❑ ❑M #3 11' -11' X 9' -5' I 1 112 SF B_2� � 46 Sr ' i r ' ' i 1 I L r / t BEDROOM #2 �R ❑ ❑M 10' -11' X 13' -0' 141 SF \\ L--- r-a• J L�— sr -u• a.c L— it -rr �Y I ar-r YU;(.:IFI (;QJ:JTY DrP,tn ":;h7T Ur h•Ei li0U53 1- qNS . PPr v C POD I'ECiiCGt; COUid'P ONLY; 3, 7. M�LV I�t�''lr 8 AM EiEifATCNB OF AM OSM MOMW W= " ME CCPYWIS M WE PAIL OFIXIM ALL COPYNO n TO PMnW OUR CIMCMAKE NYESTMMT N MUM T }ESE RAMS Alp BEVATIOMB. Fjy-(M `V K*<*- � PUWS AND ARCHITECT'S STAMP VALID ONLY « MODULAR MU.AR HOMES RESERVES THE RWff TO MAKE MNOR CHANGES 84 MIEM810NS AS REOURFD BY MODULAR CONSTRUCTION METHODS CONSTRUCT i[IN BY CHELSEA NODULAR HOMES INC. F,911,14D SR SITE LOC.: �— �[ cOO 1�DD fr6 0000 L°3 P6l�G'I MAMJFACT� I FORMAnoN Z CHELSEA MODULAR HOMES lNC. PII BOX 11 R0111E 9V RESS: 2°@Q@Qv SHEET N A -3a MARLBORQ N.Y. .r. 125ee 914- 236-3311 PRpJ. ID p: C666 DWN. BY: PW (n OcOPYRIGNI 19% OELSEA MODULAR HONES - M.L RIGHTS RESERVED SERIAL p. APP. BY: 06/07/96 MY D[ ARDHrLCrwAL v cDRrAD[D 1CA9M IS R WELTED -K. S[cTO. IW - - -- DATE: 05/29/96 W CMH X TE fl-- KT i) UiL AS AKMao ]2 -1-91 _ 1 N 06/05/96 PW X's mwu� aiA..or c xssonao w ....,.. u:cD rm cma�wnMC ..• y64YG VIrt 1— 1. R•taW Ix PG oIttCA Mt W11,��10 Q pCliC� •OYLw gat ayR RUM E SPAEt I us NNDG r PANTRY ne 2rNT 1N7II7 Vi1 r. a-1 w AwM 1 1 1 7 1 I 1 1 LIVING ROOM 20' -4• X 13' -0• 264 SF G w E� FOYER ffi 74 SF 3a r-r � �` 1r-9 lie' lsla -2 ANS AND ELEYAMW OF ALL Ci8SU MOOIL.AR HOMES ' AFE COPYFAMM WE YFLL WORCE ALL COPYMM TO PROiECT OW COlWSUBLE WE91W1i N MVaDW TRU RJAM AND BxVAToa AODULAR HOMEY REBEIRVEB THE RIGHT TO MAKE MINOR CHANGER W DOAEMICIN9 AS REOURED BY MODULAR CONSTRUCTION METHOD& BUILDER. SiTE Li]C.- m@v Qp.@@m Imam Z L`�aC} °��f OO Wrl ADDRESS SHEET N A -3 PROJ. ID AN C666 AWN. BY: PW W APP. BYE SERIAL 8N - - -- DATE 05/29/96 w w 06/07/96 MY \ a, PLANS AND ARCHITECT'S STAMP VALID ONLY FOR MODULAR CONSTRUCTION BY CHELSEA MODULAR HOMES, INC. ■ MANUFACTUHEH PFORMATTON CHELSEA MODULAR HOMES INC. P.O. BOX 1108 ROUTE 9V MARLBORII N.Y. 12542 914 -236 -3311 (D COPYRIGHT 1996 CHELSEA MODULAR HOMES - ALL RIGHTS RESERVED TTE ARONTECTIRAL WOK CONTAINED ED NKARON IS PROTECTED I1NDER SECTION 1R W TW CO"RiriNT ACT. 11 WSL wi A+ DID 12-1-91 C M H 1M11 °Y"'� ""i Noi c -M . w ww! mow! Nw -- Naw—"...ri wN0.R/G WNP°Nf fM! 09iwN n lP�� `i!!R wuNNpN IIALI r� 6 —11. �UDLLw .ai Nwc w11 ll0osaua wlcc! ..._. -- 1F1R 3/N lty 1/2' F VIA• _� 31" N 200 e4aR Va V V&30 ]ZC SAl[S V2gR Qso fOe i s s1M. D IN ING ROOM . RUM E SPAEt I us NNDG r PANTRY ne 2rNT 1N7II7 Vi1 r. a-1 w AwM 1 1 1 7 1 I 1 1 LIVING ROOM 20' -4• X 13' -0• 264 SF G w E� FOYER ffi 74 SF 3a r-r � �` 1r-9 lie' lsla -2 ANS AND ELEYAMW OF ALL Ci8SU MOOIL.AR HOMES ' AFE COPYFAMM WE YFLL WORCE ALL COPYMM TO PROiECT OW COlWSUBLE WE91W1i N MVaDW TRU RJAM AND BxVAToa AODULAR HOMEY REBEIRVEB THE RIGHT TO MAKE MINOR CHANGER W DOAEMICIN9 AS REOURED BY MODULAR CONSTRUCTION METHOD& BUILDER. SiTE Li]C.- m@v Qp.@@m Imam Z L`�aC} °��f OO Wrl ADDRESS SHEET N A -3 PROJ. ID AN C666 AWN. BY: PW W APP. BYE SERIAL 8N - - -- DATE 05/29/96 w w 06/07/96 MY \ a, PLANS AND ARCHITECT'S STAMP VALID ONLY FOR MODULAR CONSTRUCTION BY CHELSEA MODULAR HOMES, INC. ■ MANUFACTUHEH PFORMATTON CHELSEA MODULAR HOMES INC. P.O. BOX 1108 ROUTE 9V MARLBORII N.Y. 12542 914 -236 -3311 (D COPYRIGHT 1996 CHELSEA MODULAR HOMES - ALL RIGHTS RESERVED TTE ARONTECTIRAL WOK CONTAINED ED NKARON IS PROTECTED I1NDER SECTION 1R W TW CO"RiriNT ACT. 11 WSL wi A+ DID 12-1-91 C M H 1M11 °Y"'� ""i Noi c -M . w ww! mow! Nw -- Naw—"...ri wN0.R/G WNP°Nf fM! 09iwN n lP�� `i!!R wuNNpN IIALI r� 6 —11. �UDLLw .ai Nwc w11 ll0osaua wlcc! ..._. -- 14.16-4 (2/87) —Text 12 FPROJECT I.D. NUMBER BiT.21 SEAR q• Appendix C State Environmental Quality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM _. For UNLISTE6'ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant:or Project sponsor) 1. APPLICANT /SPONSOR PUTi•)arNl �-: ,iv. W, , Pu--- 2. PROJECT NAME • P-1 L_\1 t 3. PROJECT LOCATION: II F,dTT1Sj2,_ PU`rK3Arl�_4 Municipality jr,! County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) Sou -�-H 2400 FT't Piz�P>��2Ty Lo c.