Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1688
DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -3.2 BOX 15 I 11110 1 IN I III ON all V W.5 1- 6 51 t rill - t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION, OF FNVIRONMENT.AL_HEAL,TH .SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGILIREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at &e3 Owner /Applicant Name LU L ( t 4 i Formerly Do V't E AIJI-L&IC Ci4rle- Y_ Town or age ea tfr_e i' d k Tax Map 3 Block Lot Subdivision Name r►-i 1 �it l�ri Clw�1c� Subd. Lot # S Mailing Address 4 P e rsoh It A o JCIL Zip / Date Construction Permit Issued by PCHD G, 117J2J r Separate Sewerage System built by '�'t e, ywb c k—le-V , {` Address 112 a Ay Consisting of 12-q'a Gallon Septic Tank and 4 0 1� t`` �"6 c`o rn 1`I c/1 .%vr kC' Other Requirements: C v V ch, P r4, t- h Water Supply: Public Supply From, Address or: Private Supply Day' Sy-c et.� o-1I Address 1Bui din- Tyre ' ' ` W, Has -erosion cor±rol been completP(1 ?.� r . Number of Bedrooms 'A Has garbage grinder been installed? Avd. 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 County ep ment of Health. � Date: I w Certified by c P.E. R.A. lDt>qgn �Address ,i/�, /� ` , ,,, �, �.l A rG ... ee ► q V License # / 3�� 24 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 ar ubject to modification or change when, in the judgment of the Public Health Director, such revocation fication or ge is necessary. By: Title: AX_ 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 CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM 0 PERMIT # Q cl 8 Located at 3 iq E Town or Village�prrey Subdivision name P���3° `$-�u L'��Llsubd. Lot # S Tax Map ' Block _Lot Date Subdivision Approved it Renewal Revision Owner /Applicant Name j,,,,/ r Date of Previous Approval Mailing Address Zip 12-M 1 GG Amount of Fee Enclosed OU Building Type x=. Lot Area 1, 8 6 No. of Bedrooms �_ Design Flow GPD 900 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and 6-67 X jO-Ev, a� , 1- Other Requirements: C v r a- a I., — 0 r'"t a ii To be constructed by a Address Water Supply: Public Supply From or: _ Pnvate supply Drilled 'by- . ; ': A' °_ s- Address 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: Address R.A. Date Q -1 J-- 9 9 License # 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 w co sidered ne essary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe roved f scharge of domestic sanitary sewage only. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 - Te —�rw J fj 7 /a�/Ft7 PUTNAM COUNTY. DEPARTMENT OF HEALTH IDIVISION OF ENVIRONMENTAL HEALTH SERVICES 0Q_1 FINAL SITE INSPECTION Date: -Gwner C� ATZG �c e Town Permit# TM # 5 ;t , Subdivision Lot # 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 S stem a. Septic tank size - 1,000 ........ Q5 0.. ..... other .......... b. Septic tank installed level .......... ............................... c. 10' minimum from foundation.'. .............................. d. Distribution Box 1. All outlets at same elevation -water tested........... 2. Protected below frost ............ ............................... 3. Minimum 2 ft. Original soil between box & trenc e. Junction Box - properly set ....... ............................... f. reT riches T—Fe—ng—th required Length installed 2. Distance to watercourse measured ®p Ft.. 3. Insta a o ing to ... ........................:. 4. Slo trl�ccepta 1 1 1.6 1/32" /foot....... 5. 10 ft. from pro _erty,line 20M.- foundations.... 6. Dept renc <3 i c �s fro �rf�lce�....... 7. Room e on, 00 0. ...... 8. Size o - v .', ' / - 112 diameter clean .............. 9. Depth of gravel in trench 12" minimum .............. _10, Pi..___._ capped...:... .... :.:. :......:.:.....:......:........ g. Pump or Dosed Systems Size ot 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.estirnated flow /cycle.... III. House/Building a. o�use located per approved plans .............. b. Number of bedrooms ..................:.....:��... 