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HomeMy WebLinkAbout1779DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -118 BOX 16 01779 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Grid # Map Block Lot(s) Well Owner: Name: Address: t/t /'000 Use of Well: 1- primary 2- secondary _ Residential Public Supply Air cond/heat pump I igation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _mil Compressed air percussion Other (specify) Well Type Screened Open end casing X• Open hole in bedrock Other Casing Details Total length? _ft. Length below grade _ ft. Diameter _in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded X Threaded._ Other Seal: >TCement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours Yield .O gpm Depth Data Measure from land surface- static (specify ft) ' During yield test(ft) 76- 14 Depth of completed well in feet /525 Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description . ft. ft. Land Surface / If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity 11 Depth 12.0 Mode 1) Voltage 23C) HP Tank Type 3p2, Volume 4 5 ° = ' }a .:..,: / Date Well Co pleted Putnam County Certification No. Date of po �� Well Driller signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provid on at se arxte sheett plan. Well Driller's Name Address: Signature: Date: r1,311,16 -�i96 White copy: HD ' e; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH (DIVISION) OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: l Town/Village: Tax Grid # Map Block Lot(s) Well Owner: Name: Address: Use of Well: 1- primary 2- secondary _' Residential Public Supply Air cond/heat pump I igation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing )l Open hole in bedrock Other Casing Retails Total length �?Lft. Length below gradeft. Diameter in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded __-Se Threaded _ Other Seal: >el Cement grout _ Bentonite Other Drive shoe: Yes No Liner _ Yes.>L No Screen )[Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes No Hours Second Well Yield Test _ Bailed _ Pumped .X Compressed Air Hours Yield jogpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation (Description ft. ft. Land Surface A14 °u'_: If yield was tested at different depths during g drillin g, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity JjO Depth 12-0 Model ;E&5 Voltage !'.r, 36) HP T'/-4 Tank Type; -3c�2 , Volume '`'° t ��,�. E Date Well Co pleted Putnam County Certification No. Date of po Well Driller signature) (VOTE: Exact location of well with distances to at Well Driller's Name Signature: White copy: HD two permanent landmarks to be provtd bii a seearafe eet/plan. v4aL_ . �% Address: M1 Date: B 6 Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH , [VISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 2-6 1 -e-,y J La i, C, Town or Vjl<e Owner /Applicant Name 140 �'�,I ",C Tax Map Subdivision Name � •e--e',r Wc) J Formerly Mailing Address Block -i Lot I 100 Subd. Lot # -31 Zip 0 S'G Date Construction Permit Issued by PCHD A-0 -01 Separate Sewerage System built by .t &w, c' Address Consisting of 12 -1S-V Gallon Septic Tank and s L�.�1 l �/ / a v S e- - e Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by Address 16 -+ '!�'Z L. awv,C I Building Typed i r4 / Has erosion control been completed? Number of Bedrooms -1{ Has garbage grinder been installed? AID 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 regulatiops jbf the Putnam County DeR"5nt of Health. Date: q-1 -U �- Certified by Address P.E. R.A. License # ' Ce i 2--j 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 s bject to modification or change when, in the judgment of the Public Health Director, such revocation, , o catio hange is necessary. By: Title: Date: Z' White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 -PUTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISI ®N OY ENVIRONMENTAL HEALTH' SERVICES GUARANTEE OF SU13SURFACE SEWAGE TREATMENT SYSTEM 'b)mt"J�� -3 P00 Owne4 or Purchaser of Building Tax Map Block Lot