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Home My WebLink About0638DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -70 BOX 7 r , J ti. X0 11. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO + ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P-14 -q9 �_a� o/ i; Located at Z,14 G .� or Village �� Owner /Applicant Name lUAaSf 7U* l&r, Tax Map - Block Lot Formerly t't — Subdivision Name /l-/A Subd. Lot # _) A Mailing Address M C�i ?_6 �o (�/� -��V N�-% Zip / 2� Date Construction Permit Issued by PCHD 7-2 5 —5 1 Separate Sewerage System built by'!A-" r (y&AA -t,(__ Address `T39� Ose_ Consisting of 2-S-0 Gallon Septic Tank and 4W j� 0,1C A) Other Requirements: Water Supply: Public Supply From Address _ or: 1/ Private Supply Drilled by -%ejp Address Building Type P55 /QFWW_A- 44'�-Has erosion control been completed? Number of Bedrooms 3 Has garbage grinder been installed? A30 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 reg 'ons of t County partment of Health. Date: e Z_ (I c, I Certified by P.E. y R.A. �. (Design Professional) Address J-0 License 'P - r05'!V Any pergon occupying premises served by the above systems) all 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 modificatio or change when, in the judgment of the Public Health Director, such revocat' , odifi tion r an is essary. By: Title: Date: ('/1 J01 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pro essio al Form CC -97 3r PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: ' ni n �� +✓ U 'l� Town/Village: POL C'�ol -) Tax Grid # Map �?3 Block P7- Lot(s) �LO Well Owner: Use of Well: 1- primary 2- secondary Name: ,5 r) Residential Business Industrial Address: c » 39S 116le AV /VV 12S-6,3' Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) 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 Screen Details Total length 2-1 ft. Length below grade 2-0 ft. Diameter 6 in. Weight per foot �lb /ft. Diameter (in) Materials: 7 Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _A Bentonite Other Drive shoe: Yes No Liner _ Yes No Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gQgpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) 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 s „ t QA r201z -13 -1 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information A 30 Pump Type Capacity %Q -12 j pivl Depth 310_1 Model !ds 4 Voltage HP ? Tank Type by Volume Zj&d :.. Date Well Completed Putnam County Certification.No. Date of R ort Well D filler si natur) a� NOTE: Exact location of well with distances to at least two permanent landmarks to be provioejVgn a separat heet/plan. W Aifes;' Za---/ /C6 Well Driller's N e C'a"J/ /�% f G/ Address: C'i9rrm� Signature: Date: Jr�B �af White copy: D File; Yello copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 NE NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 )GA$S (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT REPORT TO: PUTNAM COUNTY HEALTH DEPT. c/o SHAWN ROGAN 1 GENEVA ROAD BREWSTER, N.Y. 10509 SAMPLE . SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliforsn (Bacteria) • E Coli (Bacteria) PHYSICALS: • Color (Apparent) • Odor • pH • Turbidity DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: LAB LD.# REPORT DATE: 215 McMANUS ROAD SOUTH, PATTERSON, N.Y. BATH SINK WELL NONE RESULTS METHOD # 5/8/2001 8:00 A.M. S.ROGAN 5/8/2001 LAB #11471 PCHD0508 5/9/2001 MAXIMUM CONTAMINANT LEVEL (MCL) OR STANDARD PRESENT per 100 ml SM 9223 ABSENT NEGATIVE SN 9223 NEGATIVE 0 - EPA 110.2 15 ND _ _ 3 Units 6.71 - EPA 150.1 No designated limits 0.49 NTUs EPA 180.1 5 NTUs CHEMISTRY: • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 • Nitrate Nitrogen 0.52 mg/L as N SM 4500D • Alkalinity 68.0 mg/L SM 2320B • Hardness 78.0 mg/L EPA 130.2 • Iron <0.03 mg/L EPA 236.1 • Manganese 3.0 mg/L EPA 243.1 • Sodium 3.0 mg/L EPA 273.1 • Lead <0.001 mg/L EPA 239.2 1.0 mg/L 10 mg/L No defined limits No defined limits 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50mg/L 20.0 mg/L ** 0.015 mg/L * ** ml= milliliter mg/L= milligrams per Liter ND=none detected MCL= Maxirnum Contaminant Level TNTC =Too Numerous To Count "'Notification Level ** *Action Level COMMENTS: -All holding times (were) met. SAMPLE, AS TESTED ABOVE: Ell POTABLE or ❑ OT