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HomeMy WebLinkAbout1322DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.73 -1 -34 BOX 12 01322 IVR T v I'6 r f� ti � h L N ,� '. 01322 ,. 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 # L.W 1) H0% 99444 PAM5�-% O Map 2L6-I f Block t Lot(s) JJ Well Owner: Name:-AHV'to -t(MT4 Address: 1,hQ Oy'� kA(z- t-IM -o e o POK*- j FLO94kL- Tit llcnjAm5 Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby v 6Ar-',fe Amount of Use Yield Sought r>+ gpm # People Served 15 ' N Est. of Daily Usage 4 oo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling pe ew AG©s c,�P/ — ��, o �" .•' Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes_ No tin'1X Name of subdivision Lot No. I- 4 Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No _'3t, Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate, sheet/plan. i°L�1�1�� Date: Applicant Signature:. c. LVA PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED.FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue a Permit Issuing Official: Date of Expiratio Title: Permit is Non -Tr s*rable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 n T'$; •, COUNTY DEPARTMENT F HEALTH Ti 8 11D ! ! "O rO ENVIRONMENTAL HEALTH SERVICES APPLIIcCA'lf'IION TO ABANDON A WATER WELL please print or type PCHD PERMIT # '� a Well ILocalfloen: Street Address: TownNillage Tax Grid # - ", � Map Block Lot(s) Well Ow meu°: Name: A r1w, LO Address: ?,o r PoQ • ftoW Ply- l �°� 1► +'���,5 Well Type: 2t Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Welfl: Residential Public Supply Air /Cond/Heat Pump Abandoned . I- pn°nmalry Business Farm Test/Observation Other (specify) T 2- seco®dairy T Industrial Institutional . Standby Water Well Name: Address: Contra Reaso® IF'oir . Abandonament `-M Cr1-0y6 TQ MG-Itk%owu IIDess> Apdom of Work To Be peirformmesl: eir� P// .,4"0 53, l/Li �t7` Date: \� Applicant Signature: #IA-A A MA PERMIT This permit, to abandon one water well as set forth.above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. too ssue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 '=/VI'L WE NIF' �JAI�I�LFj �VAGA.MT ) • �� TO 1vIF baN}6L� CVhGA r+F% X30': C. r ! AO LA FI" C, N M APVP o . N °C zl 1 I 1 I J H/ F f4 L_________J Mur+bol -' �uP. ME nT) f 1 pgr,G•E1IoN ELAVAT ION h J PFITAI L_ NOTES ° '- I . i3ONGKI;TV_ •jcX-*2 1'. °5.I a Z5 DAYS. O- i 2. ! t;Wf OKCGO KITH N° 3 ROD. 3. q° t'GKfOKATEO fJCEE CAST IN FLAGS . -4, \ }. H-10 LOADINr -. j ' OL.A 5. TKI GALLe-Kie5 TO I3r-- INSTALLED Lh VGt, `1 9 I !'IN. C-KADI5 IL`. 12 i J EXI'ITlr gT0.uG.T'u =E ic. B OEt�OI. -14 r+Ep -. j -IOOG GALLO nJ �. PEIZ.F- ry '1' J. ,/ !- y; �• ice$.' /lfjl eEPT:c TA-. - - -- 4 °A FEPF ?,a STl-D P. ?E�j 4 P-Ea' o �jplL. TO RE.f1A •Y l?E'W' -.BFI nfITer1 AND G�- 1¢T }IN WAIM 8a LF TR+•f.IPU.+:�'�'j C 10 f11 P.YI�oY •Yl>•�j I r� N _ REN nvEp A•..D REFL/Vg_ W / R°6 TDA (� OO-PT � OF -1 F'Er_T 111 WF", 'so YARDS nF y°IL 's, ¢�nr -f�wr5 of E- xlzrcw�. XarIG DISPOSED nF OFF�irrE - I-P of FFL— To yB Le,:E_ cvEiL G"- '.ER16S ' LAKE SHORE D o RIVE rC� i \ J� `L SITE T;TR r n A PERSON INTERVIEWED PC HD Canplaine # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal.of proposal from licensed professional engineer or registered architect. C a ,, Xz-'� , 4 W �.t- /tic C co IL-M J 20 0 W4J Zk3 %Lam► V :sCi./Z -�..Ms ✓G (,LL� i ('l1yYi•-P - Proposal approved Proposal Disapproved _T -a z/,,i, Ij Ah-lp )r's Signature &Aitle Da )roved with the followinq conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel) . e. Installer's none and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE, Lc, r e TITLE WM: WAbe (MV; YeUcw 03pm HU; Pink (Anliamt) DATE II Z• A y 4 Y� 1..-i - . I I I . - . - Cd it PUTNAM COUNTY DEPARTME OF HEAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 0/;& L-AY -E 5409 -E D4- ,J R Subdivision name PVTWN L(N' -EA Subd. Lot # �ti Date Subdivision Approved -� I" 1 ^,� l Owner /Applicant Name AW"I- '1' MN�-q WOFN i-0 Town or Village PAsT�i - ,Soil Tax Mapl-6'1� Block I Lot 0A Renewal Revision Date of Previous Approval Mailing Address U 5-:6�'r M VQ- 4T�LEIZ' Row- ?NK1 Hy Zip 11001-%W� 00 Amount of Fee Enclosed Building Type Pf-2 IDC HLE Lot Area • 10 No. of Bedrooms 1 Design Flow GPD 400 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of I zm gallon septic-tank and 'DO Lr- Tel" Ckk"4157 Other Requirements: y' U 6\L t:IV QF EN4 SS► K( r 01 L To XG ?VN cr —1 To be constructed by 1 Q�� Address Water Suuuly: Public Supply From Address Ior: );c Private Supply Drilled by...4 ._.r06,041, _ _ .. _. __ Address 4 I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Aa AA_,t� L I j P.E. X R.A. Date Address rn �� �� � - -� � 1 � o �o °t License # %14 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved domes ' ewage only. By: Title: `j `� ''� � Date: 4_�/7 