�. -� t� o1J • �/�I)rST S I �Ji✓. B� 12oA� 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: S � ��-c F,al� � L_y TJ vv� -►-�i r•1� . foc�'t'1�.� 7. AMOUNT OF LAND AFFECTED: �r Initially 01194 acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? as ❑ No If No, describe briefly 9. T IS PRESENT LAND USE IN VICINITY OF PROJECT? esidential El Industrial C] Commercial C1 Agriculture ❑ Park/Forest/Open space FS: ❑ Other ribe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL) ?���,,,((( ❑ Yes No If yes, list agency(s) and permlVapprovals 11. DOES ANY SPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes No If yes, list agency name and permitiapproval 12. AS A RESULT PFPROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /sponsor M � � � `^�- � � Date: I name: _ Signature: V If the action is in the Coastal kea, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (ro be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No N' B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6 ?. If No, a negative declaratlon may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels,_ existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be Induced :4Y the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. f C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART 111 — 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: Name of Lead Agency Print or Type Name of Responsible officer in Lead Agency Tit e o —Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) Date 6 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM L Name and address of applicant: JASM r.S 3303 C,�ery�� 1•�LR i o�12. 2. Name of project: �l<�I (IJ' S��S 3. Location TN: ` ATTe�SQI"J 4. Design Professional: 5-6im��ee ice, 5. Address: Io 2 fo[F-.Ner iJ.a A 6. Drainage Basin: C RPTpti I Cam. PON 6 �fAYZMaL_ tv tJ 7. Type of Pr&Ct: A Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ...::................ ............................... Type I Exempt Type II Unlisted k 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... N� 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N� 11. Name of Lead Agency 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? ........ ............. ................... 14. Has preliminary approval been granted by such authorities? Date granted: ,rs 15. Type of Sewage Treatment System Discharge ................. surface water Xgroundwater 16. If surface water discharge, what is the stream class designation? .................... /I& 17. Waters index number (surface) ........................................... ............................... t-3 /_4 18. Is project located near a public water supply system? ....... ............................... tli c) 19. C- %ee^7eya --rA ,1 If yes, name of water supply Distance to water supply I M LS 20. Is project site near a public sewage collection or treatment system? ................ hio- 21. Name of sewage system Distance to sewage 6RE*wTl52'I N sr) system 22. Date test holes observed 23. Name of Health Inspector Mc��nl 24. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 1J 26. Has SPDES Application been submitted to local DEC office? ......................... Fnrm PC-07 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ........................................................... ............................... lJ /1S 29. Is Wetlands Permit required? ............................. IJ. Has application been made to Town or Local DEC office? ............................... t-�t/A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... �Jo 31. Is or was project site used for agricultural activityinvolving 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 &JQ 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? