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HomeMy WebLinkAbout3244DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -1 -33 BOX 26 J lix I � . 1. I 6 '� r I � MMr go IN 1 r, r1w 03244 PUTNAM COUNTY DEPARTMENT OF HEALTH _ _-D. V.ISIO -N. OF K VIRO)NI N.,T - :::,H�A.L- - 'HP -SER' �.GES ��. __....�.�.�_� Located ate 5 'T Ps. ii eo /LL's ' ,P �rVillage Owner /Applicant Name 1/44'x I Tax Map ` _ Block j Lot s& Formerly so)" e— Subdivision Name (Wig ket 0- "Z ktMO Af l_ Subd. Lot # R Mailing Address Zip Date Construction Permit Issued by PCHD `Vj_ �11� Separate Sewerage System built by ji G e' p Address e;�x ltey--, 4911 x Consisting of "b Gallon Septic Tank and 0,2 2 4 Other Requirements: lY Water Supply: Public Supply From Address or: Private Supply Drilled by V), Address RAr .. irk s f /�s Lisillira�3 - °'ype t�a . -i 't. Has erosion - control been - completed? Number of Bedrooms tt Has garbage grinder been installed? /V0 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_9W PutnAm C�Cin!I,Pepartment of Health. Date: Certified by Address P.E. k _ R.A. License # 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 if the private water supply shall become null and void when a public water supply becomes available. Such rorovals are subject to modification or change when, in the judgment of the Public Health Director, such �catio ,modifi tion cane 's n c ssary. Title: Date: 13 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 Well Location =eet ess f- ' " �-- `wn/'Villa �- Tax Grid #' Map Block Lot(s) Well Owner: e: Address: Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion 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 ! Yft. Diameter G" in. Weight per foot lb /ft. Materials: Z Steel Plastic Other Joints: _ Welded X Threaded _ Other Seal: 2 Cement 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 Xcompressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 960 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 5-1' p If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 3 Capacity /0 Depth ,_k, r Model /os'0s"- Voltage 2-3 D HP Tank Type a'I/ Vol me Date Well Corn leted 2 g 5 Putnam County Certification No. Date of Re ort Well Driller (signature) NOT : �xact location of well with distances to at least two permanent l#dmafks to be provided on a separate sheet/plan. Well Driller's Name Address: Signature: Date: it 00 ell White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Y - t - ' H '.' h N.Y. 10598 9 �4�-24��-28(-�*-��'���' Albert H. Padovani, Director LAB #-. 87.0oo008 CLIENT #: 12259 NON STAT PROC PAGE I SHARP, LYNN DATE/TIME TAKEN: 06/19/00 04:00P 35 SPRUCE MOUNTAIN DR. ' DATE/TIME REC'D: 06/20/00 12:30P PUTNAM VALLEY, NY 10579 REPORT DATE: 06/30/00 PHONE: (914)-528-7952 SAMPLING SITE: 35 SPRUCE MOUNTAIN DR. SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE COL'D BY: LYNN SHARP TEMPERATURE..: NOTES...: KIT TAP COLIFORM METH: N/A DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/20/00 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 06/20/00 LEAD (IMS) 1.2 ppb 0-15 ppb 9101 06/20/00 NITRATE NITROG <0.2 MG/L 0 - 10 9139 06/20/00 NITRITE NITROG <0.01 MG/L N/A 9146 06/20/00 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 2037 06/20/00 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037 06/20/06 SODIUM (Na) 2.32 MG/L N/A 06/20/00 pH 7.0 UNITS 6.5-8.5 9043 06/20/00 HARDNESS,TOTAL 54.0 MG/L N/A 06/20/00 ALKALINITY (AS 48.0 MG/L N/A ' /)6/ 00 TURBIDITY (TUR. <1 NTU_ �� ' 0-5 NTU _ COMMENTS: BACT THESE RESULTS .,'.~.'.-~`-_�--�^�-_'�����.'�_��. INDICATE THAT THE WATER S NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI�b�THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. -iblic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive 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 is suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street ' � ei 598 . ---- (914)'245"2800° Albert H. Padovani, Director LAB #:.67.000008 CLIENT #: 12259 NON STAT PROC PAGE 2 SHARP, LYNN DATE/TIME-TAKEN: 06/19/00 04:00P 35 SPRUCE MOUNTAIN DR. DATE/TIME REC'D: 06/20/00 12:30P PUTNAM VALLEY, NY 10579 REPORT DATE: 06/30/00 PHONE: (914)-528-7952 SAMPLING SITE: 35 SPRUCE MOUNTAIN DR. : COL'D BY: LYNN SHARP NOTES..": KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE PH pH' SCALE INWATER 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 B.S. 