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HomeMy WebLinkAbout1869DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36. -3 -5.1 BOX 17 ,e:. • IIS'6! ,. ., log t;, �}��., .,, or JA rf ,, Ig logo Is r ,e:. • PUTNAM COUNTY DEPARTMENT OF HEALTH D V SIGN. -OF- ENVIRONMENTAL. HEALTH, SERVICES_ CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # p' 2-9 - "0 Located at 1FA6- PAO-A.WG14 RaA,D Town or Village Owner /Applicant Name Formerly Mailing Address PATrap.6o �4 Tax Map ' G a Block `�5 Lot _5 Subdivision Name HATO 0S 0K 6JB P"J► 'oN Subd. Lot # Z. Vag; $AAMO" P4AO DOI 45 C PATrar -�H N-Y, Date Construction Permit Issued by PCHD Separate Sewerage System built by 10ho19'1 Consisting of 1000 Gallon Septic Tank and Other Requirements: Water Sunaly: W) A Zip ; 2'5005 Address �o® i F Ik' WIDC- aghDP -Pry )4 T9ZkG1+E5 Public Supply From Address or: X Private Supply Drilled by . - -- Building. Ty-pe..._ -- :p-krE -. Number of Bedrooms *�5 P • P • B M— 4'50" !W(1- Address'} N rM NM Ma AWW67151-Hy R4 _ Has erosion-control been completed?--"----'--- _YES.. ; Has garbage grinder been installed? No 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„Deprtment of Health. Date: APkt- 0- I'M Certified by � P.E. iC R.A. (De i Professional) Address *r IC-0 cZ1-4r1-,e XT TI-1 HIWPWOA N R4 License # r76114 10601 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 are subject to modification or change when, in the judgment of the Public Health Director, such revocat = odificati n or change is necessary. By: Title: �lr� 444� A-- Date: f 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 WELL COMPLETION REPORT Weii Laicatitih Street Address: = „' - ' ''` East Branch Road - - - - - - Town/Village :­`­`-. - - Patterson - - - -- Tax Grid # Map---------. Block- Lot(s).. . Well Owner: Name: Address: Scott O'Halloran, Box 45C, Patterson, NY 12563 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment _ x Rotary Cable percussion x Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32 ft. Length below grade '31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes _ No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield 'Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 40' During yield test(ft) 505' Depth of completed well in feet 545' 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 3 Drillin in over urden clay bo-ulders 3 Hit. rnn at 31 3 32 .Draaliri in rock;.. ina, arouted . 32 545 Drillinc in rock c ran' to If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed 1/22/98 Putnam County Certification No. 002 Date of Report 3/19/98 Well Dri r g e) r Nu'rh: txact location of well with distances to at least two permanent landmarks to be provided'on a separate sheduplan. Well Drillees Name P. F al 147c. Address: 4 Putnam Avpnup, RYPwGtPr, NY Signature: Z Date: 3/1 g/93 Perry L. Be White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Inorganics Analysis Data Sheet Form I IN 7, 7- Client Name. P.F. BEAL & SONS Project Name; STANDARD ETL Sample Number: 185850.01 Clierrt I.D.., EAST BRANCH ROAD SCOTT O'HALLARAN Date Collected: 29-APR-98 Matrix; I DrinkH20 Date Received: 29.011-98 Comments: Analysis Result Units Method Analyzed ... .... ..... .... ....... .. . .... 04 Remarks: Sample passes NYSDOH drinking water standards. 315 Fullanon Avonue Newburgh, NY 12550 Tel. (914) rPS2-9$90 NYS00H 10142 NJDFP 73016 CMOHS PH-oss4 EPA NY049 PA 88576 M•Nyo" Far, (914) 662-08di ANALYTICAL REPORT Laboratory Di l� 315 Fullerton Avenue Newburgh, NY 12550 Tel: (914) 562 -0890 :...,..,.., �E .,,... NYSDOH 10142 NJDEP 73015 CTDOHS PH -0554 EPA NY049 PA 68378 M -NY049 Fax (914) 562 -0841 D Inorganics Analysis Data Sheet Form I '.IN Client Name: P.F. BEAL & SONS Project Name: STANDARD ETL Sample Number: 184615 -01 Client I.D.: SCOTT O'HALLORAN EAST BRANCH RD Date Collected: 02- APR -98 Matrix: 1 DrinkH20 Date Received: 02- APR -98 Comments: Analysis Result Units Method Analyzed Remarks: N Parameter fails NYSDOH drinking water standards W Result indicates hard water. Grains = 9.5 315 Fullerton Avenue Newburgh, NY 12550 Tel: (914) 562 -0890 ,...