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HomeMy WebLinkAbout1438DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -25 BOX 13 01438 I rm a IA L.1 xia IN Eire. -44 1 Lem r r '- '�, r' ,. l JJ. T ' 5' 01438 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES EA YES N Internal Use Only PERMIT-# 1 FOO l Repair Permit issued in last 5 years El N in Watershed ®/Repair within Boyd's Comers, W. Branch or Croton Falls Res. ®'Delegated ©/ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 108 W 4Nnu, TOWN Pct4t e.CSor1% TM # 01 a OWNER'S NAME Ac-wL ,, r �X PHONE #g45- aag- oast' MAILING ADDRESS Ib�Z ; jev0 fir:lP Q-cx-c MP_� . IQ I2l, APPLICANT Name & Relationship (i.e., owner, tenant, contractor) // 11 DATE (p ° �j pdQ FACILITY TYPE L' IG1Pd r� a� PCHD COMPLAINT # kce PNINCo%>Ct CPROPOSED INSTALLER ► c�mf%A+ PHONE# 9Q0 -1dgt(oI(1P ADDRESS qr c-0C REGISTRATION /LICENSE # Proposal (include a separate sketch loca ing the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the pature and extent of the repairA n n.. /I n n I, as owner,agree to the conditions stated on this form �� SIGNATURE TITLE VAN krLQ - DATE (P 12Z (owner) tfie'septic insti 11 g72i'to- fnpl ' ith the conditions,of this perm it for the septic system, repair - SIGNATURE `.� TITLE t-,rr1 DATE d -3 O % (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro sal Approve Proposal Denied El (0 47? 4/0,q 'el laqlc 9, (7epair ector's Signature & Title Date Exp ration Date proposal is. in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 w- ww i. • M. JL X OCY 01. T :77 s �&ff: i;; . . — . - . . 4 V--- 7! 7-f ol S zw. -j Or% 41- CP; At ol S zw. -j Or% 41- CP; 1'2/ '04/2009 01:07 197:37646404 ALLCOUNTY PAGE 03/05 o PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 00n15,r%0A1 Cf%n 0=WA0%_e &WOWL-MA ff%ff_-r%AffF% AdWft %P41W %Poway F—wi."Mn,u W a $&in Wftnhed LJ 04r' _..-R;ip* wWn Bay0i Comers, W.'Bmxh pr'.Croton Falls Rio, W- Delegated .0 Rmk WO[n 200 ft of a,yamw mme or DEd4w pea vkmend'' Q Joint RWeiV SITE LOCATION 109 H i y :,j TOWN 'ruU'e S §&D TM 0 OWNER'S NAME PHONE # Sf-1.5 a�k IS ta5j MAILING ADDRESS �J;S�Ng �euz SZ�c : q e- 'C-c - .�, � APPLICANT al A�,5 - — 0W<%4ZC Nne & Rmaoonswp o.e.. &WW, terem. amtrac" i, as owner,agrbe to the ctmditidns: stated on this form SIGNATURE TITLE DATE (P lafo -'np h the rCofdjfl6hj-tf thK p6MjfftW th4-sspdC_5$jfteMt repair' -y TITLE Ca DATE ProR mood no allowing opoWms: I Procurement of any Town Permit, if applicable. 2, Subrniss In ottifi..bulit-rMalrditaft 'ptic sy&Wvr!nsWI9r within 30 of 2"mv WshowlM �h by the ft W,Jr�dq plical), a. OwrxOs naioe, Site Sheet N", Tqwn s'nd Tax Map number b. Location of Installed =nponents Oki to two fixed PoInI15 c. System description (e.g., 1250 gal, C,6ncrete septic tank, aft.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair Is'considerdd a best fit design and them Is no guarantee to the duration at which the completed 3STS repair will fUhc1lon. 6. No completed work Is tD be ba"ed until authorWillon to do so has been obtained Worn the Departrnent. IWERNAL USE ONLY Pro Appr 'Proposal Denied 0-1 In iOs Signature &, T Me Date I 'F_'jWcvon E* epair proposal is•in oornpliance with applicable codes Yes LN'Z No 0 COPIES, PCHD; Ovinen-Installer PC-AP 99ML Rev. 2/07 PUTNAM;COUNTY DEPAflTMENT OF HEALTH Wsloa