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/L, 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 SUBMITTED BY: Albert H. Padovani, M.T.(ASCP) Director METHOD ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purch� ser of Buildlin Building Constructed by 3s �"U o n Location Street r Buildi g Type 71 2-) Tax Map Block Lot �LJT)a.im V&,L(iq TownNillage Subdivision Name u 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 1® YearCD General Contractor (Owner) - Signature Corporation Name (if corporation) Address: Wl - State A)Vl Zip Signature: Title: 1��J Corporation Name (if corporation) Address: 3 S_ 7X� A-i State--9). V Zip ly 9 Form GS -97 pioDANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS :".�` :_".�. 1 �w- : :,: :a..«.• a, zr, .a-e ,n �_,.. .. � - '. �: ' :`1.- ; - � �_ .. ,. ... - e.. . .`.`..�.:. `...iii .�:r -:�-'c ..�.�:a -..v ... . _ , _ , ''l. -_ .. -'. .�. ,.._- 120 Breckenridge Road Mahopac, N.Y. 10541 914- 628 -7576 July 12, 2000 Putnam County Department of Health Geneva Road Brewster, N.Y. 10509 Att: A. Steibling RE: As Built SSTS Lot #B Spruce Mountain Road Putnam Valley TM# 73 -1 -33 Dear Mr. Steibling: Enclosed please find: 1. Certification of Construction Compliance 2. Well Log and Bacti Results 3. Guarantee and two copies 4. Four copies of the asbuilt plan 5. Filing fee of $200.00 6. E911 Verification Letter By: Daniel J. Donahue, P.E. Site . Sanitary . Environmental Public Health Director LORETTA ""IGiOLINARI; 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 (9.14) 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 E911 ADDRESS VERIFICATION FORM OWNERS NAME: John & Lynn Sharp TAX MAP NUMBER: TM #73.-1-33 E911 ADDRESS: 35 Spruce Mountain Drive TOWN: Putnam Valley C� AUTHORIZED TOWN OFFICIAL: (Signature) DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911VERFRM) ru 1s�APY1 COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONIMMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Z r Inspected by: _ Street Locatioa-.1 N :.,:, Permits Ti`'1 r 73 1 -3- Subdivision Lot' 1. Sewage System Area a. STS area located as per approved plans ............:.............. . b. Fill section- date of placement c l� 3:1 barrier Loth. Width Avg Dpd c. Natural soil not stripped ................... ............................... d. Stone, brush,.etc., greater than 1S' from STS area ......... e. 100' from water course./ wetlands ...:.. ............................... II. Sewa6e System a. eptic tan. size -1,000 ....... (2 other ................ b. S: ptie tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box © .1. At I outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & tenches Junction Box - properly set ......... .............................. .............. T enath required 33 Length installed �v 0 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......... ........:. ...................... d. Slope oftrench acceptable 1/16 - 1 /32"/foot ...........:. 5. 1.0 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench X30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 314 -1' /Z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... ( 10. Pipe ends capped ...................... ..................... ............. . P m or. Dosed,Systetns• r { < < . Size ot pump chamber ................ ............................... 2. Overflow tank ............................. ...........:................... U 3- Alarm, visuallaudio ................ . ............. I ........ I........... u 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. HouselBuildin a• house located per approved plans ... ..............................i b Number of bedrooms ............ ..... ............................... �- IV. W Well a. Well located as per approved plans . ............................... b. Distance from STS area measured % ft ........... c. Casing 18" above grade .............................................. I... d, Surface drainage around well acceptable ....................... V. Overall Workmanship z. Boxes properly grouted ................... ............................... b. All pipes partially baekfilled ........... ............................... 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 watercours g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1197 ep)qV414 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERV10ES,,,..,�.1_.'1_._. REQUEST FOR FINAL INSPECTION For: Fill Trenches PCHD Construction Permit # Located (T) (V) Owner/Applicant Name 'f,4,4 efA TM Block Lot Formerly Subdivision Name Subdivision Lot # Is system fill completed?.. Date Is system c * omplete? Date Is system constructed as per plans? Is well drilled? — 4p, -n . Date-4 14tA& Is well located as per pans? �45 Are erosion control measures E place? 6 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 Heal Date: 1,zz�lz& Certified by: PEC—RK' 'Design Professional Address Lic. # Comments: C.:" FOR: 11 ADAM 11 GENE Form FIR-99 1 T N COUNTY DEPARTMENT OF HEALTH DIVISION / z ENVIRONMENTAL HEA i SERVICES. C P ! i � �} „ •��s �° ► �r e ^ � :9 TREATMENT SYSTEM PERMIT 17-7 r Located at Spv14 e-0 Subdivision name ow Subd. Lot # Date Subdivision Approved lV /A Owner /Applicant Name /- :� N/j( d'' 7� Town or Village Tax Map '93 Block J Lot ,2 Renewal Revision Date of Previous Approval Mailing Address fB pG1001j lh roc' l7 C /v z Zip Amount of Fee Enclosed J' t ?& vHC4-A Building Type �/ L U Lot Area � No. of Bedrooms _ -f- Design Flow GPD_ t!2 Fill Section Only Depth Volume FCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewers System to consist of JIB gallon septic tank and Other Requirements: To be constructed by Address Water Supply: Public Supply From Address .....or 3 Private Supply Drilled by /� .; ...... Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage, treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address P.E. �' R.A. Date A,, 4e" R-z License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p 't. Approved for discharge of domestic sanitary sewage only. By: Title: 6 y j N�� Date: t Z White copy - HD ile; 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 / / - euz a.t_a cype - -. . _... - _:..... _.:P.CHD- Permit # - -(/ Well Location: Street Address: Town/Village Tax Grid # Map 3 Block / Lot(s) Y- P Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Con eat Pump Irrigation rimary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought t' gpm W7 Est. of Daily Usage al. 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 yNo Name of subdivision `�'I�G��'G� /1 /) G4W4—p PP Lot No. 9 Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No y Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: /aL-- j� Applicant Signature: . I PERMIT TO CONSTRUCT A WATER WELL I This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (3 0) days of the completion of water well construction, the applicant or their designated j 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 — r_ _ti -1t _tit`__ _a7 aL- -t: -a -Al- provided by the Putnam County Health lieparunent. liunng an weir uruimg uperai1011S, mr, app1111aL1L aaiwvi 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 j 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. �nIq� Date of Issue Permit Issuing ci Date of Expiration b Title: Permit is Non- Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 { 0 j. DIN. RM. —'KITCHEN* H BREAKFAST RM. 131x1219 121x129 91x126• ........ 