Building Constructed by Location - Street Res 1, '1 -,, -cal - - Building Type.'' ype: ' TownNillage &_ e. ri.v�✓� Subdivision Name Subdivision Lot # I represent that I am wholly and completely' responsible for the location, workmanship,, material, construction anT*drainage of the sewage lreatment'sysiem serving the 'above - described` proerty,' 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 - I3istem constructed by me which fails to operate fora 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,.fexcept 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 Day �L Year M, _aAl" �-' Gen al d ontractor (Owner) - signature . Corporation Name (if corporation) Address: State ��%, _ Zip 10S,01 Signature: V - Title: JI Corporation Name (if corporation) ,Address: J State Zip 10.5-0 Form GS -97 •: yt .1; J .fall September 1, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 279 -4567 Email: hnengineer @aol.com r �J Re: Individual SSTS Compliance — Wyndham Homes, Inc. 20 Teal Lane - Lot # 34 Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-118 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -34, "As -Built SSTS ", dated 08/31/05. 2. "Certificate of Construction Compliance for Sewage Treatment System" dated 09/01/05. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 08/31/05. 4. Laboratory Report, dated 5. "Well Completion Report", dated 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 08/18/05. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichol Jr., P.E. HWN:gav 03- 056.34 Aug 18 05 08:48a TOWN OF PRTTERSO 845 - 878 -2018 P.1 AUG- •17-2BFJ =� 94:31 Pr'1 HARRY W NICHOLS 414 279 4557 P - 01 d BRUCE fit. 'FOLEY iA[tFI'IA •?.IOLMAIZI'R.�1., M.S.?J. l�eh, iieolth Fvo0ia .. Awooteu• MAO MWIA X-eslor.. .. .. .. D(wtlar pJ Parfsal Srrvkoe ; :. . DEPARTMENT OF HEALTH 1 04MV8 Road Brewster, Now York MOM twinaseard NW14 014)111.6(70 Fix (114) 27991931 Mama; ttxYteel (61 +)210 4116 WIC (911)311.4679 Pal(M)PI-6085 L crlj '1eGrtigettio'(914)t1'8••d014 Pra+c ®oo! pt4)171�Orr Poo(91d)21t•66a9 :. E91I� AIMBLESR YERIECAT2019 ZQRM OwPus laAmy; 1�V`e!tv4 Am c'(1 5 'rAx MLAP xuNlsnR: ... —�..�. .. . TOWN; AUTHOR= TOWN OPMCL41-. v� , . ' (SEgnata9re) ', DATE: _ The'Putaam County Department of r H;alth ivW not issue Certificate _ fli ' _ ... Coustruction Compliance unless the above form is completed; h&i a legal' E9i 1, address Js assigned by en authorized town oriicial. 'This form is to be submitted %Pith the applicadon for a Certificate of CoagructiQa Cotcpliatrice, i i YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights; N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 9.5O1803 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TIME TAKEN: 08/04/05 03:0O DATE/TIME REC'D; 08/04/05 03:45 REPORT DATE: 08/15/05 PHONE: (845)-279-2022 SAMPLING SITE: (LOT 34) 20 TEAL LANE, BREWSTER SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BY: JOSE TEMPERATURE..: < 41, NOTES...: COLIFORM METH: Ml::' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/Lv DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (I grain/gallon = 17.2 MG/L) SUBMITTED BY:- Director ELAP# 1032,21 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director- LAB #: 9.501803 CLIENT #: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~^~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLlNWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TIME TAKEN: 08/04/05 03:00 DATE/TIME REC'D: 08/04/05 03:45 REPORT DATE: 08/15/05 PHONE: (845)-279-2022 SAMPLING SITE: (LOT 34) 20 TEAL LANE, BREWSTER SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BY: JOSE TEMPERATURE..: < 4C NOTEg...: COL[FORH METH: MF DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 08/04/05 MF T. COLIFORM 08/12/05 LEAD (lMS) 08/11/05 NITRATE NITROG 08/05/05 NITRITE NITROG 08/05/05 IRON (Fe) 08/08/05 MANGANESE (Mn) 08/11/05 SODIUM (Na) 08/05/05 pH 08/08/05 HARDNESS,TOTAL 08/08/05 ALKALINITY (AS 08/12/05 TURBIDITY (TUR RESULT ABSENT /100 ML 4.Ckppb 2.74 MG/L <0.01 MG/L <0.060 MG/L <0.010 MG/L 9.43 MG/L 