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HomeMy WebLinkAbout3978DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.58 -1 -38.2 BOX 31 1 rm 'ua 0 1 1 1 ; ` i � l� ; i } 03978 PUTNAM COUNTY DEPARTMENT OF HEALTH -D�VISION ..OF.ENVI.RONMENTAL HEALTH SERVItCES . .,..� .....;,� o ..o a.- ....q_ . .... ,.. ..,_ _... ,a . e . _ ,..,..- :..... -. a ..►.,.,�_r., ?`:.�: , ..•,:.....,... :.i CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # '�' CL Located at L.gEQT IUl u E Town or Village Owner /Applicant Name C PEE! C:l..1F- VkOM25- JO�Tax Map � �5� Block i Lot 3&Z Formerly Nf$ Subdivision Name i f_ %+9,46E ; tk%L WL Subd. Lot # Z Mailing Address Zt ?t'4'-")L- 0LXLC'°', ''BPD,, gy Zip /05 9 Date Construction Permit Issued by PCHD'I °`��`�� Separate Sewerage S ystem built by ! MME, 199,- Address ?0)U ''V' 4,0J--e4l Consisting of 1, 00D Gallon Septic Tank and 50�f Lr Of Z'-1 14 C4�X)E AWV' -nW tk� 56J 'AF�- 6 r-zT D.C.. Other Requirements: Water Supply: Public Supply From Address, or: K Private Supply Drilled by M0 *OffasW, IAIC- _:. -- Buildit ;g Type I- Number of Bedrooms Address `/ Y. 94 lc bbl - 14-as.erosiun conb-ol -been completed? Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: Certified by P.E. R.A. ,� 4 ����' �� (De i n Professional � U� - Address �� . ` ?'J' =r , 1, ( /L)5/(e License # r ;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 revoca ' n, modificatio or change is necessary. i r By: r Title: Date: White copy - HD ile; Y llo copy - Building Inspector; Pink copy - er; Orange copy - Design Professional Form CC -97 P1UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ WELL COMPLETION REPORT Well ]Location Street Address: 2- TownNilla e: - Tax Grid # 00/�-3.5 j' Map Block 3 g,- Lot(s) Z Well Owner: Name: Address: Use of Well: I- primary 2-secondary �- Residentiaf 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 Llld ppen hole in bedrock Other Casing Details Total length ft.. Length below grade b'' 1"k Diameter (o " in. Weight per foot �lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded _X, Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: >e 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 k-t ompressed Air Hours Yield 1-9 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 300 Well Log If more detailed information descriptions or sieve arialyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 7 C5 y ' 300 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity /d Depth V S?O Mode1n&'1'- -j,& Voltage Z3 o HP ' Y Tank TypeWX P-e-0 Volurfie cPv Date Well Co m leted Putnam County Certification No. Date of Report ell Driller (signature) A N®"I<'lE: Exact location of well with distances to at least two permanent lanamarxs to De provioea on a separate sneetipian. Well Driller's Name�•�41-,v Address Signature: Date: ja i7T White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 �pM CpG . BRUCE R. FOLEY * * LORETTA MOLINARI R.N., M,S.N. f -- czWit Health ireetoa ... _ .:. ; :: . , .i�: :,s..- :.w,:« �� Yoh �.;�::._s� _ .... Associate Public HeaitrD1 ?tGtOt......4 ^.� ?: . Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: Greencliff Homes, Ltd. TAX MAP NUMBER: 83.,58- 1-38.2 E911 ADDRESS: TOWN: Putnam Val 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. T911VERFRM) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEA]LT H SERVICES Gr-eenclifff Homes, Ltd. Owner or Purchaser of Building Grreenclifff Homes, Ltd. Building Constructed by Location- Street 3 Gilbert Lane Residential 83.50 1 38.2 Tax Map Block Lot Futn 'sin' Valley Town/Village Rose Marie & Michael Burns and John Lenich Subdivision Name Building Type I Subdivision Lot # F 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 Dated: Month 12 Day 03 Year General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State Zip system. 