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73. -2 -30
BOX 26
03295
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03295
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August 6, 1996
Dan Donahue
120 Buckingridge Road
Mahopac, NY 10541
Dear Mr. Donahue:
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Re: Proposed SSDS: GORMAN
White Rock Road
(T) Putnam Valley
^' 4_§RUCEi R. - FOLEV -, 'RS::
Acting Public Health Director
Review of plans and other supporting documents submitted at this time relative to the above=
captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard."
1) Well detail is to note the water, line is to be a minimum of 4' below grade.
2) Trench detail is to be revise, as follows: _
a) note minimum of 6" of stone below the pipe and 2" above.
b) remove untreated building paper or straw note, current codes requires geotextile material.
c) current codes require the minimum distance from the trench bottom to water is 4 feet,
detail notes 3 feet.
d) maximum slope of the trench bottom is illegible.
e) allowable size of crushed stone or washed gravel is 3/4" to 1 t /z ". Revise accordingly.
3) Percolation test are to be witnessed by a representative of this department.
4) Septic tank detail is to note or show:
a) minimum 3" bed of pea gravel.
b) inlet baffle 16" below flow line.
c) outlet baffle 18" below flow line.
d) baffles extending 20% of liquid depth above liquid.
5) Location map is to be provided on plan.
....:,.:.......', ,,:-::�.., - _ '"_ ,_....n.. _-, _..,<•r.�, .. -" •�:, �x:':,- �.,�.�.._.;,'w';�,..w,,..,.�.. -r•:' -._ ` .�.;'... ..,. ;.._ _ k��, : .fit':. .
6) Entire property is to be shown reduced on plan. Location of the house, well, SSDS and drive
is to be shown on this plan.
7) Plan is to note that the ends of all SSDS trenches are to be capped.
8) Deep hole data is not noted on plan.
9) Please label the three scrolling lines running across SSDS plan.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
RM:jc
SSDSProposed
Very truly yours,
2/6'W NOV'O
Robert Morris, P.E.
Public Health Engineer
C 0
C
DIN. RM. —KITCHEN BREAKFAST Rht
131X1210 r ._121X120 911120
Ist Floor
GARAGE
202x231
WHITEHALL 27'x 36' =w /20' GARAGE
<1 7
HS 1:
WALK-IN
BR *2 CLOSET
139021D
HALL
-PUTN"LMI C"OUN"'Ify DEVARTMENT OF HEALT I
MMIV
OR
BR
ST I14 X 171
BR' 3 I BR 44
91XI01 102 x 91
-'Floor
Slomature & Title
Date
PENN LYON HOMES INC.
Old Trail Road, Selinsgrove Pa. 17870
Telephone (717) 743-0111
t mpl�
L(V. RM.
DEN
!31X129
Ili x 12 19
Ist Floor
GARAGE
202x231
WHITEHALL 27'x 36' =w /20' GARAGE
<1 7
HS 1:
WALK-IN
BR *2 CLOSET
139021D
HALL
-PUTN"LMI C"OUN"'Ify DEVARTMENT OF HEALT I
MMIV
OR
BR
ST I14 X 171
BR' 3 I BR 44
91XI01 102 x 91
-'Floor
Slomature & Title
Date
PENN LYON HOMES INC.
Old Trail Road, Selinsgrove Pa. 17870
Telephone (717) 743-0111
t mpl�
1.:.7
' DANIEL J. DONAHUE, P.E.
CONSULTING ENGINEERS
Mahopac, MY 10541
91528 -7576
July 15, 1996
Putnam County Department.of Health
9 Geneva Road
Brewster, N.Y.
Att: Robert Morris,.P.E.
RE: Proposed Sewage. Disposal System Propoeirty.
of Gorman
White Rock Road
Putnam Valley
Dear Mr. Morris:
Enclosed.herewith for your review and approval are the following:
1, Form PC -1
2. Construction Permit
3. Check for $300.00
4, Design Data Sheet
5. Letter of Authorization
6. Two Sets of House Plans
7. Four Sets of Construction Plans
8. Well Permit Application
cc: Planning Board
Sincerely,
Daniel J. Donahue, P.E.
Site ' e Sanitary o Environmental
DIVISTCH OF. HEALTH SERVICES
DFSM4 DATA STMT= SUBS'JFACE SEWAM DISPOSAL SYSTEM FILE No.
owner •. �TE'R G al�}%Yit%Y .......� _ Address .... ? ` '�' �4A
Located at (Street) 6#a:fe CYreg- Sec
(indi to nearest cross street)
ftnicipality v r#44 Al o,ff L L `l
Watershed jW,06t kir- ,L flt -rw a�i(
SOIL pE•tOQLpSICN • TEST DATA RF OMM TO BE SUBhQ'MED WTM APPLID-TIC NS
Late of Pre- Soaking
Date of Percolation Test_
8-0
Z6. y
HOLE
NUMM CL= TIME
PERCCLATION
�3 y
PERMLATICN
Run EIa:s2 Depth to Water From
Water Levu
Z
No. Time Ground
Surface
In Inches
Sci; Rate
Start-Stop Min. Start
Stop
Drop In
Min/lrn Drop
Incites
Inches
Inches
�y
Id-
2�6�.G//��
3 b
8-0
Z6. y
1 -2
�3 y
�. 4 • f "
• J—
Z
X.