POTABLE RESULTS BASED ON SAMPLES SUBMITTED: 5 /8/2001 Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 5 t s}tr ri5}YiSSifhrv<}y}5'Fii� NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH-0404 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 I ff Z11- • , '�i •' O 1N ACCOgOA�F e U U � a - x REPORT TO: PUTNAM COUNTY HEALTH DEPT. DATE SAMPLE COLLECTED: 5/23/2001 Attn :ANNE BITTNER TIME COLLECTED: 9:00 AM 1 GENEVA ROAD COLLECTED BY: ROGAN BREWSTER, N.Y. 10509 DATE RECEIVED @ LAB: 5/23/2001 TESTED BY: LAB #11471 LAB LD. #: MAY -148 REPORT DATE: 5/24/2001 o rn �c w rrl 5 SAMPLE SITE: 215 MCMANUS ROAD ° SAMPLING POINT: NOT STATED :; c—, c -SOURCE: WELL o cry cn to TEST PERFORMED RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) BACTERIAL: Total Coliform (Bacteria) ABSENT per 100 ml SM 9223 ABSENT CHEMISTRY: Chlorine Residual ND mg/L - - - - -- ml = milliliter mg/L = milligrams per Liter ND = none detected TNTC= Too Numerous To Count COMMENTS:' - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED: 5/23/2001 SAMPLE, AS TESTED ABOVE: ` ❑ OTABLE or aOT POTABLE (PER STATE OF NEW YORK 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 e OUTSIDE CT: 800 - 654 -1230 NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 203) 748 -7903 - PAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT REPORT TO: PUTNAM COUNTY HEALTH DEPT. Attn:ANNE BITTNER 1 GENEVA ROAD BREWSTER, N.Y. 10509 SAMPLE SITE: SAMPLING POINT: SOURCE: . TEST PERFORMED BACTERIAL: DATE SAMPLE COLLECTED: 5/23/2001 TIME COLLECTED: 9:00 A.M. COLLECTED BY: ROGAN DATE RECEIVED @ LAB: 5/23/2001 TESTED BY: LAB #11471 LAB LD. #: MAY -148 REPORT DATE: 5/24/2001 215 McMANUS ROAD NOT STATED WELL 1N a c c og01�cF e U cD M = -v �c C') --c)rn cnCp co 70 a r-n U1 to RESULT: METHOD # MAXIMIUM CONTAMINANT LEVEL (MCL) Total Coliform (Bacteria) ABSENT per 100 ml SM 9223 ABSENT CHEMISTRY: Chlorine Residual ND mg/L - - - - -- ml = milliliter mg/L = milligrams per Liter ND = none detected TNTC= Too Numerous To Count COMMENTS: - Holding Times (were) met. RESULTS BASED ON SAMPLES SUBMITTED:5 /23/2001 SAMPLE, AS TESTED ABOVE: AMPOTABLE or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) i{ O Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 -654 -1230 JUN -22 -01 09:48 AM DRUGS R F®l.Fy AdDltc Nedth 01rer^or �i 10309 9148782019 P. bL LOVZnA MOLWAX R.N., KI.N. Aww4ars Pub& AWRA 1)4vo r Dwwop df Pdftv srmwS '&G vUvG*tAb1 NMI* 014)2"-4130 S=(114) M-7921 9hOt14 M 30"1908 01413 78.6910 . TnC (V14) 278 - 4999 Per (914) 298.6098 lady taterrenft 19io rn .9914 Smbaol t914) 2!@4983 Pax mo 296 - 4648 OWNERS N&Nlt-. F311 ADDRESS., �� A'4 ,0124 A) e4 3 04 5°'a ems®.._ ARTHORMED TOWN OFFICIAL: (Si$A2tturel x ®l MR DA'L'E; The Putnam County- Npart ent of Health will not issue a Certificate of Construction Compliance unless the above form is completed, Lt., a legal IE911 address is assigned by an authorized town official. This fora is to be s+abmitted with the application for a Certificate of Construction Compliance. ... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by D's- A&,MANR� T-L :S Location - Street 7F,Sl W,tJT A-(.,- Building Type I Z �_) 2- -7 0 Tax Map Block Lot Tow 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 J a4tt Day o2 Year y Signati Title: General Contractor ( Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) G /«/ Address: a%s— 12�51*,V4 %Y, yec, f/, P44s"Address: State Zip IQ S-, 3 State Zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONKEN TAL HEALTH SERVICES FINAL SITE INSPECTION C Date: l z `! co Inspecte y• Street Loc (j `� S _ Owners r c -. Town �1� Permit # P-14—c-/C? TM #— Z 3 —2,--70 Subdivision Loo # 1. Sewage Systei'h 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 ...... ............................... IL. ei*aae System a. Septic tank size - 1,000 .....�5O ...other ............... . b. Septic tank installed level........................... c. 10' minimum from foundation .......... ............................... d. DistributioR B x 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 I. Len required Length installed 2. Distance to watercourse measured 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 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. PumR or Dosed Systems Size ot 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. 