7' 7 51 GARAGE 0, 202 x 231 T!BAT-H 3 LIV. RM. DEN 131 12 9 IIIXI212 FOYF Isl rloor PUTNAM COUNTY DEPARTMENT OF HEALT]i HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; EDRIOMS Si _L 6f re Ti ' ble ate WHITEHALL 27'x 36'— w/2.0' GARAGE 2nd Poor er ED PENN LYON HOMES INC. Telephone (717) 743-0111 Old Trail Road, Selinsgrove Pa. 17870 F Y . D Daniel J. Donahue, P.E. 120 Breckenridge Road Mahopac, NY 10541 Dear Mr. Donahue: DEPARTMENT OF HEALTH Division of Environmental Health Services .4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 December 14, 1998 R BRUCE R. FOLEY :. -- Public — Health Director ;.; ,.. Re: Lynn Sharp, Spruce Mountain Road TM# 73 -1 -33 (T) Putnam Valley Cali This office has received and reviewed the molt recent set of plans for the above mentioned project. We would like to offer the following comments for your consideration. 1) Please show junctions boxes on 1 " =30' plan. 2) A minimum distance of 10' must be maintained between end of trench(s) and stone wall. 3) Provide dimensions from house to.layout.of proposed SSTS area; as-well--as-:- - dimensions to' Weil from corners of house. 4) Show 100' well arc towards proposed SSTS. 5) Show 200' separation from proposed SSTS to lake. 6) Please provide a title block on "sheet 2" and label as such. 7) Provide a copy of topo used, supplied by Badey and Watson. 8) Prior to final approval, proof of neighbor notification must be received by this office pursuant to Putnam County Health Department Bulletin ST -19. 9) Please verify USGS soil classification and provide proof of CSC, soil type. 10) Please clarify absorption trench detail. * Depth to groundwater. * Depth to rock. 11) Please provide a note to junction box detail stating "trench to start two feet from box. Two foot separation to be solid pipe back filled with clean site fill." I2) Provide a note to adjacent lands stating "there are no other wells and /or septics within 200'." 13) Reference survey and surveyor on plan. _- 14) Please show roof and footing leader drains on plan. i Letter to: Dan Donahue, L-E. .December. 1 14, This. office will continue its review upon consideration of the above mentioned continents.. Please feel free to contact us if any questions arise. Very truly yours, Adam B. Stiebeling ASB:tn Assistant Public Health Engineer r" Daniel I Donahue, P.E. 120 Breckenridge Road Mahopac, NY 10541 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva.Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 December 14, 1998 BRUCE R. FOLEY -- ,Public ,Health Director Re: Lynn Sharp, Spruce Mountain Road TM# 73 -1 -33 (T) Putnam Valley Dear Mr. Donahue: This office has received and reviewed the most recent set of plans for the above mentioned FmjeR. We would like to offer the following comments for your consideration. °m ~-=� fI_ ' _ p, r ZAmi*m*rnum lease show junctions boxes on Y —30 plan. distance,of 10' must be maintained between end of trench(s) ands stone wall. G ovi e dimensions from house to layout of proposed SSTS area, as well as,� i e iisioiis to:u�elhfroin W/'Show 100' well arc towards proposed SSTS. ,t Show 200' separation from proposed SSTS to lake. Please provide a title block on "sheet 2" and label as such. 7 Provide a copy of topo used, supplied by Badey and Watson. Pri r to final approval, proof of neighbor notification must be received by this ce pursuant to Putnam County Health Department Bulletin ST -19. lease verify USGS soil classification and provide proof of CSC, soil type. Please clarify absorption trench detail. * Depth to groundwater. * Depth to rock. 4-1-1� Please provide a note to junction box detail stating "trench to start two feet Aoni box. Two foot separation to be solid pipe back filled with clean site fill." rovide a' note to adjacent lands stating "there are no other wells and /or tics within 200': Reference survey and surveyor on plan.' Please show roof and footing leader drains on plan. Letter to: ban•Donahue, P.E. - December 14, 1998 - -2 This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact us if any questions arise. ASB:tn Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer Cb 4 /* lk t 0"4-. • /. . -po P a Q) fo e r -V/ oil rU Cif Oj i I I I A I • /11 0��-s 77 HERS 0 8 1M FEET ion 50f ADAMS C0.17: P Ished.