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BOX 33
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04340
PUTNAM COUNTY DEPARTMENT OF HEALTH
DQ�: 1�ld;` add LQbJJIL10-A. A,: t:l lJl ALdATH:A,7121.:Iii.•JL�r�IIJ':,
.:L'4•Ci �? �4�."J•ta'c1.9L'R1t� ." ? ••.W '.. ..:,K' JsV y. - � . — � .� \`�C+'.�.� �`eVm sda.. ..�+4 L Ir t.. r r —... �r.i����R .
CERTIFICATE OF CONSTRUCTION COMPLIANCE F REATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # PV-3 3 - 00 o? ye�- 0�
Locatedat 34 SASSIJoRo DEIVC Town orV4Hage _PuTrJAA1 `V,9LLE- Y
Owner /A pplieant Name 3°1 CRoTdrJ p,9m )mo cope Tax Map 84 Block I Lot -'b7
Formerly
Subdivision Name _Pu -rNm e4 C,f 4lue
Subd. Lot # %
Mailing Address 34 SASS I A a IZO ORI 1/C PV Try nel V19 L L C 1. A/. Y- Zip /OS-79
Date Construction Permit Issued by PCHD -SULY I 2000
3'7 cRaTaa orgm RoAo
Separate Sewerage System built by 37 cRo-ro-r1 09i7 soigo Calif" Address oSSia vQ Go ray.' 10S6 2
Consisting of 12 TO Gallon Septic Tank and
4L 6 8 L, F v r '�O' Poz FO;ZA T6o IN c I, PC 'IN 2efGR� 1/) L.. 71Z0Nc/ -/
Other Requirements:
Water Super: Public Supply From Address
,or- Private Supply Drilled b *�F. r.J3c�' Saar i� c . � .P"7'�'FiI�+ AVENUE
!! Y Y Address Mt ws-rek , OV, V, I oz-61
Budding Type Iid GU .. 66rt.Y RCS. H48 erosao control .been completed.,...•. yCS - _
Number of Bedrooms Fo u a Has garba$e grinder
nder
.NEVY
I certify that the system(s), as listed, serving the ab vex r'iiises M
built plans (copies of which are attached), in @`wi
plans and the standards, rules and regulati utn C
Date: y, j 5 _q.0 Certified by
been installed?
ted essentially as shown on the as-
Construction Permit and approved
nt of Health.
w�
��u x
P.E. V' R.A.
n 01 (ues g"1064980 . �
\�s� ficense # D 6 2gbU Address 2 S dN� W. S H &Vo. ic ,.rl
Any person occupying premises served by the above systems) 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 modifrca ' or change when, in the judgment of the Public Health Director, such
revocatior , odi ation r e ecessary.
d
By. ^µ !Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
i
PUTNAM COUNTY DEPARTMENT T OIF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
94 Sg s s wo Ro ne. WELL COMPLETION REPORT
el ➢']Loeataoan
Stieetddress "
Put -Chase Subdi, Lot #7
Town%Village: - ' -
Putnam Valley
Tax Grid # 84e -1 -51
Map Block Lot(s)
Well Owner:
Name: Address:
VS Construction, 37 Croton Dam Road, Ossining, NY 10562
Use of Well:
1- primary
2-secondary
X Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
X Rotary Cable percussion X Compressed air percussion Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock _ Other
Casing Details
Total length 13 Z ft.
Length below grade _ft.
Diameter in.
Weight per foot ( Ib /ft.
Materials: Steel _ Plastic _Other
Joints: Welded Threaded _ Other
Seal: Cement grout _ Bentonite Other
Drive shoe: Yes No
Liner _ Yes . No
Screen )(Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed X Pumped X Compressed Air
Hours 6
Yield _8�L_ gpm
Depth Data
Measure from land surface- static (specify ft)
30'
During yield test(ft)
580'
Depth of completed well in feet
6451 .
Well Log
If more detailed
information
descriptions or
sieve aznalyses_
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
Drilled
' stin
well deeper from 145' to 645'
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type sub Capacity 7cmm
Depth 600' Model7GS20412
Voltage 230 HP 2
Tank Type WX302 Volume86 i
Date Well Completed
2/11/01
Putnam County Certification No.
