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HomeMy WebLinkAbout0783DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. s ca n y o u rd o cs . c o m 631- 589 -8100 24. -1 -92 BOX 9 a NO it . �, ,1 rr ilrel go r7, ,f . r. I.g:. 1 . I �: ; 1 6 y�NO t�, }. - 11 h �� �� 00783 � Z do Rev 3 /8ti ' PUTNAM COUNTY DEPARTMENT OF.HEALTH ip Division o[ >risvironmental Health Servlceu, Ceimel, N ]f 10512 r. } Engineer Must Provide 3 Permit p •CERTIFICATE'0F CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEMA`2�p/J vr� own orWege �/ O � Tas MaP-�i�_: Block A Lot !Ii -� Forme Snbdivlslon Ngme Sabdv Lot p _� ' Ownei /applicant Name Mailing Address A Zip. Date``Perm# Issued - i. Separete'iSewernge,Syetsm bn1U'by Address Coaeletiog of �� Gallon Septic Tank end Aoe fJ Water'Supplyt: Public, Sap ply From Address. ors y Frlvate,Sdpply Drllled,by Address Baildb.i " Has Erosion Control, Been Completed? B? TYPO' Number. of Bedepoms �:. Has Garbage Grinder Been Installed? D Other _Requirements I certify thatthe systems) aslisted'servinq.,the above premises were. - constructed essentially-as shown on the plans.of the completed,work ( copies of which areattached);`'and ; in accordance with,the standards ,•rules.and•regulations, in accordance with the filed plan, and the permit issued by the Putnam. county Depaar►t/Aent Of li��esith Oats �' 'L�U J ! Certified by`_�L I 1 •`0�7 � s 'PA. Address 7 �iiM �l� �Lll� ����t3 � � License No. �ro ' -��-- cat- �------ � ---�� • Any person occupying premises served byAhe above system;(s) (hail promptly take such action.as may be necesary to secure the correction. of any unsanitary icondlf)ons resultinq,irom wch ;usage '.°A'pproval Hof she •separate - sewerage System -shall become nuwsigd_ void as soon as. a pubti:, sanitary aevver'becosnes available and the ipprovil. of -,the. private caster supply shill - become null and void ,When a public water supply becomes available. Such approvals are subJect`to modifieufion or chaannge when,•• in the •Iudpment of, thh commissioner of` Health, such revocation, modification or' change is; necessary. Oats /// �/ 11y Title h_ af-D CR ECc- 1 S_?° C_ C=am_ G 1L� cata rM LMS III to Fi -= Lc: E. cv-c e w =_ __= h- E_ L =_ I T I =1C' c�=-z c;-GIE _ \1 �cr C C_ C = =__GC 19" atc- Ic C=-cC= y- C_ 1i pi ces f'''� i W? �Z l:'�_C_ Cf I:c•- C_ i'.�.CC'_ ^.0 �_ °= C-= G':c =C° cT.vcV c:-==-.Er ` ' i I I i I I Ag D65 Fla - T ^<<= � -_= - -___= .C• LC L! n ,1,20 C- C- re _ 100 f t_ f =�.__= c: L. /'•vc_1 crL. ' t T ='_' -- Dry S:S _ =-c 1 ,ace ,� =�� 7�,,. L_ E'=TC �C t =r. :_ T -_c== cf c--: it t tee-! L" • i � Fi � � �� CCC=_ E- iG C-0° cLz w. = 10 T' c- c= c h_ af-D CR ECc- 1 S_?° C_ C=am_ G 1L� cata rM LMS III to Fi -= Lc: E. cv-c e w =_ __= h- E_ L =_ I T I =1C' c�=-z c;-GIE _ \1 �cr C C_ C = =__GC 19" atc- Ic C=-cC= y- C_ 1i pi ces f'''� i W? �Z l:'�_C_ Cf I:c•- C_ i'.�.CC'_ ^.0 �_ °= C-= G':c =C° cT.vcV c:-==-.Er ` ' i I I i I I Ag D65 C =_C� _' S' L �= _YC- C_Z a= f Y� - T ^<<= � -_= - -___= .C• LC L! n ,1,20 51- CC.c C= `=" C" c. e f_- = -- C-c e�L,- 1 '_L•':== =_C -`- £` �' CCT G i Er^=: c ' Ci • r C l•• % / cf c--: it t tee-! L" • i � Fi � � �� CCC=_ h_ af-D CR ECc- 1 S_?° C_ C=am_ G 1L� cata rM LMS III to Fi -= Lc: E. cv-c e w =_ __= h- E_ L =_ I T I =1C' c�=-z c;-GIE _ \1 �cr C C_ C = =__GC 19" atc- Ic C=-cC= y- C_ 1i pi ces f'''� i W? �Z l:'�_C_ Cf I:c•- C_ i'.