6.5 UNITS 122 MG/L 68.0 MG/L <1 NTU NORMAL - RANGE METHOD ABSENT 1008 0-15 ppb 9003 0 - 10 9052 N/A 9162 0-0.3 mg/l 9002 0-0.3 mg/l 9002 N/A 9002 6.5-8.5 9043 N/A N/A 9001 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD����t�THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Ph/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium r U 1lNA1Vl %-V U1`l 1 I it LL rAK11V1LL 1V 1 Ur JILL AL111 4e DIVISION OF ENVIRONMENTAL HEALTH SERVICES v, FINAL SITE INSPECTION Date: J3 9 oS- Inspected by: ,<, Street Location T ,-t Owner k11Ayi,ae1j nA ,, gee eff Town Permit # / —o gl TM :9 4 -- A)'-3 Subdivision Lot # 3 !!? 1. Sewage System 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 System r a. Septic tank.size - 1,000 ...:....1,250 ........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 & trenches e. Junction Box properly set .......... ............................... 6. rfi encI es 1. Length required Length installed 2. Distance to watercourse measured-H 0 0 Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ............... 7. Room allowed for expansion, 100 %.................. ' S. Size of gravel 3/4 - 1112' diameter clean ................... 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems 1. Size of 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.estimated flow /cycle........... III. House/Buildiiie a. House located er approved plans .................. b. Number of bedrooms ................. .....................'yj.'L.... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured -L Q-1-- ft........... c. Casing 18" above grade ................ ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a.. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... Rev. 12/02 i*e I IV= WAS /IMMM F "MM M ME=,. NA, i*e AUG -31 -2005 01 mow+ PH HARRY W NICHOLS 914 279 4567 P.02 Q 3-- 0m,34f PCHD Construction Permit # 0 Located: ...�..� . (T) �° 1- g2 L . Owner/Applicant Name: �U TM Block Lot Formerly:.._..-_. -._ —_ Subdivision Name. ,A Subdivision Lot Is system fill completed? . Date:,- 1- Is system complete? _ Date: -S 1-c Is system constructed as per plans? �c _ Is well drilled? . 1,� Date: Is well located as per plans? Are erosion control measures in place? I certify that the system(s), as listed, at the above premises has been constructed mid I have inspected and verifiers their completion in accordance with the issued PCHD Construction Permit and approved }Mans and the Standards, Rules and Regulations of the Putnam County Department of Health, Date: Certified by: PE RA Desi rofessional.: Address: —._ r Lie. # (� Comments: FOR: 0 ADAM 0 CrpNE _ (��) form FIR-99 AHG -7.1 -2705 WED i..7-:48 TEL:845 -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health August 29, 2005 Harry Nichols P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Wyndham Homes Teal Lane, (T) Patterson Lot #34, T.M. 35. -4 -118 The following comments must be corrected in the field: 1. It appears the SSTS is 26 linear foot short on fields. 2. The SSTS was not installed in accordance with the approved plans. Please note that any changes or modifications to the installation of a septic system must have prior approval from this Department. 3. The outlet pipe in the septic tank needs to be trimmed back. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 AUG -17 -2005 04:34 PM HARRY W NICHOLS 914 279 4567 P.01 P6, d, AM COUNTY DEPARTMENT OF HEALTH IlDl STON OF ENMONMENTAL MULTH SERVXCIES RF j,,ST FQ,TtEYtAY INSPECTION For: Fill Date: Trenches 4ef!:77 PCHD Construction Permit # jo Located: ���.� —Q,2,e, _ ('I') 0 *Q�5Q Owner /Applicant Name: TM :.., Block Lot ILE Fomerly. Subdivisions Name: � Subdivision Lot .# Is system fill completed? Date: Is system complete? _ Date: 2 —12 4 t Is system constructed as per plans? Is well drilled? Date: Is well located as per plans? Are erosion control measures in place? 