02 Signature: --� Title: Piresident Greencliff Homes, Ltd. Corporation Name (if corporation) Address: 21 Peekskill Hollow Road, Putnam Valey State NY Zip 10579 Forrn GS -97 n& � YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights,.N.Y. 105p8 Albert H. Padovani, Director | -AB #: 32.209062 CLIENT #: 4507 STATPROC PAGE 1 LEA-ROME INC DATE/TIME TAKENL 12/04/02 11:00A P.O. BOX 687 DATE/TIME REC'D: 12/04/02 11:20a PUTNAM VALLEY, NY 10579 REPORT DATE: 12/09/02 PHONE: (914)-424-4326 SAMPLING SITE: RICCIARDI RESIDENCE : COL'D BY: JAMES SCHMIDT - NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PU^NAM CNTY 12/04/02 12/04/02 12/04/02 12/04/02 12/04/02 12/04/02 12/04/02 12/04/02 12/04/02 12/O4/02 12/04/02 ' ' SAMPLE TYPE..: POTA8LE PRESERVATIVES: NONE TEMPERATURE..: & 4C COLIFORM METH: Ml::' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE PROFILE MF T. COLIFORM ABSENT /100 ML LEAD (IMS) 3.5 ppb NITRATE NITROG 0.85 MG/L NITRITE NITROG <0.01 MG/L IRON (Fe) 0.135 MG/L MANGANESE (Mn) <0.010 MG/L SODIUM (Na) 12.7 MG/L PH 6.8 UNITS HARDNESS,TOTAL 86.0 MG/L ALKALINITY (AS 76.0 MG/L TURBIDITY (TUR__ ` � �.� � ' . � `.^.~- _~^.--__' ..-��, �<1 - ''�'~ _.~_-- NTU _ ABSENT O-15 ppb 0 - 10 N/A 0-0.3 mg/l 0-0.3 mg/1 N/A 6.5-8.5 N/A N/A O-5 NTU METHOD 1008 9101 9139 9146 2037 9043 COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN91f�~1HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS; FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. nm c� Pb/Cu LEAD limits for public schools are set at 15 ppb. C-) EPA Lead & Copper Rule for Public Systems requires that no mmse � r7 than 10% of their distribution points have a LEAD value of m&Re than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. <_/ X. c�~< «� �n Fe/Mn If both iron and manganese are present, their total value ` combined shall not exceed O.5 mg/L. �V Na No limits for Sodium are oroscribed. 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 � YML ENVIRONMENTL A SERVICES 321 Kear Street (914) 245-2800 | Albert H. Padovanir Director LAB #: 32.209062 CLIENT #: 4507 STAT FIR PAGE 2 LEA-ROME INC DATE/TIME TAKEN: 12/O4/02 11:00A P.O. BOX 687 DATE/TIME REC'D: 12/04/02 11:20a PUTNAM VALLEY, NY 10579 REPORT DATE: 12/O9/02 PHONE: (914)-424-4326 SAMPLING SITE: RICCIARDI RESIDENCE : COL'D BY: JAMES SCHMIDT - NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE issuggested. SAMPLE TYPE.~: POTA8LE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~=~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE pH pH SCALE IN WATER 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 8E CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCEN#ATION, 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. 'L -�.�����'���''VERY�HARQ-jWATER� AB[yVE 1,111., /L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: ~~ METHOD ELAP# 10323 BRUCE R. FOLEY LORETTA MOLINARI RN., M.S.N. Public Director. ;..:_.,;, Associatg:•;Pi�{ittc';.,alth l3ffcur °w= r �; .... , Director of Patient Services DEPARTNIENT OF HEALTH 1 Geneva Road - - Brewster, New York 10509 rl Environmental Health (945)278-.6130 Fax (845) 278 - 7921 Nursing Services (845) 278.- 6558 WIC (845) 278 .6679 Fax (845) 278 - 6085 - Early Intervention (845) 278 - 6014 Preschool (845).278-6092 Fax (845) 278 - 6648 FAX COVER SIZET . Date: a 3 To: G Sow From: TO Selo � ' S, t'arz' 1V^n. 1r• Putnam County Department of Health Fax. #: o &.!� - `/vat No. Pages b (Including cover sheet) . For your information Please respond. ZF' or your review Attached as requested As discussed Notes/Messages Please call w ✓e- ei n y ' o r_4-- I i 1'@ nnz o, In the event of transmission/reception difficulties, please contact this office at (845) 278 -6130 exL- 0 0 Go N co 0 0 0 rn 4- x w 0 z U a cD 0 w 0 e % LDS -0 "), RESER VED S TRIP A S SHOWN ON MAP 185 (Width Varies) AS —BUILT RELOCATION—DIMENSIONS 1A 18.0' SEPTIC TANK 1B 49.4' SEPTIC TANK 2A 20.4' SEPTIC TANK 213 41.8' SEPTIC TANK 3A 35.4' DROP BOX 313 36.1' DROP BOX . 4A 41.3' DROP BOX 46. 40.1' DROP BOX 5A 46.1' DROP BOX 5B 44.9' DROP BOX 6A DROP BOX 3�} o 73,0' 66 50.30. DROP BOX 7A 57.7' DROP BOX 7B 55.2' DROP BOX F3 ­"DROP' BOX 813 60.9' DROP BOX 9A JIM END LATERAL 913 END LATERAL 1 OA END LATERAL 7(x,0.' 