�.CC'_ ^.0 �_ °= C-= G':c =C° cT.vcV c:-==-.Er ` ' i I I i I I Ag D65 PUTNAM COUNTY HEAL Brewster;;NY 10509 Received of Oor N 07 -06 -1993 10:44AM FROM LAURENT ENGINEERING ASSOC TO 2786085 P.02 -A YML ENVIRONMENTAL SERVICES :0.21 Kean Street Yn-rktowr+ Hoi 4hts, N.Y. 10598 ( 914) 245-2800 Albert H. Padavani s Di r estop LAP #: 93, 0077.3 CLIENT #: 1370 NON VAT PROC PAGE /rN•rHM•rAr /rl.wrN /INrrMAI 1IN NNIJNNI•H•/J •. /. /JN/r /I / /•INNNN•r NIINNNNI dNNNNN IIpN1'INNIIN/+ /I / /� /!'►•++. /�Nw/,. «w «... ALAN, Rl' j$8 DATE /TIME TAKENI 06/07/93 13:3 eYRAM LANE AL' PAf'E /TIME FEC*'Ds 06/07/,,,43, ARMONK- NY 1 0504 REPORT DATE: 06/10/93 PHONE: (914) -279 -5130 yAMPLINO SITE! COURTNEY LANE WE'LL TANK. SAMPLE TYPE..: POTABLE � � : PATTERSON, NY PRESERVATIVES; NONE COL' D BY: RQ5 a ALAN TEMPERATURE..: < 4C NOTES..,: N CJ COLIFORM META: MF «I..•r•r /IH•YI/ //II //r Ir/I IIIr Ir /r Nr�. /•_y•rN•r yrn♦ �r..• r• r•r_r•�•r.•r•r� LATE /• //..yy /y� /Ir•r •rNNNNNM /llr rJ /J •rW /.• /// J/ I•:.'!/! /! /J /r / /NN�J /ih•_ i; LAO -PROCEDURE RF- ULT //rN/I NORMAL - RANOE cn 4)6/ 101`9ti tqF T. C -CI _IFI IRM A4: "ENT /100 ML. ASSENT COMMENTS: B +CT TH1=S5- RESULTS INDICATE THAT THE WATER WAS .� , (WA::-* NOT) OF A SATISFACTORY SANITARY QUALITY A� CrJRCf I N►;� O THE NEW YORK STATE AND EPA F .r)ERAL DRINKING WATER STANDARD , FOR THE PARAMETERS TESTED, •AT ,fiHE TIME OF C:OLLEC -TION. r ,Q rn . rk IRA, C� c- � � rte- e rn >n 4. �rn r� N CJ < ,2f� cn �� •— s Y � r � z ., � � ' r .. rk IRA, n " l , k'fh'� �;•, K,yj l 4. PUTNPM COMP DEPAFM�ENT OF REALM DIVISION OF ENVIRON�NT HEALTH SERVICES Owner or Purchaser of Building Section Block t go ss ����. T4 c, Building Constructed by Coin 1'�, Location - Str MunicipalityJ} Building Type Subdivi ion Name Subdivision Lot ff GUARANTEE OF SUBSURFACE SENAGE DISPOSAL SYSM I represent that I'am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above'de.scribed property, and that- it has -.been constructed as shown on the approved plan or approve 'd amendment thereto, and in accordance with the standards, rules and regul9tions of the Putnam County Depa.rt:nent of Healtli, 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 izmediately following the date of approval of the "Certificate of Construction. Compliance'.' for the sewage. disposal system, or any repairs made by rme 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 Director of the Division of Environirental Health Services of the Putnam County Department of' Health as to whether or not the failure of the systen to operate ".'as caused by the willful or negligent act of the occupant of the building utilizi.11g the system. Dated this �r day of / 19 93 �oss Alan ov", lv_dA", 10A44 General Contractor (Owner) - Signature Corporation Name (if Corp.) a,5_6 4ft"'k Address Al-Y. rev. 9/85 irk Signature< Title P,L,ivt �..— Corporation Name (if C01 l.� • ) P ess ' 4 ' I ..i. WELL LOCATION WELL OWNER I NA WELL COMPLETION R.FPOk'C DFPARTAfENT OF HEALTH Division of Enviroruoe.rital Health Servtne >s PtITNA111 COUNTY 1t) ?PAR`rMENT (IF HEALTH )DRESS: wttt tL (I. ADDRESS; Office Use Only 7;/,, LAWERR; -19 PSIVATE PUBLIC USE OF WELL YRESIDENIIAL PUBLIC SU °PLY O A181CONO3HEAT PUMP 0 ABANDONED 1 - primary ❑ AUSINESS ❑ FARM CJ TEST /OBSERVATION 0 OTHER (specify) 2 - Second4ry O INDUSTRIAL ❑ INSTITUTIONAL 0 STAND -BY p MOUNT OF USE YIELD SOUGHT -S-- gpm. /NO. PEOPt.E SERVED_V _/ EST. OF DAILY USAGE 466) . gal SEASON FOR ❑ tE:P1.ACr EXISTING SUPPI,Y []TEST / OBSERVATION [JADDTTIONAL SUPPLY DRILLING . F34 SUPPLY (Nr ?J I)LdF;I.L1Nr:) �] L�Ehl'F :y P,XISTING WELL DEPTH DATA WELL Dt PTH �a45 It. STATIC WATER LEVEL _ ft. DATE MEASURED DRILLING ❑ ROTARY CONA�PRESSED AIR PERCUSSION ❑ DUG EQUIPMENT O WELL POINT © CABLE PERCUSSION �/ ❑ OTHER (specify): Q WELL TYPE ❑ SCREENED ^ O OPEN END CASIN ; OPEN HOLE IN BEDROCK O OTHER CASING DETAILS SCREFN, DETAILS GRAVEL PACK TOTAL LENGTH _.L-- t#. MATERIALS; STEEL O PLASTIC ❑ OTHER i,EtNGTH BELOW GRADE DlAtyi� EA_ _ ^ —�._ , fl. --- -- in. .JOI,NTS: O WELDED KTHREADED ❑ OTHER SEAL. 0CEMENTGROUT BENTONITE C]OTHER WEIGHT PER FOOT DIAMETER (in) !h. /ft. DRIVE SHOE YES C] NO LINa`rR: CJ YES NO t SIZE LF _ It) DEPTH TO SCREEN (ft) OEVELOPEO? FIRST SECOND `4.:Y` J GAAYEL o No j SIZE: � WELL YIELD TEST f?IEJHOD: O PUIMPED COMPRESSED AIR ❑ SAILED O OTHER W�flo EPTH DURATIG I hr, 'n, It detailed pumping t tests Nye; a dome is (n- formation attached? ❑ YES Q NO DFtAVXfj'>'N YIELD Prn Me, .. DIAMETER TOP 90iT ht ff p ACX �. in. DEPTH ft. OEM ft. WELLt LOG �� it more detailed formation descriptions or sieve analyses _ are avail2ble, please attach. DEPTH FROM ' Wale. W" SL'gFACF. __ Bear- Di3- FORf,MAMN DESCRIPTION Cut It. iS. i'ti9 rwer _ In �urt7Ct WATER CLEAR ^ . TEMP, — QUAUTY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO PUMP INFORMATION TYPE —.._ CAPACITY - ,IAKFR WDEL VOLTAGt —_ HP STORAGE: TANK: TYPE CAPACITY _ GAk. WELL DRILLER NAME ART M. HYATT & SONS, INC. lr> uat A O Well Drilling Rte. 311 R. R. 2 Box 171A DATE O �� V ly Sri v h THIS IS TO CERTIFY THAT THE SEWAGE DISfV' SAL, SYSTEM WAS CONSTRUCTED AS INPIGATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVE(ZED OVER, THE SYSTEM WAS CONSTRUCTED IN ACWKPA90E WITH ALL, STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNT`( DEPARTMENT OF HEALTH AND THE NEW YOKK STATE DEPAK -TMENT OP HEALTH . f��1!% NDU�✓� ?G;a'(,Orl �,o. EN rj?'OM 'l *U jzVei Or pizo P��`iY t�� L,a1 q " f7al�faI L , 2, 1 q9 If A;�r;n i,"�r" '1q yo 12 aq ( 4 15 (I2 THIS IS TO CERTIFY THAT THE SEWAGE DISfV' SAL, SYSTEM WAS CONSTRUCTED AS INPIGATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVE(ZED OVER, THE SYSTEM WAS CONSTRUCTED IN ACWKPA90E WITH ALL, STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNT`( DEPARTMENT OF HEALTH AND THE NEW YOKK STATE DEPAK -TMENT OP HEALTH . f��1!% NDU�✓� ?G;a'(,Orl �,o. EN rj?'OM 'l *U jzVei Or pizo P��`iY t�� L,a1 q " f7al�faI L , 2, 1 q9 If A;�r;n i,"�r" ,., `iNJi%1L� .. -1-c S1 a�e,,�,i24. Lot . Am M seetim Depth valae•e NOW at seia gene d Ded I Flow G P D gQ d CUD Nolleda,lloa kl Yeq When Pm oa�pMOad sqwnb,uliaw $pgNt d eeait eIJ�1 —Qa9ei Soptic Teak �d �w ' r B l� Address Ti M edisiaaebd b� . . Wad sop*: 'PaYeStlppb Fees' Address eeiPehab Sdeg4 D� M-- OIYs i r,praaentAhat I am wholly and complet iy nrponsible for the design and location of the proposed syshm(s)1 1) that the separate sew dl ft no at . stem above' described, will be constructed as shown on the app!" amendment there to and in accordance with the sbndarof, rules a regulations o County,' Oepartrhant of„ meafth, and thit'on complition,thoreof a:" Certifkate of Construction Compliance** ntisfactory to the Commissioner of Meakhwlll be. eibmlttad to the ;DepaAment.' and a written.guarantae will.ba furnished the owner, his wcasewN "WI or.assigns by the builder, that said builder will pl,ee in good pN►atun condltion.'any part of me awuasi dispotal system Ourirp the period of two (2) yaws Immediately following the date of the