-by ie ogica , S 0 09 a p h "—C b y Ph e t h o d -S PUTNAM COUNTY DEPARTMENT OF HEALTH L ?BDIVISiON ,GAL SUBDIVISION (BDIVISION APPROVAL HECKED KC RATE 0 Srgj P°` ( ;,"QU1RED DEPTH TAIN DRAIN REQUIRED ANDPIPES GENERAL )CATED IN NYC WATERSHED .ANS SUBMITTED TO DEP 1 EGATED TO PCHD -,P APPROVAL, IF REQ'D '5P TEST HOLES OBSERVED WS TO BE WITNESSED APPROVAL SSDS ADJ. LOTS ETLANDS (TOWN/DEC PERMIT REQ'D ?) i I'ER 'BUZBA 00 YR. FLOOD ELEVATION OTHER REQ'D PERMITS) REQUIRED DETAILS ON PLANS ASE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES TA:P SULTS 4NRIV EWAY ONTOURS EXISTING & PROPOSED & _ , CU TION OF WATERCOURSES, PONDS S AND WETLANDS WITHIN 200 FEET DSED FINISH FLOOR AND BASEMENT EL. COMMENTS: NO BENDS; MAX.BENDS 45° W /CLEANOUT . FELL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL;S �TO ADE G _h F ECS FILL NOTES �Y FILL CER ION NOTE DEPTH G GES FILL OFILE & DIMEN V UME FILL IN EXPANSION AREA TRENCH LE TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSTS ]0' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL. FOUNDATION WALLS 15'WELL TO PL c� 100 TO WELL, 200 IN DLOD, I50 PITS l00' TO STREAM WATERCOURSE LAKE (inc. expaW --- SrQ:TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits -20') 36 INTERMITTENT DRAINAGE COURSE x'1500' RESERVOIR, ETC. _150' GALLEY SYSTEMS to CDS = >50/o IV- 4 %,25'- 3 %,30'- 2 %35' -1 %,100' - <i% to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATIONNLaTO WELL TION OF SERVICE DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS � - -•� REVIEW SHEET FOR CO \STRUCTIO,N. PERMIT, _ •� ' SiIE'I L�CA'TI�N i P.cj cr NAME OF OWNER REVIEWED BY RBI, GR, AS AIB, BH DATE ('Z f TAX MAP Y DOCUMENTS Y PERMIT APPLICATION, EROSION CONTROL:HOUSE,WELL, SSDS PC -1 / PERC & DEEP HOLES LOCATED WELL PERMIT / PWS LETTER PRESENTATIVE OF PRIMARY & EXPANSION LETTER OF AUTHORIZATION LOCATION MAP GN DATA SHEET (DDS) E . AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE ORPORATE RESOLUTION V PUMPED, PIT & D BOX SHO DETAILED ORTEAF HOUSE -NO.OF MS ' STr4TTll_� ANS - THREE SETS LLS 0010 POSED SYS. HOUSE PLANS - TWO SETS PROPE BOUND �7 �'�� VARIANCE REQUEST OUSE SETBACK NECE RY (TIGHT LOT) FEE OUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE L ?BDIVISiON ,GAL SUBDIVISION (BDIVISION APPROVAL HECKED KC RATE 0 Srgj P°` ( ;,"QU1RED DEPTH TAIN DRAIN REQUIRED ANDPIPES GENERAL )CATED IN NYC WATERSHED .ANS SUBMITTED TO DEP 1 EGATED TO PCHD -,P APPROVAL, IF REQ'D '5P TEST HOLES OBSERVED WS TO BE WITNESSED APPROVAL SSDS ADJ. LOTS ETLANDS (TOWN/DEC PERMIT REQ'D ?) i I'ER 'BUZBA 00 YR. FLOOD ELEVATION OTHER REQ'D PERMITS) REQUIRED DETAILS ON PLANS ASE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES TA:P SULTS 4NRIV EWAY ONTOURS EXISTING & PROPOSED & _ , CU TION OF WATERCOURSES, PONDS S AND WETLANDS WITHIN 200 FEET DSED FINISH FLOOR AND BASEMENT EL. COMMENTS: NO BENDS; MAX.BENDS 45° W /CLEANOUT . FELL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL;S �TO ADE G _h F ECS FILL NOTES �Y FILL CER ION NOTE DEPTH G GES FILL OFILE & DIMEN V UME FILL IN EXPANSION AREA TRENCH LE TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSTS ]0' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL. FOUNDATION WALLS 15'WELL TO PL c� 100 TO WELL, 200 IN DLOD, I50 PITS l00' TO STREAM WATERCOURSE LAKE (inc. expaW --- SrQ:TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits -20') 36 INTERMITTENT DRAINAGE COURSE x'1500' RESERVOIR, ETC. _150' GALLEY SYSTEMS to CDS = >50/o IV- 4 %,25'- 3 %,30'- 2 %35' -1 %,100' - <i% to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATIONNLaTO WELL TION OF SERVICE DANIEL J. DONAHUE, P.E. CONSULTING ENGINEERS 120 Breckenridge Road Mahopac, N.Y. 10541 914-628-7576 December 3, 1998 Putnam County Department of Health. Geneva Road Brewster N.Y. 10509 Att:.