002
Date of Report
4/19/01
Well D le si r
NQD'Il'E: Exact location o2 well with clistancq§,twat least two permanent landmarks to be provon a separate sheet/plan.
Well Driller's Name P 4.-//:j0/ons Inc e Address: 4 Ran Ave., Brewster, NY
1�
O1 19
Signature: '' -7, � Date: 4/19/01
/
Perrxv,e. Beal
White copy: H ile; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
i
PUTN
4
'DIVISIO]
GUAR)
COUNTY DEPARTMENT.- OF HEALTH.
F ENVIRONMENTAL- HEALTH SERVICES
E OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building Tax Map Block Lot
3.7 N010a DAM 12oAD aeP.
Building Constructed by
Location -Street
Building Type
FWW /Au.e
ow illage
1 uTNAM 1 HAsE
Subdivision Name
Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is has been constructed as shown on the approved plan or. approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition
any part of said system constructed by me which fails to operate for a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
system.
The undersi ed rther agrees to accept as conclusive the deterr atio o e P 1'c Health
Director f Put County Department of Health as to whether r of e i re a system
A pera cau d�y the willful or negligent act of the occup t f b i ing tilizing the
s st m.
D ` t 19 IN Day/ 16 Year Zcb ( Signatu a
� n/d
W
(ONkner) - Signature
Title:
3-r V �zo-�b� boa >> �� 3 y C'�oTOa POW Doe ►a
Corporation Name (if corporation) Corporation Name (if corporation)
Address: 3 &OTc)N AM �+ 0ss►ac106
State %V . % Zip Dom_
Address: 31 N-.0-MA) _DA+ koA%�, 0- Zi0iIAk
State I\/. y Zip /a5 6e
Form GS -97
x
39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Oert: PH -0404
��3 (203) 748 -7903 - FAX (203) 748 -0652 NY Cent: 11471
REPORT T®:
P.F. BEAL & SONS
4 PUTNAM AVENUE
BREWSTER, N.Y. 10509
SAMPLE SITE:
SAMPLING PUINT:
SOURCE:
TREATMENT:
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
TESTED BY:
LAB I.D. #:
REPORT DATE:
4/17/2001
10:30 A.M.
WAYNE MAYS
4/17/2001
LAB #11471
APR -90
4/19/2001
V.S. CONSTRUCTION, LOT #7, PUTNAM CHASE SUB., PUTNAM VALLEY, N.Y.
HOSE BIB
WELL
NONE
TEST PERFORMED RESULT: METHOD # MAXINIIUM CONTAMINANT
LEVEL. (MCL)
BACTERIAL,:
Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml
CHEMISTRY
Chlorine Residual ND mg/L -
m1= milliliter mg/L = milligrams per Liter ND = none detected
COMMENTS:
- Holding Times (were) met.
RESULTS BASED ON SAMPLES SUBMITTED: 4/17/2001
TNTC= Too Numerous To Count
SAMPLE, AS TESTED ABOVE: ® ®TABLE or �OT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
a o
Laboratory Director
oNORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 o OUTSIDE CT: 800 - 654 -1230
BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N.
Public Health Director Associate Public Health Director
__ v< =.; :, .. , . _� �4 •r.: ,_ - o - i s „ , ;': Director of - Patient • Services ,
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845)278-6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
Date: 11Z,7J01
To: ��� 12
Fax
._--- No.._Pages
~(Including cover sheet)
From:
Adam B. Stiebeling
A Public Health Engineer
,...-For-your information Please-respond..y .. .... ....... .... .. ,.. ':
For your review
As discussed
Notes/Messages uT i_
Attached as requested
Please call
f1 zD v�Wqt'-45->S�.>k 16�z
In the event of transmission /reception difficulties, please contact this office at
(845) 278 -6130 ext. 2157.
RONIN ENGINEERING P.E. P.C.
