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631- 589 -8100
34. -2 -21
BOX 13
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WE
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1I 3"'�
01435
Rev. 3�8p
1 r�
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
• Engineer Provide
Permit
P.C.H.D.
N --� —�
CERTIFIq�T CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL.SYSTEM
Located at
Owner /applicant Name
io or Village
Tau Map _ Block -2- Lot
Subdivision Named 474L.&- abdv. Lot IY_,L_
Consisting of Gallon Septic Tank and / Z .,*.' 1
,*.' .r i g � p� 1
Water Supply: Public Supply From /% Address
or: X Private Supply Drilled by ^1040 Zef Address
Building Type Z r2 �`� !� Has Erosion Control Been Completed? Ve-
Number of Bedrooms -Has Garbage Grinder Been installed?
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the lans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and req 1 tions, in accordance w th the f d plan, d the permit issued by the
Putnam County Department Of Health.
Date ���— gs /
Certified by �o P,E._ R.A.
Address ' A� . ' e- No. 5x/Z y
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 sewerage system shall become null and void as soon as a pubis: sanitary sewer becomes
available and the approval of the private water supply shall become null and void when a pyntle –wattil becomes available. Such approvals are
sub)ect to modification or change when, in the lament of the Commissioner of IHaftl% sy�et�r�irocation, Ifieation or change Is necessary,
'LT
� 4 Geneva Road (814) 278 -8130 -
`� Brewster,'PIY 10509
Ri�rciiinri •iif' . _ . /'�' _',.\ �l-ti.. .C1ii,7., z.(� .
S
-` v+ I✓+ IY+ 1✓ i,lY +.✓ +1✓ "�1✓ +1✓ +tY�l✓ +fYii✓ +I
i
y
i
+I✓ +lYUI✓il v +I Y DIY +IY +IV DIY'.
PUTIIP.M OOCiD7I'X DEPAPMaaqr OF HEALTH
ER`
__ . __. ... _.. .. OF .'S 'ICE� ^
Z�_`iN •�t.l I t�l Iv Chi I � � ... . .
O�,mer or Purchaser of Building
Building Constructed by
Location - Street
!�inic • rality �-
Building
Section Block Lot
f
-s-
Subdivision
t� -
Subdivision Lot u
GUARANTEE OF •SL'ESURF.A.CE SDLzLE DISPOSAL SXSTFI•i
s .
I represent that I am wholly and completely responsible for the loca -Sion,
workmanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it 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 Depart ent of Health, and
hereby guarantee to the <YYner, 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 i =.ediately following the date of approval of the
"Certificate- of Construction, Compliance" for -the- - sewage_.disposal,.syst m, 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 Director of the Division of.Enviroii ntal Health Services of the Putnam County
Department of Health as to wh4ther or not. the failure of the sysjte-n to operate w-as
caused by the willful or negligent act of the occupant of the building utilizin I
the system. AK 5 .
/.
Dated this S day of ` 19q3- Siam
Title
actor (0,�&r) - Signature
.11-M wm Pew
A.ddre sss I
rev_ 9/85
uric
Corporation t,(J�a (if Corp-)
Address /
4' WELL UUMYLETIUIV Lcr:rutct
* DEPARTMENT OF HEALTH
Division Of Environmental Health Services,
�� Y0� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
-
WELL LOCATION
STREET ADDRESS: W — IL 17CI I V TAX GRID NUMBER:
-
WELL OWNER
NAME: ADDRESS:
a
PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC UPPLY O AIR /CONO. /HEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY 1 O
MOUNT OF USE
YIELD SOUGHT &— gpm. /NO. PEOPLE SERVED �/ EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
❑REP CE EXISTING SUPPLY ®TEST /OBSERVATION [ADDITIONAL SUPPLY
(SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 7� ft. I
STATIC WATER LEVEL __I� ft.
DATE MEASURED -�
DRILLING
EQUIPMENT
❑ ROTARY ❑ C RESSED AIR PERCUSSION ❑ DUG
O WELL POINT RKABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED N END CASING ❑ OPEN HOLE IN BEDROCK O OTHER
CASING
DETAI
TOTAL LENGTH 3 ft.
MATERIALS: EEL O PLASTIC O OTHER
LENGTH BELOW GRADE f ft.
JOINTS: O WELDED DREADED ❑ OTHER
DIAMETER in.
SEAL: atEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT —I 7 Ib. /ft.
I DRIVE SHOE WffS ONO LINER: DYES VC
SCREEN
DETAILS _ .__ .