-Nfx. Adam Steibling. RE: SSTS Permit & Well Permit Property of Sharp Parcel B Spruce Mtn. Est. --TM # 73--l3 3 Putnam VallOy , Dear Mr. Steibling: Enclosed herewith please find the following: I.. Form PC -1 2. SSTS application 3' Well permit application 4. Design data sheet 5. Letter of authorization 6. Fee in the amount of $300.00 7. Short EAF jir`df -i6 , n-P 9. Two sets of house plans. Comments: Your prompt attention would be appreciated. Please note that I am in the process of sending out the "Neighborhood Notification Letter". By: Daniel J. Donahue, P.E. i V Site • Sanitary - Environmental 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ _..,. .,. ,._ .. ... .. .. ,. :. .._._... :. ,..-.r•,: - _ .. .r+ ... .a, • =er.- .:. s;;..,,:. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE. TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 1' !J - (3 Located at S5 �' %�� q A-rl', ,P & r Village Owner/Applicant Name 11115tX Tax Map_ Block / Lot _ Formerly 1& C_ Subdivision Name d8e atGo— Rs'r- Subd. Lot # R Mailing Address 8 .S` _ q jex cf "o- /%dam //,J %'� /�, Zip Date Construction Permit Issued by PCHD Separate Sewerage System built by 'r' r Address �,�JOW e-9 A : DtQL Consisting of I f _ Gallon Septic Tank and Other Requirements: Water Sunnly: Public Supply From Address or: jX Private Supply Drilled by Address A si. Building Ty pe /%'-,/Gk -e Has erosion control been com 1, ted..kjld -.., Number of Bedrooms t Has garbage grinder been installed? AV-0 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 gkp Putnam CVfintyj;�epartment of Health. Date: 01444 Certified by Address P.E. R.A. License # 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 revocation, modification or change is necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 .. 22 - APPENDIX C CONSTRUCTION NOTES FOR SUBSURFACE SEWAGE TREATMENT SYSTEMS & WELL WATER SUPPLIES SERVING SINGLE - FAMILY RESIDENCES The following notes shall be provided on all plans for individual SSTS and well water.supplies. Basic Required Notes 1. All trees within 10 feet of the proposed subsurface sewage treatment system (SSTS) shall be removed. 2. SSTS to be inspected by the Licensed Design Professional and the Putnam County Health Department after construction and prior to backfill. 3. The SSTS area shall be staked and roped off so that no trucks, machinery, building materials, nor excavated earth shall be allowed in the SSTS area. 4. All erosion control measures shall be installed prior to the start.of any construction. _52 5. Construction of SSTS to be in accordance with these plans, any revisions thereto, and the rules and regulations of the permit issuing governmental agency. 6. The well is to be a drilled well, constructed in accordance with New York State Health Department Bulletin. entitled "Rural Water Supply ", pump tested for a minimum of 6 hours and have a minimum safe yield of 5 gpm. Yields less than 5 Qpm gill be immediately *reported to the Putnam County Department of Health. 7. The SSTS design shown hereon does not provide for installation of a garbage grinder. Such installation requires additional design and the approval of the Putnam County Department of Health. . _ Putnarn County,Ielth:epartmnt approal is =base d one loEatton 'o €the°SST�3; �vzll;iilaing; se5acks " " "' and driveways as shown on the approved drawing. -Modifications are to have prior Putnam County Health Department approval. Unauthorized modifications made to this drawing after the date of Putnam County Health Department approval voids said approval. 9. Cut or fill is not permitted in the SSTS area, except if so specified on this plan. 10. After backfilling the system, the SSTS area shall be covered with a minimum of 6 inches of top soil, seeded. and mulched. 11. Occupancy of this structure will not be permitted until the Construction Compliance Application has been received and approved by the Putnam County Health Department and forwarded to the Building Inspector of the respective municipality as part of the Certificate of OccupancyApplication. 