The Lindy Building, , 2 hn Walsh Bl_vd.,_ Peekskill, w York 10.566
Suite 200
Jo als
T T
!°_e: C+ 7.l Y�_ 0. 3!' J_ it',. •• °.ra.n..:..(.!•JtY.iU�:)'.".. �t+:'c.sc ..qi.`„_ u; w.4 ...�:. rya- -._�. _r-i c;.e .. -'•T '...��o_r_�.'�r,v.:irr..i.•e �. �. :c �.. ,.i ?� :s
Adam B. Stiebeling,
Assistant Public Health Engineer
Putnam County Department of Health
Division of Environmental Services
1 Geneva Road. Brewster, N.Y. 10509
Re: SSTS Construction Compliance
37 Croton Dam Road Corp.
P.C.D.HPermit #PV -33 -00
"Putnam Chase AM " Lot 7
Town of Putnam Valley
Dear Mr. Stiebeling:
project:
April 25, 2001
eil :formation necessary for firml4pr6 —fcrr•th6 -abm t rfefen-e�i_
1.) Laboratory Report
2.) Well Completion Report
The original construction Compliance package was submitted and received by your office
on April 23rd for review only.
Kindly review the documents enclosed. Should you have any questions or require additional
information please contact meat the above number. Thank you for your time and assistance
in this matter:
Resp tfully submi d,
Kenneth M. Murph
Project Designer
- -"•. _- • -- . ... ��t>N ' .. ..:fie. M... a�.'+o _ - _=�e': ;.�
®41-,
01"
060. 8060
�y A6
s6 A
de
�1 � gg �►
N16-
91 IQ
�h.
6
sr
o' 0J
0° A
Off?
BRUCE R. FOLEY
Public Health -Director
LOREITA MOLINARI -R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
DEPARTWENT OF BEALTH
I Geneva Road
Brewster, New York 10509
Environmental Health (914) 279 - 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) 279 - 6648
WWW" rl 8 i 3 1 k"I 11; a Z' [I 110 11 i -:113 ! 311 "C'
E911 ADDRESS:
AUTHORIZED TOWN OF
(Signature)
DAT.E:
E(MTOA) PA M �Pe EDA-0 , 0_f .
it
The Putnam 'County Department of Health will not issue a Cerfificate of
Construction Compliance unless the above form is completed, Le., a letal E911
address is assigned by in authorized town officiaL This form is to be submitted
with the appH cation for a Cerfificate of Construction Compliance.
(E911VERFM
Ai
J"
In
F
� d�
CRONIN ENGINEERING P.E., P.C.
The Lindy Building; Suite 200
2 John Walsh Boulevard
Peekskill, NY 10566
914 -736 -3664 Fax 914 - 736 -3693
Adam B. Stiebeling,
Assistant Public Health Engineer
Putnam County Department of Health
1 Geneva Road, Brewster, N.Y. 10509
RE: 37 CROTON DAM ROAD CORP.
"PUTNAM CHASE SUBDIVISION"
34 SASSINORO DRIVE, LOT 7
P.C.D.H. PERMIT #PV -33-00
THESE ARE TRANSMITTED as checked below:
April 19, 2001
❑ FOR APPROVAL ❑ FOR YOUR USE ❑ AS REQUESTED ❑ FOR REVIEW AND COMMENT X PLEASE REPLY
WE ARE SENDING YOU attached
1.) Three copies of as -built subsurface sewageireatmenf'system plan
2.) Three certificate of the construction compliance.
3.) Three guaranties of SSTS
4.) Copy of survey showing foundation location
5.) E911 address verification form
6.) $200 certified check for application fee.
Should you have any questions or require additional information regarding this matter,
please contact me at the above phone number. Thank you for your time and assistance in this
matte.
Respectfully submitted,
r,�
enneth M. Mu y
Project Designer
PUTNAM COUNTY DEPARTMENT OF HEAL'T'H
DIVISION OF ENVIRON&IEN""TAL HEALTH SERVICES
FINAL SITE MPECTION
Dz
ee ea i'izf -- - . -
Str t o �- Owner
Town Permit # -
TM # ^ 24 —1 —SF Subdivision Lot # _ 7
1. Sewaa Svstet'n 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 ................... .....................0.........
d. Stone, brush, etc., greater than 15' from STS area..........
e. 100' from water course / wetlands ...... ...............................
