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HomeMy WebLinkAbout2796DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -17 BOX 24 %FM - F L. IL � .` : Elk NEW . . ME 02796 BRUCE R. FOLEY _ ' tyifVilV ii 4'411 %i • c ".rs +� -. +..J - r...... ... r. _i.... - =e7i:'e::fur' DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N, Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 -7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 February 22, 2000 Kenneth Hurley Putnam Engineering 102 Gleneida Avenue Carmel, New York 10512 Dear Mr. Hurley: Re: Application to Construct a Subsurface Sewage Treatment System at Brophy, Tinker Hill Rd. TM# 62 -2 -17, (T) Putnam Valley This office has discussed the above referenced application to construct a subsurface sewage treatment system at its February 15, 2000 Specific Waiver meeting. This Department has formally denied approval of such application for the following reason: . "- ' "The proposed iocatiori of the SS "1'S does not meet current s'fope requirements pursuant to q ~ PCHD Policies and Procedures Bulletin ST -19 and PCHD Sanitary Health Code. Average slope in the proposed area of the SSTS is 30 %, maximum allowed is 20% slope. Should you have any questions or care to discuss this matter further, please contact me at this Department, ext. 2157. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj ry BRUCE R...FOLEY : ealih - Direcior' January 18, 2000 LORETTA MOLINART R.N! M.S.N. - Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New .York 10509 Environmental Health (914) 278 -6130 Fax (914) 278 - 7921 (J� Nursing Services (914) 278.- 6558 . WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Kenneth Hurley Putnam Engineering 102 Gleneida Avenue Carmel, New York 10512 Re: Application to Construct a Subsurface Sewage Treatment System at Brophy, Tinker Hill Road TM# 62 -2 -17, (T) of Putnam Valley Dear Mr. Hurley: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department is incomplete. Please be advised that the following information is required before the Department may commence its review.. • Certified copy of survey showing lot in its entirety with topo. • House plans of a 2 bedroom house. • Witnessing of perc tests by.this off.ce,. - - -' a F Joint siteinspdction to verity i •pfoposed "SSTS'' area is the'best suitable area for the S S T S M The review of your application will commence once the Department receives the requested . information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter further, please contact me at extension 2157. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj V]N T AM GINEERING,PLLC. Englneers and Planners December 14, 1999 Mr. Adam Stiebeling Putnam County Department.of Health Geneva Road Brewster, New York 10509 RE: . Brophy SSDS Tinker Hill Road Putnam Valley Dear Mr. Stiebeling: Enclosed is a submission to be presented at your next waiver meeting. Our client is in contract to purchase the above property. A two bedroom dwelling is proposed, and a waiver will be required for two items. The first waiver required would be for construction of a septic on an average 30% slope instead of the maximum allowed 20% slope. The second waiver required would be for the proposed side slope of 2H:1 V instead on the maximum allowed 3H:1 V slope. Please feel free to contact this office should you have any comments or questions. Very truly. yours, PUTNAM ENGINEERING, PLLC By: Ken Hurley KH:rk Enclosure (File 990712) 3, r� 102 GLENEIDA AVENUE, CARMEL, NEW YORK 10512 • PHONE (914)225 -3060• FAX (914) 225 -2955 IVISION OF P N ♦ COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH HEALTH _ = CONSTRUCTION PERMIT !1' ®R SEWAGE TREATMENT SYSTEM STEM ZMoxwmnor PERMIT Located at ! ICS (� (.-� Village Rjm&n c.. Subdivision name Subd. Lot # Tax Map Block J-- Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name _ BaDp 0 `I / Date of Previous Approval Mailing Address 11" e, 5r Zip 1 o S`- 77 Amount of Fee Enclosed Building Type Lot Area S • No. of Bedrooms 2 Design Flow GPD Fill Section Only Depth Volume PCI-ID NOTIFICATION IS REQUIRED WHEN FILL. IS COMPLETED Separate Sewerage- System to consist of O© O gallon septic tank and 2452 l Other Requirements: '-� IRO 13 l'/ Lt-, �-M I tj • ADO G� To be constructed by �L� - I� gZf � Address Water Sup Public Supply From Address. Pri`v &tc Supl;ij i�iiiied by 1 U�lNUN�D Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewasewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any re airs eretge —•---,, Signed: Address P.E.�r R.A. Date L Ec_ / aS/ Z License # 0&-74 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be -amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: 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 APPLICATION TO CONSTRUCT A WATER WELL please prim or type- — PC?jT; T�rmst ;Ei. Well Location:��^ Street Address: Town/Village Tax Grid # T► 1 LL. &:R PLANAPI VAL4, Map &?