12. This plan is approved for sewage treatment and/or water supply only, and all other required permits and/or approvals are the responsibility of the permittee. 13. The Putnam County Health Department approval expires two (2) years from the date on the approval stamp and is required to be renewed on or before the expiration date. The approval is revocable for cause or may be amended or modified when considered necessary by the Department. t DIVISI ®N OF ENVIRONMENTAL HEALTH SERVICES. LETTER OF AUTHORIZATI ®N RE: Property of l 91(11,1 cri,1P Located at ✓�iy�%y �d.'3� T/V /e0)VVj W1,I1 -rTax Map # Block �_ Lot 3--, Subdivision of S f oe- ye ZZ F 04'7 ./' Subdivision Lot # Filed Map # 7 Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer _ e or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 ..ago 4or- 1.4.7...o.f._tk1e.T -4 uca b�ic Y_ , ta.on. Law,..t e. Pu . . Health L aw , ahci-t13e Putnam e'ounty' Sanitary C-oae. - -: Very truly. yours, Countersigned: Signed: P.E., R.A., # g%- (O ner of Property) Mailing /�I ,� Address ��,ca•��'� ©F,���,Mailin Address: X Ar State �`'j Zip %O State /v Zip l� " Telephone: �--L 4 7 /(Z 4 Telephone: L Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .._ • �..y' • ♦. .7Y. .v . r. ._r r. -r V. - � �M�' ..9 \.M a-1'_ nr> 4. . . .. ... ... .. . �..�� .. �� '1� +.. . r. vr• . v - i ^T • f \.Y .w 1-v n�> �• APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 2. Name of project: f /gyp Sf?-r 3. Location TN: Pu7M9,#1 4. Design Professional: J 5. Address: /o.v ,�•P�•r�.�•����,� -� 6. Type of Project: _ Private/Residential Food Service Apartments Institutional Office Building Realty Subidvision Commercial Mobile Home Park Other (specify) _ 7. Is this project subject to State Environmental Quality Review (SEQR)? TypeStatus (check one) ....................... ............................... Type I Exempt Type II Unlisted Y 8. Is a Draft Environmental Impact Statement (DEIS) required? ......................... '&0 9. Has DEIS been completed and found acceptable by Lead Agency? ............... 10.. Name of Lead Agency 11. If this project is an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... s 12. If so, have plans been submitted to such authorities? ........ ............................... 13. Has preliminary approval been granted by such authorities? Date granted: 14. Type of Sewage Treatment System Discharge ................. surface water V groundwater 15. If surface water discharge, what is the stream class designation? .................... At 14 16. Waters index number (surface) ........................................... ............................... —A( /A 17. Is project located near a public water supply system? ....... ............................... N6 18. If yes, name of water supply i Distance to water supply 19. Is project site near a public sewage collection or treatment system? ................ 20. Name of sewage system Distance to sewage system 21. Date test holes observed a1 d M 22. Name of Health Inspector App-r vW& Form PC -97 2 23. Project design flow (gallons per day) ................................. ............................... 6000 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... A/, 25. Has SPDES Application been submitted to local DEC office? ......................... Al /sf 26. Is any portion of this project located within a designated Town or State wetland? A10 27. Wetlands ID Number ........................................................... ............................... A/li 28. Is Wetlands Permit required? .............................................. ............................... Ad Has application been made to Town of Local DEC office? ............................... 29. Does project require a.DEC Stream Disturbance Permit? .. ............................... Al o 30. 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 ey 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ... ............................... YeQ DESCRIBE: 32. Is there a local master plan on file with the Town or Village? .........................