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number .......................... ............................... Map �: - Block 2 0 Lot S % 37. Approved plans are to be returned to ..... Applicant J� Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES do OFFICL4L TITLES. Mailing Address: ................................... l02 6t 6� ff- - G-rf . WZ-rz APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION PERMIT STREET LOCATION /5-/f LD /?A /�1GVln/ 2 ti �Lo,M 7'1z�7'SGIt� BY B. HEDGES R.MORRIS OTHER DATE / / TAX MAP # - V4 DOCUMENTS. APPLICATION PC -I WELL PERMIT M PWS LETTER ENGINEERS AUTHORIZATION DESIGN DATA SHEET(DDS) PLANS THREE SETS V OUSE PLANS - TWO SETS ARIANCE REQUEST SUBDIVISION M LEGAL SUBDIVISION M SUBDMSION APPROVAL CHECKED m PERC RATE CD FILL REQUIRED DEPTH M CURTAIN DRAIN REQUIRED mSTANDPIPES Y EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE ' 'Pt ED PIT & D BOX SHOWN & DETAILED - NO. OF BEDROOM WELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM ,PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1 /4"/FT. 4 "0; TYPE PIPE NO BENDS; MAX. BENDS 45° W /CLEANOUT FILL SYSTEMS m C ER m 10 FT HO , :SLOPE O GRADE m FILL SPECS LL NOTES m FILL CERTIFIC N NOTE m DEPTH G ES m FIL OFILE & DIMENSIONS m LU�1.fE GENERAL ETT FILL IN EXPANSION AREA X- APPROVAL SSDS ADJ. LOTS WETLAND ( TOWN/DEC PERMIT REQ ?) TRENCH r DATA ON DDS PLANS & PERMIT SAME LF TRENCH PROVIDED 3 7 60 FT MAX D: "°" ' "`" "TEIGHBOR NOTIFIFICATION PARALLEL TO CONTOURS 100% EXPANSION PROVIDED D ELEVATION I �j�W- (:_� .4 F SEPARATION DISTANCES SPECIFIED ON PLAN REQUIRED DETAILS ON PLANS LDS SEWAGE SYSTEM PLAN - (NORTI, ARROW) [N] TO P.L., DRIVEWAY, LARGE TREES TOP OF FILL U20'TO SSDS HYDRAULIC PROFILE GRAVITY FLOW FOUNDATION WALLS 15' WELL TO P.I CONSTRUCTION NOTES (GRINDER NOTE) TO WELL, 200' IN D.L.O.D., 150' PITS DESIGN DATA: PERC AND DEEP RESULTS 3- SAM WATERCOURSE LAKE (INC.EXPAN) TWO -FOOT CONTOURS EXISTING & PROPOSED m ` - T-H BASIN, 35' STORMDRAIN, PIPED WATER DRIVEWAY & SLOPES CUT m ' "OV LINE (PITS -20') FOOTING /GUTTER/CURTAIN DRAINS EE4W4�MITTENT DRAINAGE COURSE EROSION CONTROL; HOUSE,WELL, SSDS 66 f'R ERVOIR, ETC.=] 150 FT. GALLEY SYSTEMS EROSION CONTROL NOTE gDi = >5 %,20'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' <1% PERC & DEEP HOLES LOCATED SHARGE A00' WITH 182 CONS DAY DI S. REPRESENTATIVE OF PRIMARY AND EXPANSIO TAN LOCATION MAP M i � 5G,l(.-C I t -- 7a� 10' FROM FOU TION; 50' TO WELL �I Z 3F-T)?(-vOm vlei -L T3 COMMENTS: 1 .4 a f aKf.<, QiL llfe:n 4jJQ c2a 01 ij 115A I /J 202 F946 �*� &6(= _ /Iler�1 p,^;f ,tar l .�-�iy�rle�pth� --'s ,e3olulevl -�houi lot' Fnvr�F oN -a F c Tar N Ic �` , 1 :;:. z , BRUCE R. FOLEY Acting Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278 - 7921 Gary Tretch December 12, 1997 Putnam Engineering PC 102 Gleneida Avenue Carmel, New York 10512 Re: Proposed SSDS: Melvin Farm to Market Road (T) Patterson TM # 23 -2 -57 Dear Mr. Tretch: Review of plans and other supporting documents submitted at this time relative to the above - captioned 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." "You are referred to Article 128.1 of the official compilation of Codes, Rules and regulations of the State of New York; Title 10, relative to the need for approval of individual sewage disposal systems by the City of New York. You should contact city Officials in this regard." 1). Current codes require that the dimensions from the well to the property line are noted. ✓2). Short EAF has not been submitted. J3). Standard Form PC -1 has not been submitted. ✓4). Minimum tank distance from house to septic tank (10 feet) should be noted on plan. -15). Current codes require that the original documents be submitted, i.e., photocopies are not acceptable. The Engineers Authorization submitted is a photocopy, please submit an original. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Ve truly yours, mbw &YIo Robert Morris, P. E. Public Health Engineer PJWmh watershed i UTNAM 9 NMPLLE En lneers and Ps 1 December 29, 1997, Robert Morris, P.E. tnam County Health Department 4 Geneva Road Brewster, New York 10509 RE: Melvin Farm to Market Road Town of Patterson Dear Mr. Morris: This office is in receipt of your latest memorandum, and we offer the following comments: 1. Dimension from the well and property line corners have been added to the Plan. 2. Short EAF has been enclosed. 3. Application for wastewater treatment system has been enclosed. 4. The septic tank/house separation has been noted on the Plan. 5. The original engineer's authorization form has been enclosed. At this time, we would ask for your department's continued review and/or approval. Very truly yours, PUTNAM ENGINEERING, PLLC By: Az n; Ken Hurley KH.jt Enclosures File 9711084 102 GLENEIDA AVENUE, CARMEL, NEW YORK 10512 • PHONE (914)225 -3060• FAX (914)225 -2955 Date RE: Property of -Fames 921 /9q-16L'11<7 Located at (Town) Pq ff(fP Q Section 3 �, Block _Lot _ Subdivision of Subdv. Lot # Gentlemen: Filed Map # Date This letter is to authorize PUTNAM ENGINEERING PLLC, a duly licensed professional engineer 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 promulgated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 102 Gleneida Avenue, Carmel, NY 10512 Address 914- 225 -3060 Telephone and the Putnam County Sanitary Code. Very truly yours, Signed Owner of Prope Address Town Telephone 4� i PUTNAM COUNTY DEPARTMENT OF HEALTH !/ IVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # [2 -45 I Located at FtkW 'TD t/� (& C> Town or VillageiPXA�� qS Subdivision name Subd. Lot # Tax Map `23 Block "Z Lot _ Date Subdivision Approved Renewal Revision Owner /Applicant Name Ma-\/11�6 I'Tr- mate of Previous Approval Mailing Address D3 MQgE6,,j b4 C.4"g . Qq Zip o, l"L Amount of Fee Enclosed Building Type Lot Areas.14 pcNo. of Bedrooms � Design Flow GPD (� Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 0100 gallon septic tank and �jQ!5 �C�� l TIM-NCH -� 2r w I DE Other Requirements: To be constructed by To ]ne I)JE[t IM I NM Address Water Supply: Public Supply From Address or: �_ Private Supply Drilled by -1 ;2 _ 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 s sy tem 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: P.E. R.A. Date 2 Address lOi,Z.Q&�3EICA Acyr-- C1W.,,MeL &114 10,51 -2 License # 40Cy-7 4�4(p APPROVED,FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew. pe pproved f r discharge of domestic sanitary se ge only. By: Title: llL i' Date: ! de 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 # Well Location: Street Address: TownNillage Tax Grid # _ FA o Map 23 Block 2. . Lot(s) J 7 Well Owner: Name:JAMF -!5t Paivue.t4 Address: r'11 =��r1 N 3303 MA"'bg, - tJ (o- Use of Well: -X— 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 SoughtMlN 5gpm # People Served I FAr Est. of Daily Usage &0o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason up 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 Name of subdivision Lot No. Water Well Contractor: 117 -Ee- TNIC —T Address: Is Public Water Supply available to site? .................................. ............................... Yes No )- Name of Public Water Supply: N /A Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to b e on separate she t/plan. Date: I [J 2 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 well driller certified by Putnam County. Date of Issue �" ° Permit t*offi G' Date of Expiration 0 � Title: ic Permit is Non -Trap err ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 1 •• 004VIR14 1 ID • . DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner T L • TZET4!