II. Se4agge System
a. Septic tank size -1,000 ...... ,25 .;.......other........
b. Septic tank installed level ................ ...............................
c. 10' minimum from foundation ....:..... ...............................
d. ist 'bution Bo
1. All outlets at same elevation -water tested .................
2. Protected below. frost .................. ...............................
3. Minimum 2 ft.Original soil between box & trenches
e. Junction Box - properly set ......... ...............................
f. Trenches
1. Lent requir Length ins d
2. D stance to atercours m asured Ft..........
3. I stalled cording to p an .... ...............................
4. S ope of ench accepta le 116 - /3 ' /foot...........
5. 1 ft. Er m property li e - 2 fo datio ..........
6 D, pth o trench <30 ' hes fr surface ..................
7. R om a owed for ex sion, 0 % .........................
8. Si a of gr vel 3/4 -1' 2" diamet r clean ............ .....
Q th.of gravel in _nch.12" m nimum.. _ _.
10. °Pipe nds capped ... .................. ..........: .......... ..........
COMMENT'S
11 Y � k.:
g. rUMD or osea st s
Size o ump c er ....... ...... ...............................
2.Overflo ............ .............. ...............................
3. Alarm, visual/au ' .................... ........:......................
4. Pump easily essible, manhole to grade .................
5. First b fled ............................ ............::.........:.......
6. Cycl 'tnessed by H.D.estimated flow /cycle........:.
III. HouselBuild=
a. house located per approved plans ...............................
b. Number of bedrooms ....................... ............................... .
IV. Well
a. Well located as per approved plans . ...............................
b. Distance from STS area measured ' 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 to plan..
f. Curtain drain outfall protected & dir.to exist watercourse
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate ... ...............................
i Erosion control rovided
0
I
p................. ............................... 11 - 1 1
_..
04/16/2001 '16:13 9147363693 CRONIN ENGINEERING 1 PAGE 01 _
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISfON OF ENVIRONMENTAL HEALTH SERVICES
ATTENTION XADAM
,All information must be My completed prior to any
inspections being made.
13 GENE
For: Fill
Trenches Vl_�
PCHD Construction Permit* EV- 33 — 00
Located: SASS 11a 0 %a .012 E (T) (V) w'_►jA m VA LC Y
OwnertApplicant Name: 3-7 C25 VOID Q4_A_A0_12aa_&_TM 94 Block I Lot 6'1
Formerly: Subdivision Name: ?y rN A M c figa4
Subdivision Lot # '7
Is system fill completed? Date:
Is system complete? Ytl Date: • APR t L IC, 2061
Is system constructed as per plans? _YC d
Is well drilled? Date:
Is well located as per plans? Y95-r
Are erosion control measures in place? d
I ca* that the syst*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.
_ Dai.�.t c.= Certified by:�ao'::- �s2cu�r�
Design Professional
Add: 2 'rat /A Wq t1'N SL d0 P4 K.fl!! L . N. )! /t aKI,ic. # 0 6 2 `i 8 o
Comments:
Form FIR -99
PUT NAM COUNTY DEPARTMENT OF HEALTH
DIVEMON, OF ENVIRONMENTAL HEALTH SERVICES
i.r .'mil•, _ vP ., - ..
. r C.�` . S o. m. G .rJ, a :t' ..v >�.'. a - e . , - _ ... Y.?•• .. .rya . .ii ::i.. -.
CONSTRUCTION PERMIT FOR S EWAGE TREATM TREAT sT'.; 9''� EE
PERMIT # P V — 3 3— 00 : �- 00 J
Located at Sassinoro Drive/ Town K Putnam Valley
S'!
Subdivision name Putnam Chase Subd. Lot # `% Tax Map 84 Block 1 Lot
Date Subdivision Approved Renewal Revision
J'N Owner /Applicant Name
Mailing Address
37 Croton Dam Road Corp..
Date of Previous Approval
37 Croton Dam Road-, Ossining, NY
Amount of Fee Enclosed $300.00
Building Type Residential
N/A
Zip 10562
Lot Area No. of Bedrooms _4 Design Flow GPD_gQo
AC.
Fill Section Only Depth Volume
PC1H[D NOTIFICATION IS 11 1E UIRE <D WHEN ]PAUL IS COMPLETED
Sejgairate Sewerage System to consist of 1250
of 4" PVC Perf.