- Block Lot(s) Well Owner: Name: Address: rs J?--0 P44 y I I'I Lff E . ,e sr M0-4e6g�.J .., y (P5t Use of Well: 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 rIW 5 gpm # People Served - ,I Est. of Daily Usage Do al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X 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 X Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: 'I b�6 c 12 �T7- MIh1f�U Address: Is Public Water Supply available to site? ................................. ............................... Yes No Name of Public Water Supply: K /A- Town/Village Vy+nn \Ia� Distance to property from nearest water main: [� j\g , Tk , , Proposed well location & sources of con rovi ate sheet/plan. Date:/2 l 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 well driller certified by Putnam County. Date of Issue Date of Expiration Permit is Non - Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Date rZ RE: Property of .cy� l .� *CC>-Xry �t ✓ � Located at _T) - W t C.-1— R�' !�D (Town) P, j7,*jA-n4)4LLQ4 Section �O 2 Block Z Lot Subdivision of Subdv. Lot # Filed Map # Date _ Gentlemen: This letter is to authorize PUTNAM ENGINEERING PLLC, a duly licensed professional engineer 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 promulgated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the :'3�i i Said systejn_pr sy er_.•,$, in;conf2r �try �✓i _ ." izP rr_nuic;� r ' � t': *t c e-145,or 147, Education Countersi ned: ` %s g \F 01; P.E., R.A., Address 914- 225 -3060 Telephone Law, and the Putnam County Sanitary Code. Very truly yours, Signed Owner of Property '141 t:-::. MAIN sT Address Moi- 1(E.c-AWI\ Town 52-$ - S -f 3 -7 Telephone UTN4M NC-�INEERING,PLLE. Engineers and Planners SEPTIC SUBMISSION FORM TO: 4DAM S-n SP,-�e�I Nt;, DATE_: 2 I PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: -'5F4!2p �' � -f �� ENCLOSED, PLEASE FIND: / COPIES OF THE SSDS PLAN ❑ 2 COPIES OF THE HOUSE PLANS CONSTRUCTION PERMIT APPLICATION WELL PERMIT APPLICATION HEALTH DEPARTMENT FEE ($ r. SHORT EAF DESIGN DATA FORM LETTER OF AUTHORIZATION APPLICATION FOR WASTEWATER TREATMENT (PC -97) LETTER OF EXPLAINATION REMARKS: r LISGS j"0fO 9r P28�L COPIES TO: SIGNED: 102 GLENEIDA AVENUE, CARMEL, NEW YORK 10512 ° PHONE (914)225 -3060° FAX (914) 225 -2955 i /48: 60. 455.00 �� Is_5asl ROAD s•ar6) m 44si r 2D • Ase JI : 4.01 AC. 'O 4.03m SKY rm. _ 2.04 AC.� 61 AC. o� �a ;.•�' 30 29 r 2 . a•LSA „ AC. % T• ., I. s 10.19 AC. C: 8.06 AC. ► # I 25. .1 �4I �a► I ! 49 1 .!j!. s a a II C 19 _ t��Yq 64 1,/AC. CAL. I 1, / 7 S,• ^� II RS °� 21 h \ _ • ,3,4 t 2.9. 16 s 28 a o 26 �' 2.29 AC 35 8.0 AC. CAL. 8 AC. ' " A 4.21 AC. CAL. �oei g 10.06 AC. / ^ \ 36 ,; }� s 2.86 AC. 4.21 A0 8 e Ar e, 27 •Ig4 17 ti _ c- 37 ;u 2P 9.92 AC. ii ! 95 AC. C 54 (; t.a3, sa I. 14.eo Ac. i 9.99 AC. CAL. rl 4.63 AC..�`. , 50 ' 1, 20 4 . + 52 7.06 AC. ; 1 . 48.52 AC. ig �: y .7.35 AC. 7.11 AC. 12.54 AC. ` _ . �I ��+ / l 40.31 AC. J 40 36.68 Afs'�., AREA IN DISPUTE K °R �e ��• y i4 ,5 $ 51 / 5.46 AC. ` `2.53 AC's CAL. 14 12 . 2.67 AC. •', a �' 31.It i . sr"13• �+ <.,,,o�, �.p 11.2 AC �1 �j ;!.:.. F 1: ; �• '��s/ ?8.86 A6. 1.09 ti ^� 5 s CAL..J: AC r�►i�+ CL', -��• 1.�3�� Cpl. ►1.36 's •°+., WW ;.'I. I. P/0 73-1-95 .(! �, b l fi'� ���' +`ti 1.13 1 • ' 1 `'; JIM --- - - - -,; ------- - - - - --- .--- - - - - -- ..� ►e:RZ «� G. " 3 4 LEGEND 5O 51 52 MAPS 62 I ; D1TW1E0 MEOW �._. P RAE L i M i N A R Y "• 400' r AIEi UM LINE AM STA60. j canINAVS oNNER5111/ DEVELOPERS LOT NIAW 1 i. i SCALE sow DEED olmmiam Ioaol f1AEAN/NATEAIK ttsS scALED DIAATNSIOI INS) 61 63 � TOWN'OF PUTNAM VALLEY 400 .. 40 No SPECIAL DISTRICT LINE li - -f CALCULAtE0 AREA t 5 AC. CAL O �. SDN0. OISTRICi LINE ' ;,F VISUAL CENTROIO . r Q t DATE OF AERIAL /IIDiOWAPNT..... 10.17 GATE AAIr.....E•IT -SS 72 73 74 PUTI�AM COUNTY, NEW YORK IWT Di /WC0. BOUNDARY ;!I - - ^ PARCEL NUA6ER TI NT STATE PLAK COORDIRATES AK MM IN FEET ' ' • � I � NLL.YN 10{1 W)/1. � t: OF I P U TNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM., . �... - . £.Owner] G-t- Address �/' t=+- -► � ►-'� � u-t Era✓. r..! f v �l l ° 5 `f '� Located at (Street) T(N LG�-�,2. t� 1 L_L, Q r,�> Tax Map &2- Block 2 Lot t7 (indicate nearest cross street) Municipality �--� -- P ty�i.i -ra ,rv1 A j:,,�, Drainage Basin' SOIL PERCOLATION TEST DATA Date of Pre - soaking D / 1 8 G[ Date of Percolation Test (0 Bole No. Run No. Time Start - Stop Ela se Time Min.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Drop n Inches Percolation, Rate NL'n/Inch 1 4o c, 4:3 3o 3 /10 2 5:07 3o 3 S: 00 5 :35 3.'00 1'7 4 5 2 1 4,o 9-:25- I Co 17 20 ........... 3 5.3 _ 2 �4.25, . 