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BOX 16
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01754
PUTNAM COUNTY DEPARTMENT OF HEALTH
R 6 Dlvlalon of Eavlionmeafa4He," Services, Carmel, N.Y 10512
_ Eng�aeer Meet Provide
P.C:H D Pormlt N
k'A*XG )19#QSAL SYMEEM, iii e'ir G
/ b Town or V
Located Block ` + Lot
JL
C e -Poi
Owned t Name. Yr �' Formerly Sdbdipislon
MaWng :Address ` �P Date Permit Issued 1a -- J. T
Separate Sewerilge System' ballt by a
1- Address L-4 u X
Cougletiog of • Gallon Septic Tank and 1JI, cr tli�i hca: G
water ,supply=
—Pu b supply From Atldreas
ors Private Supply I We y pi F =. oL Sa.,�rTcL- Addeeee
Bulldlug ape d Has .Erosion Control Been CompletedY
Number of Bode�ooms `"/ Hue Garbage' Gilnder Beeti`Inetahell? A ,
/V
d
Other. Requirements
I certiLy.thaE the :aystaem(s)_as;llsted:.servinq the shove premises'rere constructed essentially'as -shown on the plans of the 'completed work (oopies
of which are ettacAed); and in' accordance with the etandaida sdlas' and -r lotions, in accordant with
the filed plan, and the peimit.iasued by the
Putnam county Depart"nt'o! Health
OaN •J l Ca►ttflW by. P.E.x_ R.A
Address `.;'.- _ license No.
• - z.
Any parson occupying pr misses - ssrv4t by, the fbova .syst m(s) shill-promptly taka -Such action es+ may ". rtar wry to secure the correction of. ariy unsanitary
conditions resulting from Such;usaga. Approval, of. the ,separate !"erage _system,thall beeome,.null and.vold,as soon as a .pubt,; sanitary sewer-becomes
available and tea approval of the'DNvate vvatsr wOPly shall bscoma`'riull anq +,voW when ,a publk upply becomes avaliable. Such 4porovals are
sub)octt j000..lmodifica�tiioon or change' when In thCe� judgment of the Commissloner of 44 uch rev tlonnxo Ication or change Is nscesaary,
°."` TIt s
WELL LOCATION
WELL OWNER
`f USE =OF WELL
1 - primary
2 - slicondary
MOUNT OF USE
REASON FOR
DRILLING
DEPTH DATA
DRILLING
EQUIPMENT
WELL TYPE
:CASING
-DETAILS
SCREEN
_ : _ DETAILS
GRAVEL PACK
..WELL COMPLETION REPORT
office Use Only
DEPARTMENT OF HEALTH
'T11 V 151UI1 �I E Lr6fliLLei-.Lai - Re&12//' Sbf=
PUTNAM CO�idl)t�FiKE�OF YiEt�L`°°° /
STREET ADDRESS: TOWNIVILLIG1101Y TAX GRID NUb1BER:
Steinbeck Corners, Lot #11, Patterson, New York
NAME: Est , . at Steinbeck CornereooREss:777 W. Putnam Avenue Q PgIVATE
C/0 Banker & Bander Greenwich, CT 06830 O PUBLIC
[3 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /CONDJHEAT PUMP ❑ ABANDONED
O BUSINESS `, ❑ FARM ❑ TEST! OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ''.,2 ❑INSTITUTIONAL ❑ STAND -BY ❑
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL
WELL DEPTH 405 ft. STATIC WATER LEVEL 10 ft. DATE MEASURED 2/2/95
13 ROTARY ® COMPRESSED AIR PERCUSSION O DUG
❑ WELL POINT ❑ CABLE PERCUSSION O ,OTHER (specify):
❑ SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH
LENGTH BELOW GRADE
DIAMETER
WEIGHT PER FOOT
DIAMETER (in)
FIRST
O YES
O NO
WELL YIELD TEST
METHOD: ❑ PUMPED
MCOMPRESSED AIR
O BAILED ❑ OTHER
IL ) hr.
GRAVEL
SIZE:
If detailed pumping
I tests were done is in-
formation attached?