Other Requirements:
e in 24" gravel trench.
gallon septic tank and #(�d L.F.
r
To be constructed by 37 Croton Dam Road Corp. Address 37 Croton Dam Road, Ossining, NY 10562
Xater Suntcfld: i Public Supply From Address
. h . Beal" " "Sons' Tnc : - ` "` 4 "Putnam Ave'
or: < Private Supply Drilled by .P Address' • • .•
Brewster, NY 10509
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 wi ,h owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating' y x r� Rif d sewage treatment system during the period of two (2) years
immediately following the date of I'S th e a v f the Certificate of Construction Compliance of the original
system or any zopairs thereto. � 'q
Signed:
Address ' 2 John Walsh Blvd.
of
w
,.,1:..
R.A. Date 1 1 ri - UU
566 License # 062980
�^�UF ESS�U�
APPROVED FOR CONSTRUCTION: 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 th e Public Health Director. Any revision or alteration of the approved plan requires
a new permit ppr d for 'sc rge f domestic sanitary sewage only.
By Title: Date: V1�Clcz)
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
06/15/99 TUE 14:34 FAg
b .
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.I,L .COMPLFZ'ION. Rl!,POR�'_
Well Location
Street Address: "pars Pond Rd
Lot: #7, Puma a Cruse Suk:d
TovrNillage.
PUtnata Valley
Tax Grid V
Map," Block Lot(s) 0 1
Well Owner:
Name: Address:
V.S. Coq*ratio:i, 37 Croton Dam Road, ossininj, :1Y 10562
Use of Well:
1- primary
2- secondary
X Residential
Business
Industrial
Public Supply Air cond /heat pump hrigation
Farm Test/monitoring Other(specify)
institutional Standby
Drilling Equipment
X Rotary
Cable percussion X . Compressed air percussion Other (specify)
Well Type
Screened
Open end casing X Open hole in bedrock Other
Casing Details
Total length 82 ft.
Length below grade dl ft
Diameter 6. in.
Weight per foot ig lb/ft.
Materials: X . Steel: - Plastic Other
iWelded
Joints: , :: X Threaded Other
Seal: X Cement ut Bentonite _ Other
Drive shoe: - -K Yes No Liner: Yes x No
Screen Details
Diameter (in)
Slot_$iie
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield 'test
Depth
_ Bailed X
nwre m
j ,6'
Pumped _ Cotnpressed,Air , :
-static (5; tt) P.qring yiel test()
83,
Hours E Yield 5 gpm
Deprh Of completed well in feet
1431
Well Log
If more detailed
information
descriptions or
sieve analyses;
are available;,._.
please attach.
Depth From
Surface
Water
Bearing
>Weil
Di9rncter(in)
Formation
Description
ft.
lit.
Land Surface
50
Drilli
in over
dan clay and boulders
50
Hit roe
at 501
50
82
Drilli -
in rock,
set casing, _4routed
.gi b,.
145" '
-Dri 11
f Ci' �"C`Y1r
�}t `lull "i: -
If yield was tested
at different depths
during drilling,
list.
Feet
Gallons Per Minute
Pump/Storage Tank Information
Pump Type y Capacity
Depth Model
Foltage HP
Tank Type. Volume
Dat vY
uaty Terdflacion
113ft of R"a
14VI L: EXact location of well with distances to at least two permanent lane marKs to ee prgmm or a separane-mccvpum.
4 Putnam Avenue
Well Driller`sName P. , Ja:c. 'pddress: iareV9t4'?r, my 10509
Signature: Date: 4/14/99
. arrr
White copy: HD File; Yellow copy -Building Inspector, Pink copy -Owner, Orange copy -Well driller
Fonn WC -97
May. 3. 3999 -4:46PM
I - ;-,I, , , - -
Client Name:
STL Sample Nober;
Client I.D.:
Date Collected:
Date Received-
Co=nts:
Analysis
TIM MILLER ASSOC
TINJULLER ASSOC.
201459.02
WELL L-7
13-APR-99
14-APR-99
Result
"Federal Id:.. Collected, by--
Inorganics Analysis Oata Sheet
Form I - IN
Units
No. 0174 P- 6/1 7
Project Nam: _qw
garrix: I Drirdm
Method Analyzed .
ft
1..