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design P fessio al Form CP -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTA1L, HEALTH SERVICES APPLICATION( TO CONSTRUCT A WATER WELL please print or type PCHD Permit # dV r Well Location: Street Address: , Town[Village Tax Grid # LUE kOK 9pAge phml�600 Map 2, .1f Block I Lot(s)14 Well Owner: Name: AHTIAo t 61►.Ap- Address: 0 ;M5 v NI-0 51 ! FLOW, Tit 110oj Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served 'b - e4 Est. of Daily Usage 4 oa gal. Reason for X Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for (Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes_ No Name of subdivision Lot No. 1-1, W--IA-M Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No _3�, Name of Public Water Supply: °` Town/Village Distance to property from nearest water main: "-- Proposed well location & sources of contamination to be provided on separat she t/plan. Date:...�����1�� Applicant Signature:- A PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3). Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED_ FOR CONSTRUCTION(: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue Permit Issuing Official: Date of Expiratio Title: ­:S Permit is Mon -Tr's rable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. __ ._...... APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # AIA) .•3'o v Well Location: Street Address: TownNillage Tax Grid # a kK q(�vE �� Map,5,1�lock Lot(s) Well Owner: Name: xw�olq (rAQ -i ckwA W Address: 30 IF - P ` %Q W P te- 1 14110 -gym Well Type: X Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For Abandonment: TM- C-Lo E TO VASA A 0 WAA S ST�i Description of Work To Be Performed: ljl/ i��`7 C lv-� Gv.Dl`P Date: 'I Applicant Signature: v PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. /Dlt'e o ssue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller / Form WA -97 December 16, 1999 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Repair/Replacement 356 Lake Shore Drive Town of Patterson Dear Bill: Enclosed are the following: 1. Five (5) prints ofR -1, "Proposed Repair/Replacement," dated 12- 13 -99. 2. "Short EAF," dated 12- 13 -99. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 12- 13 -99. 5. "Application to Construct a Water Well." 6. "Application to Abandon a Water Well." . . V "Letter of Authorization." 8. Two (2) copies of Residence Floor Plan(s) for `Bedroom Count Only." 9. Review Fee in the amount of $100.00. We would appreciate your review, approval and issuance of the Repair/Replacement Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOICATES, P.C. Harry W. Nic 61s k, P.E. HWN:his 99065 I LAURENT ENGINEERING ASSOCIATES, P.C. IN 20 Milltown Road .— Brewster,NewYork10509 Harry W. Nichols Jr., P.E. (914)278 -6108 - (Fax)278 -2658 CONSuLn NG srM ENGINEERS December 16, 1999 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Repair/Replacement 356 Lake Shore Drive Town of Patterson Dear Bill: Enclosed are the following: 1. Five (5) prints ofR -1, "Proposed Repair/Replacement," dated 12- 13 -99. 2. "Short EAF," dated 12- 13 -99. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 12- 13 -99. 5. "Application to Construct a Water Well." 6. "Application to Abandon a Water Well." . . V "Letter of Authorization." 8. Two (2) copies of Residence Floor Plan(s) for `Bedroom Count Only." 9. Review Fee in the amount of $100.00. We would appreciate your review, approval and issuance of the Repair/Replacement Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOICATES, P.C. Harry W. Nic 61s k, P.E. HWN:his 99065 I 14.16.4 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 SEQR 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 /SPONSOR APT}}liN-ii" + H f•I2y (mi P- R -of-Ai-0 2. PROJECT NAME I PP- Va45ED e/:Pr-i REFNi L REpuXZmENT 3. PROJECT LOCATION: PMF 1 E {�CM � �O N Pv 1 N Municipality County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) �5b t-MW 5 Nroq*, D?414F 5. IS PROPOSED ACTION: ❑ New ❑ Expansion odlflcatlon /alteration 6. DESCRIBE PROJECT BRIEFLY: Pi►it.EMew j5e , FoP- d1 bp_ K,5, vEt-,z 7. AMOUNT OF LAND AFFECTED: C 't A't Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Cl Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? §QResldentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: �IHIA� „Aml� 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? MYes ❑ No It yes, list agency(s) and permlt/approvals TOV44 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? El �No Y03 If yes, list agency name and permitlapproval 12. AS A RESULT 0 PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REOUIRE MODIFICATION? C3 Yes Co I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1 w �1UA" Q6 As A (Ae14 Date: LI'b 1 Applicant/sponsor name: Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCR.9_2APrF617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes B. WILL ACTIO RECEIVE COORDINATED RE VI AS PROVIDED. FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved.a ena ❑ Yes ❑No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be Induced by 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. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it Is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show, that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documerrliation, that the proposed action WILL NOT result in any significant adverse environmental impacts -AND prl3qde on attachments as necessary, the, reasons supporting this determination: Name of Lead Agency .. P,.rinCor Type-Nam e of Responsible Officer in Lead Agency Title or Responsible Officer _.SignatwMof Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) CTE Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PJ ANS FOR - - A WASTEWATER TREATMENT SYSTEM 1. Name and;address of applicant: AMrRDHY Vsq LI ASR -©FA" 1p a, Po Qt %�- '�)TPZF-T 2. Name of project: ��� °`'�'; �' t�� 3. Location@T, V:Rs�� 4. Design Professional: �' �`ti'�'� �' 5. Address: 6. Drainage Basin: 7. Type of Project: Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality. Review (SEQR)? Type S:atas (check one) ....................... ............................... Type I Exempt Type II � isted X 9. Is a Draft Environmental Impact Statement (DEIS) required? Np 10. Has. DEIS been completed and found acceptable by Lead Agency? ............... NN 11. Name of Lead Agency P 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......'....... - a ............. .I.....:::::::.:.:::....:...... A� � ...... . 13. If so, have plans been submitted to such authorities? 14. Has preliminary approval been granted by such authorities? 'NN Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water Ll- groundwater. 16. If surface water discharge, what is the stream class designation? .................... N A 17. Waters index number (surface) . ............................... N 18. Is project located near a public water su * system? ....... ............................... Q 19. If yes, name of water supply . C4 N Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ o 21. Name of sewage system Distance to sewage system N 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) .............:................... ............................... 400 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 14 0 26. Has SPDES Application been submitted to local DEC office? �A 8/99 Form PC -97 2 27. Is any portion'of this aroject located within a designated Town or State wetland?- 28: Wetlands ID N umber ..... .... ................. .............. ............................... MA 29. Is Wetlands Peanut required? .............................................. ............................... G 0 Has application been made to Town or Loci? DEC office? ............................... 30. Does project require a DEC Stream Disturbanze Permit? .. ............................... �o 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste. disposal, landfillino, 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 �0 other potentially,knolAm source of contamination? ............................... Yes/No DESCRIBE: 3?. Is there a local master nlan on file with the Town or Village? ......................... tti 34. Are community water and/or sewer facilities planned to..be developed within, '• 5 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? �0 36. Tax Map ID Number .......................... ............................... Map Z51 Block r Lot 37. Approved plans are to be returned to ..... Applicant )� Desi&-.1 Professional "NOTE: Ali-applicators for re-view-and approval of G new- S STS to be located within the NYC ' latershed shall be sent to the Departmeni, and need not be seat in duplicate to the DEP, although the project may require DEP approval of the SSTS prar 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 sho =old 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. !.Aereby affirm, underpena�ty ofperjury, that infgrmadon provided on thas;for is true ;-Iq therhest of my knowledge and belief. False statements made herein are punishable as �q =Qd1 A misdemeanor pursuant to Section 210.45 of the I�enral p 1 �YV'- S,& O.1 FICUL TITLES: NISI - dots;: Malin"' dress : 9-0 i�}�(,Tmr►�► il' ..................... Harry W. Nichols P.E. 311 Clock Tower Commons Route 22 Brewster, NY 10509 Telephone (914) 279-4003. - - Date: J I�j_Ot3 To: PJob No.: � 1+ D as -- OZ-1. 00 Project. C- 1l��Ao !, "ention: DI W, I"I0)61 J Gentlernzn: We enclose (5) copies of: • 81W Prints O Reproducibles O Reports O Tracings • Specifications ❑ Memorandum O Copy of letter O Desvip'ion: P.eyision /Date No. fLAH Vi7. O'�-' ❑ 6;ueprin.er O Y:) _' i.; -2 eng-2 ❑Hind 0311;3 ^ / O Firs; Cross Mail Special cod I D Very L•u'y years.