0 IV. Well a. Well located as per approved plans .......................... b. Distance from STS area measured 0 0ft...., c. Casing 18" above grade ...............: d. Surface drainage around well acceptable ................. V. Overall Workmanship a. Boxes properly grouted ............. ........:...................... r b. All pipes partially backfilled...................................... c. All pipes flush with inside of box .......................... d. Backfill material contains stones <4" diameter .... e e. Curtain drain & standpipes installed according to p f. Curtain drain outfall protected & dinto exist waters g. Footing drains discharge away from STS area........ h. Surface water protection adequate ........................... i. Erosion control provided ........... ............................... Rev. 6/97 �y �r� ELF( v16 7 L,F\ �T 4-q, I ) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM we P a- k,e,^ 3j-, -3 Z-2- Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Town/Village ICO Al ir) S A �h J Location - Street SubdivisioK Name 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: Month 9- j f5, -i i Day 11$ Year 1-1 `j General Contractor (Owner) - Signature Corporation Name (if corporation) Signature: Title: Zriyoej AO L-i Lf - 2� C. Corporation Name (if corporation) Address: -1-7 �, G� Address: patil ft� i State /��i Zip ( 2s-(e, State Zip Form GS -97 1 PROP-"4r:-o 100' i1v �y� �Vll 16 7?-f, �� 7 CZ a f —t1 -1777 U4.00r'l I r-Kul•l ct� rf 9 ClAn�`s �o OV /j;6 FCM 1?dwo lu 92787921 P.01 PRINCIPAL LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE / Rour* 22 & NkIlta N Rosd V , " Br*wseeF7Ni%V York WSW (914)2784108 . (FAX) 278 -2858 CONSULTING SITE ENGINEERS RICHARD S. CLARK ENGINEER LAURENT ENGINEERING ✓ �1� `„ G✓ O0 ASSOCIATES, P.C. MILL6ROOKE OFFICE CENTRE Route 22 d Mlftm ROSE Brewster, New Yom 1OW9 (9, 4)27t66,0e . (FAX) 278-2658 f/o UJ _ CONSULTING SITE ENGINEERS r C�l'rC - /-/ � Z*t;r � 1 / �� LFIELDC6WNSULTA R "IT E, JR. 7 — -NT LAURENT ENGINEERING ASSOCIATES, P.C. L4 MILLBROOKE OFFICE CENTRE _ r - Routs 22 & Mi town Road _._._ . _ _.. _: .....__...:._....... _....:_: ».... - _ Ce +�_.L , �_ . @rcw:;Or. M6xY;�rx ,J !f �� (914) 2784108 • FAX 2se -2858 Q Vi N CONSULTING SITE ENGINEERS T11 r,:: Ll 'lop TIM �i � A Z0'd "7H101 - I Q � J a� .... _.....r --. idr. 00V n�r,2 /,gRk`S joTS~ 'ROA) 015P W� 11 Off x FIV- 71 y. _ 1 0 4- .A ZO'd TZ6L8LZ6 01 WOS=l Wd99:00 666T -TZ -LO 0 401-0 WCZI7 1'49 4:9r perml I -/- zo * d _biol ;PUTNATM COUNTY DEPARTNTENT0KHEALTH ZT?yf! r_rr; ...... 71 "DIVISION OF ENVIRONMENTAL HEALTH SERVICES UMMS1 FOB FINAL INSPECTIQN For: Fill �a J Trenches—_.... PCHD Construction Permit 9" fba;s -4 P-4nz ;C& eta Located- Aj'6FzM 92AD T) 3_;j Owner/Applicant Name 4V 00 01� Blo L 4� ��_ SubdivisionName /_11Al2*Z Is system fill completed? Date 9-,-.— 7 7 Is system complete?_ Date 7,—,; -) 9 Is system constructed as per pl&W.' Is well drilled? Date (� ''� "_ �i Is well located as per pla&7 64FS' Are erosion control measures in Ace? J, & I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards. Rules and Rtgulations of the Putnam County Department of Health. 4 Date: Certified by: PE_ Disign'Professional Address 47?59A A A.14:�e Lie. # Comment s f5 ZO'd TF648LM 0i Form FIR-99 PUTNAM COUNTY DEPARTMENT .OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner a r j S fA PW0 61C (L-k Address %�I �/v� �� Located at (Street) J 9ji Tax Map Block Lot f(;nd* ate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test -7 /(6/ff ........ ..... .......... ...... . .. 'N': ..... ...... ....... ... ..... .......... FID's" T ........... W. ...... Q:'N Water From G dio�f.l ph" .... .. v ....... . pp I N i'o- e R .. ............ ..... .... ... ........ ... ..... .... ........ .. .. ......... to P �`��'-1 =� �� 3-�,� /� as 2 Pw -�:/j -30 3 X1 3 JO-2, SO 70 23- 2y Vy /� �� 4 2.1.3` 0 q3 2 1 5 V 1,21 11 1 -7 11 "t ---I 2 1: il 30 a3 -2� � l �� 20 3 _2 3 - 2 4 �2_5y- 30 01 27 20 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 f LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE. Brewster, New York 10509 j\ (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS June 17, 1998 Mr. Gene Reed Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Clarke Subdivision - Lot #5 Big Elm Road Town of Patterson, New York Dear Mr. Reed: The owner of the above - referenced; parcel, Patrick Clarke, is responsible for the repercolation tests under a purchase agreement wi th the future owner. The design of the system will be the responsibility of the purchaser. The existing well to be abandoned shown in the northwest corner of Lot #5 serviced the existing �t_# 41?' l3f '�1- t�lP•��1�Jd��nS ?r ?!�:! }IaS 3Y�1rol'Q•�, .T ..S �Vell.aV S&U' 3S`:d!y 3}'-.°... med an a^ - . __...__ new one drilled which .will service only Lot #5. Lot #4 also currently has a drilled well. At this point, we request that percolation tests be scheduled to be witnessed by your department. Feel free to contact our office at your earliest convenience to set up an appointment with us. Very truly yours, LAURENT ENGINEERING #4 0 LA Harry W. ichols, Jr., P. E. HWN:tr 89015 r� RECORD OF PHONE CONVERSATION Time: Date: Person calling: Y7 phone Reason Inspection- Weeps and/ , I er C(!! . - 2 - Scheduled Field Meeting .Pry S Time.- Date: Y N Tentative/to be confirmed ( ) ( ) Town:. rte, Road /Street �LzEI Tax Map #-, Comments: z 0-� �;` 0 5 J Brook ^V �P•' ? \ �K 0; 12563 1,4 7 64 CNIft 1-laviland 1 ti �, �f' ollowi } £ !' iMendel Pond 164 65 ames Corners F �, �, a tb •` , t l� 62 Qq 67 Ip PUtna g i f 'Lake rndJPn 4•:' rn c `..Lost f b jD xi: iu �= ,IBS +. Y 3teinbeck } ! 1 IPA& 3 Corners d ��t Lake .r•Fl.,�ne'i+fpn8yg 1 �harlcs yr Fri - O 22 1 . _ eraoTc -QeF r st _ lque Area tEbo �'` rf rs !ltd? Corporate _1 e HS 2 f Alt Corner .. pES $ S (.l 1lDs v Pond $ h 8 a ,. g Poi � ' utdoor ��. /' , rl / ! eer e�H� E � � � Center{' =.. � � Brewster - cC) M r, `�� }ir> Pond ° ss 441 ms ®Stale nOR CO O \ P 1 Q PAX - Police a a To: , Dew i, CT c tom. -e, v: �Q o Attention: A �-r My r r Gentlemen: We enclose OtAll Prints O Specifications Description: j copies of: ❑ Reproducibles ❑ Memorandum Job No.: Q d 6 3 C Project: r SS TS* ❑ Reports O Tracings ❑ Copy of letter O Iylt-,� ,ttS' ~s-(oy,l Cam►•- c������ �1' l...ahs�rU�>>�ti �a�m [c2v►c � Ts eel A cv Pevision /Dote No. r Sent Via: ASSOCIATES. P.C. ' - W-0--ur tile3senger O Elueprinler O first Class tAcil O Special Delivery O Your Messenger C Hand Delivery O Ro,.t• 2i& M-I`rr n Ra+d M-.. l Gfww%,•r Nwr Yoex Mscg < C U (214)2134 IC4 . (PAX) 2) }2•..d Y Very Truly Yours. CONSUt•TING SME ENGINEERS J 1-41JRENT ENGINEERINIa ASSOCI,TES,RC. i -�" M r:7C0 To: , Dew i, CT c tom. -e, v: �Q o Attention: A �-r My r r Gentlemen: We enclose OtAll Prints O Specifications Description: j copies of: ❑ Reproducibles ❑ Memorandum Job No.: Q d 6 3 C Project: r SS TS* ❑ Reports O Tracings ❑ Copy of letter O Iylt-,� ,ttS' ~s-(oy,l Cam►•- c������ �1' l...ahs�rU�>>�ti �a�m [c2v►c � Ts eel A cv Pevision /Dote No. r Sent Via: W-0--ur tile3senger O Elueprinler O first Class tAcil O Special Delivery O Your Messenger C Hand Delivery O �A M-.. C = < C COP'/ to: Very Truly Yours. �"� -.7., 1-41JRENT ENGINEERINIa ASSOCI,TES,RC. -a -�" M r:7C0 A"7 Par: DO M BEDROOAA 3. 13' -0'• z 10••0" r BEDROOM 4 9••8:' tt 12••0•' 48° DRESSING. WALK' IN CLOSET MASTER BEDROOM BEDROOM 2 OPEN 17'-0 n 16'•8" 11 0 • 15••s •' — - ,Pr. UTNA I COUNT' DEPAs TMENT OF HEATF FIOUSF. PLANS APPR, 'VLO FOR . f BE ROOM COUNT ON..Y; EP . IS SECOND FL0.0R � M 44SF ,; f r-,natAre & Title DUCU KITCHEN DINING ROOM p MORNING AoOAA (r( 13' 0'• a 12'.0- �- LIVING A0OM 13'.0- a 10•.0•. FIRS T, FLOOR _ o AB ,w Foy � : LC S+�l 1. • .