10 YES ONO
L . gCm.
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
PUMP INFORMATION
TYPE SubmerslbleCAPACITY 5gpm
MAKER Goulds DEPTH 360;
MODEL 5GS07412 VOLTAGE 230HP 3/4
41` ft. MATERIALS: ® STEEL O PLASTIC O OTHER
40 ft. JOINTS: O WELDED ® THREADED ❑.,OTHER
6 in. . SEAL:. 91 CEMENT GROUT ❑ BENTONITE O OTHER
1 gib: /ft. DRIVE SHOE O YES ONO LINER: OYES ®NO
'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (It) DEVELOPED?
O YES ONO
Malcolm T,g Beal, Jr,
DIAMETER
I
TOP
BOTT661
OF PACK
in.
OEM ft.
DEPTH
It.
WELL LOG
If more detailed formation descriptions or sieve analyses
are available,
please attach.
DEPTH FROM
Wale,
Well
SURFACE
Bear,
Dia-
meter
FORMATION DESCRIPTION
code
ft.
R.
Land ::..::
Land'
5urlace
26
Dr,
11
ng
in' -overburaen clay' & bout
e.r'E
26
Hit
r
ck
at 261
26
41
Dr
it
Ina
ng
in rock, set casing, grow
ea
41
405
Dr
11
in rock cxranite
Malcolm T,g Beal, Jr,
STORAGE TANK; TYPE Well Xtrol WX #251
CAPACITY GATE- 62
WELL DRILLER NAME P e F . Beal & Sons n ATE 3 /6
AooREss 4 Putnam Ave. SIGNATU / I
Brewster, NY 10509
1
Malcolm T,g Beal, Jr,
RANDOLPH W. LAURENT, P.E.
HARRY W.' NICHOLS JR., P.E.
March 9, 1995
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
LAURENT ENGINEERING
ASSOCIATES, P.C.
Route 22 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FAX) 278 -2658
CONSULTING SITE ENGINEERS
ATT: Mr. William Hedges
RE: Individual SSDS
Lot #11 - Ice Pond View Estates
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing S -11 "As -Built Plan ", dated
3 -9 -95.
2. "Certificate of Construction Compliance for Sewage Disposal
System ", dated 3 -9 -95.
3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal
System ", dated 3 -9 -95.
4. Well Completion and Well Log Report, dated 34-95.
y 5. Water Analysis Report, dated 3 -7 -95.
6. Check in the amount of $200.00 payable to Putnam County
Health Department.
If there are any questions concerning the enclosed, please call
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichors, Jr., P.E.
HWN:bd
93046 -11
enc.
cc: Mr. S. Banker .w /1 copy ea.
PM .Z1.1 0001,Yrx DF_PP_tW/IIR\rx OF rTR
DMSYOv OF ZgVZRgkCENTZAL PYA-MH SERVXCES
p.Y•ne or -Z-lxchaser of Fu.r. Sect-i.on Block 7.ot
Buz.idzng C>rns'uucted try
ry, ram i
xf�c 1 ?.on
1 .lrizcIt� I_ i t'y %
�tild_a_r:g err_
1 cl /�! u G_ _ I__ /_�
� ���d G
4ubd,LVlsion Hart°
Subdi.visioa Lot:
SUB - 7RSAa -; M E &:fir' S%STEEM
I repze_ent that I am wholly and completely responsible for. the
:.or:c;.r.�snz?r n?tn„x.ial, constnAc:tion and drainage of t-he se-wags disposal
serving the dbovP de!rc:ib&& aapd, t.ba` it has -been constricted as
t?ie at)w:oved plan or app):oved amer(3aent thereto,• ancI': i n aetvzdanCe Ft i l'_ ,
standards, r_it).es and regui at.i_ons of.- the .Fut-r. lm' codnty• VeuaxL-z -It. of I ea).Uh
,bcr.�.t;� � �xa�it.fa to the cs,nerr, his rucxtissors, heirs o>: ass,.gns� ,�U Q��Ce a..n
opera{ ing condition any pa X. t: of said sys Le-,ii cons t meted by mr which faiI:
okerabo for a p^ari-od of t�:o ye2J_S �r:ea'I"ately foi cwing the ' date of: app.oval of �Ai=
Consttuctiorn Ccx -lol iancle" for the seh,,a'gc diJrosa) -YsLem� l`." _
ma .to- su_,_41 :SYSEeM, exCQDt w_ here tl e f_2a. -=e -tom
the by ;if�e willru'l or i: tax >t<x :cop -- t ,of the bu�di.ng ut.7 .-
the sys ly11.