5,/Q 12, r
.� o
.� �t
I "
C?
l
fd llo /G
0
�y
ri z
4// //
36
c>2 ,-t
24..1
a - f-
,� z
1
y/f
3
4
WrES: 1. 'Tests to be repeated at same depth until approximately equal soil rates
are obtained at' each 'percolation test hole. All data to' be submitted
for review.
2. Depth measurements to be made from top of hole.
n Inc
• Y �• Y: F, 7AN LOLY 0 Kcs, •
G.L.
1' � •
2' #S
3' Cwt Ac1�G
d 4fa p
4' c e
5'
6'
7'
8'
10'
11' .
120
13'
14'
INDICATE LEVEL AT, WHICH C- itC?MJL7GQM IS ENOOUN'T= /V
MICATE LEVEL TO WHICH MTM LEVEL RISES AFTER MING ENMUNTEPED A161V/r
DEEP HOLE OBSMATIONS MADE BY: 24.1- D64,4hfa e g 4%K #o' eJ' DATE:
DESIG4
Soil Rate Used �_ Min/]." 'Drop: S.D. Usable Area Provided
No. of Bedroans Septic .Tank Capacity 4arQ.Eo gals. Type PG.
Absorption Area Provided By r6 0 L.F. x 24" width trench
Other
Name Signature
Address 1 �Roe : e J R G X17, _ . SEAL _ ..
THIS SPACE FOR USE BY E EALTH DEPARTMENT C NLY:
i
s
UTNAMCDUMff DEPARTNENrOFEWAVIrk,'
C-
AJLJ!k WE Wl�
C0 N ]FOR SEWAGE STST,zm
PUMIi 45
AMOSAL
P, ic�k
)-e p owe or
Albino
L01
Tax —D
isawiO 0
Ownw/AppOwild Nelms
Doft of Approved
M@Sbg Addilow TwM
D at g Subdivision.Apbroved- xl/ r Fee Enclosej4:'-.amhllnf-
Lot .Area
Fin Section Vokwile
Nqgg e d Ai, ieal o' � Design FWw G, P D L—PCHD
SMI-Ide. S--"W Sys*— to -a" .1/-M! Go. Spd. Took wad -foe Ao�,V C1, ;V
4a Address
Wool! Sw*., Adteas
rim Sgow" if
--Mw S"� 6 D AW by eev C) 't, --Addma
oftelf.
I represent that I am Wholly and co o isly iasooni" for the ,deign and "')"'Oon of the proposal 'sYstem(s). 1) that the rate di rah AASMS
u 0 approved amendment there to'and in accordance with the standir s. rules
above described will bi,constr i t d W, —Qu F In. 57
County' Department of ."!t therip, -a "Certificate Of. construction tomplia"Cle"Utisfacto► y, to the Commissioner of Healthwill
Oa is "and that
submitted lii' furn -ci"SslitS. hairs or &signs by th*.bui"., that aid bulkier will
fthed the"ner. is m
PIK* . in- go" .pert of aid,L.;s"ii;ie �.-iisO�iial iiitim,�iturini'iniesiief*"o!,t;ioiD (2) *Sais'linnodlatoly foll6ivinw thoslisis of the law
o- �eoeirs thereto; that the drill ad well 101�111441
an" it the agioroval 0--4� nstruction c6nipiii6is system or,"! �ws tnerst
rdan rLt and slatted A rules a requSYMns of the Putnam
nly Deps mom a abdw
WIN to the approved; plan and that said weii:4iill," in
Cou
Del
S nWd P.E. PA.
/e 67 I'TX License NoTp
APPROVED FOR CO
NSTRUCTION- This ioorovais.ows, two Va." ro . the date -1 �construction of. the bulldlnghas,beep undertaken and is
rewo'b f Tay 60 a bin or M641fied when considered ry by the. lorAr of Health. Any change or we ion of construction
Muiri�a ApProvoll for. dispbal of domestic sanks' 0, and/or. at supply 6011y.
D
Rev. 1.
11.41 -11?-f, . . 11, 1 ... V.,
10/88 By Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
_u:,. -.- :APP,ICifiO1J�T0 CONSTRUCT�X"in�AYt
�—� PCHD PERMIT
WELL LOCATION
Street Address
� �QG�
y4e��l Village Cit
�t A �� -0
Tax Grid Nudber
,3'�-
WELL OWNER
Name Mailin Addres
�T �? d, �ax /�sL ���icit'�2J ��
LAP ivate
�� O Public
USE OF WELL
O- primary
2 - secondary
OWSIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
® BUSINESS O FARM O TEST /OBSERVATION p OTHER (specify
® INDUSTRIAL b INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT_ gpm /#
❑ REPLACE EXISTING SUPPLY
NEW SUPPLY NEW DWELLING)
a- ED /EST.