of_Eovkonmental He�Ith Servioer,`Caemol, N.Y. 10512 C. Separate Sevrway.Sytltem bgflt by n K Addieee S�avl� . _ oe- Consisting of Ca11on Septic Tank and y est.GLf Water Supplyt Pabpc Supply From Address on %f' PH' 'Smi 7 Y Drlled you b Address N PP Balldmg Type hA a l Joi4� Lot Size QQ Has Eros io N ®ber of.Bedroome - .3 Has Garbage Grinder Been Ins �F EccLpNA� va Other Requinments - �S�V F PJ•� Gib 7 I certify that the systems) as listed serving the above premises were constru ,s6ntiaaTy t shoYtf th plans of the coapleted;ivorlt ( copies of which are attached), "and in accordance with the standards, rules and regal 8t( ac r cerivit►i! `e -f ed plan, and the permit issued by the Putnam County D tment Of Health. .. Data ? �'� Certified. DY P.E.. j� . R.A. . Address Al" � License No. Y0 23 0 Any, person occupying premises served by the atlovesystem(s) shill p omnptly take sash q��}�}tl»y�bFtt to secure the correction' of'any unsanitary conditbns resulting from such asps *Approval of dM separate sewerage system shall tmirDpl�,�jah as soon as a pubt;: unitary now becomes available and the ,epproyal of the private water supply, shall become null and void when a : r , pply becomes avallabie. Such approvals we subl et Lo lfwatbn. or cAange wheh, in the Judgment of the Comntiasaena of M h, such revotatbn; modifkation or chargs Is necessary, By Title 4 n' WELL UUr'1rLC,11UV mr -rumi * # DEPARTMENT OF HEALTH Division' O_r Environmental -Healfh Setvfces Y01 PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only = WELL LOCATION STREET ADDRESS: TOWNIVIELA171cily TAX GRID NUMBER: Windsor Oaks Carmel NY Lot #5 35,/ .2-2-5— '-2-5— WELL OWNER NAME: ADDRESS: Crompond Contracting Corp.,Box 451,Crompond,NY ❑ PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary 1] RESIDENTIAL O PUBLIC SUPPLY O AIR /COND.IHEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY UNEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 625 ft. STATIC WATER LEVEL 60 ft. DATE MEASURED 3/29/93 DRILLING EQUIPMENT J0 ROTARY Q COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING EkOPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH _?1_- tL MATERIALS: IS! STEEL O PLASTIC O OTHER LENGTH BELOW GRADE 20 ft. JOINTS: O WELDED ® THREADED ❑ OTHER DIAMETER 6 in. SEAL: ® CEMENT GROUT O BENTONITE 0 OTHER WEIGHT PER FOOT 1A lb./It. DRIVE SHOE: ® YES ONO LINER: ❑YES ®NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (1t) DEVELOPED? FIRST OYES ONO GRAVEL PACK O YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK In. TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST If detailed pumping METHOD: ❑ PUMPED t tests were done is in- I j[kCOMPRESSEO AIR ,formation attached? O BAILED Cl OTHER ; 0 YES O NO V_-ELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Pear. ing Well Dia- meter FORMATION DESCRIPTION cool tt tl WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Land Surface 1 Drilling in overburden clay & boulders at 1 625 6 540 5 1 21 Drilling in rock, set casing, grouted, 21 625 Drilling in rock granite. 4/8/93 Hydrofracked Well. WATER ❑ CLEAR TEMP. QUALITY O CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ❑ NO STORAGE TANK: TYPE WellXtrol 250 CAPACITY 44 GAT,. PUMP INFORMATION TYPE submersible CAPACITY 5 g MAKER Gould DEPTH 5T0' 0412 VOLTAGS:230 HP 1 WELL DRILLER NAME P . F .Beal & Sons n c . 