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 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. • Curtaiin 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 nrovided ............. ............................... . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # / . ff Located at /&eA(."_S ee"i JOd4 or Village l`01(scl- Subdivision name �U��q Subd. Lot # A A Tax Map d23 Block a Lot 7-0 Date Subdivision Approved iv Renewal Revision Owner /Applicant Name fye,Dry dt,tr Ic Date of Previous Approval lu R Mailing Address 35.5— Zip llS6 Amount of Fee Enclosed Building Type CA. —, if Lot Area t3 Ac.No. of Bedrooms __E Design Flow GPD Yab Fill Section Only Depth Volume Separate Sewerage System to consist of 1,77_!�_6) gallon septic tank and 4166 F+ Other Requirements: a_%`v�'e_ To be constructed by t16A Address Water Supply Public Supply From or: V Private Supply Drilled by J`16-A Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage 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 foll�pair a issua of the approval of the Certificate of Construction Compliance of the original system o to. Signed: y P.E. R.A. Date s Addres � � License # 496 -7 �` <o �� APPR VED FOR CONSTRUCTION: This approval expires two�azs from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved or isc az of domestic sanitary sewage only. By: (� Title: Date: 7J7,0191 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 BRUCE R FOLEY Public Health Director LORETTA MOLINARI RN., 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 Fax (914) 278 - 6085 July 28, 1999 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 Mr. Gary Tretsch WIC (914) 278 - 6678 Fax (914) 278 - 6085 Putnam Engineering 102 Gleneida Avenue Carmel, NY 10512 Re: Burdick SSTS (T) Patterson East Branch Reservoir Basin: Dear Mr. Tretsch: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on July 28, 1999 is complete. The Department will notify you by August 17, 1999 of its determination. The Project has been delegated to the Putnam County Heath Department for review 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 fled 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 of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 148. Respectfully Michael J. BqazinskP. MJg /jp Director of E gineenrig cc: J. McColgan i 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: Town/Village Tax Grid # 14 g,WVA -t S' A0 Sji, A S6+1, Map �?.3 Block v2 Lot(s) 7(j 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 _ gpm #People Served Est. of Daily Usage 3dc? gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason cR AJ&ld /' ;Sit;Q. -46 for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No iC Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision /UIK Lot No. ti A Water Well Contractor: Address: Is Public Water Supply available to site? ............... Yes No �( Name of Public Water Supply: A, /'A Town/Village Distance to property from nearest water main: d- % M 17--f Proposed well location & sources of contamination to be provided on separate sheet/plan. 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 well driller certified by Putnam County. l Date of Issue --7/z,,8/9C1 t Permit Issuing fficial: Date of Expiratio z Title: 141F, Permit is Non - Transfer abl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 LETTER OF AUTHORIZATION RE: Property of 142/1 ty 4 u J i' L k Located at '5)U(W T/V / et #%1 c,,(, � Tax Map # --23 Block - Lot Subdivision of /U Subdivision Lot # Gentlemen: This letter is to authorize Filed Map # Date Filed 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 tretment and/or water supply systems in conformity with the provisio six -Pi• • 'cle 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam Countersigned: P.E., R.A., # 06,7 Mailing Address 1y2_ State W q Zip )D5-12- Telephone: Z.ZS— ?app -c;� Very truly yours, Signed: (Owner of Property) Mailing Address: '39 S` l6/w. 4Q State N. L/ Zip Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES J, APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: WPAJr ig tl/Y['ic�iL Al 41 5c"" 2. Name of project:1W1,V,�1vy5 id - 5v)64 . 3. Location TN: llgyAsc --, 4. Design Professional: 5. 