❑ TEST/ OBSERVATION
® DEEPEN EXISTING WELL
OF DAILY USAGE_izr�al
CL ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
4 (yam g ,�// `✓
Ed� /'D /% /v G
WELL TYPE
, DRILLED
DRIVEN
®DUG
® GRAVED 0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot Ito.
WATER WELL CONTRACTOR: Name &j�,e Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES v^ NO
NAME OF PUBLIC WATER SUPPLY: �� TOWN /VILA /CI`TY
-DIft- C- S �TC}PROPERTY� FROM DEAREST _WATER .MAIt1.:
LOCATION SKETCH & SOURCES OF CONTAMTUATTnN PRnUT
IAON SEPARATE SHEET
(date)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirtA, (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drills} operations be contained on this
property and in such -a manner as not to degrade or others' a cont a to surface or groundwater.
Date of Issue • 19 1.-0
Date of Expiration' 19� Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
0
0
DIN, RM. BREAKFAST RM.
121x1219 91x125
D)
TtBAT-H 3
7
UV. RM. DEN
131 x 129 x 12 ID
FOYZR
Ist Floor
b.
GARAGE
2OQx231
WHITEHALL 27'x 36' —w /20' GARAGE
BATS t-WLAOL
BATH 1:
K-IN
CLOSET
BR*2 OS
ET
�j
HALL
211d Floor
—7
13 &
S igna ij
BR* I
Ilfxl7i
BR #4
102 x 92
PENN LYON HOMES INC.
Old Trail Road, Selinsgrove Pa. 17870
Telephone (717) 743-0111
PUTNAM COUNTY DEPARTMENT OF HEALTH
Date /`� e
Re: Property of
Located at
(T) eZ' i' -A'rH l/XZ-d,N `1Section 93 Block .2 Lot 3d
Subdivision of
Subdvo Lot # Filed Map # Date
Gentlemen:
This letter is to authorize Zd looL
a duly licensed professional engineer or registered architect_
(Indicate
to apply for a Construction Permit for a. separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of.the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
ceiririectiori- With this' matter` "and °to' supervi "se" -tie coris'triicton of ' said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sa -.ni-
tary Code.
Countersigned• !�
P.E. , R.A. ,
Address
e;aLP' % g'
Telephone
Very truly yours,
S i 8ne
Owner of Property
a ??oxly z
Address
Town
Telephone
�UTNAM .COUNTY - DEPARTMENT OF HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
me and' —A:a i ress ' of App l'i cant : �• .. c l � 0 �f' /�'!f N
P6 A�� x
Name of Project: Sfpf— 4)AyG4,e F9r /L 1,4�4'fOr,3. Location T/V /C: l�U ?N�1i'r U�JuC¢-
Project,.Engineer: io4. 5. Address: A40 ,7,Py�c,r,E.vWAVIC
License Number:— gW`71,,H Phone: 4,X00-91Z4
Type of Project:
Private /Residential Food Service - Commercial
Apartments Institutional -Mobile Home Park
Office.Building Realty.Subdivision Other "(specify)
Is this project subject to State Environmental Quality, Review (SEAR)? r'
,Type Status (Check One), Type, I.. Exempt
Type II. Un l 'i sted 1�
r.
R
..Is a- Draft Environmental Impact Statement (DEIS) required? ........ ...... Ad
Has•DEIS been completed and found. acceptable by Lead ,Agency?
Name of Lead Agency
Is this project in an area under the control of local planning, zoning, „
or other.officials, ordinances? .................... ...:... ...............
J
'if'so; "have "'pi'ans been submitted to such authorities? ................... �/V r
Has. preliminary approval been granted.by such authorities ?N Date Granted:
Type of Sewage Disposal System Discharge...... Surface Water _ XGround'Waters
If surface water discharge, what is the stream`ciass designation ?........ _
Waters index number (surface) .. ............ .......... /u ! /f
Is project located.near a public water supply system? ................... Al 4)
If yes, name of water supply Aid Distance to water supply
Is project site near a public sewage collection or disposal system ?..... N 40
lame of sewage system / Distance to'sewage system
)ate observed: 23. Name of Health Inspector: tom.` 14.12 -e 1
roject design flow (gallons per day) ...................... 8d d
2;
5. Is State Pollutant Discharge Elimination System.(SPDES) Permit required ?... A10
.. ,. ". ,_w _... ,r e;.nnl.ia+o.:01+'..•,MrIC C ;fn.A?.� -.: ..�i
:; ,.. 6: alas - R ®E3aApal Eai for -been • asubmiAtted - ircr•lvc"a °I�DEC OY`ffce?`�'o .......... e ... l�
7. Is any portion of this project located within a designated Town or State-
wetland ?............................................................ ... .. No
3. Wetland ID Number ..... ..................................... _ A _..
3. Is.Wetland Permit required? ..e., .. ............... ...... ...: 0
Has application been made to Town or Local DEC Office? ...................
).,Does project require a DEC .Stream Disturbance Permit? ........... ......