50ATE ADDRESS 4 Putnam Ave . SIGNMODEL Brewster NY 10509 - J /toy v \ ` ' PUTNAM COUNTY DEPARTMENT OF HEALTH . , ..._ ......�. �_ - DZ,UISIODL OF. ENVIRONMENTAL_ HEALT H .SERVICES. ..._ _ ....» .�_ �.�,... 0 0fnA0 Al�> OJOV lv Owner or Purchaser of uildin ��� Building CoSnsstruc�ed by Iocation - Street �W�teA 50 Municipality / Lt Bui ing Section Block Lot �l c Subdivision Name Subdivision Lot # GUARAjgrEE OF SUBSURFACE SENMGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, materi<<1, 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 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 _._ " -Cerrt fieat,e_.oaf.._Cc,nstruction . Compliance" for. the sewage disposal._.W.sten, -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 Environinental Health Services 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 this ,.day o 19 Signature Title / o (�07.I0'QQT6a (_v Corporation Name (:.f Co ) 6 loOh/,d Address rev. 9/85 mk Corporation Name (if Corp.) Address Ju 1. 29 ,633 8 "58 N. RMER I CRN LABS TEL 1- 914 -278 -7754 P. 1 i NORTH AMERICAN ' LABORATORIES, INC. PSIS DATA SHEET TYPE: Pw LOCATION: Crompound Construction --- Windsor Oaks REPORT TO: P. F! Beal & Sons ADDRESS: 4 Putnam Ave' CITY, STATE, SIP:Brewoter NY 10509 DATE COLLECTED: 07 -20 -93 TIME COLLECTED: 3:451PM i COLLECTED BY: P. F� Beal REPORT DATE; 07 -2� -93 w SAMPLE ir 9 3 3.x.2.2 . • _ . -- SAMPLE SOVRCXs Lot 45 ANALYSIS DATE. UNITS METHOD ANALYSED Total Coliform MF Absont SM 17 (9215D) 07.26 =93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REOUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. MEN YORK STATE ELAP CERTIFICATION NUMBER: 11218 7 J n 2 J ' Y � a V FI y C p Q od cd o � O d q Ir m m m m '6 ,D O 93 0 O Cd 0 d 1 m U B (yp� ,- m a oa Y �N t- 0 Jv J O N -F IJ a� s N ° � a IL Z ? 3 w l . -e V.� i s Z '. ' Y � a V FI y C p Q od cd O d q Ir m m m m '6 ,D O 93 0 O Cd 0 d 1 m U B (yp� ,- m a oa Y � Jv J N ° � a IL Z ? 3 w l . -e V.� i s Z '. DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 .APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # P_6_Y� WELL LOCATION Street: Address Town/Village/City Tax Grid Number view Daiy . ARrr6zgs -oW :?--f, WELL OWNER r Name . Mailing Address U m PoA70 coo) ma ez --Aj co P, P, tiQr Jr- Fi4La .imrer ®,Private c3 Public USE OF WELL 1 - primary 2 - secondary ® RESIiDENTIAL O PUBLIC SUPPLY ® BUSINESS O FARM ® INDU,3TRIAL O INSTITUTIONAL ❑ AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY O ABANDONED O OTHER (specify, AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 0C? Xal ® REPLACE EXISTING SUPPLY O TEST /OBSERVATION M ADDITIONAL SUPPLY LrNEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR 'DRILLING kl e-w i46 U.S� FWLL TYPE DRILLED ®DRIVEN ODUG OGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES _X _NO IF WELL IS LOCATED IN A ]REALTY SUBDIVISION, NAME OF SUBDIVISION: 15 F T" Lot No. WATER WELL CONTRACTOR: Dame .B G A l_. Address: R EQ 5 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 ON SEPAPJiTE SHEET (date) signature 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 be contained on this property and in such a mEnner as not to degrade or otherwise contaminate surface or groundwater. �=" Date of Issue: °�2 - 19 Date of Expiration 19 Permit Issuin=ffi���� Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 