The undersi.gi)c?-! fkirt_hc-_')_ aq) -"CCS to dcccpt as conclusive 'the
the Vi ectoy. of ule Division of }ie?J tft Services o' the Pxit nam C:'.
DeparLn-,ent_ of . Is(?aith as to or not Q)e failure of Jte system to cc• =_L�:
C.rU:= e d bjr `�';C'�'rri�1fU_i_ C�': iiN'i.1.j.geji= F -ct-- of the occupant- of the building Ll�l.��.'.. ?f•'�
U-�r.. Jj Jl n.
,
1?wted this c�1 d~y C!f 1p,;,- .._ 19 4J_ , sicnat"t;xe l
G�Ti t1 e
ContraCIE -Or (Owner) - S! gaatL re
,� �STA7E.5 /17 s7C`"rPJE�`l CtJ'2r.lLnj
( ox-porat ion NP-ze (if Corp.)
p�dress
rev_ 9/85
DL
�s
t
TOTAL P..02.
PUTNAM 000NIT DEPARIVANP.OF IMALTH
mmm d 81.vbeisessaw Hed& Seavlomo. CUMOL N.Y. IASI2 hoar b Piwslils Pss�it!
J a• CRRIV[CATE OF QO
commumm Psitui[ FOR UWAM DUPOSAL
at TOW *t4qlluol
_.. P Ir= lot
n Ow. K�A� ■I..cN...��/���A_1�11�i1'L emew.l_O Eevld�n o —
r J Dee of Pnwbus App mvd
1 L Ad&lw 1A) fl TK) A M AVJi Town A kz Ep
A ---- a G# 1,9 1:....`I -A'❑
Type ? ��'LL Lot Area Fi0 Seotlan Only LJ Dept Vahme
Nlsr & of Hero "T Deaip Flow G P D— PCHD Nodflostlon In Regoha! Wlsm FW b completed
Sepenfe Seweeap sydm to allsetat d 2 "{-- -U fia0en Sepik Tenk ••••t
To be eets4neled -by � %ii7 AfMhen
Water Slf * P '11, Supply Fitton Addreeef
on 4 •Pdwalle Soply Ddkd b7 —_ Addmn
Odmir
1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate taw di tai s stem
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ens o nom
County Department of Health, and that on completion thereof a "Certi /kite .of Construction Compliance" satisfatctory to the Commissioner of Hwlthwill
be submitted to the O,epartment, and a written guarantee will be furnished the owner, his successws. Mks or assign by the builder, that said builder will
phce in .good .operating condition .any' art of : Mld sewage disposal system during the paled of. two (2) yert Immediately following the date of ,the issu-
on" of the approval of the. Certifteate of. Construction Compile 'rice of t e original system or any repairs thereto: 2) that the drilled well dualbed above
wilt be located as shown on the approved plan and that old well will be inst 1
in accordance h the anda s. rules and rpu ons of the Putnam
County Department of Health.
Dat =�Tr�i Stoned P.E. R.A. -
,l
Address License No A t_
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless (construction of the building .has been undertaken and is
revoeaile for cause or may be amended ournedified when considered AaMary by tM Commissioner of Health. Any change or alteration of construction
O uires� permit. Approved f0� of domestic unitary sewa�s. at w to supply only. ..