1 Is or was project site used for agricultural activity- Anvolving application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling,.sludge app'l,ication or industrial activity? ........ YES or. NO
?'. Is project located within 1,000 feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, .landfill, sludge disposal site or
any other potential known source of contamination? .. ......:......YES or NO. Ate)
DESCRIBE:
..Is there a local master.olan.or.file with the Town or Village? ............
Are community water, sewer facilities planned to be developed within 1,5 years? ,1110
Are any sewage disposal areas in excess of 1,5X slopeI .........................
:....:.............. e ....... o t,
C,
Approved Plans are to be returned to: .:... Applicant lI�Engineer
the application Is signed by a person other than the applicant shown. in Item 1,.the
:.1ication must _be.aecompanied by a Letter of.Authorization. Failure to comply with this
)vision 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. Fa Ise statements made
herein.are punishable as a Class A Misdemeanor pursuant to Section 210.45 of
the. Pena 1 Law_ .a
:NATURES & OFFICIAL TITLES:
LING,ADDRESS:
_•11,
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
-•• .. .. -. L•iDI;;L'r lrA° ii +Y�1Li'�lRvt't�IRYi`,`f�N�I�i YS�il��"'_•'. +c. ,'a •, __
Associate Commissioner of Health
DEPARTMENT OF HEALTH
May 25, 2007 1 Geneva Road, Brewster, New York 10509
John Karell Jr., P.E.
121 Cushman Road
Patterson, NY 12..563
Dear Mr. Karell:
ROBERT J. BONDI
County Executive
PE-
Director of Environmental Health
Re: Proposed SSTS —White Rock Dev., LLC
White Rock Road, (T) Putnam Valley
TM # 73. -2 -p /o 30, Lot # 2
Review of plans and other supporting documents submitted at this time relative to the above
regarded project has been completed. Comments are offered as follows:
1. The fill section on the SSTS profile is incomplete. Also the profile shows thirteen
junction boxes, 12 are required.
2. It appears the fill pad depth is in excess of what would be required for grading. Please
note that an excess of fill depth may require a separate fill plan, also add fill notations on
the permit.
3. The pipe from septic tank to SSTS shows a 90° bend, which are not acceptable. Please
show and note two 45° bends.
4. The trench detail is to note dust free crushed stone or washed gravel.
5. Erosion control measures need to be shown below the house and driveway construction
6. The pipe from septic tank to the SSTS needs to be labeled and note the minimum slope.
7. Stand pipes need to be proposed for the curtain drain along with details.
8. Flow diffusers (rip -rap) needs to be proposed for the roof leader /footing drain outlets.
9. Please provide a copy of the valid wetlands permit for the subdivision.
10. The curtain drain needs to be within the property line.
The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Respectfully,
Gene D. Reed
Senior Environmental Health Engineering Aide
GDR:1dy
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 F&x (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
February 27, 2007
John Karell Jr., P.E.
121 Cushman Road
Patterson, NY. 12563
Dear Mr. Karell:
ROBERT J. BONDI
County Executive
- �... v. i�• ;...:••i•,G;�•.r•-+s+VKaa�ew�ni •.Cr- :.r..- s^;�.. ..+nom �e -c ,a .r.. —..sr. w.� i.�r.
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT MORRIS, PE
Director of Environmental Health
Re: Individual SSTS Application for 28A Subdivision
White Rock Road
(T) Putnam Valley
During the review of lots #.land # 2 for the above mentioned applications this Department has
been made aware that the above referenced subdivision has not been filed with the County
Clerk's office of Putnam County. Please be advised that no further review will be conducted by
this Department on any_lot.in the subdivision until documentation is provided that the _
'µ s bti visi n has`be�n` fried:' Applications for lots 3, 4; `and 5 will be >;diliined to-you:`°Pl -ease do
not respond to any comments submitted by this Department until the subdivision is filed.
Please contact us if any question arise.
JSP:kIy
Sincerely
Co I seph S..Paravati, Jr.
Assistant Public Health Engineer
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
PUTNAIVI' COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH -
INDT DUAL WATER SUPPLY & SUB C& v 7 A.TMElYT SE'S il'i5
bO STRucm0N PERMTT
NAME OF OWNER: el /le, -&rk U. 1-4c- STREET LOCATION: _Lr/nJ' T�octr�
REVIEWBD.BY: RM, J5P, SRDATE: 2 �8 /07 TAX MAP#: (CONFIRMED) 73 . 02 po ��
Y�j DOC UMENTS YON (REQUIRED DETAILS ON PLANS CONT'PERMIT APPLICATION (UUHOUSE SEWER - /." FT. 4 "0'; TYPE PIPE. CAST IRON
WELL PERMIT ORPWS LETTER ( Y=N0TENDS • M; AX-B ENDS45-� -W, /CL•EANOUT-: ft.-51 w-- --.l-= =179 d5
U Je— )PC=97 ua s " �" 8 r f1� RENEWALS "k t �=
C �rLETTEROFAUTHORIZATION •- �?r�Q- SITE NOTE (NO CHANGE)
(� _ DESIGN DATA SHEET (DDS) "�" '' FILL SYSTEMS
( '�'�CORPOPATE RESOLUTION (U(�10' HORIZONTAL; PAST TRENCH SLOPES• 3:1 TO GRAD
SHORT EAF
UU _ _ .� •. L--)L.. SPECS /FILL NOTES 1 -5 `� � w�
UUPLANS THREE SETS
UUFML PROFII.E & DIlVIENSIONS el
�
HOUSE PLANS =TWO "SETS w+v�:Sb_wcffe�P . U��L IN EXPANSION ARE'
A '`
SUBDIVISION
VARIANCE REQUEST FILL GREATS THAN FEET
(II,EGAL SUBDIVISION (--)� CLAY BARRIER .