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ❑ NO
HOU95
SECOND
GRAVEL P
❑YES
GRAVEL
DIA
PA K
E��tt.�
OAt
DEPTH ft.
WELL YIEL9 -TEST ' If detailed pumping
r
METHOD: LIMPED 1 tests were done is in-
• COMPRESSED AIR , . ormation attached?
• BAILED ❑ OTHER ; ❑ YES O NO
�IELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
inQ
Well
Dia-
neter
FORMATION DESCRIPTION
coot
It.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Surface
S®
^,,
✓ 4
T
M
WATER EAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
0 COLORED ANALYZED? ES ❑ NO
ANALYSIS ATTACHED? _ ONO
STORAGE TANK: TYPE d PEf h7 PA
CAPACITY GAir. O
PUMP INFORMATION
TYPE S V e CAPACITY
MAKER S DEPTH _
MODEL • Fats VOLTAG --2 HP TO
WELL DRILLER NAME /Vy� I� �C�v OA E
ADDRESS R� ,� / dA Aor
c R o-a ,,
fC 1 •'
YMI_ ENVIRONMENTAL- SFRV I CES
321 Kear Street
Yorktown Heights, N.Y. 10598
(914) 245'2800
Albert H Pad
ov ni 0 , irectar
1-AB #: 93.011641 :CI-TENT #: 5669 NON STAT PROC PAGE 1
------------ IVrIPIIVN------- -------- - -- --- - ---------------------------------------
MALANCHOK, DENNIS DATE/TIME TAKEN: 12/05/95 09:00
BOX 313 DATE_ /TIME RECD: 12/05/95 10:00
CROTON FALLS, NY 10519 REPORT DATE: 12/08/95
PHONE: (914) -277 -3192
SAMPLING SITE: ZENITH CONSTRUCTION LOT 9 SAMPLE TYPE POTABLE
: PATTERSON KITCHEN TAP PRESERVATTVESt NONE
COLD BY." DENNIS MALANCHOK TEMPERATURE..: < 4C
NOTES...: COI._ I FORM METH: MF
NNN------- IV------------------ -- - -I4 - ---- - -- -- -- -------------------------------
DATE FI -AG PROCEDURE RESUI -T NORMAL - RANGE
12/08/95 MF T. COI_IFORM ABSENT
COMMENTS:
BACT THESE RF_SUI -TS TNDICATF THAT THE WATER (WA'
SATISFACTORY SANITARY QUALITY ACCORDIN i
AND EPA FEDF -RAI_ DRINKING WATER STANDARDS,
TESTED AT.THE TIME OF COLLECTION.
�C�G�
SUBMITTED BY:-.--- -----------------.-----
Albert H. Padovani, M.T.(ASCP).
Director
/100 ML ABSENT
P q ,(WAS NOT) OF A
_ THE NEW YORK STATE
FOR THE PARAMETERS
ELAP.# 10323
PUTNAM COUNTY.- DEPAEY�PT OF SBiCLTD _
11 Seev9o�a. Gael. N.T. low ; to FwYlae re..lt 0
agitutepirAn ;OF OO
NPSTRUCTM PIMST FOB SEWAGE'DWOSAL STSTEM
_h a* /iii do G�S/1�2.__.— �G
_._... .
Sabi�liw daibd. W 0 _� Tes limp �T_ Lsi4_
i',; OP50y oa6�.s
EeNewel_ a Iloaska o
Dmte of Pr0*, A fproval
J� A.I. 33 g No r� films i✓ RoeP IVY Tewb ZIP
rate Subdivision Awnroyed Fee Enclosed A,nn»nt
swlftg �es %, vii / Ls , 3,12-2— M . ..
"u �' Dep16 �_velsma %�4GY
Nsambu d Bedirea a �,_ Dea V Flow GI D' grime PLED Nom Reg dhm Wbm *46 asa 64W
Sopoeibit Snr1110106 Sp1a. a Comm aq / 220 G-sob Saptic Teak xma S l a-
Th be.esmok And.b7 � Addnm
Wotan S"*. PdAe SEEP* Fro® .. Adffi e
an 6001 . Pdvaft Supeb DdOed by
otwr
1 reprosent'.thst 1 am wA_ ally and: comPNtoly nspona0le ter tha dasgn and location of the proposed system(s); 1) that .the separate soar disposal atom
above described win be constructed as shown on thwapproved' amendment there to and in accordance with the standards, rules a regulations or
Mm
County Oepa►tnront o1 Haelth,,.and that on complation thereof a °Certificate of Construction compliance' satisfactory to the Commissioner of Health will
be submittal. to ;th.:Oopartinent, ind'� written quaiima*;witl be'furnished'the owner, his tucceesors; heirs o► as% by tAe builder . that Paid builder will
pbeo in goed..operN&W eondltbn'anY pelt -Z Z7 ewago, disposal system duiing' the period of two (2) years bnnNdiatNy followin/ tMdate bf this isau-
W49 ,ot. the ;appmi l �et ,the._Certq*ate.; of Construction compliance, of he orgiML system or any repv1s ther"pi 2) that the drilled well described above
wiN be located as shown on the approved plan,and that sell well will eo ." in • accordance w A the sa rd ' Ns and raouS oil ns of the Putnam
County ,Department of HeNth.