� ... NYSDOH 10142 NJDEP 73015 CTDOHS PH -0554 EPA NY049 PA 6"78 M -NY049 Fax (914) 562 -0841 3. If the water supply is from a drilled well: a. Satisfactory results of a water analysis, for the parameters in Table I below, conducted and reported by a NYSDOH approved laboratory under the "Environmental Laboratory Approval Program (FLAP)." CONTAMINANT MCL (1)(4)(5) Coliform bacteria Any positive result is unsatisfactory Lead 0.015 mg/1 (15 ug/1) Nitrates 10 mg/1 as N Nitrites 1 mg/1 as N Iron 0.3 m Q/1 Manganese 0.3 mg/1 Iron plus manganese 0.5 mg/1 Sodium No designated limit (2) pH - No designated limit Hardness No designated limit Alkalinity No designated limit Turbidity 5 NTU (3) r.;., NOTES: (1) Maximum contaminant level. (2) Water containing more than 20 mg/1 of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/1 of sodium should not be used by people on moderately restricted sodium diets. (3) NTU means Nephelometric Turbidity Units. (4), mg/1 means milligram per liter. (5) ug/1 means microgram per liter. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH, SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 5Gor1- p' µAL1-0R -IAN Owner or Purchaser of Building Building Constructed by 1aA0W OP404G44 P--o P Location - Street . Fmmr-- . Building Type / . l 5 Tax Map. Block Lot TownNillage HAToUgc1L Subdivision Name 2 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 Day ?3 Year ' Signature: ble, "U", --- Title: _ ' r2,i) ff Genera ontractor (Owner) - Signature Corporation Name (if corporation) Address: C4 r• CZ /2/ State r/' s04 Zip Corporation Name (if corporation) Address: 3 7 C« %tir,,, Pd - State A ly',g V f Zip Form GS -97 PLo159FR-T HOB CR )6, P•E• Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: - Individual SSDS Compliance MATOUSOK 600157- �OTf 2 E/6,5T Ur�ANGi -F i ='ri/Q Dear . Hx • Mop-P-)-:5 Enclosed are the following: 1. Four (4) prints of Drawing S -1 "As-Built Plan ", dated APJLIL- 'L, i qq 8 2. "Certificate of Construction Compliance for Sewage Disposal System ", dated APtJL- 2, 1948 3. "Guarantee of Subsurface_Sewage Disposal System'.', dated MA"H 19,18 4...- Well. Completion Report, dated MA��H ►� , 1,198 5. Laboratory Report, dated APr-&�, 2, 19 q e 6. Application Fee 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. Nichols, Jr., P.E. PUTNAM COUNTY DEPARTMENT OF HEALTH Vj DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PE # Located at �.c� S io.v�C -V ® Town or Village +P,: >, � y� Subdivision name W% Subd. Lot # Tax Map 3 - Block 3 Lot Date Subdivision Approved Owner /Applicant Name S c 6t� Q' i4 g>,� o,-aty) Mailing Address 41 c- Amount of Fee Enclosed • uilding Typei c•, Renewal Revision Date of Previous Approval Zip Lot Area 5_.2 { No. of Bedrooms 3 Design Flow GPD 6 00 Cd�5 Fill Section Only Depth Z `° Volume (�5 C -Y PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of lye© gallon septic tank and 3� 0' b� i 241,w -,.Ae_ x 24i c bsnrTy Other Requirements: IQ /A To be constructed by -'� Address Water, Supply: Public Supply From Address or. 1C Private Supply Drilled by T. R _ D Address I represent that I.am wholly and completely responsible for the design and location of the proposed system(s) and that the seFarate sewage treatment 6ystem 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: V . , ZI P.E. Date 10-22 -c;,7 Address 1�'�9�OoS�I � k� (��+ / C'eon$re . W i 1 gw-, `kcl . . 