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HomeMy WebLinkAbout3882DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.16 -1 -3 BOX 30 r*oj- 61 me IN go LINN is .� - INN, - . PUTNAM COUNTY DEPARTMENT OF )ESEALrH ' Rye � 'w3 f, � 6 Divliloa of Environmental Health Serviceet, Csnmel, N 1' Yf x Mast Provide ✓o Engtineer P CH D Permit q CE£tTIF1CAT>; 0�. 9NS ONOlVIp11ANCE�OR SEWAGE DISPOSAL S %STEM_.. C°t - — E N Located at �/9 i ,�`° Tax Msp lS „d Bloek Lot . 3 Owner/applicant Name Q ° �� �� . tisedy Subdivision Name- Sabdv. I;ot q -� �7 /o�"Gd Mailing Addres "a �Ois9� r/i^i ✓- . , ZIP - Date Permit Issued Sepuate Sewerage System built by -/ Addre ConetaHng of �f � Gallon'.Sepde Tank and Water Supply.: Public Supply From' { Address Private Supply DtlIIed' by o 1` .Nl.W Address . �^�° s✓3 Building Type , ! � Has Eroslon Control Been Completed?' Number of Bedrooms Has Garbage:Grinder Been Installed? Nd Other Requirements •I certify that the system(s) -as listed serving the above premises were constructed essentially as shown on the plans of the-completed work ( copies of which are attached), and in accordance with the standards, rules and` regulations, in accordance with the filed plan, and the permit issued by the Putnmi Counnt�y Department Of Health. :.�f. • f/ . Oats �/ ii� 7 tlfbtl by Cy C�e%L� ( P.E. R,A Addisss _ License No. 'S Any person occupying .premises served by the ove system(s) shall promptly. take such actto .as may be necessary to secure the correction of any unsanitary ' conditions.resulting -from such usage. .Approval of the•separate_"erage system shall become null and.void as won as a pubt'_ unitary sewer becomes available and the approval of the private water supply shall'become null and void when 'a public wale► supply' becomes availabk+i Such approvals are subject too�moodification orr change when, In the. judgment of the Commissioner of .Health. su 'revocation, modification or change Is necessary. I "� .�/ /G/ // / by Title Date ° PUI'NAM COLUN DEPARTMEnTr OF HEALTH DIVISION OF ENVIROL IE'hiTAL HEALTH SERVICES Owner or Purchaser of Building Section Block Lot fJ Building Constructed by Location -// Street /dr✓ /"/i61� 1�Q // ftunicipality Building 'Ripe Subdivision Name 3 Subdivision Lot # GUARANTEE.OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it 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 1`.. ..._.___ .._ertif icate of :Constructs on.:Compliance "..for the disposal system, or any repairs made by--m-16" sucti -gyst m' except where-the- failure ,to- opera.Le ..pr-pr -ky_ -i. 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 Director of the Division of Environmental Health Services of the Putnam.County Department of Health as to whether or not the failure of the stem to operate was caused by the willful or negligent act of the occupant of ttiebui�lding utilizing the system. Dated this day of 19 7-� Signature Title General Contractor (Owner) - Signature 054 Corporation Name (if Corp.) Address rev. 9/85 mk Corporation Name (if Corp.) Address 4 t? , ,Q`�t. Wr,LL %,Ilj rLG11V1V L %x!z Vl\1 DEPARTMENT'OF HEALTH - iDi- V1s1.un' .,Of --Hal h-= s erm *4,;ea;: -. W 04 PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only - - WELL LOCATION STREET ADDRESS: tOWN/ViLLAMEICIFY TAX GRID NUMBER: Upland Drive Putncm Valley WELL OWNER NAME: ADDRESS: USA Contracting & Contruction Corp.,, Cortlandt, NY