10B END LATERAL 145,0° 11A END LATERAL 7q"o 11B 3w END LATERAL 12A 49.3' END LATERAL V -d 128 fW END LATERAL 13A 55.0' END LATERAL . U-0 1313 MW END LATERAL 14A 61.4' END LATERAL 1413 dW END LATERAL t I, 0 ` 15A 10W END LATERAL 1513- END LATERAL a(% nl I - A I A -=SO I r►ln I •rrnnI LDS -0 "), RESER VED S TRIP A S SHOWN ON MAP 185 (Width Varies) 14 . h C*4 o6 Lo pli GO III co C14 z w LL. 7-i 6B 50.3' DUA 7A 57.7' DROP BOX 7B 55.2' DROP BOX 8A .63.6 DROP BOX 8B 60.9' ffwop-'60R- 9A JM END LATERAL 9B END LATERAL of 10A END LATERAL 10B. END LATERAL 11A END LATERAL '7q,o 11B END LATERAL 12A 49.3' END LATERAL 9;,d. 128 OW END LATERAL. 13A 55.0' END LATERAL S&-0 13B MW END LATERAL 14A 61.4' END LATERAL 14B dW END LATERAL S1,0'' 15A VMW END ..LATERAL 15B END LATERAL 16A END LATERAL 43,o' 16B 4W END LATERAL 7A, VW END LATERAL 411 178, 4w END. LATERAL 8A END LATERAL 188 -44W END LATERAL 19A MW END LATERAL 510' 19B INW- END LATERAL 20A 26.7 CLEANOUT 20B 35.1' CLEANOUT WC 103.4' WELL WD. 89.1- WELL &-)�r jo2 Al .W--O- .00 rV BADE' & WATSON LETTER of TRANSMITTAL .... ...,SGbl:.reying-• =Y.onglneering. Z.0 _ .. .. �._. .. .. .... .. .. •.<. ..- .. n. 3063 Route 9, Cold Spring, New York 10516 Date: 03 Jan 2003 File No. 02 -165 W. 0. # 15496 RE: TO: Gilbert Lane Mr. Joseph S. Paravati, Jr. Putnam County Department of Health 1 Geneva Road Rose Marie & Michael Burns and Tax Map 83.58 -1 -38.2 Permit/Title/P0 # Subd. Lot No. 2 Brewster, NY 10509 Sent via: US MAIL ❑ UPS -NIGHT ❑ MESSENGER ❑ UPS -2 DAY ❑ PICK -UP ❑ UPS -3 DAY ❑ FAX ❑ UPS -GRND D We are sending: UPS -COD ❑ copies date description of document 0 03- Dec -02 ISSTS "As- Built" 3 Gilbert Lane ❑ ❑ I I REMARKS: Copies to: File Yours truly: John P. Delano, PE Tel: (845) 265 -9217 ext 12 Fax: (845) 265 -4428 Email: jdelano @badey - watson.com 40 40-05 490400 624800 20528 DEC -03 -2002 12:38 BADEY & WATSON, PC P. 01/02 tom![: COIJh?T4 DEPA',RTh'IENT OF.- HEAL'a.`If3 .. .:,..... . DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FINAL, - INSPECTION Date: 1213/2002 PCHD Construction Permit # __..-- .._..._ PV -4.02 For: Fill Trenches Located: Gilbert Lane (T) (V) Putnam Valley Owner /Applicant Name: Greencliff Homes Ltd. TM •.. .— - Block 1 Lot 38.2 Formerly: nla Subdivision Name: :....._ Subdivision Lot # Is system fill completed? nla Is system complete? .— _..._..__........_.yes is system constructed as per plans? yes Is well drilled? yes Is well located as per plans? generally Are erosion control measures in place? yes Burns Date: Iva Date: 12/3/2002 Date: _ -• -- 11/27/2002 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 Health. Date- 12/312002 , -J s -^ Certified by: John P. Delano, P.E. I3esigri�Pro�es�or�1 -___ _,_ Badey & Watson, P.C. 3063 Route 9; Cold Spring, NY Lie. # 062505 _ CpmmPn„�• - FOR ❑ ADAM ❑ GENE ❑ Joe Paravati (NANE) Form FIR -99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONME:ENTAL HEALTH SERVICES FINAL SITE INSPECTION :s- :1 � r-7: 'ri• r.,. -:t - , 9. Date: I a 'J t .. .. _A. , Inspected by: TSP Street Location Owner ' Grcj,'Faisu! L�tO . Town - P��-r�� Val" Permit # 1., Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil.not stripped..: ... , i ........... .................:............. d: Stone, brush, etc., greater than 15' from STS area ......... r e..100' from water course /wetlands ............... ... .... , II. Sewage System a. Septic taakTize - 1,000 ......... 1,250..�..other ................ b. Septic tank installed level ..................... : .............. :.......... c. 10' minimum from foundation............, - ::....................... d. DistriDtuioi Bo 1. All out ets at selevation -water tested .......:......... 2. Protected Low frost .................................................. 3. M, iaifrium 2 ft.Original soil-between box & trenches Jruncgion —Bow - roperly set ..,. f ............ ... .......... ;.:................. . � L. Length required ti5� Length instal�d 3 t .2. Distance to watercourse measured 3. Installed according to plan.:....... ., ............................. 4.- Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10. ft. from property line - 20 ft.- foundations........:. 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 1' /2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... �.1.0: Pipe e n&! eapped- ::.................... ............................... g. rump or ijosea bvstems 1. Size o pump c am :.......... ............................... 