22 License # 5 6 127 4 APPROVED FOR CONSTRUCTIOW 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 ,t. Appro for discharge of domestic sanitary sewage only. By: , �l PC Title: p �LL� g)� Date: /-J 13 v A I White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION . Street Location Town TMr 3 lo. — 3— 1. Sewage System Area 1 on 3/��/y ' 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 a. eptic tank size 1,000 ....... ..1,250.........other.......... b. Septic tank installe evel .......... ............................... c. 10' minimum from foundation .... ............................... d. Distribtuion Box 1. All outlets at same elevation -water tested............ 2. Protected below frost ............ ............................... 3. ivlinimum 2 ft.Original soil between box & trenc Junction Box - properly set .................. ............................... 1. ength required 34!90 Length installed 2. Distance to watercourse measured -i- 100 Ft..... 3. Installed according to pl 4. Slope of trench ccepta a 1/16 - 1/32" /foot......., 5. 10 ft. from grope 1' e - 20 ft.- foundations..... 6. Depth o ch <� nches from surface ............. 7. Room ' low for e n, 00 % .................... 8. Size grave 3/4 - 1 z" diameter clean ............... 9. Dept of gra 1 in tre ch 12" minimum .............. 10. Pipe ds ca ped .............. . . ... ................:...:..:.:. g. `Ptrm or Svste s _- _ -._ -_- ,.h. size ot pump c n er. ... ................. 2. Overflow to .................. ............................... 3. Alarm, vi aU dio .............. 4. Pump easily ac essible, manh e t grade.. 5. First box baffle .............. ..........................:.... 6. Cycle witnessed by D.e timate ow /cycle.... III. House/Building a. House local p r xIs ............................ b. Number of a ms .............. ............................... IV. Well a7--Well locate per p roved plans .................. b. Distance fro ST area measu L4' ft..... c. Casing 18" ab a grade .......... ............... d. Surface drainage aro well c ........ V. Overall Workmanship a. Boxes properly grou ed ............ ............................... ........................ b. All pipes partially b c ed...� c. All pipes flush with 'n of box ............................. d. Backfill material co t ' s stones <4" diameter........ e. Curtain drain & standpipes installed according to p] f. Curtain drain outfall protected & dinto exist waterc g. Footing drains discharge away from STS area......... h. Surface water protection adequate ............................ i. Erosion control provided ........... ............................... Rev. 1/97 Date: 3ja 01�'8 Inspected by.:.. � �. A k7a ­' >..... Owner S�o�! O'flcc / %r�cvr Permit # P 2- q - 0' 7 Subdivision Lot PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type- PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # Ec, 'T r av%l � R J . a7 * P Map :56 Block Lot(s) 5 Well Owner: Name: Address: GCe- O'u i 0rC VX ?ranC� RepA Q cnt 4 :5,r— Use of Well: _`L Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served 2 - 5 Est. of Daily Usage 4 0 gal . Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type J_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No n Is well located in a realty subdivision? ........................... ........... ............................... Yes No X Name of subdivision W /A Lot No. W /N Water Well Contractor: 'I-. R.. D.