Rev. 2-
p p Title
- - - - -- `!. -re_
10/88
TYPE:
LAB ID NUMBER:
LABORA'T'ORY REPORT
PW
95 -1011
CLIENT: P F Beal & Sons
4 Putnam Ave
Brewster NY 10509
SAMPLING LOCATION
DATE COLLECTED:
COLLECTED BY:
Kitchen tap: Lot #11, Estates at Steinbeck Hill, Brewster NY
03/06/95
P F Beal & Sons
TIME: 3:30 PM
DATE OF REPORT: 03 /07/95
A.NA -L-- i'' - P .... - - ....RESULT . UNITS- .. - .- METHOD . ANALYZED--
-
Total Coliform Absent Colilert 03/06/95
E. Coli Absent
This sample, as collected and submitted to the laboratory, did meet the requirements of the
New York State Sanitary Code Part 5 -1 for bacteriological (sanitary) quality.
E rT�
Laboratory Director
NYSDOH ELAP #11218
618 Clock Tower Commons, Rte.22, Brewster, NY 10509 /914-278-7600 /Fax 914.297 -0536
- 11IM4 C)UNI Y DEPARTKEW • OF M.
VISION ':OF:- = HEALTH SERVICES• . "''
_
DESIGN: allh-SHEFT --;,'- fBSUi'ACE SEWAGE:-D):SPOSAL'SYSTFki _ -'FILE N0:
' Omer- ` ��� _ - °•Addiress' -.'J7� '!l�_ ���M �y.�, C -= 3��i�Jlr� -�• fib
Located -•- {Street) . A� 3r ->r:z pc :Sec ° o_:Block Lot
at• p j
(indicate nearest cross streety
Municipality W N oP P Artr tr-r2 -<o )-J Watershed 6t2.o70 JJ -
Som PF CQMION DATA REWIRM TO BE SOB�'rTED WIM APPLICATIONS;
.Date of Pre-Soaking 3y - ~� Date of Percolation Test
HOLE
140M R ...... T O TIME :.. :.::.:. PEROOLATION PE=LATION
Run (Elapse Depth to Water From Water Level
!Tim Ground Surface In -Inches _._.._.._.._ .:..:Soil Rate.
Start -Stop Min. Start Stop Drop in Mi�/In Drop:.:
C(�7l () :...._. ..................... :.: Inches .... _....::::..Inc3�es :. .._ Inches - - ...
r _
�• 2 • 135 - 2;05• :30 • • : •?r¢:;•..., ....._. ���t ....- -� %Z.. 2d
t _
5,
2
3.
4 - -
NOTES: 1. Tests to be repeaters' at same depth until approximately equal soil rates
are obtained .at each percolation test hole. All data to* be susmittod
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
24
2CP 2 15
r
-
3
5,
2
3.
4 - -
NOTES: 1. Tests to be repeaters' at same depth until approximately equal soil rates
are obtained .at each percolation test hole. All data to* be susmittod
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
No. of Be3roans Septic Tank Capacity - 1,7,5V gals. Type 'Corv`G
Absorption Area Provided By L.F. x•24” width trench
Other
Name L/�c12 N7 Ca�aJE fz�NC� ,�S3o� P(. , Signature_
Address 73 • ffm m F-i gL D (LI V r,=, SEAL
�/�77 3orU Wy- 125(a3
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft,/gal. Checked by
Pig
Uj
Date
r
TFS'i Pr. ATA'RDC2U]RED:.Zb'BE SOMITTED''..6. -d APPLICATION
DESCRIPTION OF. SOILS IN : TEST •HOLES
-DEPTH
HOLE NO. I 110 .? LV.J e r . ... ROLE NO.
.
..j. ....1'vi.l,.�i•.1::3L t'cr`'•• :n r.. Cial. ,.u'i ^ „ti•�':r :';`<:r�•�' :1 _e•
.-
..
...:_ .y� . td - - ¢L"'-
_ _ : %o r!:.F.f4.'�`r.•.,r, •n�.ry_••s:f;..':w�•e•{ � - +ai�q�.:::I:- .
ro P90
Ps L
'
= 1.' -tiA'
ii'- ,�.'a, "��ti.:ti',.% MKS" av:.;,:, �;- 7R•—: � .:,,�.::.•:;,;'l..f:,l.:w<��'•. �:' .. ..
.... ...
� ..
..
2t
..