6R 0 M PO A) p Address Located at ( Street Jf ( u &,-Ii} J)pi Sec. Block�Lot Indicate nearest cross Isree77 Municipality 779 TTe R sahj Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Elapse Depth to Water a er ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 ,2 3 4 3 4 5 Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2)' Depth measurements to be made from top of hole. TEST PIT EATA „REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO._ HOLE NO. HOLE NO. 6” 12" 18" 24" 30" 36•• 42" SCE 50,8 D U 151W 48" 54 60" 66" 7211 78t' 84" INDICATE LEVEL AT 1TjiICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO W IICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY Date DESIGN _ Soil Rate Used MMWJ "Drop:- S.D. Usable Area Provided '-5--o 'o D No. of Bedrooms -3 Septic Tank Capacity 1060 Gals. Type t¢<. Absorption Area Projn.de By L.F.xNll width trend . ' her Name Lt1l Signature Address •7-/?O Si+ L 9nS E L THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved_ Sq. Ft /Gal. Checked by Date Gentlemen: PUTNAM COUNTY DEPARWO- I T OF HEALTH -DIVISION'OF ji�TVIRONMENTAL HEALTH SERVICES Date 1-2 - ,- - >3 Re: Property of Located at }- ��<�1f�J /CLrI �Rl�� -pA-Tr So/J Section Block c._ Lot This letter is to authorize_}, a duly licensed professional engineer to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County Department Of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of.said ' sy`stein'or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. e s gned: P.E., �•, # R0Y / "9/,j (Seal) Address SEO rbr2A,�A� Cqt)a73.- 3 -377 elephone Very truly yours; Signed L, 0 r o Property V Address i •�� fir. 9C) Telep one pil.111 (111 VATA 131 , `"r -SHIMI M BLIM" LPL), v:iJua "O "'s ---- - �'.�' I1ddt�enn 1►wteal;� RidII�.l],.LLLY Road_r�r,.,,,� eelutl ut cUta -eat Fair Street Oe17o 77�_� � ` Uloulc • 1 Lot 21.2 �liiillcate ueaiee arum �GaeeG� 1, Iluttial �tllt Pad -son_ - - _ VU1L 1'EIIUU1.11'r1U11 'rl'S'r LY 1rA 11L U111LU '1'U 1319 13U11PIl'1 "1' 111'1'll 11I'1'L1C11'1'lUiiJ I1�11 it 'I rL11UUL1U11 1'Ll1UU111'1'lUll Pw 1111' CLUCP TIMID wCec-� iivel lilt' Lli3jiee• ' h. v �7at;ea� IWO '1'lmEt From urowid. Surface i.tt L c Ieen Roll I11l;n Start Stv Drop II Idist• /ltt drop L1Lua-t -ULop 1Uu• ( Inches lttcltas Inches lull n3 -2:33 3,3 it 21 23.5 2.5 �• �, - �� � • . 23 5 2 5 1� — 2 7.33 -3•Q3 3D 21 • 3:03 -3:33 30 1` I.! 21 23.5 2.75 10:9 _. �fi - • 2 • n4 -2.34 ' 21. 22 5 1 5 gn U 2•�a_3•n�� ",n 91 29 ^" ..,-r j 3:04 -3:34 :;0 �I, 21 , I i 22.5 225 1.5 20 • 11 tt e g 1) 'lbuty to be repeated at: enin® lept-h uIetil ent Bole.: e � u'nxln►ately e� 11`1.1 nS��. 11� daLu to be uut�mIL6o� Jaen at'u ubLal ue t eaol� eraglettiva` d t p e'lur a'ev eN• 21 W j,LI, P.I 111GELeua'eliiel1 td to be made '!'rom top or I101e'- Jill a, •• e• mrse e. ••....�..r•... —..e e...e o s wr.we ►.�..•:•••• 1 I1 •I� LA:JL-ZUX.L-LLJL1 W: LJ%JJ-LA:) LLI 11-AJ1 LALJJ-U►j DEPTH HOLE M. 5A I AOLE DO. 5B BOLE. M. G.L. Topsoil Topsoil 21 Sandy loam Sandy loam 41 61 71 101 12' 131 141 IMICATE: LEVEL AT 1-1111CII GROUNIAWER IS ENDOUNTERED N/A MUICAIE LEVEL 'M MUCH HATER LEVEL RISES PETER BEIM arotkrfam N/A DEEP BOLE CBS PMATIOUS MADE BY.