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HomeMy WebLinkAbout0845DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25. -1 -9.6 BOX 9 I�yL :� { Ir J I I 9 11 ''� r r : Z�.�, ti 11:� PUTNAM COUNTY DEPARTMENT OF HEALTH - - DIVISION OF ENVIRONMENTAL- - HEALTH SERVICES -- CE IFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P- It -9 S Located at 1"O -4t-i Aca,e� LAr� Town or Village �0.-i-�r5x1 Owner /Applicant Name Shei tm M Lf5hat Tax Map - S. Block Lot 9 Formerly. N[QCGt DeVetW rnent- Cc>rp , Subdivision Name CAr- gee- SA i J i' Sl bn Subd. Lot # (o Mailing Address (o par+f ; dae , Lane, o . t"I �A Zip t a�b3 Date Construction Permit Issued by PCHD Separate Sewerage System built by 6i - WJ . tPC . Address P0• Bm 5q. Consisting of Ia50 Gallon Septic Tank and 402- L F - A13S. Tr, Other Requirements: Water Supply: Public Supply From Address or.-____X_ Private Supply Drilled by wrm 6roS. Address 1ba BaHer PJ,i �bxb'V% (-T Building Type�'SiciPn-E-ia�� Has erosion control been completed? 1e5 Number of Bedrooms 4 Has garbage grinder been installed? I r) I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam Co un De artment of Health. Date: 3' Certified by P.E. Y R.A. Address i I brace ���. fQ� r es 9 fessionat) License # 516 I a� Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, ification or change is necessary. By: �P/✓� /`� Title: �l�LG I�G� "�=1'� �/1 Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy. - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Partridge Lane Town/Village: Patterson Tax Grid # Map Block Lot(s) 6 Well Owner: Name: Address: Custom Modular Homes P.O.BOX 411 Kent, Ct. 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 2u ft. Length below grade 18 � ft. Diameter 6 in. Weight per foot 17 lb /ft. Materials: _ Steel _ Plastic _ Other Joints: —Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No ILin er: 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 2 0 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) 225 Depth of completed well in feet 225 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 10 6 Soil , Grave l 10 225 6 Granite , Quart z - 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 Completed 9/30/97 Putnam County Certification No. Date of Report 10/2/97 Well Driller (signature) Wragg Bros. NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sneettpfan. Well Driller's Noe Wragg Bros. Signature: f(/ Address: 162 Baker Rd. Roxbur Ct. Date: c S' White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 i - � r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot C���� -`gym �' 1� �)�C� ✓ L(�CX• �ca.t'1P�CSb�1 . Building Constructed by Town/Village Location - Stre'e't Subdivision Name esJe-VA d I Cp Building Type 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: nt D Year lqqS Genera ontractor ( caner) - Signature Corporation Name (if corporation) Address: F. 0 - B&K Li 1 i - t e-ni- State �-r Zip Signature: Title: . - - C) � JN Corporation Name (if corporation) Address: q & �( 590, State tom,,;,"; ,� , tK, Zip ��SC�S Form GS -97 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Summons, M.D. Deputy Camnissioner of Health - FIELD ACTIVITY REPORT - Sheet 1 of INSPECTION NAME/ �J`_EI/GOP/'�IN i' G ©R+�� Orig. Routine Orig. Complain ADDRESS ✓1TT&?:S"a � lli Orig. Request No. Street Tawn TM No. _ Compliance _ Canplaint Canp MAILING. ADDRESS l 7 --�r HaL M fg R � /� �3 / Final P.O. Box Post Office Zip Code _ Group Illness _ Construction TELEPHONE `/ AI Reinspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED �/' Field Conference Name and Title Other DATE ;L/ TYPE FACILITYjU% TIME ARRIVED] 3p it%J TIME LEFT; DO p✓19 Wk AO Explain PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: AIIIA __ EWA / i .! 01 WWI v PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: AIIIA __ PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME /`'JAG.4G D�V�GoPiti /vT Go7ex�, Orig. Routine Orig. Complain ADDRESS ?A22Tr'Q1T�,c G,¢V,� PATTO —k30& �l�X o25 -1 -9, _ Orig. Request No. Street Town IM No. K Campliance _ Complaint Camp MAILING ADDRESS Yoe-N1 E S T D.AD f% L..MC6 . AI.?, ! Final P.O. Baal Post Office Zip Code Group Illness _ Construction TELEPHONE I'/z2/ - Reinspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED -41154 Field Conference Name and Title Other DATE 1/��� % '� TYPE FACILITY 4drAx,,�e `5,1�-,T9. TIME ARRIVED y✓ O TIME LEFT' j<<d - � Explain FINDINGS: - - �/ODl? G0{R9lYlPh�S rYlaeQP -I-a ��rti�� p�f^�ra/Y)ivia �o 101�1� /9'7 i�?