2. Overflow tank. ....................... ......:........................ 3. -Alarm, vis audio .................... ............................... 4. Pum ily accessible, manhole to grade ................. 5. box baffled........ ....:.........:. ............................... Cycle witnessed by H.D.estimated flow /cycle. . III. A ouse/Buildin a. House located per approvedplan�. ,�„�,.,..� .. ............� _ . Number of bedrooms...... . ................ .........................�.�... IV. We]I Well Well located as per approved plans . ............................... b. Distance from STS area measured ' N' . ft ........... c. Casing 18" above grade..... ...........:.. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ....:...... ................:.............. c. All pipes flush with inside of box.. d. Backfill material contains stones <4" .diameter .............. e. Curtain drain & standpipes installed according anal f. Curtain drain outfall protected & dir.to exist e o se g. Footing drains discharge away from STS a ............... h. Surface water protection adequate ... ............................... i. Erosion control provided......... ..... ............................... Rev. 1/97 Subdivision Lot # oRE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # e Located at G I L fP_ f P, Ai � i t`' o or Village P„� rA,f � V i4Ll E�7 Subdivision name i,1; AR,,J _�) Subd. Lot # y Tax Map S 3. s � Block 1 Lot 3S- Date Subdivision Approved TT © k Renewal Revision _ Owner /Applicant Name 6-(C ' c i FF ffv,-i ES LTD . Date of Previous Approval V O>- MailingAddress Peo(cSkii -L. }koLLc,_j PATIVaM, V,4LLcy Zip OQcf 7 Amount of Fee Enclosed � 15 0 Building Type S AJ crLl: F4,4, Lot Area I SRS No. of Bedrooms _3 Design Flow GPD &oC.) Fill Section Only _ Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 10 oy gallon septic tank and 900 Other Requirements: 1. 5 Fr OF PO 6 F«� C(tQr,- t-V - k"wAt(\) To be constructed by L E A - kSo m E, Ste' c�_. Address Pk T ti's- ✓ 4L- ICY Water Supply: Public Supply From Address Iled' . . . . .. � 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: P.E. R.A. Date G Address )20 i2p. M 14 HVPA -c. / u y License # y Ky K I 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 ne ermit. App oved for discharge of domestic sanitary se age only. B 7 z( -� By: Title: Date: White copy - F' flow copy - Building Inspector; Pink copy/ O er; range copy - Design Professional Form CP -97 ' PUT NAM COUNTY DEPARTMENT 07 HEALTH DffVlSffON OF IENV RONMIENTAIL HEALTH S E118WCES APPLICATION TO CONSTRUCT A WATER WELL - - please print or type - _ .. = " «PCHI�"Perrriit #l/ — L� �►- ".• 1 Well ]Location: Street Address: o illage Tax Grid # 6(1'w'tr LIA I c/, )VnAk kf A"C Mapg; <S lock I Lot(s) 3� -Z Well Owner: Name: Address: VAt4'Ey Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation (P primary Business Farm Test/Monitoring Other (specify) 2-secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 3 6EO2ohEst. of Daily Usage :9 o o gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _,y- New Supply (new dwelling) Deepen Existing Well Detailed Reason SEkje A /Jew for Drilling Well Type _� Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes I/ No Name of subdivision ►3c,a 2:0 S Lot No. �2_ Water Well Contractor: /Vocni4J Ai i?- .J Address: P(,.rd++ -,-,-- SZAL4,c4 Is Public Water Supply available to site? .................................. ............................... Yes No J, Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be pro ided on separ to sheet/plan. �4!-- pplicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. A Date of Issue — 2 Permi Date of Expiration/ Title: Permit is lion- Transffea rabl White copy - HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller M Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFl AV1'd' - .:00121'0R_ .0YVNM.APPL1CA'I j0N .. : . FOR ^PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: Consrtuction Permits for Sewage Treatment Systems & Water Wells 1 Steven Leardi represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Greencliff Homes Having offices at: 21 Peekskill Hollow Road, Putnam Valley, NY 10579 Whose Officers Are: President - Name: Steven Leardi Address: 21 Peekskill Hollow Road, Putnam Valley, NY 10579 Vice President Name: Daniel, Romanello Address: 21 Peekskill Hollow Road, Putnam Valley, NY 10579 Secretary -Name: Address: _.i..