Date' Si Sig be
..
`i
P.E..'A -R1J1.
Adaa - License No 2
APPROVED FOR CONSTRUCTION. This approval;expiresitwo years from the date awed unless st►uction of the building has been undertaken and is
revoeabie for cause or may be amended or modified,whan considered,n"siry . _ issioner of Health. An ngo or alteration of construction
requires a permit. Approved for dispo.set of do Ic sanitary e,' only.
Rev. yQ
Oats Tit L
�,x��
10/88 -
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
:•_. _., -.. A PPLIi :AiG+N'`i�C-"%.Giv Sr- Fc- �-T� -s -�A - 'WAEit` W7 EI;L--_ - -; . , .......y .._ � �,�.�� .,.......�...,
PCHD PERMIT
WELL LOCATION
Street Address
Ffi' -
o Village City
Yso
Tax Grid Number
. °ot -
WELL OWNER
Name
Z�, o%�►
Mailing A dress
r 33 r ,
MPrivate
O Public
USE OF WELL
primary
- secondary
;0 RESIDENTIAL
D BUSINESS
D INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP D ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specifq
U INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT j_gpm /#
13 REPLACE EXISTING SUPPLY
jgNEW SUPPLY NEW DWELLING
PEOPLE SERVED 3-S /EST.
O TEST /OBSERVATION
U DEEPEN EXISTING WELL
OF DAILY USAGE �jcygal
12-ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
Alew we v Alw es 'off
WELL TYPE
DRILLED
DRIVEN
DDUG GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:�r Se� 5� °viSiy
Lot No.
WATER WELL CONTRACTOR:
Name
%��/j
Address:
.IS PUBLIC WATER SUPPLY
AVAILABLE
TO SITE:
YES >< NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DISTANCE TO-PROPERTY FROM NEAREST WATER MAIN: -- - -
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
�2ON SEPARATE SHEET
(date)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations a contained on this
property and in s a manner as not to degrade or otherwise face rou_ndwater.
Date of Issue • _ 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
�2 �C7"'� N.A_)`? C C:� .J N"'� �"• 7� � � ,E� S�.'T >`:C l� :::� 2' O � )�X �.P,_ �, 'Z':
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
A0p1`icant7_- =.r "-- ��' DZ.,.'
3 3
10. oi= Lead Acenct - 1
11 . Is this project in an area under she ccntrol of•iccal planning,- zoning,
or other officials,- ordinances? -
12. 1f so, have p-lzns bee en' . suc:- ii.tted to such, aUtho .r.i tie s ? ...................... _ 1/•
Ras prel ininary approval been :g.ranted by such _authorities? V0 Date Granted:
T ; :.�• ..... :
Type of Sewage Disposal :Syste_m Discharge,..... Surf ace .Water Ground Water:
I5. If surface water discha -roe, what is the stream class designation ?........
S. Waters index number (surface) .....................................
/. Is project located near a public water supply system? /lJ G
-1 yes, name o-Ir water supply ZYJ °7 Distance to water
'• Is project site near a public sewage collection or disposal system ?.....
0' 'fame of sewage system / V/*/ Distance' to sewage
'• Date observed:
23. Name of Wealth Inspector:
supply -
�G
system
v
• Project design glow (gallons per day) ..................................... 80
_
- L-
2.
Name of Project: 41- o
SS 3.._•- Locatio T V /C:
ti.
Project. Engineer:
r 5. Address:
License Hur-iiber: 5� l24
Phone:
,•
6.
T •�De of Project:
�' Pi iva; e /Residential
Food.Service ..Cor;;,ercial
: part �;ents -
Institutional L`obile ;- ;cme�Park
OiiiCe Building _y
Reaity Subdivision Other (speci�y)
7.