PRIVATE 0. PUBLIC USE OF WELL 1 - primary 2 - secondary X41 RESIDENTIAL ❑ PUBLIC SUPPLY - ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 2-4 gpm. /NO. PEOPLE SERVED I EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL. SUPPLY ]NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 505 ft. I STATIC WATER LEVEL ft. [DATE MEASURED 1/10/93 DRILLING EQUIPMENT ❑ ROTARY )6XCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING XKX OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 41 — fL MATERIALS: STEEL ❑ PLASTIC ❑ OTHER LENGTH BELOW GRADE ft. JOINTS: ❑ WELDED )Q THREADED ❑ OTHER DIAMETER 6 in. SEAL: CEMENT GROUT ❑ BENTONITE ❑ OTHER WEIGHT PER FOOT 19 1b./ft- DRIVE SHOE O YES ❑ NO I LINER: G YES O NO SCREEN pETA ILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑: YES, - Q NO -. . - 1iOURS�. ._. ... SECOND :. _ . _....__.... - _ ..__ ... GRAVEL PACK 11 NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping METHOD: O PUMPED t tests were done is in- t )O(COMPRESSED AIR , formation attached? O BAILED O OTHER ; O YES O NO 1 ELL LOG )f more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing Well Dia meter In FORMATION DESCRIPTION CODE ft. ft. WELL DEPTH It. DURATION hr, min. DRAWDOWN .1 It. YIELD gpm. Land 4 Silt & cobbles 4 505 Hard grey & white granite 200 1 - 200. 2 300. 1 IE 300 3 400 2 3C 400 5 505 6 300 Lu H: WATER CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? YES ONO ANALYSIS ATTACHE YES ONO STORAGE TANK: TYPE Diap ragm CAPACITY 62 GAL. 17 PUMP INFORMATION TYPE _subrmersible CAPACITY 7 MAKER GOULDS ° ? MODEL VOLTAGE HP WELL DRILLER NAME MILL DRILLING, I ADDRESS Putnam .Ave. s,GiXTU Brewster, NY R I den" J/ V7 E,77T_ ca7 rE7 - - - - - - - - - -- - - - - C:2/cr 1-- cr C, ................... ------------ e5 ............. . . . . . . . . . . . C-n. I -lk ........•• ............ - - --- - - - - - - - - 71 --- - - - - - - - - - - - - - - - - - - - - - - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . - - - - - -- - - - - - - - - - - - - - - - --- - - - - - - - - - e �S...r ^Y.x. �..s a ..• - T^.'PCI4.• r.. ia... .� t -s ...v@ •..M1.r Y.-.. ... •... ��1 .• - r..v+aJa �..: M, +"'�'6� . .r .- e- ar �.. .__ ..- -� NORTH AMERICAN LABORATORIES, INC. ANALYSIS DATA SHEET TYPE: PW LOCATION: U.S.A. Homes, Putnam Valley, NY REPORT TO: Mill Drilling Co. ADDRESS: Putnam Ave. CITY, STATE, ZIP: Brewster, NY 10509 DATE COLLECTED: 08 -31 -93 TIME COLLECTED: COLLECTED BY: B. Mill REPORT DATE: 09 -07 -93 LAB # : 93 -4216 SAMBLF- SOT URCE e DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform MF Absent SM 17 (9215D)08 -31 -93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY DID MEET THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS. Laboratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914 - 278 -7600 / FAX 914- 278 -7754 - ...._ -•__V LG -- - err.: C_ G.._J �v vlazis c b_ i�e„ Date Cr- � F , i cGcr_nt ":C_Dom^ - C_ r L. t f= =- E" .� ; � -- 1,000 ( J le 1 c _C:1 C�c _ �--•• I I l_CSZ _ 7 j16_'!_ L - - Cz CZ if C lo V - I ✓� V_,I /a = =-o - I I _ 1 •_ '.� -� E =�__'i GC- - - - -Jl C li,_'�Q �= t.' C =r i J I I F��� �V CC= _ -_ L =T G�.TL, v G•'-, i- -=- C - f ml C_ .. Ci � _' -_•'� hl;_� tit' G'= � .• =as ^wi:_z --- - CZ �`� _ =as f - t� -"^ < " 1 n r -r. *'1s ^.E� I I ?r_i17 Ii.. =_ .7 CC'= = = SG.:. I I E_ C *1 cCG�`^ -C t7 ^�'_ =`1 1— =-: C_`- C:_� = 1 i �'�': tam •1� Sc C_:. _ �7 E' -=-..' C� I I .? �_ �__�.C_° G•c�._ C =CL r' -'C=1 cCc._':�_` . _r a._ =n l_�_ ( � 1 _ Z=Calcn CZ-. CC -CC r r. b COMMUCMN s Ldngsd as r '- e .