fasu- •nee oCthe 'approval, of'.ttle Certificate of Conirudtion codnptianee ot- t e Original systerdor any f"Wirs theratol 2) that the drilled well a.ad�ibed a6oee WIN• be locates as shown on the approved plan and that staid well will . Instal in accord, with the seta rose, ules and FORDS omens of the putMm County Depart of lseslth. SM� -- Addle h� license No APPROVED FOR CONSTRUCTION: Th6 aP0riA i axpkq two oars from the date issued unless construction of the building has been undertaken and is revocable for. cause or may be amaddea or modifled when considered ,neeessery by the Commissioner of Health. Any change or alteration of construction weOuNe�s/%a haw permit. pporf� disposal of domettk unitary swiigiand�tew w OtY only. Rev. �tQ/ '17 By 10/88 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # f�—J�3 WELL LOCATION Street Address / t,..OUrtinL To Village City Tax Grid Number e , INV f O WELL OWNER Name f 2d Y 4� Mailing Address w Private O Public SE OF WELL 1 - OF 2- secondary SIDENTIAL U EiSINESS 0 INDUSTRIAL C UBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE j�e gal E] REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION G'4 ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES &--'-NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: J Lot No. WATER WELL CONTRACTOR: Name �J3 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ J� NO NAME OF PUBLIC WATER SUPPLY: /VJ/9-- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET I (date) (si ature) cz 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 third- (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 otherwisk—c-orntaminate surface or groundwater. Date of Issue: /�'���`u` 19 Date of Expirat 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller s P*rT''i Oaury DEPARTMENT OF HEALTH­_., DIVIS._ . -'OF_ENVIPZRiENrM HEALTH SERVI( , DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Address Z st" /R/� rt %1 GA%f,� �D. 1 ')? '16,. //t A/Y.. /o So � ocORoA � � sec. . '. . Located at (Street) /V.. 2 2 �l (, E/ M R o A , / 9. Block S . Lot 7. Z (d (indicate nearest. cross street). 1 q �i�rrti Municipality /�1� TT�� v. �C . Watershed C1',) 7r,) ACV SOIL PERCOLATICN TFSr DATA REQUIPED TO BE SUPMI= WITS APPLICATICNS Date of Pre'-"Soaking g o l q? Date of.. Percolation -Test 41 8q HOLE 5 NUMBER CLOCK TIME /2: ¢ 3 Z o PERCOLATION 2 7_�,;_.. -- _._ PERCOLATION Run.... Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate 9 start-atop Min. Start ..Stop Drop In Min /In Drop Inches Inches Inches 1 12 :IS- 12:26 ,1/ 2¢4 27" 3 3.7 2 lz,z7- /Z:qG �l9 z4'' Z�., 3.,1 . 4 5 4 5 - 2 / 2 : 2 3 - /2: ¢ 3 Z o �.¢,, 2 7_�,;_.. -- _._ ...__3.;' 6,7 2 4 5 2 4 ;. 5 NXES: 1. Tests'to be repeated'at same depth until approximately equal soil rates.:, are obtained at each percolation test, hole. AU data to' be suh itted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST 'PIT DATA REQUIRED TO BE SUlilITTED.• WITH APPLICATION DESCRI' ON OF SOILS ENCOUNTWM IN 'M 0LES DEPTH ROLF, NO. A HOLE NO. HOLE NO. G.L. yI Idt]. 21 3' 41 51 61 71 91 10► VO V14 7,e—,f If. 121. 13' 14' INDICATE LEVEL -AT WHICH GROMUM= IS ENCOUNTERED INDICATE LEVEL To WHICH- WATER LEVEL .RISES AFTER BEING ENCOUNTERED ;71L1,5cj DEEP HOLE OBSERVATIONS MADE 'BY:— DATE: Z DESIGN Soil Rate Used min/ill Drop:. S.D.-. Usable Area Provided No. of Bedr . oans Septic Tank Capacity 12 -S gals. Type Absorption Area Provided By L.P. x 24" width trench N E Other Zst: ILLIA N "I -Voi Name S o (f Signatur Address 7-3 SEAL 0. 