- J. Eberle DATE: — 1/9/86 DESIGN •Boll ]Rate Used 20 k1i V/1" •Drop: S.D. Us'able Area Provided 5,000 Ila. of Bedrooms 3 Septic Tank Capacity 1,000 gals. Type Masonry absorption area Provided j3yi 429 L.F. x 2411 width trends Other I . .. Vane bojoILD CR 6 -7T'q signature looAArw BALDWIN & CORN91JUS, P.C. Ad&ess RD #6, R T F 99 SEAri BREWSTER, N. Y-,. 110509 SEAL 1980 '111hi— SPACE -ibR USE M IIEWill DEPART IUM ONLY IV Y J:.. ...... 00, Soil Fate approved •s4.f t,/gal.' Checked by f OF IvEIV b. &I JA 0 ay .j Date r%.— i pU']C`NAM t:t�UN'I'Y S�EPa4gtTP�Ei�7T APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER 5. 1. Name and Address of Applicant s . } 2. Name of -Project: Ld:� �� //�GG�//o`i/� <�.� 3. Location T/V /C: -4. Project Engineer: �/ ���1�/[�///+ _ 5. Address: uR P: At ' 7rro+ -1 ri Rpafet�.- � YAW License Number• �G L Phone: � /(/— ;2 6. Type of project: rivate /Resi dent ial Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject: to State Environment-al Quality Review (SEAR)? Tyne Status (Check One" Type I.. Exempt Type N. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. Has DEIS been completed and found acceptable by Lead Agency? ........... 0. Name of Lead Agency _ 1. Is this project in an area under the control of Iq;al 1 nnin zoning, �� ice► . _ _.__._... - -. - - - or ... other officials, ordinances? ......- � /,�... >,.._....._.... -4._.. 4 ✓� ... .. . � . 2. If so, have plans been submitted to such authorities? ............... _ 3. Has preliminary approval been granted by such authorities? Date Granted: 4. Type of Sewage Disposal System Discharge...... Surface Mater Ground Waters 5. If surface water discharge, what is, the stream class designation ?........ ;- It . R1 1. -5. Is State Pailutant Discharge Elimination System (SPDES) Permit required ?.._ ?6. Has SPDES Application been -submitted-td local °DEC Office'?' :: •`::Y•`� ?7. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... .4. Wetland ID Number .............. .............. ........................ .?. Is Wetland Permit required? ................ .............................r/ Has application been made to Town or Local DEI Office? .................. :0. Does project require a DEO Stream Disturbance Permit? ................... 4; Is or was project site used for agricultural activity involving application ^T CES�ICIdes orchards or oLner crops. sC'iC Cr idZ3r:Cl:c W2Stc d1SpQSa1, 12nQ1 -I ! i ir; s��d application or indust. :Iai: _ �iY i%y? YES Or NO J _5 c'Jec CC �=^ 'r! i �.. i n 1 , C'G0 Tcet OT exl S . rig- CT a ^a "G G': °_Q 1 anC- i 1 1 , ',ti St s i �e- t S�Cckpi le, landfill'. _! Cr j na= P.r�Ct:S " J 2n'f Ct, ^e' {Mcwn scarce C i con t_!:.m4: na t ; cn? .............. v Cr NO 2. _._ t om. a cca . ;pas 7=. p l an cr fi ie wit: i -car : r `! :.. __ ? J� r a 1 _� w i -n-;n 15 years? :�. Are Ccmmuni ty water, :ewe fac i i : l @S pid: ^inEd be d vS icPG -- _ Are. any.. sewage disposal areas in excess of 15' slope ?_.._ J :5. Tax Map ID Number ............................. .:`.7Appl r. ...... ... Approved Plans are to be returned to: ! ........• -•• ' ant Engineer If the application is signed by a person other than L scant shown in Item 1, the :Dplication must be accompanied by a Letter of Authorization. Failure to comply with this )rovision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Pena 1 Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: n cm P Irw A. �, ��j I� i�c o° m 1 o� I N9° R/VF t c r SCqL