- SU2c7� /� have ,b r 'I' tarwAl, W. i : / _ APO- , - / o + �. ,� ..tom i -• MOWN � • � ' � I TiI /lam � v INSPECTOR: S tle PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity.Report. SIGNATURE: 6/86 TITLE: TELEPHONE: a-7 3 0 SHEILA H. MARSHALL #6 PARTRIDGE LANE ` PATTERSON, NY 12563 February 13, 1998 Harry Nichols Laurent Engineering Milltown Road and Route 22 Brewster, NY 10509 Re: ,Septic- vytem._ Dear Mr. Nichols: It has come to my attention that there are several trees .which I are too close to the septic field for my house on Partridge Lane. would like to keep these trees and understand that the trees could possibly impact the system. Thank you. Sincerely, J. _ NORTHEAST LABORATORY OF DANBURY 39 -3 MML PLAIN ROAD - g DANBURY, CT 06811 L43S (203) 748 -7903 - FAX (203) 748 -0652 LABORATORY REPORT -- WATER SUPPLY. TESTING REPORT TO: WRAGG BROTHERS 162 BAKER ROAD ROXBURY, CT 06793 DATE SAMPLE COLLECTED: 2/12/98 TIME COLLECTED: 10:00 A.M. COLLECTED BY: GREGG M. DATE RECEIVED @ LAB: 2/12/98 TESTED BY: LAB #11471 REPORT DATE: 2/16/98 CT Cert: PH-0404. NY Cert: 11471 SAMPLE SITE: CUSTOM MODULAR, LOT #16, PARTRIDGE LA., PATTERSON, N.Y. SAMPLING.POINT: TANK SOURCE: WELL -NEW TREATMENT: NONE TEST PERFORMED RESULT: MAXIMIUM CONTAMINANT LEVEL BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml PHYSICALS: pH 7.33 no designated limit Turbidity 0.20 NTUs 5 NTUs CHEMISTRY: Nitrite N ND mg/L as N 1 mg/L as N Nitrate N 1.60 mg/L as N 10 mg/L as N Alkalinity 103.0 mg/L no designated limits Hardness 148.0 mg/L no designated limits Iron <0.03 mg/L 0:30 mg/L - Manganese <0.01 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 8.42 mg/L 20 mg/L ** L:,ad . <0.005 Ing/1" 0 .0i5 *** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED:2 /12/98 SAMPLE, AS TESTED ABOVE: MOTABLE or DOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) t. 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 March 17, 1998 Robert Morris, P.E. Putnam County Health Dept. 4 Geneva Road Brewster, NY 10509 RE: As -Built Plan Car Dee - Lot #6 Partridge Lane (T) Patterson, N.Y. Dear Mr. Morris: With regard to the aforementioned project, the invert elevation out of the tank and the existing grade elevation at the highest point of the expansion area are equal. It appears that approximately 60 or 80 lineal feet of pipe will be required to connect the existing . tank to the first expansion area trench end or center, respectively. 80 feet of pipe at 1.0% slope would allow an invert elevation into the first box of 559.7, or 0.80 feet below existing grade. In light of this information a pump system will not be required for the expansion system for this project. - - Kindly issue a compliance at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:TR:bd 94051 -6 G LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE I Route 22 8 Milltown Road /`I^11 II 1VI IVI� Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. V \ s CONSULTING SITE ENGINEERS March 17, 1998 Robert Morris, P.E. Putnam County Health Dept. 4 Geneva Road Brewster, NY 10509 RE: As -Built Plan Car Dee - Lot #6 Partridge Lane (T) Patterson, N.Y. Dear Mr. Morris: With regard to the aforementioned project, the invert elevation out of the tank and the existing grade elevation at the highest point of the expansion area are equal. It appears that approximately 60 or 80 lineal feet of pipe will be required to connect the existing . tank to the first expansion area trench end or center, respectively. 80 feet of pipe at 1.0% slope would allow an invert elevation into the first box of 559.7, or 0.80 feet below existing grade. In light of this information a pump system will not be required for the expansion system for this project. - - Kindly issue a compliance at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:TR:bd 94051 -6 G 9 BRUCE R. FOLEY 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 March 11, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed Compliance Macal Development Corporation Lot #6 Partridge Lane (T) Patterson TM# 25. -1 -9.6 Dear Nichols: 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." 1) It appears a substantial portion of the installed SSTS is within the 100 feet wetland buffer. Therefore, a Certificate of Construction Compliance will not be issued until this matter is resolved. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yours, 6a &, Robert Morris, PE Public Health Engineer IsIW PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREA'rMENT Sti'S'1'EM_S - REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION _ �Ic9/1V L t N L?9I V NAME OF OWNER ®1LDW 8P,dDk AZD j& LORI? REVIEWED BY RM, GR AS, MB, BH DATE 3 - 7g TAX MAP # DOCUMENTS PERMIT APPLICATION PC- I WELL PERMIT_ PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS THREE SETS HOUSE PLANS - TWO SETS iANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE If 1 FILL REQUIRED _� DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL LOCATED IN NYC WATERSHED -cRomv PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED —f-,X-APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME - 1969 NEIGHBOR NOTIFICATION ItffTER BI /ZBA YR. FLOOD ELEVATION Ol'I IER REQ'D PERMIT(S) —a I�� REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN- (NORTII ARROW) SSDS IIYDRAULIC PROFILE GRAVITY FLOW +hank EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE W- P•FJMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO .OF BEDROOMS trvtvt �6vke, 'Pl4t' PROPEUYMI:TIrS & @aLW -- 1Hrc:npiete HOUSE SETBACK NECESSARY (TIGHT LOT) IF OUSE 11 f% FT. 4 "0; TYPE PIPE . god A,,rd oui- o l( fur►k FILL SYSTEM ;LAY BARRIER 0- FT. HORIZONTAL;SLOPE 3:1 TO 1'SL SPECS Elm ILL C&&TIFICATION ILL PROT� & 'FILL IN EXPANSION AREA \ TRENCH LF TRENCH PROVIDED / 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSTS TV70 P.L. Amt LARGE TREES, TOP OF FILL 20' TO FOUNDATIONN ALLSt3'WELGTb 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. cxpan) 50-1'0 CATCI l BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 3mTrRmh i= 14 -,i,- ?ttAiNA- t 3rOUR,f -- 5ho w 6-o' 7�o y v I ,er �(r&;n rmd 200'/500' RESERVOIR, I' I'C. 150' GALLEY SYS "rEMS • CfOlVSTR ,ncor►1�iPi¢ CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <I% DESIGN DATA: PERC & DEEP RESULTS o CD discharge /100'with 182 cons day discharge T CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES, CUT I O' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES �TIIbIE1VSi0NSi O'PROPER rY�G71 —TITLE BLOCK; OWNERS NAML',AUDIZESS pE TION QFllLRVlC t7�SNNL'C[ -IONS TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING /REVISION 13 - C'o✓ 5� Ivry � Tv�o LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET =PROPOSED FINISH FLOOR AN< Br L` ENT COMMENTS- 0 T!r i n44r- i�xq Mewed �dI .AVA-ere- me -2o7y �ly.,u i� 9 g(oN , `20 -ORE .. _510, gi gF g u Z� -All .DI X 3 -APPEN x S4 ,%I -A' COU NTY DEPARTMENT -OF,' H tALTH -DIVISION-0-F ENVIRONMENTAL H EALTH SERVICES 'bj§0bS4L SYSTEMS, 'SEWAGE, WATER'S. INDIVIDUAL WATER, PLY,& SUBSURFAC E REV - SIJEET 'for 'CONSTRUCTION , PERMIT .00ATION '_—:NAq�E.bF.O.%k- ER U x P T MORRIS OTHER Q`' 11 - � 30CMEN ,T A MA LOW, SUFF-SIZ, SHOWN GRA 01T APPLICATION- S "s . B IF PC PE p wM 'ki PERMIT , I . 0W§ LET —lr_R 7-, TION. :SOLLTIO SET SET 'T' NVO S �UEST .77 Ll�DS-�,NLAX--B E S CL�xx`BARRIER' A L, an PO'CIT pf: �A w-n H B E�f Alf. ES- RTY -�.M 'NI f HOUSE SETBACK U- SEWER Ll�DS-�,NLAX--B E S CL�xx`BARRIER' HOR! PO'CIT pf: -------------- z�- R66M /1\, 200 E D S FT OF OPOSED SYSTEM R LOT) � E PIPE.. /C LE 'AS Y AD E -I-, VTO, 0 FL PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 2 Street Location IETRI D6E 4!10- Owner , Inspected by: ;-2_,00 Town /D,4 7-7 Permit # F - TM # h - I - 6 Subdivision Lot # 6 1. Sewaee 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 - 1,000 ....... .1,250 ........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1. All out ets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - properly set ...................................................... ength required # oo Length installed 3 9 2. Distance to watercourse measured -�- /00 Ft.......... 3. Installed according to plan ......... ............................... .4. Slope of trench acceptable 1/16 - 1/32 17foot ............. 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. Pump -or Dosed Systems 1. 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. 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.± 1 o o ' 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 & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 A10 - e- (' 'DUB -fo Me b r✓5h 4 G YES N NO C COMMENTS One eX4rd raw o f lai-t. 11- ,/ d d v icy No &cvx s " ghm� IT V C Called 4r 7 •ow 'n-i a1140 V ✓ " "'r u Dw P' re No ?v m P o 11 Do se °f2e V Y 133 a° u nab I e fo me vre b - - - Form - . 