� I""" Q m DRESSING. WALK' IN CLOSET MASTER BEDROOM BEDROOM 2 OPEN 17'-0 n 16'•8" 11 0 • 15••s •' — - ,Pr. UTNA I COUNT' DEPAs TMENT OF HEATF FIOUSF. PLANS APPR, 'VLO FOR . f BE ROOM COUNT ON..Y; EP . IS SECOND FL0.0R � M 44SF ,; f r-,natAre & Title DUCU KITCHEN DINING ROOM p MORNING AoOAA (r( 13' 0'• a 12'.0- �- LIVING A0OM 13'.0- a 10•.0•. FIRS T, FLOOR _ o AB ,w Foy PUTNAM COUNTY DEP. DIVISION -OF ENVIRONME TMENT OF HEALTH AL HEALTH SERVICES :.._..�., . rr TR rcrr N pERn Y�. _R =S. W PERMIT # �U C Located at *D I G EL-FA PAD a Subdivision name NN + Pft • C(A4-E Subd. Lot # '5 ,GE TREATMENT SYSTEM or Villaw_ PIi"r5�L644 5 • Block_"_�' Date Subdivision Approved 2 hq j q l Renewal Revision Owner /Applicant Name WUMA Date of Previous Approval Mailing Address 41 P #rreP�aH V(L L ,9' PAM EP-60N NY Zip M161 j Amount of Fee Enclosed � &D W Building Type 9,F7JPrNl.i5' Lot Area No. of Bedrooms 4- Design Flow GPD 606 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: GAR -TAIN pPWlN To be constructed by T•l��n, Water Supply: Public Supply From gallon septic tank and Address Address r :.:.. ..LP,riv;#6 Supt ly.Drillecl.by .Address 667 '-F 44 iftML14 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: Address R.A. Date q `l Ii ' 9b License #lo�'�- 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 pe pprove discharge of domestic san itary s age only. By: Title: ��tC Date: 1 L. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 "PUTNAM COUNTY DEPARTMENT OF HEALTH CONSTRUCTION PERMIT FOR SEW Located at 151 (A FEWA PAD Subdivision name NP h+ PK• QA4 -�-E Subd. Lot # Date Subdivision Approved 2ljq) y Owner /Applicant Name V O WA M Okg.&� Mailing Address 41 411T P� m 111 L-�A49' Amount of Fee Enclosed I w)aV IL HEALTH SERVICES GE TREATMENT SYSTEM or Village PXTT"0-6DN Tax Map 5 Block '� Lot VL Renewal Revision Date of Previous Approval PA 6P_1 oft my Zip 1 ,7,10 Building Type P-F71P15NG-�_ Lot Area No. of Bedrooms 4- Design Flow GPD 006 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 111-V gallon septic tank and Other Requirements: C-4 -1-404 DP*N To be constructed by 'T' 6 , V, Address 667 LF Aty ►' H04 Water Supply: Public Supply From Address .0i.:1 `Y,- Private Supply Drilled-6y " Address__ .,._- ...__:. _._. _. ....... . 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: P.E. X Address R.A. Date '1 `1S' 9 License # Z� & Z -I- y 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 wh considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe i . pprove discharge of domestic sanitary sowage jonly. By: Title: j�C Date: 1 �- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1JD 7L H E'lr - SUBSUP -.FACE - -SE`��I- i:GE I - ATRYEN -1-T lEiji._....- Owner Address �� PA�TEA�oI� yil'PRiT I`Lab'� Located at (Street) Tax Map Block 3 Lot (indicate nearest cross street) Municipality PPxTTV�L'5°►4 Drainage Basin X44 �(1- �1NG1� SOIL PERCOLATION TEST DATA Date of Pre - soaking 7 �15 �� Date of Percolation Test -71161% Hole No. Run No. Time Start - Stop Ela se Time Min.) De th to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 10 '�o �'� 2H'��� 1114.. ' 1 I 2 5 � ... 1 �� IAA �0 2�., ���,�, ��►� n l i 3 �ti� - 2 X10 �� �L�i'k," Ilia 4 2sy . �ti� �� ' w ILIV I 4 'Loll 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are Otamea at eacn percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA (DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' f 9.0 9.5' 10.0' HOLE N6.' HOLE NO. o -t -p I TOF1501l. L.D prM •2 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered fi` -D T Deep hole observations made by: LEA -(AM MiTWL40L Date 10,24,89 Design Professional Name: I}A \ J, HILl-iOL6 JME Address: U NML-LTOOc A MND asap Signature: (Design Professional's Seal r�(-4.