T�SUBDTVISION APPROVAL CHECKED (-- )UFILL'CERTIFICATION NOTE
PERC RATE / UUDEPTH GAUGES
I (�LJVOL. ON PLAN FOR R.O.B., lJNCLASSIFIED & I11+1PERVIOUS
C ��FILL REQUXRED. ' DEPTH (��SEPA.RATION DISTANCE FROM 'TOE OF SLOPE
U�,T TA 24 DRA V REQUMED 7 TRENCH
GENERAL (U+/ LF TRENCH PROVIDED 60I+T MAX.
(___) ATE D .IN NYC WATERSHED PARALLEL 'TO CONTOURS
PI;ANS SUBMITTED TO DEP ULJ100% EXPANSIONPROVIDED
ELEOATED TO PCHD 4 DETArMMUSTFREE CRUSHED STONE =OR- WASHED °GRAVEL'°-°
E PROVAL, iF REQ'D - )GEOTEXTILL COVER.
EP TEST HOLES OBSERVED
SEPARATION DISTANCES ON PLAN FROM'SSTS
P �S TO BE WITNESSED ,
1:101
0' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL.
- APPROVAL SSDS ADJ, LOTS 0' TO FOTMATION WALLS
WETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 200' IN DLOD,150' T0, MS
ATA ON DDS PLANS &PERMIT SAKE TO S TREAM, WATERCOURSE, LAKE (iac. ezpati). ^ , _•
U 1969 NEIGHBOR NOTIFICATION _
50'
TO CE4 TCH I3ASIP?, zS °. STOP,MD1'rAF,= iF'1�D' WA'i'E
1 O WATER LINE (pits - 20')
`YR: FLOOD ELEVATION W/I 200''
50 DRAZCIAGE COUiLSE.
�) SOIL TESTING LOTS >10 YEARS OLD 200'7500' RESERVOIR, ETC. 150' GALLEY SYSTEMS
REOUIRED DETAILS ON PLANS 0' MN TO LEDGE QUTCROP
U ✓ ✓✓ SEWAGE _SYSTEM PLAN- (NORTH ARROW) SEPTIC TANK
SSDS`$YDRAULIC PROFITrEJ�=k.+
� GRAVITY FLOW 0' FROM FOUNDATION; 50' TO WELL
WELL
CONSTRUCTION NOTES 1 -15 ( _ )DIMENSIONS TO PROPERTY LINES
DESIGN DATA: PERC &DEEP RESULTS j��LOCATION OF SERVICE CONNECTION
2' CONTOURS EXLSIWG & PROPOSED UU 15' TO'PROPERTY LINE
DRIVEWAY & SLOPES, CUT SLOPE
FOOTINiG/GUTTEWCUATAIN DRAINS
USDA SOIL TYPE BOUNDARIES U :6WOPE IN SSTS AREA (S20 %)
TITLE BLOCK; OWNERS NAME ADDRESS t-U REGRADED TO IS %, I� REQt7IItED
DOSE/PtTMP SYSTEMS
TM, PE/RA; NAME, ADDRESS, P'HONiE# UMp NOTES .
;DATE OFDRAWINGMEVISION ( ) DOSE 75% OF PIPE VOLUME /DOSE VOLUME NOTED
DATUM REFERENCE . ETAM FOR FORCE:MAIN, (PIPE TYPE, ETC.)
,,,,)(___)LOCATION OF WATERCOURSES, PONDS TT AND D -BOX SHOWN &DETAILED
j LAKES,WETLANDS WITHIN 200' OF P.L. 1 DAY STORAGE ABOVE ALARM
PROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS CURTAIN DRAIN �� w U a PAS
��WiLLS.* SSDS'S WAN 200' OF SSTS ` STANDPIPES, 5 BOTH SIDES, DETAIL - ' ' �
.>(___�PROPERTY METES &,BOUNDS (15' 1!$�I to CDS�S %, 20' -4 %, 25' -3 %, 35' -1b /o, 100 %�1%
-)C _„)EROSION CONTROL XHOUSE WELL & • C 0' MIN to CD DISCHAItGE/100' with 182 cons day discharge
SSTS, EROSION CONTROL NOTE a,'= �J r 1 jo��x; (- -)L--)10' MIN to NON PERFOReATEDppPIPE q.