- Address: Is Public Water Supply available to site? .................................. ............................... Yes No _X____ Name of Public Water Supply: Ki /A Town/Village 14 /A, Distance to property from nearest water main: /A Proposed well location & sources of contaminatLto provided on s Grate sheet/plan. 1 Date: Applicant Signature: - 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 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 1 driller certified by Putnam County. i Aj Date of Issue /O Permit Iss fficiak ' Date of Expiration ,a �' ' Title: , Permit is Non- Transfirrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 -R-IF. � ORD .PH - RSATL NT, Time: i t Date: 3 A02O% Person calling : Phone #: Reason Inspection: ( ) Deeps and /or Peres: Scheduled Field Meeting Time: lVog P Date: F12:9:9 3/2 3 ^?arrr %Kq Y N Tentative /to be confirmed () ( ) Town: Road /Street- i3Ygv4e4, P— Tax Map #: '3&" t Comments: '�. VEERING ASSOCIATES, P.C. LAUREN � E G Millbrooke Office Centre Brewster, NY 10509 (914) 278 -6108 October 22, 1997 - Robert Morris, P.E. Putnam County Health Department 4 Geneva Road _. Brewster, NY 10509 RE: Individual SSDS Scott O'Halloran East Branch Road Patterson, N.Y. Dear Robert: Enclosed are the following: 1" Four (4) prints of SS -1 "Proposed SSDS ", dated 10- 22 -97. 2. "Application For Approval of Plans For a Wastewater Disposal System ", 10- 22 -97. 3. "Construction Permit for Sewage Disposal System ", dated 10- 22 -97. "App ication to.Construct a Water Well'', dated 10- 22 -97. - - - 5. "Design Data Sheet ". - 6. "Letter of Authorization ", dated 10- 22 -97. 7" Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8. Money order in the amount of $300.00, review fee. We would appreciate your review, approval -and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Ni ols, Jr., P.E. HWN:RTL:bd 97025 DIVISION OF ENVIRONMENTAL .HEALTH TH SERVICES LETTER ®F AUTHORIZATION RE: Property of S G 0.A+ O H c:.1 Located at E css J ra.:n < -Ra cx c, T/V 'Pc,4e_r s©" Tax Map # 34 Block S Lot �5 Subdivision of �r��� Ni c to U l� Subdivision Lot # Filed Map # _ Date Filed ' 7 Gentlemen: This letter is to authorize I Hc3s r r� 'U,) N i ctn o 1 s Jr. _F>_ E. a duly licensed Professional Engineer k 61=Rvg tered=A=hitett._ 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 Putnam County Sanitary Code.---­­ F NEW yo Very truly yo s, Countersi a Signed: r P.E. R.A., `L (Owner of Property) 2J, FO No. 56124 Mailing A Mailing Address: RA r w + • . s' State y Zip 1011 01_ Telephone: (y /4 7 / d F State w )Lc::� r \-, Zip Telephone: & /—*) G %3 — 6 -�_/ (I Form LA -97 / Brook Nkins 8 r A 1 • 311 ;O laser r :: aL.. Cranberry l Mo g untain i ... Id6te Mai(agement s. t _ 1 J r \•- 11 I..y tij i 12563 1, ji1 ;Mendel Pond ' 164 1 .�' 65 '� • , ,,,,yi rfgt �.; � 1 t i (•� fph a cb Haines RID 1 / Corners ~ 1 2 lit •\ •: 8 no R wg� b � �• •�'i� �Tt�r 7 a a dcdol 1 � n Putt'! Lake a CIA s . ,... m 13urii4,� ! .. Lost ru 16 / $ Lake 'j 3'"ereerg , S i harlesjpol Farm Center' •: , 0 Der( r, st P Unique Area "' ^;i Mount Ebo r U, s –•— `4' ;:`:Corporate "•, .,, i 4 3 � t,, /.,0 4 F � N�7kde� a :a f Corner S Pond C I O� y..: `�`✓ sCerNer •' r . Pond lQ �` ew State ,S \ / PoUce fOOld Southeast a e' > �ij / Church PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES { DEiSIGN­ DATA=SHEET"- SUBSURFACE -SE`VVAGETREATMENT SYSTEM Owner ��c� �1 � �� � ®Y`C V\ Address Located at (Street) �, cv.v� c� °j�d _ Tax Maps - Block Lot 5 (indicate nearest cross street) Municipality r 5oy Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre - soaking 15 — 9 7 Date of Percolation Test Hole No. Run No. Time Start -Stop Ma se Time Min.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 23s 2� 67 .. ...2 .._. Z.2712. 3q 10 Z A'\ I Z 7" 3 4 3 24� . x',55 1Z 2 ' +/2- 7 3 / 4 #Z 5 2 ;-SV/21:41 I t 24 27'' 3 �•�� 3 3 -67 3 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 2 TEST FIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Hoc r; s Date 9- /6 '97 Design Professional Name: Address: ���;��N a r Signature: Design Professional's Seal �,�q•���.ssrc�o` 0/r Ply. BKO124 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _.._ . ,,.,., APjPL�C ;A.TION:.k'O.R:APPROVAL:: ®E PL�NS�'O �: A A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Scot" n' H c6 l o f c n go is 4 5 c 2. Name of project: 0 r'{ cam, i ic)<-Gv� 3. Location TN: 4. Design Professional: J:s Jr 5. Address: r c "Rcl 6. Drainage Basin: - 7. Type of Pro,Lect: . X Private/Residential Apartments Office Building Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review -(SEAR)? Type Status (check one) ........................ ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? .................... VA 10. Has DEIS been completed and found acceptable by Lead Agency? ............... /A 11. Name of Lead Agency N /A 12. Is this project in an area under the control of local planning, zoning, or other.. officials, ordinarices� ..,.____� . _ _ ... .. -_ .... ... ..... . _...�_.._..___ ..__._.. �...� ............................ .............................o' 13. If so, have plans been submitted to such authorities? ........ ............................... N 14. Has preliminary approval been granted by such authorities? Date granted: NZ6 15. Type of Sewage Treatment System Discharge ................. surface water K groundwater 16. If surface water discharge, what is the stream class designation? .................... A, 17. Waters index number (surface) ........................................... ............................... N /A 18. Is project located near a public water supply system? ....... ............................... 1� 0 19. If yes, name of water supply Distance to water supply N A 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system ts� f A Distance to sewage system W/A 22. Date test holes observed 916 - 9 7 23. Name of Health Inspector = r� arriS 24. Project design flow (gallons per day) ................... 600 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N o 26. Has SPDES Application been submitted to local DEC office? ......................... N/A Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number................................. s ... J ... ....... 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? ............................... A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... �o 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 c> 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 p otenti ally known source of contamination? Yes/No N o 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? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... VIA o 36. Tax Map ID Number .......................................................... Map 36. Block 3 Lot 5 37. Approved plans are to be returned to ..... Applicant X 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-,Depa rridnf, and'need not be sent in duplicate to the DEP, although the proj ect 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 I .,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 Law. SIGNATURES & OFFICIAL TITLES: �� -,fit`. i(%(, 1 Mailing Address: ................................... �-�� l/ y t �, L 0S C, 1 jj f 7 I �5k01 50 �0% PS.2 i IOtJ cP•2 // // / Z�� c:o.. �� \ \ PANi'� �•� / �� S6a' +ter: Q��ry''J s \ BOx \ 1 I � I I _ _ /,0004, \ \ \\ PROPOSED J B R/yE SE �z0 �\\\�\ \� \\ \��• \\ \ \\ \\ LEV. 70.0 577,9-- \\ \ \ \ d i vvl •� ......, .. _ _ - -- uAt¢aTnoarAnxcx . -.. ... . :. .w-� _ __ ....._ TRIN•REDI 7-000- 345 -7334 Yoeao P/0 25-1-02 j L. 36.22 36.23 c. T5 ac. CAL. l 1 �. 101IM41W LAKE f 36.30 36.32( ! 36.05 36.31 ' � 36.30 \ � •\ I•T.I AL. Iry I l NOAH 36.39 6. OZ, K. 'o• �� I T * z37' y�'�„ �TJ s LOST LAKE '-0js• 1.93 AL \ x '.1 5.56 AC. �.. 36.09 36.40 \ ii. •� AL. Ifi %�.. 227 fiCpJar / pyF �3 107.30 AC. \ ✓ k� AC. 36.48 36.4 47.27 AC. r \. 3.30 A IS • ^ v 33.64 AC. _ 2 CAL. y .. , U� r �Y.n wr ..x"133.00 AC. - - CAL. 1 ; Y 3 56 22 18 AG 22 _ j 20 a r' �� ' 3.52 AC, 'P¢ 25.36 AC. CAL. 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