4 trea:6ure,4 d n ey, lQ1fiAN[ 0001r1Y D�ARi�E�T OF SALTS Dh lip �t �:w/d @ SanfeN Qo�el. °II:Y 153? $fK to Ai . .. . en Ci�1II�IG18 OF 0i MMM P®M IN =aWAGB DMOM SYS= bcabd r _.. : Stir�dd�n hififafa W N Tai MAP-- 'G�Hloek T Rm,!,el_ ❑ QevlaMn" : O Ora /ApOmd Nile SA P h� Dade of �preevioo App°"ai Mild bg Address 2 ����•N1�'�✓' cf'�(� Town t 1 � I-M` tj aF pC Subdivision Annroved �— �7 Fee Enclosed ®/. Am�;,rt4D. sLO. jd l G. sew vabtata TM la Aiia N*bw 1. Detlgt Fbw, G P D P ®NaUdcitliaid Regti4ed Whed F® la ca�pbtad S.P.ew sangp S�.a.:ft son" D s.pu� T. k SAW Ti M,atllAa �qd b� ' . Address w1sw Sa*!b Faiic Sap :Fta� Addrees aim Pd" Sop* Dead by _.Adilreei; Ofd ■egoYe�a�b I' represent; that 1 am wholly and Completely respoesible'for the desfon and location ,of . the' propoe*d system($) f 1) that the a rate .per dot 'feral •Rem above.described will be Constructed as shown on tiiiapptoved amendment than to and in accordance with the standards, rules an 1regu ns cdV4;a�i C County 0*1a tment of, Health; and.that on completion thereof a "CertffiCaU Of ,Construotion Compliance" satisfactory,to the Commissioner Of Health will bi eubniitted to the' Department, and 'a. written guarantee will t» furnished th*'ownw, his successors, hairs or' assigns by the bulkier,tMf..ia OulkNr will place in pod ,OiserafinP ewbltbn any Part. of. �pii »wall* dispasel system during the Period of two (2) yews Immediately following thedate of the Isw- on" of the approval of the Ceriifkete of, consUUctbn.-Coanplience of ah* original system or shy repairs t etof 2) that the drilled well described a600e will 'be located ea'ibare f apaowd Plan and that said well will tH instil in "aaccordanim with toe at ds, a and rpu ns : of • ' the Putnam County pepa`t f . Date a'T i / 3) ,. S Nnb . P.E. R.A. hens* No APPROVED FOR CONSTRUCTION: Thill4pproval xpir�s two years rom the date _i;u unkKS structton. of ten building lies been undertaken and U revoCabN for CauN'or may W amendeA or'modifi d won c6"dwed mc"iy by rthe Commisstomr 61 Health. Any change or alteration of construction requires 4.41aw permit ApprwVed for disposal of domestic sanitary sewage' w pr era ppy on . Rev. oat I, 9/° By g .. Title 10/88 y DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL P C H D PERMIT WELL LOCATION Street Address own Village City Tax Grid Number J1 WELL OWNER NAme ok Mailing Address 4 215 . /). Private JO Public USE OF WELL 1 - primary - secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT r gpm /# PEOPLE SERVED /t—/57/EST. OF DAILY USAGE S Sal O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY MNEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN ODUG GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES 7/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: G� Lot o . Co WATER WELL CONTRACTOR: Name, Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES // NO NAME OF PUBLIC WATER SUPPLY: 44 TOWN /VIL /CITY _..._ DISTANCE .TO_PROPERTY_FROM.NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ry ON SEPARATE SHEET (date) b s 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 thirt -y (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 su manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: A T/ 19 Date of Expiration 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 .... ,. , .. ..,w ,�,.<, _ . .. i . _. I i ti -� a New York State Department of Environmental Conservation 21 South Putt Corners Road, New Paltz, NY 12561 -1696 -(914) 256 -3000 - Division of Regulatory Affairs FAX -(914) 255 -3042 _. April 28, 1995 ATTN GREGORY MACALUSO PRESIDENT MACAL DEVELOPMENT CORP 175 E HOLMES RD HOLMES NY 12531 Re: Freshwater Wetlands Permit Permit No.: 3- 3724 - 00100 /1 -0 Town of: Patterson, Putnam County Facility Name: Car -Dee Building Corporation Subdivision FW /SD Resource No.: BR -3 Dear Mr. Macalnso: PERMIT MODIFICATION SIN DAY 4P 1s z m z Michael D. Zagata Commissioner In accordance with your consultant's written request of April 20, 1995, the above permit is hereby modified as follows: 1. To change the permittee to Macal Development Corporation, and 2. To extend the expiration date to December 31, 1996. All other terms and conditions remain as written