Is this. pc•oject subjGct'to Slate
Environmental Quality Review.(SEQR)?
T vice Status (Check One) - T yp:e. I..
Exempt
_ i ype. IT
Unlisted.
s.
Is a Or En,ifran :n rental 'T„ioact Stateiment,
(DEIS) required? ...
�(y
g.
.Xas DEIS, been co:m'pieted and • found'
acceptable by Lead Agency? ......... ..
10. oi= Lead Acenct - 1
11 . Is this project in an area under she ccntrol of•iccal planning,- zoning,
or other officials,- ordinances? -
12. 1f so, have p-lzns bee en' . suc:- ii.tted to such, aUtho .r.i tie s ? ...................... _ 1/•
Ras prel ininary approval been :g.ranted by such _authorities? V0 Date Granted:
T ; :.�• ..... :
Type of Sewage Disposal :Syste_m Discharge,..... Surf ace .Water Ground Water:
I5. If surface water discha -roe, what is the stream class designation ?........
S. Waters index number (surface) .....................................
/. Is project located near a public water supply system? /lJ G
-1 yes, name o-Ir water supply ZYJ °7 Distance to water
'• Is project site near a public sewage collection or disposal system ?.....
0' 'fame of sewage system / V/*/ Distance' to sewage
'• Date observed:
23. Name of Wealth Inspector:
supply -
�G
system
v
• Project design glow (gallons per day) ..................................... 80
2
5, Is State Pollutant Discharge Elimination- System (SPDES) Permit required ?.. /v o
SUDES - App ? 1- oa.tia.n,...beegr,,.uba,i.�teli
27. Is any portion of this project located within a designated Town or State �!
wetland ? ........ ........................................................ a
23. wetland ID Number ..........................................................
29. -Ts ;; ^,etland Pe m it • required?' .............. ...............................
Pas applicati~bn been made to Town or Local DEC 01 1 ice? ...................
30. Does project require a DEG Strean• Disturbance Pe mi, it? ... • .... - - -.. - - ,/VG
3i- IS or was project site used Tor acricul.tural activity involving application _.
OT Casticide5 to orchards or other crops, solid or hazard-Gus waste: disposal
filling, sludge application or industrial activi�y? YES ,or :NO
32: !s project located_-within 1;000'feet of eXlste.nc2.0-" abandoned` landfill,
hazardous waste site, salt sto6kpile, landfill, sludge- disposal site or
any other potential kncnn •s'curce of ccntanination? ....YES or I'0'-
DE C�1,BE: _
3.3. Is tnere'a local Waster plan oG 1 ile.-:4ith: the Town or Village? ..:.
-.34: Are co;;:rrunity: rate , sewer faci 1 ities plannEd to be developed within is years? v
35- Are any sewage disposal areas- in excess of 15-- slope?
S. Tax H, ap ID ,,u;:ber .......... .. ..........
37.. ;:pprcved Plans are' to' be returned to: "pp �l icant �/' Enginc
-T IF the application is. signed by a person other than the .applicant shown in Item •i, the:
pplication rust be•accc.��panied by •a'Le.tter o;= Authorization: Failure to cc.:-.-.ply with ttii
•:�roviSiOn r,-ay be grounds For the rejection of any suCa'llsslon.
X hereby a;;�ir7, under p -ra7ty o� peerjury;• that information provided on this `
on•.. is true to the best of my knculc�'ce and ,:-r 1 ieF. False statE;�ents rade
herein are punishable as a Class A Xisd�Aanor pursuant to Section 210.43 or' _
the Pena 1 Law. 1 �
>IGN;;;T DPES 8, OFFICIAL TITLES':
=:i LI1IG ADDRESS:
_PUTNAM COUNTY DEPARZYff�Nr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE_SEWAGE DISPOSAL SYSTEM FILE/ NO.
Owner Zee ',/2 V7 0 „ Y Address _3 l ►hr` �6 ✓�, �� .:./��Z, Ile �/
Located at (Street) 1yiq ? v�Pu/ �y� ✓P -rte N,°c�ss�:� Sec. . Block 2 Lot P-/
(indicate nearest cross street)
Municipality Watershed C va
SOIL PERCOLATION TEST DATA REQUIRED TO -BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking Date of Percolation Test
HOLE
NUMBER
CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water.Frcm
Water.Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start -Stop Min.