�•.5.4 •.e .Tr.ea.... s.. urer -e ., Name: n.^.• `'.+..;.',.. war' ... _ .•.0 -. ...<"" r '. y..•un ..v. ...... .. ... ... -. .�...�.. �.. Y. .7 . .....♦ ... r.1 ..y-. .. - Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: Title: President to before me this ( day of (month) C� 6 year Notary Public MARIANNE B. DINATALE Notary Public, State of New York No. O1 DI5 ^20567 Qualified in Westchester Coun Commission Exp res Nov. 22. Form CA -97 Corporate Seal il► { `�� � �,� } ;� ",,,+ t�'� } } � °� r e' ��3 �.�, � � °� } '� } iii •� { } { } °� i } a ,1 } � � � LETTER OF AUTHORIZATION RE: Property of C��'��LIY� i�U,�► ES c-TD . Located at 6-1 t._ tim r l.. W - T/V A�tx _/ Tax Map # 3. s,, Block 1 Lot 39- z Subdivision of `&uyej Subdivision Lot # 2— Filed Map # Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer '>c or Registered Architect Ao apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations -as .promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and -the : Putnam- County. Sanitary C oche.:. Countersigned: P.E., R:A., # i 4__ Mailing Address/ " /- State A'7 Zip Telephone: 4�/_ / 4:51, Very truly_ yours, -� � Signed: 4,� r� (Owner of Property) (y�E�✓c:�� �:i= �;;.�G s L� Mailing Address: .21 �CELSI<«L, R p State . ,ki Zip I coS79 Telephone: 52_s - "Y Q, Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH # � DIVISION OF ENVIRONMENTAL HEALTH SERVICES C,O/NSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at own r Village Subdivision name 20 /flYf' Subd. Lot # LZ Tax Map�� Block 2- Date Subdivision Approved T0/ Owner /Applicant Name Are ±W C Renewal Revision Date of Previous Approval Mailing Address )�J— loZ7 /fI"44,yo 4k2 ��l°G9�V K �� Zip r Amount of Fee Enclosed IP �Dv Building Type Lot Area l.r� No. of Bedrooms Design Flow GPD Z Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of lQU gallon septic tank and Other Requirements: To be constructed by -.7, � Address Water Suunly: Public Supply From Address or: - Z— Private Supply Drilled'tiy "�lr� /� � " 'Address' I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewaggtreatment 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: P.E. R.A. Date 1Z / !a Address f� �'� �/>t �t C� /`� ��'� 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 anew rmit. Approv for discharge of domestic sanitary se age only. n 1011-1- �� Title: Date: By: y White copy - HD ile; 411+ copy - Building Inspector; Pink copy - Own ; Or copy - Design Professional Form CP -97 PUT NAM COUNTY DEPARTMENT ENT 07 HEALTH IID1I gSff ON OF ENVIDRONMENTAL HEALTH S ERWC1ES APPLICATION TO CONSTRUcCT A WATER WELL IL pfeasepiintortype: PCiiD'Permlt# — y� Well Location: Street Address: To illage Tax Grid # j0�;, ��� Map �� , f � block/ Lot(s)3 i WeRlOwner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation Primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm °ec Est. of Daily Usage 24gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling mew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling WeIR Type rilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes/--'*" No Name of subdivision OLIX14 r Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ......................:........ Yes Nom Name of Public Water Supply: N/, TownNillage Distance to property from nearest water main: Al Proposed well location & sources of contamination t<bbe rovided on separate eet/plan. Date:./ . - 6/ A licant, Si nature: PP g PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a mariner 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 wat r well driller certified by Putnam County. ff . A I /1 Date of Issue / -7. q :i) Permit Issuim Official: Date of Expiration _1 7 SV, '-0 4f Title: —LZ Permit is Non- Trahsfferrable I I /' U White copy - HD file; Yellow copy - Building Inspector; Pink copy - O er; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY, ALL SUBSEQUENT REVISION WLTE, IIATT ONS TO THESE HOUSE P ' NS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL all Z SIGNATURE 0 TIT DATE 1{•ltii (2187) —Text 12 PROJECT ).D. NUMBER s1i.21 SEAR Appendix C ..,. :,�•w.:- •Stet •EnYlron ;. .