PtJ�;'(a_ ghrws /3 E7oXeti �(a.. SkoJ~j /a l'�;'y�/ °JhCtJ �° ys °�CNFsef7 �!K@Owj�Kle '1=y )�� % 5 QNC� �6LIJ�C j
SCENTS: ;5k00 CvlA . e o,
`7i�� }mGG o��ocJ i1[fi) i �O�nle�� /i'Xe- �(� »c7'w{: ksS'i s w %��o/» SNiv1 i . liAOtJ .'...sQXaYiiil 74C.wY (lilfr
ROOF! LEADERS &
D,RA,1)4 DISCHARGE
I
,dam&
FOOTING
TO DAYLIGH T
-7%44�4
t /� f
212 LF/ 15
RDP/E,7 0 4.
C31.
82 1 2±
81 7.`givi 5"
2"d,
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
4- LORETTAMOLINARI, RN MSN
Associate Commissioner of Health
February 13, 2007 DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
John Karell Jr., P.E.
121 Cushman Road
Patterson, NY 12563
Dear Mr. Karell:
ROBERT J. BONDI
County Executive
Director of Environmental Health
RE: Application to Construct a
Subsurface Sewage Treatment System.
for White Rock Road Development, LLC
at White Rock Road, Lot # 2
(T) Putnam Valley, TM # 73. -2 -p /o 30
The Putnam County Department of Health (Department) has determined that the above
referenced application, received by the Department on January 25, 2007 is incomplete. Please be
advised that the following information is required before the Department may commence its
review.
Questions 27and 28 on the PC -97 form reference wetlands. It appears that wetlands do
exist on the above referenced lot per the subdivision map and therefore would need to be
addressed on the PC -97 form. Also question 22 reference the inspector and date. Please
be advised that the deep test holes were inspected by Adam Stiebeling on 12/16/99.
(Returned for your use).
The Letter of Authorization form needs to be fully completed (returned for your use and
correction),. -
~� • Three sets of plans are required for submission.- Only one set was submitted.
• House plans have not been submitted for review. Two sets are required.
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 Putnam County Department of
Health regulations.
Should you have any questions or care to discuss this matter, please contact me at (845) 278 =6130
ext. 2261.
Very truly yours,
Gene D. Reed
Senior Environmental Engineering Aide
GDR:kly Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
A
V
PUTNAM COUNTY DEPARTMENT OF HEALTH
_ .DIVISION. OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: �,-: j�-Di✓ ��% �N T + �--�- C.
S 3 vVe�sTc f;e�v
AYc /Os73
2. Name of Project: LO T 44 3. Location: T /V: -Pv77V 1fM VAIA -E� 7
4. Design Professional: --I"DHW ll:A-E-L --LJ- 1 79 • '*' 5. Address: 12.1
6. Drainage Basin: P6;Fk,Sl ILL, N- LWW SIZOOLL � ` �' J A) j
7. Type of Project:
_ Private /Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
S.
9.
10.
11.
Is this. project subject to State Environmental Quality Review (SEQR) ? .............. Yes/No 11/D
Type Status (check one) ...................................... ............................... Type I Exempt
Type II Unlisted —
Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/No /10
Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes/No
Name of Lead Agency
12. Is this project in an area under the control of local planning, zoning, or other officials,
ordinances ?- .......
............, .:.,._ :....... .....:...:,.......:....:...� ........
..:_..,.....,..........: Ytil - =•A CS _.._� .:Y :. e,
13.
If so have plans been submitted to such authorities Yes/No
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) ............................................. ...............................
18.
Is project located near a public water supply system? . ............................... Yes/No
/\/O
19.
If yes, naive of water supply Distance to water supply
20.
Is project site near a public sewage collection or treatment system? .......... Yes/No
/10
21.
Name of sewage system Distance to sewage system
--
22.
//
Date test holes observed 3 LI (O 23. Name of Health Inspector
24.
Project design flow (gallons per day) ............................. ...............................
�i fDQ
25.
Is State Pollutant Discharge Elimination system (SPDES) Permit required? ... Yes/No
Mo _
26.
Has SPDES Application been submitted to local DEC office? ......................... Yes/No
IVO
Rev.
11/02 Form
PC -97
Pg.
] oft
A
W
27. Is any portion of this project located within a designated Town or State wetland ?... Yes/No A/ 0
33. Is there a local master plan on file with the Town or Village? .........................Yes/No
34. Are community water and /or sewer facilities planned to be developed within
15 years in or adjacent to project site? .................................. .........................Yes/No N
35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No /V d
36. Tax Map ID Number .............. ............................... Map 7 3 Block y2- Lot „5 0
37. Approved plans are to be returned to ................ Applicant >e- Design Professional
NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall
be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require
DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious
surfaces, and the project applicant should obtain.the,appropriate forms for such activities from DEP and submit
those forms to DEP for review and approval.
If the application is signed by a person other than the applicant shown in Item 1, the application must be
accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds
for the rejection of any submission.
I hereby affirm, under penalty ofperjury, 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 misdemeanor
pursuant to Section 210.45 of the Penal Law.
SIGNATURES & OFFICIAL TITLES
Mailing Address: ...........................
Form PC -97
28.
Wetlands ID number .................................................................. ...............................
'-
29.
Is Wetlands Permit required? ...................................... ............................... Yes/No
A/0
Has application been made to Town or Local DEC ........................... Yes/No
30.