2150.....
Arsenic
Mo U
UG/L
16-APR-*
T"
Silver
r
her ilia
4.6 U
Swirl F
q..
:14
Sul-rate
Clilorides
8.0
WL
4560-CL4 16-APR-99
ow
AB
Color
2.5
PIT-CO
2120 B 15- 49
VO 0%.
cyahide. total
0 .010
WVL
ot
5066E' AFR•99
Fl uori de
W
0.411
'H Woo
Lead
1.0 U
3113 20- APR -99
Ap
Hercur
0.2 U
245.1 !V-PPRI
"..
Odor
1..
2150.....
14-APR-99
T"
Silver
19.0 U
00'. 7"
If,
Swirl F
q..
:14
Sul-rate
19-8
PS/L
300
15-APR'"
ow
AB
RLS
9''
14.1-99"
Zinc
20.0 U
UGIL
200.7
16-APR-99
ReuarKs;
315 FuDwtwo Avowg
NewbA MY 12.550 .sno Leg .__ Tak (914) 552-CM
May. 3. 199,? 4:46PM TIM MILLER AQV")'OC
Federal Coll Octed-By:-.--:;
3X
`Voraifi I—e' 5��t.
Faml VOA 50?.2KW
No - 0174 P• jilt
11
Client ID:
VILL L -7
'Date Collected: 13-APR-99
STL Sawl e Nwber:
201459-02
Date Received: 14-APR-99
Client Name.
TIM MILLER ASSOC.
Date Extracted;
Project Name:
980
Date Analyzed, 17•APR-"
4 Sol i d:
NA
Report Date: 27-APR-99
Matrix:
I bri nMM
Column; RTX-502.2
Sample WWI:
5ffi1
Lab File Id; A4756.D
Level:
Low
Dilution Factor: 1.00
.5
COW. Data
A
Lialt
CAS NO.
Copound
ug/l ug/l Qualifier
108-38m3/10 •
99.87-6
74-a3-9
97-6913'
4f:
4
id
156.59-2
107-06-2
P
14.99-1
1 f
.*61.. 6 A�
'
106-93-4
ene
sec-Butywenzene
4-Isopropyltoluene
�UTJ
,5
U
U
Z,
S
U
sec-Butywenzene
4-Isopropyltoluene
�UTJ
SIS Puft" AVOW
N*wWgk MY 125W
Tok (gsq set-on
U
S
U
5
..0
.5
U
A
.5
U
U
5 ..
. Wf
U
U
U
U
U
s
U
e
U
U
SIS Puft" AVOW
N*wWgk MY 125W
Tok (gsq set-on
6
Mat /. 3. 199'3 4:47PM TIM MILLER ASSOC No•0174 P. 8/' 11
_.._- , .._. ;• ... ; Volatile Organics Analysis -Data Sheet.
FormI VDA
502.ZPg1BE
Results are continued from the pmicus page for 201459 -02
CAS NO. Copeed
ug /l
ug /1. Qualifier
.i'�C'i��^GI,J. �.
�•�•:•'•�Y. �Cil�': •.. �.. .•... •. .n.' •
•1.1.1.2Jetrachloroethane
..��, � ..
r. �.{'i'u'. :�:IN•���.
- -�.6
5
••
,63304-�20
JZ *
2 .1 -� itt�ryayck� oroethane
..
.. .Q ,
q19
yLyf�
: k ` ':`'''
108-90-7
Chl orobenzene
y
`ei'
U
..�".j' •'::.
.'w: +.a . ./� ..::.."r ,
.::: 'r '•'CJii•�e'j:�.:. .:•<.:...
.'2-
: •Y; : ;y�yy:.V .�^ .
: �. T"f.'. •.
ty' •;jam..•,. ..
v`S : ?. V.:t ".�;.:a'•
9.49.8
..
Chlorotoluene
.. ..:7iY:2. . .. .t.i:
S
v .
p"
541 -73 -1
1.3 -D i obenzene
.5
...
UJw';'.