•. ._....:..a- ......„ .. . .� • _,;,�,_ �.. sI>�nte {�Oailslity iRl►>iiw .•�.. .~ _:..� :;:: .:..�- ..�• ..: "' �` '" ""` ' " IWORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION Cro be COMDleted by Acattcant or Protect snonsw% 1. APPLICANT (SPONSOR 2ROJECT NAME 3. PROJECT LOCATION: Municipality T N County PUT t. PRECISE LOCATION (Street address and road InterMeCtions. Prominent landmarks, etc., or provide map) S. IS PROPOSED ACTION: WI New ❑ Ex ;ansion ❑ Maditicatiordalterallan 5. DESCRIBE PROJECT BRIEFLY: CUJ,/,r % of 0 G?`(d.ti OF 7. AMOUNT OF LAND AFFECTED: o. J Initially I- acres Ultimately acres 8. WIL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 1Yes Cl No . it No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ❑ arAesidential D Industrial D Commensal [3 Agriculture lJ Park/Forest/Open space Other Describe: 1C. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING, NOVI OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATWe$ R LOCAL!? 1 ❑ No' if yes, list agencyts) and permlttapprovais 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes tJ No It yea, list agency name and permlUapprovai 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes vj No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE i 6%i �%1 f' �— �• N� �'� V Q/ Date: AppiicantJSpomor name: Signature: rr• If the action Is ln*the Coastal Area, and you are a state agency, completetthe Coastal Assessment Form before proceeding with this assessment OVER 1 PART II—ENVIRONMENTAL.ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN a NYCRR, PART 617.12? It yes, coordinate the review process and use the FULL EAF. ❑ Yas: No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN a NYCRR, PART 517.0? It No, a negative declaration may be superseded by another Invglvod agency. ❑ Yes Nb C. COULD ACTION. RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WIiTH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing alt quality, surface tr groundwater quality or Quantity, noise levels, existing traffic patterns, solid waste productlon or disposal, potential for erosion, drainage or flooding problems? Explain brlellr C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources: or community or neighborhood character? Explain briefly: NBN/5 . , C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or ondangerod species? Explain briefly: /V o AIE C4. A community's existing piaris or Goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly /V /V 4 C5. Growth, subsequent development, or related activities likely to be induced,by the proposed action? Explain briefly. CD /V.aw rn <i C6. Long term, short term, cumulative, or other effects not Identified In C1-C37 Explain briefly. n tits Cl. Other Impacts (including changes In use of either Quantity or type of energy)? Explain briefly. ; Jr c-I D. IS THERE, OR IS THERE, LIKELY TO 6E, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENViRONMENTAL IMPACTS? Cl rr Yos ONO If Yes, explain briefly PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It insubstantial, large, important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.s. urban or.rurak(b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachmerits 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'slgnIfIcant adverse impacts which MAY occur hen proceed directly to the FULL EAF and/or prepare &' positive declaration. eck this box if you have determined, based on the Information and analysis above and any supporting documentation, that 90 proposed action WILL NOT result In any significant 'adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Belly Title of esponsi a officer OV,, ature of reparer different from (espOnsV e o Mcer) z ate a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES iyE`3IG1�` DATA�:3frl °EET = sI7D'►S ' :t-E•,-SEWAGE.