�r--t Address VD5fARM Ta NlV�l<r,-T A-2 , rVJsTE� Located at (Street) WM 1b ET (ZD Sec.25 . Block Lot Si p (indicate nearest cross street) Municipality PATTV5FGct4 Watershed 0?Cr e jt i Date of Pre - Soaking rW4=44 31192 Date of Percolation Test AML (� 9 HOLE to *40 30 2�• NUMBER CLOG TIME PERCOLATION Z PERCOLATION Run Elapse Depth to Water From Water Level 2�4 No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop 24 Inches Inches Inches 1 27 3 1� 2 TiO Io :10 30 24 Z (4 -' /2 2 /2. J2 3 Io 0 to *40 30 2�• 2�v%2. 2'/2 Z 4 (0:40 11 "10 50 Z�F 2�4 214 l � S 1 IS 1:,+5 30 24- 27 2 3 (n:ls to�4s 30 2f• 2� 2 (5- 4 l0 4s I I IS 30 24 NMW: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained.at each percolation test hole. All data to'be subaftted for review. 2. Depth measurements to be made fray top of hole. DEPTH G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED I + INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: G�� DATE: 1 `L -V DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided 5 No. of Bedroans Septic Tank Capacity i� _gals. Type C ONC Absorption Area Provided By 375 L.F. x 24" width trench _FRED Ap_ Other Name Signature jor Address C� �� �-�� 2� SEAL 0,1 018084-N rF OF NEW THIS SPACE FOR USE BY HEALTH DEPARM1ENr ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 3 Inspected by: 6;E�� Street Location fA�Nt TD /✓IA dZl E7' li? ©AD Owner l ELyml / Tg-6T:5c -N Town PATTE25��/ Permit # P— 5 93 TM # Z B - a -- 67 7 Subdivision Lot # 1. Sewaize Svstem 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. Sewage System a. Septic tank size 000) ....... 1, 250 ......... other ................ b. Septic tank installed-level ................ ............................... c. 10' minimum from foundation :......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. Trenches required � Length installed a 7S 2. Distance to watercourse measured t- iaco Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... - 8. Size of gravel 3/4 - 1' /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ .......... ...................... g. Pump or Dosed Systems Size of pump chamber ................ ............................... 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. HouseBuildin a. House located per a pp roved plans s......y..c.., .f Li . .j.Z..o..a..a.� . .. b. Number of bedrooms ....................... ............................... IV. Well a Well located as per approved plans . ............................... b. Distance from STS area measured ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 N P BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 7 Date: �/O d To: k9W &0:41- ITI�. J"CE`y /N �Ty'ETScf -f From: Gene D. Reed Putnam County Department of Health -X For your information For your review As discussed Fax #: No. Pages (Including cover sheet) Please respond Attached as requested Please call Notes/Messages G ©MM�/�! T i �e�st�t/�>Q� .�TLEA A?P,5AJRS GLo5E Tf) 6-roc' aLaPEE — 2zoVE cOc,, ' ow &S - Rvs L77-. 4�A/- 7-2e6iven in 5 s L5 T� 17? --rY /VOe --n -B g DKOOM eCUA/'T Z.-POV McEa 70 V,6:TZI fy WCU Upon( r©c-)T 11.14 b' AtH W*n-, lIOT f-oc-w�r-), !- LE45 E Loc. -ATE. In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 ext. 157. FROM PUTNAM ENGINEERING PLLC PHONE NO. : 914 2252955 Mar. 06 2000 09:45AM P1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION 13 ADAM REQUEST 1EOR EINAL INSPECTION All information must be fully completed prior to any inspections being made. PCHD Construction Permit # _P- 9 GENE For: Fill 'Trenches X _ Located: 644mt -nn. r-n ARIL 7' t'^°ZZ (T) M „ FA tt'�i 0 N Owner /Applicant Name: UpOIN ZPA.6 TM. 7..5_ Block �2 Lot _ Formerly: _. 