��' 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................. ............................... A10 .. ......:. 34. Are any sewage treatment areas in excess of 15% slope? . ............................... No 35. Tax Map ID Number ........................... ............................... Map Block_L Lot 3•� 36. Approved plans are to be returned to ..... Applicant Y Design Professional 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: ................................... /�iE'E�.c -.� ,� /�J4.� 2-p AIJW78� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -, .. t... O -. Vt «�. i w.. t .- :r-- •v1. -+. ..— • ^:'.r- � � i. _ - S a i .. ..�.. .. s- ♦ - -- fS.. l`.-wz..4 . -. �. r .. r. - - DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Located at (Street),CPRoG0 , Tax Map % 3 Block �_ Lot 0 (indicate nearest cross street) Municipality Watershed ' /Xu ,dJ'crA_ SOIL PERCOLATION TEST DATA Date of Pre - soaking Ill ,1¢�ye _ Date of Percolation Test lf�j � 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 1 "�, 3`' l,y i 2 S-fr iY 3 4 3:L �S-Y 5- a �- `� a-7 3 3 r�' �- 7 3 �. G 4�° 5 13 ©4e d" d-7 01-7 3 1 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 DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES 2 DEPTH ;..:., HOLE NO.' / HOLE NO..Z - -- _ . HOLENO. G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' R-Si 66L Its Indicate level at which groundwater is encountered N6 'AI C Indicate level at which mottling is observed Indicate level to which water level rises after being encountered AS _ Deep hole observations made by: 19" to e j' — Date Design Professional Name:&Lw/f4 J pzA+ � Address: ae,,O F , - ,q.7.> Signature: Design Professional's Seal /OFCSSIQrV q - CY LU T No. 48431 �C 40 OF N�� PROJECT I.D. NUMBER 617.21 SEQR nvironmental Qual•Ity- �tevievr . -. -- - SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1 . PPLICANT /SPONSOR 2. PROJECT NAME L"p nllw ' S MWI-) J ,r Tr 3. PROJECT LOCATION: Munlclpality P2l .12* County � ! a. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) S. IS PROPOSED ACTION: ew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: GalYO'7a'17r�. a� /}� �-7—f ��Q d' //ft`,j✓�L tJ li "l OA"-z a. 7. AMOUNT OF LAND AF F TED: 0 , �� Initially acres Ultimately acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? " Wd—fes LI No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY O�• PROJECT? L�<identlal ❑ Industrial ❑ Commercial ❑Agriculture ❑ Park/Forest/Open space ❑ Other Describe: _ 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? 19' es E:2190 If yes, list agency(s) and permit/approvals R"e -l) 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 13 Yes No if. yes, Ilst agency name and permittapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes Ono I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor Signature: Date: 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 :Z4 June, 1993 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.1:? If yes, coordinate the review process and use the FULL EAF. B. WILL ACTION RECEIVE COORDINATEe6 REVIEW AS E D F FOR UNLISTEb-'ACTION`5'IN bNYCRR, PART 617 --O" 'il hto, °a negative decliratioV may be superseded by another involved agency. C3 �l Yes tF�rro 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: a 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: I-NLdlello-- 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. CIS. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. /(Y& V C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. 0. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? L`:'f ❑Yes 1Vo 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 Print or type Name of Responsible Officer in Lead Agency Title of Responsible Otfxcer Signature of Responsible Officer-in Lead Agency - Signature of Preparer (If different from. responsible officer) Date TiiT1p 1007