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 Regulations of the Putnam County Department of Health. Date- -`!o. p Certified by: PE RA Profeapional Address: Lic. # Comments: FOR: C] ADAM ENE U (NAM) Form Flit -99 AUG -17 -2005 WED 16:52 TEL:845- 278 =7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 +°, PERMIT # AM COUNTY DEPARTMENT OF HEALTH TSION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM n Located at T-Ehl- L A"s Town or Village . PAS X00 Subdivision name DE4D9 Subd. Lot #'4 Tax Map ; 6' Block A- Lot Date Subdivision Approved �� �1 Renewal Revision Owner /Applicant Name 1.(�/A Date of Previous Approval Mailing Address i A Via'— pj� Amount of Fee Enclosed �o Zip 10 t�z� Building Type i 1DtK -5 Lot Area f= i")INo. of Bedrooms Design Flow GPD ;DO Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of I �- gallon septic tank and G 6-1 iF— Other Requirements: ' U—, To be constructed by `'D Address Water Supply: Public Supply From Address or: A Private Supply Drilled by I'i L� 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 5ysteM 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 67/1061 License # Q L4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme stem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh co idered n cessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. proved ischarge f domestic sanitary sewage only. By: ' l,% % Title: Date: AX White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUT NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL IHIIEAIL')I'IHI SERVICES APPLICA'T'ION TO CONST'RUC'T' A WATER WELL please print or type PCHD Permit # ts - =cq Well Location: Street Address: Town/Village Tax Grid # i TEAL � H� ?Arrw d � Lot(s) � 1� - Map , Block Well Owner: Name: ' l,, i � t oMz wl, Address: �� , ,� �, � ,/ q Co l.LitJ�lIM V OIC16 ' 04 tai''— i", 10W Use of Well: 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 -St gpm # People Served � 16 Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ............................... Yes No ................................................. Is well located in a realty subdivision? ...................................... ............................... Yes -X_ No Name of subdivision 96Aoo Lot No. Water Well Contractor: 'T Fs D Address: Is Public Water Supply available to site? .................................. ............................... Yes No 'X, Name of Public Water Supply: — Town/Village --- Distance to property from nearest water main: %- Proposed well location & sources of contamination to be provided on sepazate heet/plan. Date: �1 �'Vg04 Applicant Signature: 1 4-2 V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONST'RUCT'ION: 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 . //An revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ,W/ ell iller rt1 l d by Putnam County. Date of Issue b),; to L Permit Issuing Date of Expiratio 4: )4 Title: Permit is Non- T'ransfferrEble �j White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 August 31, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 279 -4567 Email: hnengineer@aol.com RE: Proposed SSTS - Wyndham Homes, Inc. Deerwood Subdivision Teal Lane - Lot #34 (T) Patterson T.M. # 35. -4 -118 Dear Mr. Morris: Referencing your comment letter, dated August 11, 2004, we note the following: 1. New original corporate affidavit is enclosed. 2. 6' minimum is now provided between all trenches. 3. Two feet of solid pipe is now provided for all trenches. 4. Bedroom count is now noted on the plan view. 5. Minimum 6" fill is now provided over the entire SSTS. 6. Fill extends 10' horizontally past ledge of any trench. 7. Trench lengths have been checked and revised as warranted. 8. 667 LF of trench is now provided. 9. Sewer line is now shown perpendicular to foundation. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, iTe j Harry W. Nic ols Jr., P.E. - IN:gav 93:ti56.34 CL - -- LLJ O PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: REVIEWED BY: RM, GR AS, SRDATE: -N DOCUMENTS LPERMIT APPLICATION ice! )WELL PERMIT ORPWSLETTER (_)(,_)PC -97 L,)ULETTER OF AUTHORIZATION �(DESIGN DATA SHEET (DDS) L)CORPORATE RESOLUTION C,Z f SHORT EAF PLANS -THREE SETS (_))HOUSE PLANS - TWO SETS L)(-)VARIANCE REQUEST / SUBDIVISION ('_)LEGAL SUBDIVISION (__)SUBDIVISION APP�OVAL CHECKED L /JL)PERC RATE L)( _)FIL HIED 4, a DEPTH CURTAIN DRAIN REQUIRED GENERAL (eL_)LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D ( DEEP TEST HOLES OBSERVED IPERCS TO BE WITNESSED L) EX- APPROVAL SSDS ADJ, LOTS ' WETLANDS (TOWN/DEC PERMIT REQ'D ?) L)DATA ON DDS PLANS & PERMIT SAME _)PRE 1969 NEIGHBOR NOTIFICATION (._)LETTER BUZBA (_)100 YR. FLOOD ELEVATION W/1 200' L_)(_)SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS Le� SEWAGE SYSTEM PLAN - (NORTH ARROW) LSSDS HYDRAULIC PROFILE ( /)(i )GRAVITY FLOW )NSTRUCTION NOTES 1 -15 ?,SIGN DATA: PERC & DEEP RESULTS CONTOURS EXISTING.& PROPOSED AY & SLOPES, CUT E;/GUTTER/CURTAIN DRAINS -D( USDA SOIL TYPE BOUNDARIES i )TITLE BLOCK; OWNERS, NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# ((�� DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )L_)PROPOSED F OR BASEME4EVATIONS i WELLS & WJN 2Q0' O SSTS PROPERT NDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMWNTS: (REVSHEET)09 /01 /00 LOCATION: TAX MAP #: (CONFIRMED) Y N (REQUIRED DETAILS ON PLANS CONT'D) �18USE SEWER -1/4" FT. 4 "0'; TYPE PIPE CAST IRON N�0 BENDS; MAX BENDS 45° W /CLEANOUT � RENEWALS (- I SITE NOTE (NO CHANGE) FILL SYSTEMS L)10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS/ FILL NOTES 1 -5 L-WFILL PROFILE & DIMENSIONS (__) FH.L IN EXPANSION AREA FILL GREATER THAN2 FEET BC_�) CLAY BARRIER ( . VMLL CERTIFICATION NOTE (_) I m VDEPTH GAUGES C--) VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS (� kPARATION DISTANCE FROM TOE OF SLOPE TRENCH (_)LF TRENCH PROVIDED 60FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED L_) DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL L�GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS (_)L,10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL C__)(_)20' TO FOUNDATION WALLS L_)L)100' TO WELL, 200' IN DLOD,150' TO PITS L_)L_)100' TO STREAM, WATERCOURSE, LAKE (inc. eapan) ( _)L)50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER (___)(_)10' TO WATER LINE (pits - 20') C__)(__)50' INTERMITTENT DRAINAGE COURSE L)L,200' /500' RESERVOI , ETC. _ 150' GALLEY SYSTEMS L _)L_)10' MIN TO LEDGE OUTCROP SEPTIC TANK (x(__)10' FROM FOUNDATION; 50' TO WELL WELL (_)(_)DIMENSIONS TO PROPERTY LINES (_)(_)LOCATION OF SERVICE CONNECTION (__)(__)MIN 15' TO PROPERTY LINE SLOPE )L)SLOPE IN SSTS AREA (S20 %) L__)(__)REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS (_)( _JPUMP NOTES (__)L_)DOSE 75% OF PIPE VOLUME /DOSE VOLUME NOTED L)L)DETAH. FOR FORCE MAIN, (PIPE TYPE, ETC.) (_)(__)PIT AND D -BOX SHOWN & DETAILED (_)(_)1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN UUSTANDPIPES, T BOTH SIDES, DETAIL MEN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %, 100 % - <1% (_)(_)20' MIN to CD DISCHARGE /100' with 182 cons day discharge (_)(_)10' MIN to NON - PERFORATED PIPE _. - -- PUTNAM COUNTY DEPARTMENT OF DIVISION OF .ENVIRONMENTAE HEALTH -SERVICES. LETTER OF AUTHORIZATION RE: Property of��� Located at T-5k, LAO T/V TO Tax Map # Block _Lot Subdivision of—� Sub division* Lot # 1" Filed Map # ! _ Date Filed. — ©� I Q Gentlemen: This letter is to authorize e !� tiV�-S J!- a duly licensed Professional Engineer _ or Registered Architect to�ply for the'req' ed 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 I4ealth Director of,tlie..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 tretment 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 Putnam County Sanitary Code. of KEEN Y rul `�- nncyo �`��- Very t 1 y yours, . -Countersigned: P a gned: - P., R.A., # w .E (O ncr of Property) Mailing Address Mailing Address: 7 C,ojc,i�w(0 GPI. State Zip' d `a Telephone: TEV State Zlp Telephone: Form LA -97 PUTNAM COUNTY DEPAR'T'MENT DE HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: 1A represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation:��� ®'�� L° Having offices at: (5PW4 WON O/M W�4 v)_ ��'�0 1 Whose Officers Are: President - Narne: Address: Vice President - Name: Address: I Secretary -Name: Address: Treasurer - Name: _ Address: ell 10 �.01- .. ____ - and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. .,► , sew � �► -- . worn to before me this f , day of - (month) , :3 (year)". N ?9fy Public Form CA -97 Signed: , Title: N� i Corporate Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Having offices at: Whose Officers Are: President - Nam`e73 � C�L Address:PS Vice President - Name: Address: Secretan, -Nam6' Address: Ce�.