Start -Stop
Drop :In
Min /In Drop
Inches Inches
Inches
l
I
- 7
•i
4
s
NOTES: 1. Tests to be repeated at same depth.until. approximately -equal soil -rates
are obtained at each percolation test hole. All data to be submitted
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
mk
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
2'
3,
����T v
4, _
/D G tom-, IOG !ten
5'
6'
7.1
8'
9'
10'
11' -
12'
13'
14'
TNDICnTE T- "� EL AT HICH GROUNgA ATEP 1.6 /y
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used 1 / -/S Min /1" Drop: T S:D..Usable Area Provided
No. of Bedrooms _ L/ Septic Tank Capacity 1;?Se gals: Type
Absorption Area Provided By /2 L.F. x 24" Width trench -
Other
Name �� C✓, /y�c% '" Signature
-
Address SEAL
�'L`'� NICy
rid
w
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
No. 56124
Soil Rate Approved sq.ft /gal. Checked
by `:
�p0,!: -,�� e
PUTNAM COUNTY DEPARTKENT OF mHEALTH
Dade
Property of le*6) 1= 6: /"'g' / � 5/1 v1 024
Located 1Q
(T) section: - -_Lot_
'S 7?e
Subdivisio�-i of r�,
Subdv. Lot 4` Date
C'eatleme-n!
This letter is- '%'.o Sut"116-rize :147-
P. duly licensed profcssi;0n3l r,1329i.-It!cIr or ve,-x-stered architect.
(II, d i. C a
:t-0 apply for a Con.-jtj-ijc.-tjon -Pe.1-m; L for a separate se.fabe system, to.
Serve.--the. above: * noted ProodzALIV with -the standard-i ulef3
or regtxIatiozis nm promuloga led 1) v t3te Curnmissioner; of thEi'. Puicnam County:
Der,artment of Health, 11,-)* si.gn all iio.Cessary papers on My behalf in.
connection with -�hj$ and ro -*.uper-,Fise the Gonstruc.tioi'L of said
or
system or -c.v;ster�js il-L CorrEO-,-jjjj ty %�-j tll(-,. pl-Ovii sion--,� of- Article I
'1147, Educ'e".ion La -,r, the Pulhlie. Health La -v(, and the Put"natit. County S-Anil-
Code.
C 0 Unt L
e x, s i gn e &j
P DIE� , R. A
Addres
Or-51A
I+R4 11 1 4;:�;fz
_,Ar, - blo
ieZQphone
Von, tru
Si.Sned X
AdlOsg
6j A- I Al 1W,4 Z_ z--
To-mn'
Telephone
Nrnam County Depai-Ment: of Health
• Division of cnv5votirnental Sanitation
AFFIDAVIT - c6pPORATF, a,j,%4FH APPLICATION
FOR: CERMIT. XMICAT-101f
.FUTKAM COUNTY HEALTH DEPARTMENT
TO: C0nMi8E;5.onez, of Healt} In the matter of application f:or%'
pepredent,
that .T am an officer or er,,ipYoye_e of the corporii.tion and em, ixut)iOrlied
t act fo FFT, 8
o — — — — — — - �_Sq. V/ _AL'5��
. (»ame of corporation}
having offices at
L- Whose offtcers Are
F--
Ev w dame and d
Vlce-President
_CN_;z_rre acid Address'
secr,eitary IL
Tres carer
(Nam Q and Address)
and t;
,ba t I, am.- tm.d wall be in'divi6Ua7_3.y responsible foh any t' I 'aotpl
approval ' 't d .
of. the- corporation t•tith respect to the re qs sub-
L
seque'n't acts "relatlhg -thereto.
C� r� t this 4 C�X' 0 day Signed 5 1bl
a r
e
eot' any*
(,u t d Ub
d
q:_j 4 tle e� I
f 19 Ft
Notar Pu b 1 iQ'
NATALIEI•�,. COLLETTA
No Ti ARY PUBLIC StI.e of New York
No. 4i9300$':
()vaIjrie-d in Ulser C
Corpori.te Seal.
f
a IVY'—
Z/ L �e
w 1
ZQ
/ r
,z ' d
l
l2.0
9.0
20: 0
3
15.0
.195
4
`2/ 5.
255
5
28.0
32.0
6
34:5
3 9.0
455
8
475
53 0
g
54.5
60.0
lQ
.34 �
49:5
11
370
51:5
/2
42.0
55.5
/3
46.5
5B5
54 0
_... 65.5
/5
59.5
70.0
16
6'50
75.5
/7
/B
57.0
42.0
/9
E/. o
470
20
64.5
S2.0
21
69:0
5710
Z2
74Q
63.0