� �cc W J'� iVo.56124 ca,� 4 `°goFi:ss%a�'� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of WIWAH Located at Bl<n euA PAP T/V PAIT6 - 04 Tax Map # f66, Block `� Lot '-ban S_ Subdivision of 1DP'b t P11+LA- C,09*9 Subdivision Lot # 5 1 Filed Map # 1069-A Date Filed Gentlemen: 4116N This letter is to authorize 4hpPY W, H1(410 54 A PE` a duly licensed Professional Engineer _X _ or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnay. ary Code. _.... :..:.:._..:..: _ _ . 0 Very truly yours, ` Countersigne 1 Signed: 1�iQ��✓ P.E., R.A., # d' No. 56124 Z (Owner of Property) llo Fn SI�NPV Mailing Address �0 V W9 Mailing Address: 41 FNTMWH NILL*E 0P_6W1,EP1 State W J Zip 10 601 State �''�✓ Zip Telephone: (91t.,) Tl�- Gob Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL P 1-D OW ;P, ri':I4-Yi Well Location: Street Address: Town/Village Tax Grid # &b ELJ',,A (_-0AV PPV Rb0IA Map Block '� Lot(s) "'VL Well Owner: Name: Address: Ep_604 1N`pAMA Al p p; Use of Well: I Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought � gpm # People Served Est. of Daily Usage No gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling �t New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type X Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Pa P_111 4, fftnUt,iG CtrIAGC Lot No. 95 Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No 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 sh-ea t/pl Date: `� ` �' y� Applicant Signature PENT 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 (3 0) 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 a driller certified by Putnam County. Date of Issue j Z L Permit Is g Official: °� Date of Expiration /2- Title t Permit is Non- Transfferr ble White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WP -97 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 November 9, 1998 Jeff Moore Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: Baker Big Elm Road, Lot #5 (T) Patterson, TM# 75. -3 -22 Dear Mr. Moore: BRIUC Public. Health Director Review of plans and other supporting documents submitted at this time relative to the above - regarded 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. _ If percolation tests were not witnessed by a representative of the New York City Department Environmental on this lot, percolation tests must be witnessed by a representative of this Department. 1) Minimum distance from the house to the effluent line is 10 feet, furthermore, separation distance of 10 feet should be maintained between the deck and the effluent line. 2) 100 feet setback line must be fully shown. 3) The minimum of 2 feet of R.O.B. fill should be shown due to mottling at 3 feet. Upon receipt of a submission, revised to reflect that above comments, this application will be considered further. V truly yo , �UW ' Robert Morris, P.E. RM:tn Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS •RFYLEW SHFFT FO.R CONSTRUCTION PER,:, IT STREET LOCATION 131 G Et M WA Q NAME OF OWNER REVIEWED BY RM, GR, AS, MB, BH 12AIE LO(6-1,19 TAX MAP # g Y DOCUMENTS Y PERMIT APPLICATION EROSION CONTROL:HOUSE,WELL, SSDS PC -I PERC & DEEP HOLES LOCATED WELL PERMIT _ PWS LETTER REPRESENTATIVE OF PRIMARY & EXPANSION LETTER OF AUTHORIZATION LOCATION MAP DESIGN DATA SHEET (DDS) EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE CORPORATE RESOLUTION IF PUMPED, PIT & D BOX SHOWN & DETAILED SHORT EAF 2,1— ?j J OUSE - NO.OF BEDROOMS PLANS - THREE SETS WELLS & SSDS'S WAN 200' OF PROPOSED SYS. HOUSE PLANS - TWO SETS PROPERTY METES &BOUNDS VARIANCE REQUEST 7 HOUSE SETBACK NECESSARY (TIGHT LOT) FEE 7 H SE SEWER - 1/4" FT. 4 "0; TYPE PIPE SUBDIVISION O BENDS; MAX.BENDS 45° W /CLEANOUT LEGAL SUBDIVISION FILL SYSTEMS SUBDIVISION APPROVAL CHECKED CLAY BARRIER PERC RATE 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL REQUIRED DEPTH FILL SPECS FILL NOTES CURTAIN DRAIN REQUIRED FILL CERTIFICATION NOTE STANDPIPES DEPTH GAUGES GENERAL fILL PROFILE & DIMENSIONS LOCATED