0451 Al 77zf� 2- S-6-3 LFESSk THIS SPACE: FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq;ift/gal. Checked by Date •sue PUTNAM COUNTY DEPARTMENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: 90-�f e Z� ze G 2. Name of Project: � �, ,�,� ss ni 3.._ Locationamc: 4. Project Engineer: ,0-_ &A. &a—, 5. 'Address: X/ . License Number: fi4121 Phone: a. CO 6.. Type of Project: _(G Private /Residential Food -Service .,..Commercial , Apartments Institutional M6bile'Home Park Office 'Building ; Realty 'Subdlv.sion Other (specify) 7. Is this project subject'to State Environmental Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted -z 8. Is a Draft Environmental Impact-Statement-(DEIS) required? ::.:...:..::. 9. DEIS been completed and found acceptable by Lead.Agency? ........... /U 10. 'Name of Lead Agency Al JA 11. ' Is. this -project ' in an area under the' control of•-local =planning; - zoning,..•° • or other officials, ordinances? ......... ............................... 0 12. If so, have plans been submitted to. such... uthori.tles?..._...._.. _.- .....:...:....... 13. Has preliminary approval -been granted by such authorities ? A/'�- Date Granted: ,.. 'fir ._- ° •: ` ; _ • - _ 14.1 Type of Sewage Disposal. System Discharge..`.... Surface Water __4/Ground Waters 15. If surface water discharge, what is the stream class designation ?........ ZAL 16. Waters index number (surface) ............................................ A 17., Is project located near a public water supply system? .................. 0 18., If yes, name of water supply /I/ / Distance to water supply 19., Is project site near a public sewage collection or disposal system ?..... 1110 26.'Name of sewage system AIZIL Distance to sewage system 21. Date observed: 7 23. Name of Health Inspector: 24.�Project design flow (gallons per day) ...... ............................... 0 C 25. Is State Pollutant Discharge Elimination System (SPDE S) Permit required?.. 26. Has SPDES: Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State wetland? ................... 9 .............................................. . A/0 28. Wetland ID Number ....................................................... 29.-Is Wetland Permit,required?�.............. ............................... Has application been made to Town. or Local DEC Office?* .................. 30. Does project require a DEC Stream Disturbance Permit? .................... A0 31. Is or was project site used for agricultural, activity involving application of pesticide4 to orchards or other crops, solid or hazardous waste disposal;`'`' landfilling, . sludge.appli cation or industrial activity? ........ YES or NO 32. Is project located within I-,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known-source of contamination? ..... : ......... YES.or NO /t/O DESCRIBE: 33. Is there a local master plan or file with the Town or Village? i f 34. Are community . water, sewer facilities planned to be developed within 15 years? Na 35. Are any sewage disposal areas in excess of -15% slope? ... i ......................... 36. Tax Map ID Number ........................................................... V-1, 92- 37. Approved Plans are to be returned to: ................. Applicant �Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must bey accompanied by -a Letter of Authorization.' 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: /Oc'