Does project require a DEC Stream Disturbance Permit? .... .........................Yes/No
/110
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
/16
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? .........................Yes/No
34. Are community water and /or sewer facilities planned to be developed within
15 years in or adjacent to project site? .................................. .........................Yes/No N
35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No /V d
36. Tax Map ID Number .............. ............................... Map 7 3 Block y2- Lot „5 0
37. Approved plans are to be returned to ................ Applicant >e- Design Professional
NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall
be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require
DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious
surfaces, and the project applicant should obtain.the,appropriate forms for such activities from DEP and submit
those forms to DEP for review and approval.
If the application is signed by a person other than the applicant shown in Item 1, the application must be
accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds
for the rejection of any submission.
I hereby affirm, under penalty ofperjury, 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 misdemeanor
pursuant to Section 210.45 of the Penal Law.
SIGNATURES & OFFICIAL TITLES
Mailing Address: ...........................
Form PC -97
1E:
_ _PTJ'I' ®y/1q�� ■iA ■ ■��� ■ ■�. COUNTY D `�'.: �']�� •� . � � � ��
+•���lyC�.:y�,r ae ■/�* ■a .
NTAE HEALTH SERVICES
Property of t ijkle ..
LETTER OF AUTHORIZATION
Located at wh a4 c- 4 c lc
T/Vl°V, /fl L!� Tax Map #
Subdivision of
-73
C,�, L./— c.
Block °� Lot 3' C)
Subdivision Lot # c�, Filed Map # Date Filed
Gentlemen:
This letter is to authorize _
a duly licensed Professional Engineer __ or Raogtn4nAtehkeo to apply for the required
wastewater treatment and/or water supply pennit(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. tx th the provisions of Ar icle 14.5:aadGar:147:.a£.tkie:: ddc tiod l AW-the ) b
I.awi� arid"the fiutiiam Couc Sanitary Code.
pF NEW-
Very truly yours
eount=is d,� � Signed:
P.E.,�R --.A , #' " (owner of ProPmy)
Mailing Address / Mailing Address: W cS� Lies 7F X VC
ej
State zip
Telephone- oZFf 7/ )4�Y
State � ve Sro c % NJ Zip (OS *2.3 —
Telephone; 51'1 - '7J � '_O PP J
Form LA -97
('o -�-1/
'L WTNAM COUNTY DEPARTMENT OF HEAL.T H
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner WHITE ROCK ROAD DEVELOPMENT LLC
Address 538 WESTCHESTER AVENUE
RYE BROOK, NEW YORK, 10573
Located at (Street) WHITE ROCK ROAD Tax Map 73 Block 2 Lot 30
(indicate nearest cross street)
MunicipalityPUTNAM VALLEYWatershed PEEKSKILL HOLLOW BROOK
... _:..r._._......__._.._-...._ .- SOIL PERCOLATION TEST DATA
Date of Pre- soaking 5 1_5A Wb Date of Percolation Test 3I y 1t b
Hole
No.
Run No.
Time
Start - Stop
Elapse Time
(Min.)
Depth to Water
From Ground
Surface (Inches)
Start Stop
Water
Level
Drop In
Inches
Percolation
Rate %: ,
Min/Inch
%40
30
1 -201
V1
2
1 yto
IA;I
7Nk
3
��0 240
Zbyk
7"Ve
1
5
2
1
1%S 1 5-
30
7,1 2(0 V1,
- 7-11[—
tom'
4
5
1
.2
3
A )T
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, 5 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
Pg.. 1 oft
Indicate level at which groundwater is encountered IC _
Indicate level at which mottling is observed �; _
Indicate level to which water level rises after being enc untered
Deep hole observations made by: L �2.� Date 3
Design Professional Name: .Ta ! mess
(� � l�' � H"It•( �. l f"fl
Signature :'
Design Professional =s Seal
o� C w U\
�o. 5 321
A�FE'SS1oNP��
TEST PTT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST ]SOLES
sCY 'R+ti'.:..� •}.- 'ad�r�.�1i.'.a' }-.
.'.. {. .. .. _X ♦a .J�•tir �..`w.: p.w.0 , ..w .'.yi,- `s.'Tfrn _4- r. ... ... �_ - w C 4r'. a.r ..Yfw � +f .are r� L^ti, of
n'o:.•yr�g. a - .wa.o.,myy., _:C . r'. ,..r:.. p: -: i. �:
l '�'
DEPTH
HOLE N0. HOLE NO. HOLE NO. i
G.L.
7v 950 1 t� -i-� �5a ► C--- -
0.5'
,1.0'
Ar y 5A . 15') L Z-
1.5'
/rd 0 0C-je#77 "� -`'1'
2.0'
_
2.5'
3.0'
3.5'
4.0'
4.5'
wkrV4 ID a q)C i
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
9.5'
• -t.-, � .10.0..
Y -.. _ � _.- -,�_ .� . � ..: -'�� . vr. _.... .P - ...... __L_ > > ..,.�a . _ . _ ., .�3�.�.�•_ r. �;,_.sT .� ..va_.... ��,..