- REATMENT SYSTElI : Owner Rose /y Aye I E 8 u,P Ajl Address a 7 #16,6 Gyn n Located at (Street) G' L R g e7 `- L 4,V Tax Map ,Block �--Z- (indicate nearest cross street) Municipality P Uj"V A �1 AlAt t ii ti Watershed Os e 4 w °,9 ,r t &its SOIL PERCOLATION TEST DATA Date of Pre - soaking �,2 �/ bto Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately eq rates are obtained at 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 De tb to Water Water mm Ground Level Percolation tole-No'. :Ruet'No. Time Start Stop 3✓la a Time IViin.) Surface (Inches) Start Stop y�rop In Incites Rate Mi�/Incit a ' ya" 3 v 2 ti7lb #4-7 0 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately eq rates are obtained at 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 ;f &T Mf Ag® 4U U A� DESCRIPTION OF SODS NOOiJNTER ED IN TEST HOLES 'r uw: .:..r ... q..:..: :.�•.�.. r:•wi�.. ._..✓.��, a Win. ...... . -.. ... .. .. DEPTH HOLE R10. ff0tr IO G.L. -.0.5' 1.0' 1.5' 2.0' 2.5' 3.01. 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'. M Indicate level at which groundwater is encountered a • Indicate level at which mottling is observed �,� eta Indicate level to which water level rises after being encountered g g Deep hole observations made by: Date Design Professional's Seal �CSS1Q V `- r7 L.` t � t qT 0.434- OF N Ew �� rn c� - 4 Indicate level at which groundwater is encountered a • Indicate level at which mottling is observed �,� eta Indicate level to which water level rises after being encountered g g Deep hole observations made by: Date Design Professional's Seal �CSS1Q V `- r7 L.` t � t qT 0.434- OF N Ew �� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL, HEALTH SERVICES S •Y _ 4.. ..'F.. •1; ... r'.T^�..W• v _..3•'APPLICATION FOR. a A\ . PPROVAL OF PLANS FOR A ACTEWATL ...t ,w.��!•... .P.r .l•. .f r._ 4 :...��.. •�.O _ �'i2E'A?'I�+I�Pi7`��YSTL`1Vr I. Name and address of applicant: ,( f 2. Name of project: SIM4 g ro",c. Y d F r 3. Locatiao/: G &y#1 -*r 8k.. 4. Design Professional: A4w /*/- J. DOM4.10 _ 5. Address: -1.10 f..y,e iQte'.vo 6. Drainage Basin: ©J'/ 041.1,9/f / ?'tea -< Mil��dl�.rtt 7. Type of EMject Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status check one ..... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... All --f 11. Nap ar of Lead Agency 'is' this pTojeect in an area under the control of local planning, zoning, or other officials, .. ordinances? ................................ ............. ..,.,. ,13. If so, have plans been submitted to such authorities? ........ ............................... 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? .................... IVA 17. Waters index number (surface) ........................................... ............................... �-- 18. Is project located near a public water supply system? ....... ............................... �!/J 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage. ct llection or treatment system? ................ ND 21. Name of sewage system "' Distance to sewage system 22. Date test holes observed -- �_ 23. Name of Health Inspector I�/ IMIlie L 24. Project design flow (gallons per day) ................................. ............................... to b0 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... 40, 26. Has SPDES Application been submitted to local DEC office? ......................... 8 /'► Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? ka 2$, Wetland III Number... 29, Is Wetlands Permit required? .......................................:....:. .....:......................... N y 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 hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes 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& - DESCRIBE: An !