'Address: 6. Drainage Basin: . -,qsi- 7. Type of Proiect: _ Private/Residential .Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) .......................... :........................... Type I - Exempt Type II Unlisted X 9..Is a Draft Environmental Impact Statement (DEIS) required? ......................... A,10 10. Has DEIS been completed and found acceptable by Lead Agency? ............... ti A 11. Name of Lead Agency 12. Is this project in an area under the co trol of local pl in _zoning, or other officials, ordinances? :.w..... a` :��.......... �.��:.:.. ......... 13. If so, have plans been submitted to such authorities ?� 14. Has preliminary approval been granted by such authorities? Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water ±fg–roundwater 16. If surface water discharge, what is the stream class designation? .................... A 17. Waters index number (surface) ...............'............................ ............................... �v 18. Is project located near a public water supply system? ......... 19. If yes, name of water supply /U Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ AJO 21. Name of sewage system N%A Distance to sewage system 1 22. Date test holes observed f i 23. Name of Health Inspector Zvht 6k2 ( ' 24. Project design flow (gallons per day) .............. ., �.............................................. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... A10 26. Has SPDES Application been submitted to local DEC office? ......................... A 2D P-- nn n�i 2 27. Is any portion of this project located within a designated Town or State wetland?� 28. Wetlands ID Number ..............:........ 29. Is Wetlands Permit required? At o Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance 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,- 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 V 0 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 ? .............................................................. . _ A10 35. Are any sewage treatment areas in excess of 15% slope? .. ........................:.....� 36. Tax Map ID Number .......................... ............................... Map ZQ3 Block o- Lot 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 Penal Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... �� T�P�"Sa✓U �dS'�v� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �&/t' 4 y 8 4 R D) C k Address _3 q s- &4V- X&I Located at (Street) K0' Sc)ag Tax Map 93 Block -'� Lot (i dicate nearest cross street) Municipality 7r" . sovl�- Watershed Ei 8¢ A ^A A✓- SOIL PERCOLATION TEST DATA Date of Pre - soaking / y f Date of Percolation Test G% f 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 2 y- 7-31 4 5 1 /�- �a I > / /`�� /�l 3 3-6 2 a 1- 73 5— 1 Y / -/ 3 3 3S s`r /� /11- /. 3 5-.33. 4 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 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. ,�? E ` oo ,,5, -.HOLE NO. I F. Indicate level at which groundwater is encountered A10AA – Indicate level.at which mottling is observed /u0AP— Indicate level to which water level rises after being encountered 1,1dh.- Deep hole observations made by: Id, Date Design Professional Name�14io --4 Address: C 07,- Signature: Design Professional's Seal ()F NEW �. HAEL(y�Y Q � 4 `Sc�OA 067 4 46 �,. ROFES31ONP�� 2 14 -16-4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 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 ISFONSOR n A / p ✓rcCir A — APV 2. PROJECT, NAME 3. PROJECT LOCATION: 3. Municipality SC'►'t County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) — N/IGiiv$ o'23 �0CG x 5. IS PROPOSED ACTION: 8aew ❑ ❑ Expansion Mcdificationlalteration 6. DESCRIBE PROJECT BRIEFLY: {� 7. AMOUNT OF LAND AFFECTED: Initially �OZ� acres Ultimately �'a S acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? es n No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? RResidentia' C Industrial ❑ Commercial ❑ Agriculture ❑ ParkJForest/Open space ❑ Other Describe: 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING; NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? MYes C1 No If yes, list agency(s)nnand, ppermitlapprovals %CNS� /'`4 Sol-% II. ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? �DOES j9Yes ❑ No If yes, list agency na a and permltlapproval sue,. / ., ; o c�...