��: � j fi iV:
r� •. - .. t. -. :.: -•.l:J .�. •1rf:•i':t'; ' /•�'i �.{�.:1�•�. .•: �.F4�� �... A :1 ,
t
6!
t'
9t
`
10,
No. of Be3roans Septic Tank Capacity - 1,7,5V gals. Type 'Corv`G
Absorption Area Provided By L.F. x•24” width trench
Other
Name L/�c12 N7 Ca�aJE fz�NC� ,�S3o� P(. , Signature_
Address 73 • ffm m F-i gL D (LI V r,=, SEAL
�/�77 3orU Wy- 125(a3
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft,/gal. Checked by
Pig
Uj
Date
PUTP' COUNTY DEPARTMENT OF HEP'.` y t
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..
Re: Property of 0 A-W,- X� 5 —T454M
Located at
(T) Section '�7 • Block ., Lot
Subdivision of i f'OIJ1� V►f- t�T,�T�
Subdv. Lot # Al Filed 1,4ap Date 2 -.I0 -6 -
Gentlemen: _
This letter is ' to authorize HA(-zri
a duly licensed professional engineer ,/ or registered architect
(Indicate)
to. apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules.
or regulations as promulaga.ted by the Commissioner of the Putnam County
•S�
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
sys-tem..or systems in conformity. with the.. pro -visions of Article 145 or - - -
147, Education Law, the Public Health Law, and the Putnam County Sani-
Lary Code. melA
a
NICly r� -
Q. lS, 0 Very truly yours ,
14 � �
Signed V'
Oun mer � � o�f t Property � tti ��tCb� S►, � Cou nters FNQ
y
No.
_ Apo s o,��� �T 7 w • ('v► r�- /j �r .
P E., R.A.' Address
��ir_'•r1����G -1=� L7�ll/�. ��r- �w...��� �I UGa'3G ,
Address
Town
61" 30
Telephone
Telephone
i.epart•ment of Health �•\
Q Divisic 'f Environmental Sanitation
AFFIDAVIT - CORPORATE a,�NER APPLICATION
FOR PERMIT.APPLTCAT•ION SUDMTTTED• TO
...PUI;NAM CpUNTX ,`. �rA4 ':t{,.DEPA•RTI°1F.,�.Y=�°,., „��""-..�.�,:. " °,°.' - .. _ _
TO:
'Commissioner of Health - In the matter of application for '
-�
I, �-1 - -- - --- ---- - - - - -- _r• _ ._ � represent.
that -I am an officer or employee of the corporation and am, authorized'
to act for* A-� ..0 � �— — — riO — `.°i � �G _ _
(name of corporation) `-
having offices at — -7� - - -
- .___ - -.. — — _.._,__.__ — r-
— — ^ — _ — — — _ —•�•_ _ — _ Whose officers are
President
- --' -- -Name an��ddress)---- ._..___ —__
Vice - President -
- (game and Address)
Secx,6tary
_
• - --- _. —._— �Nar _ and Address) - ---
Treasurer' _
—_ — _ ----- -_--._ _.._ .. —__...
(name and Address)
- -and t�,at'X= r�i'aiid will be individually responsible fon any' or all aptp.
of. the- corporation with respect to the approval requested and•all .sub -
aequerit acts relating -thereto. _
S,aorrk to before me this _p day Signed
of - Q ILa 19 -R Title Y� ��c4
Notary Pull '
BOW E J. DAM
NOTARY MBIAC, STATE OF NEW YOH$
REG.14985305
QUALIFIED IN DUTCHESS COUNTY.
MY COMMISSION IXP 10 AUG. 1Z A&_
Corporate Seal
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLTCATTON TO. rCNS.TP CT..A- WATER,..W.E L-- .,_..., -
PCHD PERMIT #
WELL LOCATION
Street Address
.6,
o Village City Tax Grid Number
. -
WELL OWNER
Name Mailing
Add es
rivate
O Public
VE OF WELL
0- primary
2- secondary
® RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL b INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm/ #
EI REPLACE EXISTING SUPPLY
® NEW SUPPLY NEW DWELLING)-
PEOPLE SERVED !j _,E--:; /EST . OF DAILY USAGE bew gal
O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
D
WELL TYPE
®DRILLED
13DRIVEN
DUG GRAVEL.