1-y)OLI - -=z54:d Subdivision Name: Subdivision Lot # Is system fill completed? Y09 JVIA _ Date: "`/A Is system complete? Y Date: 3 /y 2 Io a Is system constructed as per plans? YA Is well drilled? `«? Date- Is well located as per plans? "(',5 Are erosion control measures in place? V6 S I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: '3/0L0 loo Certified by. N PE Y.,— RA Design r ssional Address: ItjL !a (_6djrpA- AyE cftt2iF..cLbL.uiS Lic. # Oid74410 Comments: Form FIR-99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of JET L •� Located at f "r0 nw.KiT (T) I�/�tTT�;RSoN Section - Block 'Z Lot Subdivision of Subdv. Lot # Gentlemen: Filed Map # Date This letter is to' authorize �, }�{J ABC jA- t!!! C a duly licensed professional 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 in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Educat tary Co Counters P.E., R.A., the Public Health Law, and the Putnam County Sani- Very truly yours, Signed I5C�l er of Property r&rM -TO iA r-% r Address I t *,S G r-&Afti yf-r � n-l\ ddress Town Telephone Sl? � _�G9 3 Telephone | i ___-` _-� . ~ ' � DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION pSptpreeetq^ Address Town Village City Tax Grid Number �F'tT . 1 `Ili ' WELL OWNER Name C.+ Mailing Address Xprivate %P'EC1 �5�". fJ����n� O Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ® USINESS ® INDUSTRIAL ® PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, b INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT S Mjjj• gpm /# PEOPLE SERVED 'S /EST. OF DAILY USAGE >al C] REPLACE EXISTING SUPPLY O TEST/ OBSERVATION M ADDITIONAL SUPPLY SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING FcE, L WELL TYPE DRILLED ®DRIVEN ®DUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES XNO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name 0 66 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: T r-1 (L LOCATION SKETCH —& SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET kz.49 date) signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under 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. - 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or othe wise contaminate surface or groundwater. Date of Issue: � 19 7_5 Date of Expiration 2 19 q,5 Permit Issuing Off' ' i 1 Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller --rM 23 --z -S7 DE ?AEnvircm OF :E.eL- Division C•f _nviren��.encai ^eaitn services 4 Geneva Road, 3re,.v- ;per. \e,.v York 110509 .911. ^78-61310 NOTICE JOHN KARELL Jr.. P.E. ,AS. Public Health Director TO: ALL APPLICANTS FOR INDIVIDUAL SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMITS You should be aware that the construction of an individual sewage disposal system 1. 'lay be subject to local wetlands regulations. 2. Is subject to the provisions of Section 128.1 of the Of= icials Compilation of Codes, Rules and Regulations of the State of New York, Title 10, relative to the need for approval by the City of New York You should contact local and City Of= is -als early in the approval process regarding their regulations. r Imo, S�� w TO 1'2i - - -' _ � -7z 40 ,- 1J is °g4ma.l ��1 °2j2o °yJ 998 - _- -- -'� - - - - -- ��� - 7— ac�,o>J EX I . FAZA `V d SURVEY NOTE: H605E LOCATION AND SETBACKS BASED ON 5URVEY BY TERRY BERGENODRF COLLIN5 DATED MARCH 50, 2000 A!t� -!E:5U I LT 1\4EA5URrMENTS ( IN FEAT` .)° 2 i 8 G 10 11. 12 13 14 15. 1� 1 Y 6o-7 &q .-7 Z -7.5 -76 105 10(9'. `. f L10 X03 34 4 S 5 (o B 29 , 82 0 &_ G%D q4 Raj j 1 1-li . _ {21 I2�-� yW- 4 6 � (3 -%O X75. Putnam County Department'of Health Division of Environmental'Health Services gppro d as noted for conformance,wth app le Ru and Regulations,of the o y Health. D_ epartme Signature. Title ate Al ` . . .' . ` ` FRAW Uc rIN try WoRrr n° MI. �� '