� .w�f.1/-& �jQcP 0A 4ut/'A4a,�V� 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE i UKr 1C c-�Q' Date: Applicar,Usponscr name: Signature: Q ry.. If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this 'ssses`sment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT.(To be completed by 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 A410 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 Y_]iVb 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 orpflooding problems? Explain brlefly xz w' 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: • s 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 /U� C5. Growth, subsequent development, or related activities likely to be induced.py the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified In C1-05? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes AQ 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'slgnificant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a posltive 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 Title of Responsible officer Signature of Responsible Officer in Lead Agency Signature of Preparer (it different from responsi le officer) Date #3A Mal �Pyar' pla.l APaar AfgAl Afu r AP-2,�i AP3a f ya r�L%P IWa8.3iD fwa8ya MULL ' �x 16 PO TNAl�I OUNTY DEPARTMENT OF HEALTH HOUSE PLANS APP=ROVED FO BEDROOM COUNT ONLY, r%nr r11 AM ALL SUBSEQUENT PEVT.SiO` IAL ,RATT',OPTS TO THESE HOUSE PLANS MUST BE SURINUTTED TO THE PCDOH FOR APPROVAL SIGNATURE & TITLE DA E PRELIMINAR t Rd ��s� ti y 4:2-5-63 r a �o �O A SECOND FLOOR PLAN PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, BEDROOMS ALL SUBSEQUENT REVISIONIALTEitATION S TO THESE HOUSE PLANS MUST BE SUBMITTED TO THE PCDWq- FOR APPROVAL SIGNATUIiE & TITLE I DA E s a L t y G. � m c r _. PREL1 s �� ' �' �, �� 3 ° 4 3' �� , � ,__ 0 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 House Addition/Replacement Guidelines ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health 1) The Putnam County Department of Health must review all proposed additions, which will result in an increase in living area. A) Any addition which is considered a potential bedroom requires a formal approval of plans (Construction Permit) by the Department and plans are to be prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code, unless system is presently designed for proposed number of bedrooms. Plans will provide for the installation of additional and/or new sewage disposal area meeting rp esent code requirements. B) The determination of whether a proposed room addition to a house is considered a bedroom will be made by Department staff based upon: - location of the room in the house - size of the room 1. Accessory rooms such as dens, libraries, studies, computer rooms, offices, sewing rooms, etc. may be considered potential bedrooms. 2. Large bedrooms, which may easily be divided by a partition wall, may be considered two potential bedrooms. 3. Storage areas or unfinished portions of the addition may also be considered potential living area. C) Any addition which is not a bedroom will require the submission of a plan prepared by the property owner (to scale) showing the entire house floor plan existing and proposed. The determination of what constitutes a potential bedroom will be made by Department staff (i.e., an office 8' x 10' may be considered a potential bedroom). Once the review has been completed the plans will be stamped noting the number of bedrooms, including potential bedrooms. If the number of bedrooms remains the same as existing, no further expansion of the sewage disposal system will be required. If however, it is determined that any increase in potential bedrooms is proposed then refer to "A" above. A letter from the Department will be issued indicating total number of existing bedrooms and no expansion of sewage disposal area will be required and any other permits or variances required are the jurisdiction of the Town. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 r,Supply Section(S43�22-5--a486— Fax - 045) -223 -3418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 r 2) The Putnam County Department of Health will allow the replacement of an existing residence utilizing the existing sewage disposal and water supply for the following reasons: A. Hardship due to fire or other .catastrophic event. "';�B. Dwelling has become a hazard and risk to human health of safety. C. Case by case request approved by the Commissioner of Health. The applicant must comply with all of the following: A. Septic system operating satisfactorily. B. Potable water supply meets bacteriological standards. C. Square footage of replacement essentially same as existing structure. D. Footprint of replacement essentially same as existing structure. E. Same number of bedrooms as existing. Note: Definition of what constitutes a bedroom will be made by Department staff using same criteria in House Addition Guidelines. F. Approval by local town building and zoning laws. Note: any increase in square footage of dwelling or increase in number of bedrooms requires formal submission of plans from licensed engineer or architect meeting present code requirements. Revised July 2006 kly r SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health ADDITION APPLICATION RESIDENTIAL ONLY STREET J/S'AC1Y& -V J_ /AV- ls�p* TOWN TAX MAP03- d NAME " c.� Z1_?'06-XJ PHONE p y� 1_74e' / �o "9CHD# MAILING ADDRESS �� %l%G /�laJd.S 1&v DESCRIPTION OF ADDITION NUMBER OF EXISTING BEDROOMS _PROPOSED # OF BEDROOMS d (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) * *Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 -6130. 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #) *Non - professional sketches are acceptable 4. Copy of survey showing well and septic locations to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 W2ter Smpply- Section (845) 225 - 5186- Fax045)-225,54-IS Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Town LeLyal Bedroom Count ROBERT J. BONDI County Executive Re: (Owner's Name) i Tax ap #: Address: Town: -A �'° . Year Built: o2a;2d / According to records maintained by the Town, the above noted dwelling, is in compliance with Town Code. is not in compliance with Town Co je. The Legal Bedroom Count is: This information has been obtained from: Certificate of Occupancy: K Other: Building spector Date ` ronmeri aT'Healtb r84�Z78 fi3Tr'Fax 45f2'1$7�J2 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 154 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Shawn Rogan and Marianne Burdick 215 McManus Road South Patterson, NY 12563 Dear Mr. Rogan and Ms. Burdick: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health August 18, 2008 Re: Addition Approval — A- 145 -08 No Increase in Number of Bedrooms Burdick/Rogan at 215 McManus Road South (T) Patterson, TM # 21-2 -70 This Department has received and reviewed the plans for the proposed addition at the above mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from the Department dated August 18, 2008. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at two Q without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be water saving devices (i.e., new low flush toilets, restrictors for shower heads and faucets, etc.). 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not obtained proper approvals. Any permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Michael J. Director of MJB:kly cc: BI, (T) Patterson Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, BEDROOMS ALL JUBSEQUENT REVISIONIALTERATIONS TO THESE HOUSE PLAYS MUST BE SU "ITTED TO THE PCDOH FOR APPROVAL DATE APa1 TO GOOE ' '6N_H OPTION _ *:fCI I $ STEPS. LAN�Inta. M1M HAIORAIL - CY PI.RGHASER Ff TYP OF 2 ...._ .. . <I G i.mUS1 5p _P. DECK OF DALGOHY . SQNKOOM �EIJSE CEU A - -� - -- 9' -II 311 I R' -0 V4' . F-3W- FM4J AP FWH71685 v43 WOLr rW2632 A r 7Q- - �F,.,M w�/ 5af CLOFE DINING ROOM KITCHEN MUOROOM � ®®' a I/a. 5' -6 V4- p' -6 V2' J -J' 24 -5 - EDGE of ;.OFT ADOVE .. n ',. STORAGE I ., 6x6 P.T. SLPPORi POST -•. 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JL� ,C,(7E rr�. r Ce w*6 R ID&E DEAN 41 2X6 BUILT -ur- Eve, POST .1 OETECILW -WIPE LOFT -SAIL TO LODE Z -'OhLH OPTION L 1,� PUTNAM COUNTY 1APARTMtNT OP REACH HOUSE PLANS APPROVED FDR BEDROOM COUNT ONLY, BEDROOMS ALL SUBSEQUENT REVISIONIALTERATIONS TO THESE HOUSE PLANS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL SIGNATURE & IT116 DATE 13 .ABLE WNLL' .Oul 1.1-rr-3 a3.- a - -4-o