in the original permit. Please attach this modification to the front of this permit (copy enclosed). MDM /LGB /btrnacaiuso.11r MMl) Enclosure cc: Law Enforcement (2) R. Wood S. Smith ti Nicho l s -- Laurent,-: Engineering Sincerely, Michael D. Merriman Deputy Regional Permit Administrator Region 3 •14-0 DEC PERMIT PERMIT NUMBER 3- 3724- 56 -1 -0 FACILITY,fPROGRAM NUMBER(s) NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Ak v r PERMIT • Under the Environmental Conservation Law Article 15, Title 3; 6NYCRR 327, a 6NYCRR 608: 328, 329: Aquatic Pesticides Water Quality Certification Article415, Title 5: Article 17, Titles 7, 8: Protection of Water . SPDES a Article 15, Title 15: Water - Supply Article 15, Title 15: Water Transport Article 15, Title 15: Long Island Wells aArticle `I Title 27: Wild, Scenic and Recreational Rivers Article 19: Air Pollution Control' Article 23, Title 27: Mined Land Reclamation N Article 24: Freshwater Wetlands N —New, R— Renewal, M.—Modification, C— Construct ('only), 0--:-Operate ('only) EFFECTIVE DATE EXPIRATION DATE(s) December 31, 1990 Article 25: Tidal Wetlands Article 27, Title 7; 6NYCRR 360: Solid Waste Management' . • Article 27, Title 9; 6NYCRR 373: Hazardous Waste Management Article 34: Coastal Erosion Management Article 36: Floodplain Management aArticles 1, 3; 17, 19, 27, 37'; 6NYCRR 380: Radiation Control PERMIT ISSUED TO PERMIT ADMINISTRATOR De ty Car -Dee Building Corporation Attn: Pat Carbone o % ADDRESS OF PERMITTEE New Paltz , NY 12561- 6 9 Quincy Lane White Plains, NY 10605 AGENT FOR PERMITTEE/CONTACT PERSON ELEPHONE NUMBER Laurent Engineerin Associates 7-cl�914) 278 -6108 NAME AND ADDRESS OF PROJECT /FACILITY (If different from Permittee) Proposed subdivision west side of Haviland Road south of Brimstone Road.: - LOCATION OF PROJECT/FACILITY COUNTY TOWN1(XT0%bXDt 1M UTM COORDINATES Freshwatei'*Wetland BR-3 � Putnam Patterson DESCRIPTION OF AUTHORIZED ACTIVITY Place approximately 330 cubic yards' of fill within the 100' buffer of the above wetland in order to construct drilling rig access roads and drill three wells; construct a stormwater.drainage outlet structure in the buffer in accordance with a preliminary sub- dated March 31, 1988 prepared by Laurent Engineering (last revised " Mardi 23 1989 and as conditioned herein. GENERAL CONDITIONS By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compli- ance with the ECL, all applicable regulations and the conditions specified herein or attached hereto. 1. The permittee shall file in the office of the appropriate regional permit administrator, or other office designated in the special co(+ditions. a notice of intention to commence work at least 48 hours in advance of the time of commencement and shall also notify him/her promptly in writing of the completion of the work. 2. The permitted work shall be subject to inspection by an authorized representative of the Department of Environmental Conservation which may order the work suspended if the public interest so requires pursuant to ECL §71 -0301 and SAPA §401(3). 3. The permittee has accepted expressly, by the execution of the application• the full legal responsibility foc all damages, direct or indirect• of whatever nature, and by whomever suffered, arising out of the project described herein and has agreed to indemnify and-save harmless the State from suits, actions• damages and costs of every name and descrip- tion resulting from the said project 4. The Department reserves the right to modify, suspend or revoke this permit at any time after due notice, and, if requested, hold a hearing when: a) the scope of the project is exceeded or a' violation of any condition of the permit or provisions of the ECL and pertinent regulations are-found; or b) the permit was obtained by misrepresentation or failure to disclose releventfacts; or c) newly discovered information or significant physical changes are discovered since the permit was issued. S. The permittee is responsible for keeping the permit active by submitting a renewal application, including any forms, fees or supplemental information which may be required by the Department.1no later than 30 days (180 days for SPOES or Solid or Hazarduous Waste Management permits) prior to the expiration date. 6. This permit shall not be construed as conveying to the applicant any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work or as authorizing the impairment of any rights, title or interest in /real.ar pi'tsonal property held or vested in a person not a party to the•permit. 