� of PM. � 77d e Tmm et VEfte 1-1 o...dw�e..t ti... 10-If Date d PWvk Fee Enclosed a AmnnnY Yis lyre / O- L CD' dmt pees �ll� lr7 G' FE See" Oarb LJ DpNh v l... Ntie stt leieebn Dnly Flow G P D - � PCMI NNdestlen Is Regabed Wbm FM M eeyleMd fwmb Berme SysMse a Comm d Z2 � w,, SeStle 1'adli md To be esMskadd bP � Millie WWW Ss*irt PM S "* Pan Ad&m fib, Dd d by Add..m Ober Ds**4= aft 1 fepaaant.tlet 1 am wfroMy Ind COm01atNY so, to for the design and location of the proposed syd m(s)S 1) that the operate osr di al em above described will be constructed as ~non the approved amendment there to and in ae eordanes with the standards. rules a reguMMMSOW County Deportment of Haab. and that on completion thereof a "Crtificate of Construction Compliance" satisfactory to the Commissioner of NesMhwlll M lebmM W to tike Department. and a written awaritse will be furnished the owner. his Yliaaseo► assigns by the builder. toes said builder will bleed N food .dprrtbq co"Ition,afry part of aid aernaea disposal system during the period medletey foliewke tledsts of the utu- saw of the 01 - I of the Certificate of Construction Compliance of the original system M that the drWW wall des- OW above reveal M lbrated as Mlarrw ow the approved pen and that sae weN will be instal ce red r" amens of the Putnam ferelty ►t FlMlth. d2'091 Addre License No AFpltovED FOR C TRUCTIONe This I eapires two om the • kue•d u u n of ikfkng has barn undertaken and is NeOaable /r Yee 0• ay M amssndad Or mod led when y by the mi ell• or atlration of construction reWiraa perm per'M for 411, veal Of d=01 and/ ate ReV.. �.�... X41 10/88 pea �y Title Eir'Pi75 IM to Ok(+7:TT Ci6MAItToWM',; RU-0J Y WF.:aJ_T',F.i au �rtGgTiY1Y'�..aTiE liii' l�ai, c i +::r: C nve_J! f �� �• Pt:+d 6�''.s".S.Sa@S -'=r..:•. ti.±.�tcc'�:x 'Xe13a• � i F �6 _ r :iaind Irc I Tx.� ?d.y Wim, -► ti ®.r . m� ■ s. ■ i1Mia,o tr! Y' r c .Imes ! �mw + ri r -� bb xARz f, Taps X I �r �.r•.. ti /� FARR "• +eAP.aa'?aw d�-w.� _ 'p+nsJ.�yn rll—K W IP I" �MEIIUr Aa<rfb.•awo b it.rpciiswt nL' k �m a`n! v.> : ct c. ` b 6=2= c'l -46m m„rl= zc:;� Tach n--I 2-vey d er -2 41 Sb LS: c .l`�r A&h= C32 ; 'b L�aq caw-r B relprtamd,that 1 aft W"Diy and eompmoly r0a$ohaibl© fCr tho dosion and kacation. of tho swoposd systom(s); 1) that tho as ate .raw di !W6 Rain aD"O dwancs tbill W m aatruetc o as Oman on tho Omworcd amndamt thcro to and in accordanco with tho standards. rulma a Fugu na coustq of D=m6% auto tau on eompecu a.thcreof a •'Certificoto of CofastrfulConWkw cd• eatioaetory to the Commiulonov of Hulthwlll to gomatm to em t t. Ong a mium 6wroatco t7iil bo furaish�d tho Wloia mfsm'�s�i� hobs o7 ot�s Dy tho DuiNw. tW sold builder will t In 41� .epom ^o, 0=0mmo c�ay mat ®f 019 ®itpowl ovamaa 49WWQ 1tlo0sgfarl .. flr�. -j81 t1�11 bwcaifiatoly foltowim tho date of the Now Cf W of Wo o of V M Ccati ltcoto ®f Conc rWian CoramnDnco of tho wlp� o . €rti @6t t03ot 8) that tho drilled well desoraw 460" wm we taiaw 0a GM= cm =0 c3meved Won Ofts thOt Meg vme will Do Itstolicd In � e� t - { o rutoa arA red s of the Putnam COW" DQ=A== Of KC314M $lmoll n r , P.M. _ R.A. iJl ®Vft® ROW COtd8Y0911ICCV1 s 9, s 10DIp"al ompe7cm teva ye a drown tho dpi ugt "a of tho DuRSing has bm a undortaken and is ocucesbco for cam OF Pcaay 690 099==2 N rnuflifics twrgrl COO y by tffOh P 94QOWh. Any Chum or alteration of Co11atrmtkan 6eTMwbp a 6m =ML ACxov= dp diuml of dommec aged/ aNa' 1�s�tty only. AO/88 � T54 to PC -1 1PUTNAM COUNTY DEPARTMENT OF MEALTH .APP_3CAT10;V'FOR- ;AFPROVA �CF Pi=ANS:.:FF( °'- A=WASS -'�tiW-A R.