IN NYC WATERSHED YOLUME PLANS SUBMITTED TO DEP ILL IN EXPANSION AREA DELEGATED TO PCHD TRENCH EP APPROVAL, IF REQ'D F TRENCH PROVIDED 60 FT MAX. . DEEP TEST HOLES OBSERVED P100% ARALLEL TO CONTOURS FRCS TO BE WITNESSED EXPANSION PROVIDED EX- APPROVAL SSDS ADJ. LOTS SEPARATION DISTANCES SPECIFIED % WETLANDS (TOWN/DEC PERMIT REQ'D ?) ON PLAN - FROM SSTS DATA ON DDS PLANS & PERMIT SAME 10'. TO P.L., DRIVEWAY,.LARGE TREES, TOP OF FILL - ... PR.F., •1969NFIrFiRnR.NOT.!FICATIONT -, 20' -T 0le G'JNDATION WALLS 1 Y WELL T O PL , LETTER BI/ZBA 100' TO WELL, 200' IN DLOD, 150' PITS 100 YR. FLOOD ELEVATION 100' TO STREAM WATERCOURSE LAKE (inc. expan) OTHER REQ'D PERMIT(S)_7z 0' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER REQUIRED DETAILS ON PLANS 10' TO WATERLINE (pits -20') SEWAGE SYSTEM PLAN - (NORTH ARROW) 50' INTERMITTENT DRAINAGE COURSE SSDS HYDRAULIC PROFILE 200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS GRAVITY FLOW CONSTRUCTION NOTES 4 15-MIN to CDS= >5 °/g10'.4 %,25'.3 %,30'- 2 °/q35' -1 %,100' - <l% 77DESIGN DATA: PERC & DEEP RESULTS q 20 'MIN to CD discharge /I00'with 182 cons day discharge 2' CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES, CUT F/f–1 10' FROM FOUNDATION; 50' TO WELL /GUTTER/CURTAIN DRAINS WELL fiFOOTING SOIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION TM #,PE/RA; NA ME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: RD THE CITY OF NEW YORK DEPARTMENT OF ENVIRONMENTAL PROTECTION JOEL A. MIELE SR., P.E. Commissioner �y�'RONMFNrAL PROS� WILLIAM N. STASIUK, P.E.,Ph.D. "$eputy 0ommiss on PHONE (914) 742 -2001 FAX (914) 742 -2027 October 21, 1998 Robert Morris, P.E. Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Baker SSTS (T) Patterson; Big Elm Road East Branch Reservoir DEP Log #7762 (Joint Review) Dear Mr. Morris: Bureau of Water Supply, Quality and Protection The New York City Department of Environmental Protection has determined that the above - referenced application is complete. However, the following comment is submitted regarding the system design: 1. The system effluent line should be shifted to maintain the required 10' separation from the residence and an adequate separation from the deck footing. Perhaps, the applicant _.P....= .shnulrl consider relocating -the septic•tank.'. If you have any questions regarding this matter, you may contact me at (914) 742 -2028. Sincerely, Matthew Giannetta Project Manager xc: James Covey, P.E., NYSDOH 465 Columbus Avenue, Valhalla, New York 10595 -1336 RUCE R. FOLEY DEPARTMENT OF IiEET�-I Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278 - 6130 Fax (914) 278 - 7921 October 6, 1998 Jeff Moore Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 RE: Baker Big Elm Road (T) Patterson, TM# 75. -3 -22 Reservoir_ Basin East Branch Dear Mr. Moore: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on September 28, 1998 is complete. The Department will notify you by October 26, 1998 of its determination. ❑ The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. Joint review with the NYCDEP will commence pursuant to the guidelines set forth _ _ uutbe Watershed Agreement: If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. V/6571ruly your �obert Morris, PE RM:tn Pnhlir uPaith Pna;M -1-r - naaw THE CITY OF NEW YORK DEPARTMENT OF ENVIRONMENTAL PROTECTION 0" JOEL A. MIELE, SR., P.E. Commissioner NrAL WILLIAM N. STASIUK, P.E.,Ph.D..._ ._ a . ` Deputy Commissioner PHONE (914) 742 -2001 FAX (914) 742 -2027 November 24, 1998 Robert Morris, P.E. Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Baker SSTS (T) Patterson; Big Elm Road East Branch Reservoir DEP Log #7762 (Joint Review) Dear Mr. Morris: Bureau of Water Supply, Quality and Protection This letter is to inform you that the New York City Department of Environmental Protection (Department) has determined that the above - referenced application is complete. In addition, the Department has no objection to the approval of the above - referenced regulated activity. This determination is based on the review of submitted documents including the plan titled "Proposed SSTS Lot #5," dated 09/15/98, revised on 11/11/98. The applicant must contact Matthew Giannetta of my staff at (914) 742 -2028 at least 2 days .....p n;o,r to ih_- start of construetiurrof the-SSTS' so-thai d Depai=tinent representative may inspect` and monitor the installation. Sincerely, Margaret Lloyd, P.E. Supervisor Engineering Design Review xc: James Covey, P.E., NYSDOH 465 Columbus Avenue, Valhalla, New York 10595 -1336 m a a HARRY W. HOLS JR., P,E. November 10, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSTS . . Big Elm Subdivision -Lot #5 Baker Dear Mr. Morris: LAURENT ENGINEERING / MILLBROO EIOFFICE CEN RE Routq. $ MI)ItMiM.Road— . �.. .r�►ewst ®t;`ri'e�YcYK'i"o�s..., .....�� : _. �,v .. - . , .. . _ .. ,_ .� (914)278 -6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS In response to your comments given November 6, 1998, we offer the following: 1. Effluent line has been moved 10' from the proposed deck. 2. 2' Fill has been reflected on the plans. 3. 100' Wetland line has been extended as requested. We trust the above adequately addresses your concerns and request the issuance of the Construction Permit at, your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. J Harry W. Ni hols, Jr., P.E. HWN:JM:hs 98035 00 AON 66 LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE O_ FFICE CENTRE Brewster, New York 10509 V (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS September 15, 1998 Mr. Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS William Baker Clarke Subdivision, Lot 5 Dear Mr. Morris, Enclosed are the following: 1. Five (5) prints of Drawing SS -5 "Proposed SSTS," dated 9/15/98. 2. Short EAF, dated 9- 15 -98. 3. "Application For Approval of Plans For a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 9/15/98." - - 5: Application'to'Constrtict a Watef Weil; acted 9- 15 -98. 6. "Design Data Sheet." 7. "Letter of Authorization." dated 9- 15 -98. 8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only." 9. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours,. LA NT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. 98035 14 -16.4 (2/87) —Text 12. PROJECT I.D. NUMBER 617.21 SEAR k Appendix C State Environntentet,laualt! -r sta {igw- - -� - :,.•.- SHORT.ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant. or Project sponsor) 1. APPLICANT /SPONSOR W Ii -14AH 13Ak - PLor . PROJECT NAME, C- -) INAIv IpUAL. 561"5 3. PROJECT LOCATION: p,� PP'TE�0� `v,Hal� Municipality County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map). $((L I:L A 5. IS PROPOSED ACTION: XNew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: C,0Hh7'12VGTI0N Dr— 51MLlLE F IAII Y. M50EH44� 1 IIJEL41 6EiM 7. AMOUNT OF LAND AFFECTED: Q, I. f � Initially acres Ultimately V� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 9§Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 1 Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space Other Describe: 51j�(t'�(f,E FAm1►.� ._..� _ ...... _�.:._..::.':.__..:- .,�._..:... 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL) ? ray ❑ Yes Z No If yes, list agency(s) and permlVapprovals 11. DOES ANY ASPECT OF.THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? . Yes D�No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes. ® No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE d IA� HI Jr` PE E• A6 *EW Applicant /sponsor name: Date: Signature: I✓ V 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 z 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAR ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration . ..,,:..Wray be- superseded by another kivoivad'agency. ❑ 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. I..D." lg- .THERE,.QR..IS T!