7. The permittee is responsible for obtaining any other permits, approvals, lands• edssements and rightsoi•way which may be required for this project. 8. Issuance of this permit by the Department does not, unless expressly provided or, modify, supersede or rescind an order on consent or determination by the Commissioner issued heretofore by the Department or any of the terms, conditions, or r quirements contained in such order or determination. 9. Any modification of this permit granted by the Department must be in riting and at hereto. PERMIT ISSUANCE DATE PERMIT ADMINISTRATOR De ty ADDRESS 1 South Putt Corners Road o % William . St le New Paltz , NY 12561- 6 AUTHORIZED SIGNATURE ) 1 4 Page 1 of :06a ( 1186) -25c Wetlands )DITIONAL GENERAL CONDITIONS FOR AR..�LES 15 (Title S), 24, 25, 34, 36 and 6 NYCRR Part I>— ( Freshwater 1 ) That if future operations by the State of New York require an al- teration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense'to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be com- pleted, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. That the State of New York shall in no case be liable for any damage a, " tk the structure or :, ✓. k her in acahor._ c' .:h.,.h r•., :y be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right W compensation shall accrue from any such damage. Granting of this permit does not relieve the applicant of the responsi. bility of obtaining any other permission, consent or approval from the U.S. Army Corps of Engineers, U.S. Coast Guard, New York State Office of General Services or local government which may be required. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the proiect. 14. Any material dredged in the prosecution of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 15. There shall be no unreasonable interference with navigation by the work herein authorized. 16. If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 17. If granted under Article 36, this permit does not signify in any way that the project will be free from flooding. 18. If granted under 6 NYCRR Part 608, the NYS Department of Environ- mental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 197-7 (PL 95 -217) provided that all of the conditions listed herein are met. 19. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as pai&t of the permit application. Such approved plans were prepared by on 95.20 -61 (1:87)—:3c NEw.Y. STATE DEPARTMENT OF ENVIRONMENTAL CONSERV. .4 SPECIAL CONDITIONS . For Article 24 Freshwater -Wetlands ' d, 1. To satisfy the requirement of General Condition.No.l, the permittee or a representative shall. contact, by telephone, the Division of Law Enforcement in New Paltz (914/255 -5453) 48 hours prior to the commencement of any por- tion of the project authorized herein. 2. The permittee shall require that any contractor, project engineer, or other person responsible. for the overall supervision of:this',project reads, understands and complies with this permit, including all special conditions to prevent environmental degradation, 3. Prior to commencement pf any of the wetland buffer disturbance activities authorized herein a row of staked hay bales; silt fence; or. other erosion control measures shall be installed at the perimeter of the areas to be disturbed. This barri er to sediments (including well drilling slurr� is: to be maintained until all disturbed land is heavily vegetated.' , 4. As depicted on the approved plan and in accordance with detail sheets dated June 15, 1988 submitted with the permit application, the stormwater drainage outfall structure shall terminate with a runoff dissipator trench immed- iately precee'ded by a temporary sedimentation basin. As indicated,the latter shall be fully maintained until all exposed are fully stabilized. 5. All areas of soil - disturbance resulting from this project shall be seeded with an appropriate - perennial grass seed and mulched with hay or••straw within one week of final grading. Mulch shall be maintained until.a suitable vegetative cover is established_ 6. No disturbance to the wetland proper is authorized. 