-.DIf 1. Name and Address of Applicant: dl�� L ��i',� idiom �' �r / • /® � V 2. Name of Project: . � 3. Location T /V /C: 4. Project Engineer: / ��� 5. Address: License Number: % i- Phone: 6. T e gf Project: A Private /Residential Food Service Commercial Apartments Institutional .Mobile Home Park Office Building Realty Subdivision Other (specify--) // 7. Is this project subject to State Environmental Quality Review (SEAR)? /V� Tvoe Status (Check One) Type I... Exempt' Type II. unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ...... .R... 9. Has DEIS been completed and found acceptable by Lead Agency? .......-':. 10. Name of Lead Agency 11., Is this. project in an Area. .under the control of.local planning, zoning, -- ----or -otter off -o-rdi :......... .. 12. If so, have plans been submitted to such authorities? .................. 13. Has preliminary approval been granted by such authorities? Date Granted:.ZE�_ 14. Type of Sewage Disposal System Discharge...... _ Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ............................................ 17. Is project located near a public water supply system? .......:.......... 18. If yes, name of water supply,,. Distance to water supply%_* 19. Is project site near a public sewage collection or disposal system ?..... /lU 20. Name of sewage system Distance to sewage systemi 21. Date observed: 23. Name cc��of Health Inspector: 24. Project design flow (gallons per day)........ g-(�70 ...................... 2. 25. Statp-1Pol.lutant_ Dischacae. - i.imination S stem (SPDES. Perrnit._..requiredT � . .: -- .—.. 7' «,..- ..ac>.^+t -... ,a.�. r= »..,.�,,..�...a ......� ....... ,..:.. .. a -,_ .P . • ..a ..y � �a 'v,- epa•^.! O'e =.mai�:��•.�,.::.: 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State �, 9 wetland ?.......... :.. ............. ........ ............................... 28. Wetland ID Number ................ .... ............................... 29. Is Wetland Permit required? ................ ............................. rte Has application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? ................... <� 31. Is or'was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazar0ous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO ✓t! 32. 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 �U DESCRIBE: 33. Is there a 'local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? 35::are any_.sewage..dis�l_.Ar°eas'.in: excess of. 15 slope ?_ , 36. Tax Map ID Number ....... . 3.:f� ._ � ... .......................... ........ 37. Approved Plans are to be returned to: ................ Applicant _ Engineer 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. 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. .1. SIGNATURES& OFFICIAL - TITLES: MAILING ADDRESS: DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 r;•rr :.. .. ... :. .r. .; r. `�.:_ �ti :u -:I - ":icee: .;.,- yr::.{,:. ^•.ro «. .�.: -. °.. . a :.mo. •�.... .. _:.. .._ ...,,. .. .. -: ..,.. :w rte,.•. ...