Indicate level at which groundwater is encountered IC _
Indicate level at which mottling is observed �; _
Indicate level to which water level rises after being enc untered
Deep hole observations made by: L �2.� Date 3
Design Professional Name: .Ta ! mess
(� � l�' � H"It•( �. l f"fl
Signature :'
Design Professional =s Seal
o� C w U\
�o. 5 321
A�FE'SS1oNP��
NAM COUNTY DEPARTMENT OF HEALTI
IVISION OF ENVIRONMENTAL HEALTH SERVI
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # ?`� "N ::V()
Located att
Subdivision name 11V11 -17V /-0 C-14-< Subd. Lot #
Date Subdivision Approved
Owner /Applicant Name
Town or Village
Tax Map �J
Block
-9-- Lot
3 0
Renewal Revision
Date of Previous Approval
Mailing Address ���7a��� �& Xk� �D�i �` Zip yT 3
Amount of Fee Enclosed `mil -\,--Oro a �
Building Typewb M �"� Lot Area 3'q No. of Bedrooms Design Flow GPD
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of f 2 gallon septic tank and ZsC 27-
rqj&tJ C j4 , k.S" L-F- -7C-1 !DM--P Cs- 10-TAI A-) L)A7N
Other Requirements:
To be constructed by Ivy �.� �/✓� Address
Water Supply: Public Supply From Address
:.,obi _ -fir vats Si gpry -Drilled' by_� `� �� 13 j - _ �._ �_ _ 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 s,, sYtem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed:
Address
R.A. Date Of /0 67
License # 2J
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
PUT NAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION, TO CONSTRUCT A WATER WELL
please print or type _ PCHD Permlt #
ICJ l L
Well Location:
Street Address: Town/Village' Tax Grid #
/
r/rif,1 elk' /*/�V ���N I V �PMap T5 Block )-- Lot(s) 3 G
Well Owner:
Name: kJbWj Av _
Address:
&dk
cue..
Ali'
Use of Well:
Residential Public Supply Air /Con e t Pump Imgation
1- primary
Business Farm . Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby _
Amount of Use
Yield Sought g' gpm # People Served " Est. of Daily Usage ZZb:L) gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes >( No
Name of subdivision aL Sv 6 i �li5LVI Lot No. dL
Water Well Contractor: .A.,Q Address. & rum P- l r
Yes No
Is Public Water Supply available to site? .................................. ...............................
Name of Public Water Supply: -- Town/Village —�
Distance to property from nearest water main:
Proposed well location & sources of contamination t be pr vided on separate sheet/plan.
Date:;. I :- : - t S e: PP licani
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. iDuring 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
14.164 (9195) —Text 12
ECTJ NUMBER ....s6.i7.20' , . .. e . r '� a 'S.EQR
Appendix C
State Environmental Ouality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR
V,1417,5 r� o c; K r--O,� u vim° LL G
2. PROJECT NAME ,
� T
3. PROS ECTPOCy LOCATION: P ✓TW_4_14 10L/ Al-h/L1
/landmarks,
County /
4. PRECISE LOCATION (Street address and road Intersections, prominent etc, or provide map)
,5.0 Itl 5'.a t �56' 1t::e_C i�jV(f'45 /190
S. IS PROPOSED ACTION:
I Mew 0 Expansion ❑ Modiflcatlonlalteratlon
6. DESCRIBE PROJECT BRIEFLY:
C0M57%L)L-7 /0/✓ O` —• i Slit/f/GC lc�f/V /L f- / -DivS � 0012 I1/t��79
.5E/t,,/,7C 1 �%-✓q 411471-�
7. AMOUNT OF LAND AFF CTED:
Q D
Initially ° acres Ultimately r acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
PYes 0 No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
0 Pnduitdal _ 0 Commercial) Agriculture 0 rest/Open apace 0 Other Y
pit�iealOentlaip
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
0 Yes %No If yes, lest agency(3) and permit/approvafs
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL?
Ayes 0 No If 113t agency
Y03, name and permitlapproval
0 �✓ 41L) Al 6V 10V T/�% V� _
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
0 Yes l0
1 CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THE BEST BEST OF MY KNOWLEDGE
_ABOO /VVEE
A DD llcantls Po nsor name� Date:
Signature:
If the action Is In the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
`9
N yt
, f
ROOF'I LEADERS & FOOTING
DRAT, DISCHARGE TO DAYLIGHT 1 .\
p 4 /
o. GAR. 834.01
M T 82 7.0,
Le eA
so
Lij
1 Lit
� � ear � �; � � , s° - • o � � � ` -_. ___. � / l � ._.-
'
� 1
PROPOSED
WELL '
PERFORATED ° .P¢,e'
Sp: i HDIP 04. ! T I
,
,;RIM 821.2± CB' C3A 1
i 1 I . � f t
_ V 81755
+ K M 81 .4 . I
3. o,2,g` SFs� °3d Do" INV 8.' M I 1
b
LEA 15 D
i
-• � pA �� e hsx q:�
20&15
R� + 1CB 1
CB
RI,M 1 � �� .r .