7. For any of the lots in the subdivision containing portions of Freshwater Wetland BR -3 or the adjacent 100 foot control._-area, the :deed _for­ each. such property shall contain a restrictiop as written below: "For as long as any portion of the property described 'in this deed is subject to regulation under Article 24 (the Freshwater Wetlands Act) of the Environmental Conservation Law of the State of New York (ECL), there shall be no construction, grading, filling, excavating, clearing or other regu- lated activity as defined by Article 24 of the Environmental Conservation Law on this property within the wetland area or 100 foot control areas as shown on the Final Subdivision Plat at any time without having first secured the necessary permission and permit required pursuant to the above noted Article 24. This restriction shall bind the Grantee's, their successors and assigns and shall be expressly set forth in all subsequent deed to this property ". If requested by the Department, the'permittee shall submit a copy of the deed of the first sale.for an affected lot to the.Regional Permit Administrator in the New Paltz office within 30 days of receipt of the request. DEC PERMIT NUMBER Continued on next page.. . 3- 3724- 56 -1 -0 FACILITY 10 NUMBER PROGRAM NUMBER Page of_..;• M 3161 (7'871 -25c NEW YL. STATE DEPARTMENT OF ENVIRONMENTAL CONSERVA. .,N SPECIAL CONDITIONS For Article 24 ( Freshwater Wetlands ) STATE ENVIRONMENTAL QUALITY REVIEW ACT Under the State Environmental Quality Review Act (SEQR), the project associated with this permit is classified as an Unlisted Action with the Town of Patterson Planning Board designated as the lead agency. It has been determined that the project will not have a significant effect on the environment. DISTRIBUTION P. Keller _ .Law Enforcement R. Wood J. Steeley f Laurent Engineering DEC PERMIT NU&ABER 3- 3724- 56 -1 -0 ;ACILITY ID NUMBER PROGRAM NUMBER Paae 4 of 4 FYJ'7C'N'A.M COTjW,3C- - DFF.A.R'TMFN -3C OF X -1:E:A X..'DCX-J APPLICATION_ .FOR- .APPROVAL OF PLANS. FOR A WASTEWATER DISPOSAL. SYSTEM 1. Name and Address of Applicant: q�o L.A 2. Name of Project: 3.._._Locatio,n(j�wC: 4. Project Engineer: W. IJIGN T- �-l- l.. 5. Address: MV29I =1% Oi16 10 4 .M i 4, PIN row License Number: X012 Phone: 21 _ lof of3 6. Toe of Pro ect• >I: - _ ✓ Private /Residential' Food.Ser:vice ..Coma ercial- Apartments Institutional Hobile Home Park Office Building :t3 ,.Realty Subdivision Other (specify) 7. Is this project subject t6 State Environmental - Quality Review (SEQR)? Tyoe Status (Check One) Type I.. Exempt ✓ Type II. Un l i sted 8. Is a Draft Environmental Impact Statement (DEIS) required? �.IU .9. Has DEIS been completed and found acceptable.by Lead•Agency? ......:.... rJ /� 10. Name of Lead Agency tt. Is this project in an area under the control of-local planning, zoning, ; or other off- cials;"' ordinances? ....... ............................... ti1d ,2. If so, have plans been.submatted to such. author .sties ?..................... /A `3. Has preliminary approval been granted by such authorities? Q/A Date Granted: 4. Type of Sewage Disposal.. System' Discharge...... Surface Water v Ground Waters 5. If surface water discharge, what is the stream class designation ?........ 1jIA 5. Waters index number (surface) ........ .......... ..................... . KI /h, I- Is project located near a public water supply system? .................. N U If yes, name or water supply Distance to=water supply , '. Is project site near a public sewage collection ar disposal system ?..... Uo Name of sewage system W/A Distance to sewage system Date observed: 2 23. Name of Health Inspector: 1.4r �1 A-;71.127 •.� 1 <<! i Project design flow (gallons per day) ..................................... g� 2. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.._ eJp 26. Has SPDES Application been submitted to local DEC Office? ............... ►.11A 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... r.)il 23. Wetland ID dumber ....... ....... .......... ............................... 0/4 29. -Is Wetland Permit.- required? ............... ............................... to b Has application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? +.10 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal',' - landfilling, sludge application or industrial activity? :....... YES or NO t,)0 32. is project located-within 1;000- feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or .............. YES or h0 I�)Q ' any other potential known•source of contamination? . ' DESCRIBE: 33. Is there a local master plan or file.xith the Town or Village? h. 34. -Are community water, sewer facilities planned to be developed within 15 years? U)JL1QA0.0 35. Are any sewage_ d- isposal.. areas in. excess o". 