-., n 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ............................. ............................... _ 35. Are any sewage treatment areas in excess of 15% slope? .. ............................... eily -- 36. Tax bap ID Number .......................... ............................... baps Block l Lot,2 — 2 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All- applications for review- and - approval of anew 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 Tans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms or such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item I .,the application crust 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, I under penalty of pert ury, that Information provided on this fora is true to the best of my ksowledge and belief. False statements made herein are punishable as a Class .A misdemeanor, pursuant to Section 210.45 of the Penal ,Law. SIGNATURES& OFFICL4L TITLES. Mailing Address: ................................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..��.3, .�..�a: -��:.a .1 +fiT!YC. .".� P^ * �,i __ •.:.��:. ',.'.':.__... ... �._ Y_: �_.__ �....... _..���.._..— .O�• ^a.w.C��.r��c«. �:._,C. _.. . —..— _ . LETTER OF AUTHORIZATION � r.::r•+'i �n • -_ .. F RE: Property ofLi�e /y-r Located at �' /f� /3 r- 1- . Iytt%&f Map # _;i"� Block ,�_ Lot 2-. Subdivision of Subdivision Lot # -2 Filed Map Date Filed Gentlemen: This letter is to authorize ,Q,� a duly licensed Professional Engineer 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 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned:. P.E., R.A., Mailing Address /k/8 �tiR�DF ie0 State- Zip l - 1yz Telephone: rF. 7 /r t _ ~fiery truly yours,...__, - __-- •--- __...._ .. .. � ...- _ .. _. . Signed: � � Si4et (Owner of Property) Mailing Address: E. cy - '-S-S^ State / if • Zip 7� Telephone: Z3 .a _ Fonn LA -97 i Daidd 1. Donah,e, 01. ' 200 Breckenridge Road Mahopac, N.Y. 10541 _ ......:................. ......:..... 914.628.7576 TO . WE ARE SENDING YOU Altachod O Under separate cover via • Shop drawinss • Copy of letter onto —'— .too ►ao. a�tty *ioa •��� PB tho folknving Items: U Prints ❑ Mans O SC� P68 O Spocifications D Change order O �COI•ISB CATS P40. CSRIPTION � 44 r AlfJ THESE ARE TRANSMITTED ae checked below: For spproval C Approved as submitted O Rezubrnit"r for approval. G For your us® r) Approved as noted O Submit copies for distribution. 1C, As *uastad . C Returned for corrections U Return corrected prints D For r©view and eommsnt 0 E) FOR 8105 DUE 19 0 PRINTS RETURNED AFTER LOAN TO US REMARKS— COPY TO - SIOF3ED: o•e —t 00 #000d. 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SLSL\ 7 l . p _ /,r as SIC( xvi O � / :3.LYC S `sd `aD )"Tu :AE G3.il kn (9 1 :I\OLLYOO'I i3'32i.LS :2D. to io 311TYH uI�2i3d t�OIlon'di S \OJ uod i33HS Mmau SI13.LSAS IKaIklIYaUl 30YM3S 3oY31I1ISafIS T A'Iddns Uaj.YM'IYnQL'1.IQ'I HI'IY3H'IY.L \3 IZOUM3 30 AOISIAIQ HllY3H 30 .L\3I4 - 'ayd3Q Ail\f100 I1iymma j Map- CONSERVATION EA SEMEN T 15-8 76 si 1 G) 1.535 Acres (66,847 S.F.) Under 2 7/7 - i Fr. -g t. ( 0 undatli7,)f (F a 41.31' 37 4' CAP 6' SDR 35 1000 GAL SEPTIC TANX 35 PVC 51.3 LF. F. 51.1 LF, 42.3 LF. USMDR 4 50.7 L.F. 42.6 LF. 5 50.3 LF, 44.0 LF. 6 48.2 LF. 45.1 LF.. 7 100 x Sri M -7- L:j 7 3 507 3.. OF ABSORPTION TRENCH -" 'LANE� pole 0 pmp Mon. Sl 3,002 00 .00.o.. Prop. Palo Mo. n "OL, LANE e000e- a pment Macadam Pave -%1 -1 - �nr- p 7 - 0 0 N f0 0 0 rn X w 0 z U_ S CL a c� O 0 1, . N Cd OD M N M 10 m I N O d z H IZ J a 0_ } m a d' O O a } M� AS -BUILT RELOCATION- DIMENSIONS "LAKES PEEK . . 1A 18.0' :SEPTIC TANK FILED ON 5, 16 49.4' SEPTIC TANK � lk Palo 2A 20.4' SEPTIC TANK 2B 41.8' SEPTIC TANK LAKE M. 3A 35.4' DROP BOX 3B 36.1' DROP BOX 1 N57 4A 41.3' DROP BOX ' 51.440 0 4B 40.1' DROP BOX RESERVED STRIP AS SHOWN ON MAP 185 Mi 5A 46.1' DROP BOX (Width varies) M 5B 44.9' DROP BOX 6A 51.1' DROP BOX N ro 68 50.3' DROP BOX CONSEI 7A 57.7' DROP BOX 7B 55.2' DROP BOX 8A 63.6' DROP BOX 8B 60.9' DROP BOX 9A 34.4' END LATERAL 96 73.1' END LATERAL _00 00"E 10A 39.4' END LATERAL 10B 75.6' END LATERAL 11A 45.0' END LATERAL 11B 78.9' END LATERAL 12A 49.3' END LATERAL m 0 12B 82.5' END LATERAL 13A 55.0' END LATERAL 13B 85.7' END LATERAL 14A 61.4' END LATERAL 148.:.90:3'. END LATERAL.,. �, _ -- - K _ ._ .. ,: .�• . 15A 81.4' END LATERAL 156 38.6' END LATERAL 16A 84.6' END LATERAL 41.31' 16B 43.6' END LATERAL 17A 86.6' END LATERAL 6' 17B 47.7' END LATERAL i ice\ 1000 GAL. SEPT 18A 89.2' END LATERAL 18B 52.7' END LATERAL 19A 92.0' END LATERAL 19B 57.5' END LATERAL F 20A 26.7' CLEANOUT W 20B 35.1' CLEANOUT ° WC 103.4' WELL r; WD 89.1' WELL