- .:.e. �, . ...:..... o... APPLICATION TO CONSTRUCT A WATER WELL�y PCHD PERMIT # WELL LOCATION Street ddr as To Villag Ci y Tax Grid Number WELL OWNER Name �'Iailing Address.: d. -Yir✓h ,,Z ailing rivate �ri eGrl�% O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL D PUBLIC SUPPLY 0 BUSINESS O FARM 0 INDUSTRIAL b INSTITUTIONAL Q AIR /COND /HEAT O ABANDONED O TEST /OBSERVATION O OTHER (specify, O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 44 /EST. OF DAILY USAGE dz%�'6 gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION M ADDITIONAL SUPPLY SMEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL DETAILED REASON FOR 'DRILLING WELL TYPE ,DRILLED ODRIVEN ODUG aGRAVEL OOTHER ,IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name h**e*4jr,-y71,}" �i�d�r�a� Address : ,g&,r / ,it. � �• IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: "'" TOWN /VIL /CITY .__ _w UYSTxTE°TO' �RDPERTY FROtf 'NEAREST WATER ,MAIN':r »� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED JEON SEPARATE SHEET to (signature) 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 thirty. (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 requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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 drilling operations'be contained on this property and in such manner as not to degrade or other s contami ate surface or groundwater. Date of Issue: 19 472- 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 t .n --I - D1•. _sic'i CC '-'1 a COL- J • I I =�r:1, %. _a%^= 1iC. =Li cif to �esclut_cn plans - Z nrae sets /s I E:1;ia ers zuthorizat_cn Cam•= ___ -- V_ �r=C-q �_ =C c013 Deo h Ca Two Sets PC - I Weil Ii ecal S::bci v- 0,-1 CC'�'ii "viS10*1 ��J?"OGc! C °C{ =1 tc1 � C SAS ril � �S l? �-'- I I its? ana (_� ._ /_�C I�ib�r no�_iicat o n I OZ DDS P & ,�s °_=�'- = ='�•'- p I Qij � !J=_II ST Z, i de - CPlan af--cw) Fca D _C� 5 - �JO_'_c _1 l _1 tG CO =Ot=T 3 I - .- r._•G•i /C= i 1 = =r; -a 'D T e� � �� if cc=r :•=-. O= Or Lma: j and ex-za _~ 10 ft. ii11 rot =_ l is & SS�S'_ :; /? a 200 =_. of P_- xs 3' a s r.=OLr1 ='-1 es ' r '�5= (Ti'- i= lot) No Ba . S; Max Bez -,:S � ]� w /C! = j .^.L'• 100 v r -17..1'.1 elev. ( ( 'fTl^'_V D T S:-�= J S� `L' ON PLAN ' P r'�o' Lo 'P.L., D- Zive'ca%, ar—e l: C_.J,r�� 20' to rO'. m-ticn ►•t_i is 100' to 200' in D.L•.O.D, 1501 -=s 200 zt. rss :z o- - -, etc. 100 1 , � Wit= . _K- n) 150 :1/l-1 ^nom 10 to W =_ter Liao (o_ zs -20' ) I ( 50' ir_l�--^attsnt jai ^?_e =arse I S= otic'T r_�:s I 10' iran t JLZG3ticn; 50' We- Weil 1 l j' to 7T - PC -1 P'U'1�'Z�TAi�2 C ©>LJliT' 'Y DE:3PARi1 -f I=:1;' —r C>1' ! :-1 rLT>t-3C APPLLCATIQN..FOR .APPROVAL OF PLANS FC=c A V�ASTEWA, DISPOSAL SYSTEM I. Name and Address of Applicant: r'r�;000, T 4. 6. Name of Project: 3, Location. T /V /C: Project Engineer: 5. Address: - .�-i- . License Number: Type o J Project: ri vate/Res i dent i al Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? A/o Type Status (Check One.) Type I.. Exempt Type IL. Unlisted 8. Is a Draft Environmental Impact_ Statement 05IS) required? .....6G..... 9. Has DEIS been completed and found acceptable by Lead Agency? ...... 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or other off icialsa ordinances? 12. If so, have plans been submitted to such authorities? ..... �� _ F y y ✓ 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge...... 40"" Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ............................... 