15%,* slope? 1,0 36. Tax Hap ID Number 37. Approved Plans are'to*'be. returned to: ................. App-licant - Engineer If the application is signed by a person other than the applicant shown in Item.1, the. application must be-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 know7edge and belief. False statements made herein are punishable as a Class A Hisder,eanor pursuant to Section 210.45 of the Pena 7 Lair. SIGNATURES & OFFICIAL TITLES: 'AILING ADDRESS: A •� t DI• . li • . t� +i� .`j�•�I•)�D!� \ /tCf'�uli� /Y: :1 : Y. 31, a . DESIGN DATA SaEET- SUBSUFACE._ SERAGE._ DISPOSAL _SYSTEM _ _ _....... FILE NO. Owner „A1 .Address L'( , l>LI�1zi rk,: 44r_S N Located at (strut) UC)C�-....LAWA _ _ .sec. Block I Lot O-Y d.iea nearest cross street) Municipaiity Pfr7'T6W_60IV Watershed, 6100 -rV AI SOIL PE� r A.S' cy = DATA REQUIRED TO BE SUFMITM) WITH APPLICATIONS Date of Pre - Soaking 5 27I Date of Percolation Test 5 Z-7 HOLE -- NLI.MRER CLOCK TIME P�tCOLATION PERCOLATION Run Elapse _ Depth to Water Fran Water Level . No. Tim Ground Surface In Inches Soil. Rate Start -Stop Min.. Start Stop Drop In Min /In Drop ° Inches Inches Inches 1 S:ZZ -6 -6' 18 27 3 (o 2 5: 2- 10 =03 27. 3 7 i 5 2 3 � 1 2 3 5 NOTES: 1.- Tests' to be repeated at same depth until apprcximately-egual soil rates are obtained at each percolation test hole. All data to'be suhmittlad for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 DEPTH HOLE NO. i HOLE NO. HOLE NO. . G.L. 2' - . 3' S (QTY L Arm 4' 51 SALTY SANTA :.. 7' 8 go - - 11' . 12' 13' - 14' - INDICATE LEVEL AT WHICH GROUNU ATEt IS ENCOUNTERED N P INDICATE LEVEL TO WHICH SKATER LEVEL RISES AFTER BEING ENCOUNTERED �1j9 DEEP HOLE OBSERVATIONS MADE BY: 640 c y4.a r, E �/ u zc� . DATE: /Z DESIGN Soil Rate Used %p --7 Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity gals. Type (,_-4 /V6. Absorption Area Provided By OD L.F. x 24" width trench Other Name 1 GH '" (� Siture gna s` ®° `( 1n) ) Dec? RI. .Address SEAL N SSfza eo THIS SPACE BUR USE BY HEALTH DEPAF27MIINT ONLY: Soil Rate Approved sq.ft,%� : Checked by Date i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date 1,7 6 Re: Property Of Located at k Section -Block Lot 6P Subdivision of f-j Subdv. Lot Co Filed Map Date Gentlemen: This letter is to authorize /4 --z a duly licensed professional engineer or registered architect (Indicate) to-apply for a Consttuction Permit for a separate-sewage system,.to serve the above noted property in accordance with the standards•, rule• or .'regula:t ions as promulagated by the Commissioner of the Putnam County D epa: rtm*ent 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'conformkty with the provisions of Article 145 or 147, Education Law, the •Public Health..Lai-*, and the Putnam, County Sani- tary Code. I Countersigne P.E., R.A., # No. 5E124 Very truly your Signed 01,7�of' Property Y r2- r-71 Address Address /°(141 2 _T8_ Telephone H ig Town 'Telephone Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE agNER APPLICATION FOR PERMIT. A PFLICAT•ION SUBMITTED- TO - .PUTNAM COUNTY HEALTH DEPARTMENT TO: Co 'ssioner of ealth - In the matter of application for represent. that .1 am an offi er or employee of the corporation and am: authorized' to act for, (name of corporatio ) having offices at `,2�� ' Khose officers *are President /�`ZOD" 7 ��C �� �% /T • /� �-�l, ' � — (Name and A- ddress) Vice - President ' '•� —^'_ -- '(Name and Address __ - -_ ^ ~`�� - -- • Secretary (Name and Address)— Treasurer' _ _ - — ^ —_ -- .(Name and Address} and that IL am-and will be individually responsible fon any' or all _apt¢ of. the- corporation with respect to the approval reques.te .rid -all .sub -` . sequerit acts relating thereto. Sworn to before me this q day Signed of � 199ij Title Notary Pabli I�MJ. DAVIS !!ommPET c,swtoF.,*,Ti m-tx REG.149953Z QUALIFS IN DiEFCN.MAUG. t( °^I Rfi' CCh,,W,& T4 Mir 12, jL ' Corporate Seal an. - v kk _ , -.�,.i •, , MOM t 1 t � • 1 i '.. 7-s4 p,iS�ON. -.NIS VL ^�; / ^ll r L F . C va -Z- m No ti w �.i r 4 .... � 1 - ` � � 1 It �. '.. i i. l