�..� ��c�c�— i'���`- �C =�r Treasurer - Name: Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: Title: Sworn to before me this �- day of (month),= (year) Notart' P- -ublic JEOIN T EniDSAOo Corporate Seal Notary Public, State of Now York NO.OIROB103M QU21111od in Putnam County Form CA-97 July 12, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Re: Individual SSTS Deerwood Subdivision - Lot # 34 Teal Lane Town of Patterson T.M. # 35.4-118 Dear Mr. Morris: Enclosed are the following: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2791003 Fax: (845) 279 -4567 Email: hnengineer @aol.com 1. Five (5) prints of SS -34, "Proposed SSTS ", dated 07/12/04. 2. "Short EAF ", dated 07/12/04. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System, ", dated 07/12/04. 5. "Application to Construct a Water Well ", dated 07/12/04. 6. "Design Data Sheet ". 7. "Letter of Authorization & Corporate Resolution ", dated 07/12/04. 8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only". 9. Review Fee in the amount of $400.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. ichols Jr., P.E. HWN:gav 03- 056.34 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM `` /I Owner Wi 4 f4DRA`'i � 95 1Hb Address T Cbi•Li�Jii * DFA �j 5i6 hOM Located at (Street) TEAeL LlR, ji."n"Tu 14[W Tax Map s Block Lot (indicate nearest cross street) Municipality Watershed- SOIL PERCOLATION TEST DATA ( r Date of Pre - soaking jU I r -4 Date of Percolation Test . e NOTES: 1. Tests.to be repeated at same depth until approximately equal percolation rates are obtained at each 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 1107. tD 94?k 1� 1 2 i �': I i�� 2�. 25 ti 3 1,2Y ` 0 4 .5 [ 2 � ti� 12 � � uioc 3 �0 1,0)/4 - `'�`� 2A. 4 5 1 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 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 DESCRIPTIO OF SOILS ENCOUNTERED IN TEST HOLES DEPTH t_ 'tii � c_ , HOLI✓ ' O ' HOLE NO. HOLE NO. G.L. 0.5' ®� JUL 1 1.0' 1.5' LXAM 2.0' 3.0' 3.5'� 4.0'- 1-04 URW 4.5' 5.0' 5.5' R �n 6.0' 6.5' 7:0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level- at which mottling is observed Indicate level to which water level rises after being encountered Wtv Deep hole observations made by: M� Ll-dlo Cam, Date Design Professional Name: 1*j. t1 L\jVWW Address: Signature Design Professional's Seal NEW Y R NICHp� s I z LU LU �yJ'�►�P No.5612a R0 rsSV0 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: i N rR RD M66 2. Name of project:' L kj- 3 4. Design Professional: �Q Q�� ���� J� Q� 5 6. Drainage Basin: 7. Tvne of Proiect: 10�'O I�4(i Location TN: P d tJ Address: `L05'© 1 1-!�- xo >-, 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 Exempt Type II Unlisted `4 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... , No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other. officials, ordinances? ......................................................... ............................... i 13. If so, have plans been submitted-to such authorities? ... : ............... : ............... :... [� 14. Has preliminary approval been granted by such authorities? 00 Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ...................................... ............................... . �. 18.. Is project located near a public water supply system? ............ 19. If yes, name .of water supply Distance to water supply 04k, 20. Is project site near a public sewage collection or treatment system? ................ �l 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23.. Name of Health Inspectorui%i��'i 24. Project design flow (gallons per day) ................................. ............................... �p 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... �i Q 26. Has SPDES Application been submitted to local DEC office? ......................... { Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? -V1 28. Wetlands ID Number .......................................................... ............................... 29. Is Wetlands Permit required? ......................... :................................................... Has application been made to Town or Local DEC office? ............................... ►� 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landflling; sludge application or industrial activity? ............................. Yes/No �D 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 " 'DESCRIBE: J_ 33. Is there a local master plan on file with the Town or Village.? ......................... t 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... �0 35. Are any sewage treatment areas in excess of 15% slope? .................. �) O 36. Tax Map ID Number .......................... ............................... Map's - Block 4 Lot I( 4 37. Approved plans are to be returned to ..... Applicant_ Design'Professional NOTE:.All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, 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 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 1.,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 Secliln 210.45 of the Penal Lalq. _ SIGNNAT RES & OFFICIAL TITTLES: L. 1 :6 HV � i inr u Mailing . ➢�{ f�4� -� /f /111 Atire5 :, t +' �; ............... 4 05 A46R- 14.16.4 (2187) —Text 12 - PROJECT I.D. NUMBER 617.21- SEAR' Appendix C State Environmental Ouality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR .', e�i; a t 2, PROJECT NAME /► Lr Is1 3. PROJECT LOCATION: Fr ` � �r Municipality f{ � L�'T J� County �� 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) -TEAL,. LNol� , PCPI' 14I1I. ��� 5. IS PROPOSED ACTION: %ew ❑ Expansion ❑ Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AF EPED: ,9 rf�' I Initially a acres Ultimately a +i acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? .Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open ❑ space Other Describe: A,. ,, GG i 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, I STATE OR LOCAL)? %Yes ❑ No If yes, list agency(s) and rmiUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 09 Yes ❑ No If list yes, agency name and permlt/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes zNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 4 J,,ti Q I tbi;1 Applicant sponsojn e,, �W'Date: I Signature: If the action is in the Coastal Area, and you are a state agency, complete' the Coastal Assessment Form before proceeding with this assessment OVER 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 EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved 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. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether It Is substantial, large, important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ 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 �Q Print or Type Name of Responsible Of in Lead Agency " t )) �� F rt e.:o fR '_a R e O icer i i 7 Signature of Responsible Officer in lead Agency � Signature of Preparer (It ditterent from responsible officer) Date 0) CASWA EX r3 1, 1). RESIDENCE c. ol C!4 SLIPTi c TA rq;< az Za 274 p C 9 0 SOL I_r' Pv p '7 (73'P) 6 tq. ts- O.C' l i6 4 G` ,3 f;7 Pvc fe I 0? J. 'C> --,.# W eta (ryp) & IL fl >19 5xlsr WELL C=Z) M==ZMM= Putnam C-011TAY r - Divisi on of ErTjvtrOnlllc'- `x. Witt, A -P, d P 0 ( app, CUE DR, ��L2,6£'o9LS OL 9-, 82 SIP L2 2S L£ SZ Lb 5i �Z %E S£ ZZ 17 1 I 61 I 0z 91 I o2 1 61 81 I IZ 1 81 221 22 1 L1 X21 £21 �I a2 i 52 I I I£I 121 �I -b£ 1 82 1 £ l S£1 1£1 ZI E0 1 06 I I 86 LS 0 I t6 5`3 6 06 sa S 98 is L Z� 08 9 6L 6L- 5 L 8L Z I E 0L eL Z 02 zt I (:s