17. Is project located near a public water supply system? 18. If yes, name of water supply Distance to water supply 19. Is pro eot ;ate ne=- a public sewage .collect*.c. or disposal_ system ?..... Ale 20. Name oF sewage system --- Distance to sewage system 2 1. Date c:servea: 23. Name _- Health Inspector: 24. Prcjec . design f lor, (gallons per .day) ....... ,U od ........................ . t 2. 25. Is State Pollutant Discharge Elimination System (SPDES).Permit required ?.. �d 26. Has SPDES Application been. submitted to loca��d f ice`? '. ".:. ........... •27. Is any portion of this project located within a designated Town or State wetland ?........ ..... ... ... .. ..............................� 28. Wetland ID Number'... .... .. .. . ............................... 29. Is Wetland Permit required,?.",,., . ........ Has. appl ication been made; QL- Jgwn;.or Local DEC Office? .................. 30. Does project require a DEC. Stream Disturbance Permit? A1,0 1. 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 or NO 2. Is project located wi:thin.1,00.0 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 .DESCRIBE: .3C. Is there a local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? - 35. Are an sewa a disposal areas n excess of 15.04 slope? ....... G 36. Tax Map ID Number ........................................................ 37. Approved Plans are to be returned to: ................ Applicant J,*� Engineer .f 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. Failure to comply with this ?rovision may be grounds for t.he.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 Pena 1 Law. ,IGNATURES & &FICIAL TITLES: (AILING ADDRESS: H. Y.F J • 1Y. - 1 J• '26{4ek�it, ^anmv # d 4+„n,n a,•nn +xh 511-4 �+ Cf m .n ti f �� {� - ,,,$d.f.•_ri +n,...^...�.,..,,.�.,,- ..yam. „,m,�,.s .. R' �}• vL�uM a�, mmm. v...wn.sc:,rsas,:r..,+in' -+c,.: .".:•,.m -• _ t, }� _ , [ '!i.., �x', ��{ Vn. arX1R '..'^N11N.YS °�r�= •s.�:.iT-W,.:. tucw.yy��,..��1'n.+.� ( ._ ? J )/ ,A + 1� ` • T���.a.aen....m� .'^+.ea. x.o. _ , :x1RF«!�nasvasFrs �i n� l / - i t' • •' • •' •; ' 1� Y' 'i �• emi . DESIGN "DAM _ SHE i= StTBSUFACE- S3gAGE -DISPOSAL tYS'S�i-.- Owner �gj lee, r,--' ��''�� Address Located at (Street) 44J74raG Sec. 93141�- Block Lot (in/dicate nearest cross street) Municipality 0)20 Watershed .• • 0i ,t!! NJ 0 • Z 0 NV.-7- Ij��T1WV,1001 0124- •N�•��'J��'i�IVVN20-12" /Yii 6.1?j?j n •l: M •,� � Date of Pre- Soaking Date of Peroolation Test / r_ _ HOLE NUMBER C= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches /w, 3v __V ,2_ -3 /C2 3 4 5 4 5 1 NOTES: 1. Tests to be repeated are obtained at each for review. 2. Depth measurements tc rev. 9/85 at same depth until approximately equal soil rates percolation test hole. All data to'.be submitted be made fran top of hole. 0 wp�,*ADVVA WIN 0_1 _DEM -H -NO HOLE NO. HOLE G.L. 21 31 41 51 61 7' 81 91 10, ill 12' 13' 14' INDICATE LEVEL AT WHICH GROUNUATER IS ENCOUNTERED a� E' :: INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: 7 DESIGN Soil Rate Used /cP Min/1" Drop: S.D. Usable Area Provided 6"r/ "Cl el 5 No. of Bedroans Septic Tank Capacity /a 0 a _ gals. Type Absorption Area Provided By 3 ',Ael L.F. x 24" width trench Nam Signa YOR sa-1Z Address THIS SPACE FOR. USE BY HEALTH DEPARTMENT ONLY: P R& IZIZ%_=7:.-,*�,._,_ Soil Rate Approved sq.ft/gal. Checked by Date