4� s _t 20 117 2A 3 12 3 4, 40 5:06 Zo 1 7 2„o 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, _< 2 min for 3 1 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' ArjOA rAA "tLA^ DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO HOLE NO. Mr-- M pgur-j mow ►J , Indicate level at which groundwater is encountered ri/A. Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: r S , , Date Design Professional Name: Q Tr uce-, .,�.,, � rvc- _ Address: Lot P/ Signatut Design Professional's Seal 674��°.��. 14.164 (2187) —Text 12 PROJECT I.D. NUMBER 61 %21 SEOR Z Appendix C State Environmental Duality Review SHORT ENVIRONMENTAL ASSESSMENT, FORN1 : �W ' NLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME -3 3. PROJECT LOCATION: �1 Municipality A M VA-L-1- - County ?"T-N -M 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 5r� S i i F_ M A-P m z L-R-e . 7-1, " 5. IS PROPOSED ACTION: kt^^new ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: jcr �•� �)CI 5'C' I r—�!o �p 7. AMOUNT OF LAND AFFECTED: _ 5 9 S S ' 4:7 Initially , acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ryes ❑ 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: Iii. -bbES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ,�r� ED Yes 9No If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes &No If yes, list agency name and permlUapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes &No I CERTIFY THAT PROVIDED ABOVE TRUE THE BEST OF MY KNOWLEDGE �THE {INFORRM,ATIIOON /IISS, �TO Applicant /sponsor name: I ""' ' "' Y r y` �a �'� �! 1' �-�-� • Date: Signature: J 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 1 PART II— ENVIRONMENTAL ASSESSMENT (ro be completed by Agency) A. DOES ACTION EXCEED ANY TYPE_ I THRESHOLD IN 6 NYCRR, PART 617.127 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. 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 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. ISTHERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? .T I 1` @2 Jri NC1 . ..li Vac arnlain hriwfiv _ 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 Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Prepater (If different from responsible officer) Date 2 iL %,iL.Lq ruri %.., V V lr 1 Y LL' rAK 1 lYlL1V 1' € Y. HEAL 1 H DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT Su�'I'EM 1. Name and address. of applicant: 2. Name of project: :RgDF4 `{ 3. Location TN: �[ 1IAL. , 4. Design Professional: o&,w,c��,izi,�� 5. Address: AIv-e 6. Drainage Basin: - I- i11'p�o ►.� ►2► ��-YZ �_ h l U 12 7. Type of Proiect: X_ Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ... ....... o .............. A10 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 .:....:.. ....:................................................................. 13. If so, have plans been submitted to such authorities? ........ ...... .......................... 14. Has preliminary approval been granted. by such authorities? 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) ........................................... ............................... AXI 18. Is project located near a public water supply system? ....... ............................... v 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ 21. Name of sewage system Distance to sewage system"` 22. Date test holes observed 11 115 23. Name of Health Inspector - UCj a�k,s 24. Project design flow (gallons per day) ................................. ............................... �00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... A-/ U 26. Has SPDES Application been submitted to local DEC office? A 27. Is any portion of this project located within a designated Town or State wetland? A/ Ci 28. Wetlands ID Number ........................................................... ............................... 29. Is Wetlands Permit required? .............................................. ............................... _ !� Has- app ion been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Al D 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 ^ 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: 33. Is there a local master plan on file with the Town or Village? ......................... NO.- 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... _ /J0 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number .......................... ............................... Map_LL Block Lot 37. Approved plans are to be returned to ..... Applicant_ Design Professional NOTE: All applications for review and approval of anew SSTS to be located_wit the NYC-Watershed shall .. be seat +o :i� 1� ;�a rr►)e*�'; ^_d•.. ^. ' sct ; s�r� irrua� ; Laic Er; aitriougri tfie project may iequue 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 l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES &OFFICIAL TITLES: Mailing Address: ................................... 10-2— 0 LfW C liM A �,IC CAgmlVe-�t /Dz'sl2