+ERE -'I IKEL•X Te,,£E; ^O N-q TP-. CY- ERE�Y-!QEa_ATED•T0-P9TENTIAL- ADVERSE ENV!RON49ENTAL !MPAc-TS ?_.. ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (7o 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. ❑ 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 documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on` attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) Date 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _.... _ _ .... AP-PLICAT10N, FQR.A- .PJPROVA.L OE-PL A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 'VU II -U,AM . BAY-0- 4'1 AARrERSo Viu.��t PA P-%H N� 2. Name of project: 1-07 S WD1,410JA- h,�aT'j 3. Location T/V: pArrc- 606 4. Design Professional: 5. Address: 6. _Drainage Basin: E*r URANG0 B 6- H' ► 'DS ®q 7. Type of Proiect: X Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Exempt h Unlisted No NA Nq 12. Is this project in an area under the control of local planning,.zgping, or other - ..._ ........................ ..............................� ..� .ev . y _ �.... 13. If so, have plans been submitted to such authorities? ........ ............................... N o 14. Has preliminary approval been granted by such authorities? Nn Date granted: - 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... NA 17. Waters index number (surface) .......................................... .........................:..... N A 18. Is project located near a public water supply system? a 19. If yes, name 'of water supply Distance to water supply -- 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system _ Distance to sewage system 22. Date test holes observed l0(' l I9 23. Name of Health Inspector 0-6... 6JPzJN6H 24. Project design flow (gallons per day) ......:.......................... ............................... too 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... N 0 26. Has SPDES Application been submitted to local DEC office? NA Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? %10 28. Wetlands ID Number ................... J r - ... -. 29. ,Is Wetlands Permit required? ........................................ ....... ... ............................. �9 Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Ma 31. Is or was project site used for agricultural :activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................. Yes/No 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 other potentially known source of contamination. Yes/No �9 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ... ............................... No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... N . 36. Tax Map ID Number .......................... ..........:.................... Map �6- Block O� Lot 4),4- 37. Approved plans are to be returned to ..... Applicant }( Design Professional NOTE: All applications for review and approval ofan.ew SSTSo be locate�i�iniirhin .th?�?•YC- Wa +Pr�>?ed- shall - be sent -to the 061 a merit, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior 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 4 impervious surfaces, and the project applicant.should 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. I hereby affirm, under penalty of perjury, that information provided on this, form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section, 210.45 of the Penal L%P. � SIGNATURES & OFFICIAL TITLES. Mailing Address: .................................... 14 1NU N(-cM©L-5, JP-, gc A6 AAEHT 7 0 �►��►.i oWN 6��� g p-fo5Tf�R toy i 4 rDol ,k I 1 1 i- 'i Ak- Ay �r I /. 53 °4B 57E • /z. • / I / r � ,�1- :mod 2 4¢.¢05 1 � SB'S /'•58� \. t I SP 4'0 f4C OKOR 9EPfr _.rrwK WELL $ / ,ur :tee I 1 v s� / / pn9 WdB' 3G /' S2 '07 54•'¢3' . . �, � � � _ ; � I do 'Q lP� I � / / - / ./ / :. / 1 / ~z W ,� \jam 4 @ _- "� /. /// /� /i. j / / p� // •" /.. r rio) - f/N/SHtD 6RADE / i