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:!
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 2/ NO
NAME OF PUBLIC WATER SUPPLY: K4A TOWN /VIL /CITY
_._. DISTANCE.TO PROPERTY FROM NEAREST WATER MAIN: - - -
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET 14tY 4,1_1
( ate � gnature) /
t.
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirt;- (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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: e 9 2 1915
Date of Expiration 19 j Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
p Y.7'7C N' A M C O'CT J.V"'X' �L" X� � 7P,A. R'9C" M)� N'2" • O)E:' >r3C E.A. 7C.'T �
PLANS-- fi0i2 °"fi- 'F'Sl'EW7�"I�R"DTS'POSA" SYSTEFi°"'
1. Name and Address of Applicant:. �✓t(j�H '� ) , �/, P•
2. Name of Project: 1�IP4��� ��pry 3.._•_Locationm/v /C :Ohl _
4. Project Engineer: �Lm ` ldl. ill GI-10� -T� 5. Address: 7����i2f'tt✓1.1'J I i��
x'12 Phone: .. _ loo. �2Sli�j
License Number: e: 21 �f aft —�
6. Type of Project:
✓ Private /Residential•, y Food-Service Commercial
Apartments Institutional Hobile Home•Park
Office Building: Realty Subdivision Other (specify)
7. Is this project subject :to State Environmental Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt ✓
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? .............
9. Has DEIS been completed and found acceptable by Lead-A 9 ency? ........... nl /A
10. Name of Le,ad Agency
:1 _.._Is_ h _s p �QJeCa.�i
u ,.. �..an:a�-Pa._�nde_r_. the.. cont€ �o. 1Mo�- local-- p- larni:�9,•'zcni -ng, •---- ..s....___._ ,. __ ...
or other officials, ordinances? ...... ... .................... .I.......... �)d
12. If so, have plans been..submitted to such: authori tie s ?...................... r /,Q
13. Has preliminary approval been* 'granted by such authorities ? Date Granted:
14. Type of Sewage Disposal. System' Discharge....... ..Surface Water y Ground Waters
I5. If surface water discharge, what is the stream class designation ?........ t�lA
6. Waters index number (surface) ........................................... nl /�
7. Is project located near a•public water supply system? .................. iJ V
3. If yes, name of water supply t.1�A Distance to�water supply
9. Is project site near a public sewage collection or disposal system ?.....
). Name of sewage system Q/A Distance to sewage system
1. Date observed: 5 23. Name of Health Inspector: _ ►�1E-7L I IG-
Project design flow (gallons per day)....... ............... �D'D
2.
s .S.tate Po.l.l.utant .Discha.rge�E_1�i.manatYi.on_ y�g , ��I 1' q
z, cF)P * -e� ui.red�_
26. Has SPDES'Application been submitted to local DEC Office? ...............
27. Is any portion of this project located within_ a designated Town or State
wetland ? .................... ............. ............................... r�)D
28. wetland ID Number ..:...................... .............................. /d,
29. •Is wetland Permit, required? .............. ...............................
Has application been made to Town or Local DEC Office? �JI1�
30. Does project require a DEC Stream Disturbance Permit? ................... I.1D
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous .waste disposal;.'
landfilling,'sludge application or industrial activity? ........ YES or NO 0
32. Is project located-within 1.000•feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ..... ' ......... YES or NO Q d
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? .... ......
34. Are community water, serer facilities planned to be developed within 15 years? MI Q,9100
-- .3S - ,Are- - -any- sewage -- disposal areas—in, excess of'i`5p `s1'ope"1 .....�.....:`.... : __:,0
36. Tax Hap ID Number .........................................................
37. Approved Plans are' to''be;.returned to: Applicant Y-1/ _ Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application. must be-accompanied by•a Letter of Authorization. Failure to comply with this
Provision maybe grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury,- that information provided on this
Porn is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Hisde7,-anor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:- v(i'Ll
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