�•�:�7TF -' k:
106 =46 -7
' r.� e3: .r�• ,�,p�7y,�,,y •,vti�
1.4- Dichlorobenzelie
vro•:i6 <.�
"
.
.5
•,5
..s:. u....
-OZ -6
trans- l.3- Dithloropropene•
,IO`0j6I
_S �j';.
.... ::JjS� `yJa,��. i.. _. ...... .. ..� �^ .v. �k, t :y� � .... ..
�' .•g�ir� ...
•. v ..: JN.... •. .. ., .
"•" "'.: iS� >:�,;i1':
71-43 -2
Benzene
-5
, ,::kv;(�e
100 -414
_ Ephy�penaer�e
s
315 F ti Av¢7M
---...
11r� NY 13$.?D'
r-
Td MAC Cn
No
E
LABS
NORTHEAST LABORATORY of DAN13URY _
T'Certi 'i'I= 0404`
39 -3 MILT, PLAIN Roan - DANBURY, CT 06811
(203) 748 -7903 - FAX (203) 748 -0652
NY Cert: 11471
EPA METHOD 524.2
Measurement.of Purgeable Organic Compounds in Drinking Water
by: Gas Chromotography -Mass Spectrometry
REPORT TO:
P.F. BEAL & SONS DATE SAMPLE COLLECTED: 7/15/99
4 PUTNAM AVENUE TIME COLLECTED: 3:00 P.M.
BREWSTER, N.Y. 10509 COLLECTED BY: W. MAYES
DATE RECEIVED @ LAB: 7/16/99
TESTED BY: LAB #10916
REPORT DATE: 7/29/99
SAMPLE SITE: V.S. CONSTRUCTION, LOT #7,.PUTNAM CHASE SUBDIVISION, KRAMER POND RD.,
PUTNAM VALLEY, N.Y.
SAMPLING POINT: HOSE BIB
SOURCE: WELL -NEW
(all results expressed in micrograms per liter)
COMPOUND
AMOUNT
LIMIT OF
COMPOUND
AMOUNT
LIMIT OF
DETECTED
DETECTION
DETECTED
DETECTION
1,1,1,2- Tetrachloroethane
ND .
0.5
romoform
ND
0.5
1,1,1,- Trichloroethane
ND
0.5
is- 1,2- Dichloroethene
ND
0.5
1,1,2,2- Tetrachloroethane
ND
0.5
is- 1,3- I)ichloropropene
ND
0.5
1,1,2- Trichloroethane
ND
0.5
arbon tetrachloride
ND
0.5
1,1- Dichloroethane
ND
0.5
hloroform
4.2
0.5
i,l- Dichloroethene
ND
0.5
hlorobenzene
ND
0.5
'1,1- Dichloropropene
ND
0.5
loroethane
ND
0.5
1,2,3- Trichlorobenzene
ND
0.5
oromethane
ND
0.5
1,2,3- Trichloropropane
ND
0.5
thyl Benzene
ND
0.5
1,2,4- Trichlorobenzene
ND
0.5
richlorotrifluorethane
ND
0.5
1,2,4- Trimethyl Benzene
ND
0.5
exachlorobutadiene
ND
0.5
-I;II _.`:;
-. _ 0;5:::� ..,
saGyreticge:.
0.3..__ ._
1,2- Dichloroethane
ND
0.5
ethylene Chloride
ND
0.5
1,2- Dichloropropane
ND
0.5
- Butanone (MEK)
ND
0.5
1,3,5- Trimethyl Benzene
ND
0.5
aphthalene
ND
0.5'
1,3- Dichlorobenzene
ND
0.5
-Butyl Benzene
ND
0.5
1,3- Dichloropropane
ND
0.5
-Propyl Benzene
ND
0.5
1,4- Dichlorobenzene
ND
0.5
Xylene
ND
0.5
2,2- Dichloropropane
ND
0.5
Isopropyltoluene
ND
0.5
Dibromochloromethane
ND
0.5
ec -Butyl Benzene
ND
0.5
Dibromomethane
ND
0.5
tyrene
ND
0.5
Dichlorodifluoromethane
ND
0.5
raps- 1,2- Dichlomethene
ND
0.5
2- Chlorotoluene.
ND
0.5
raps -1,3- Dichloropropene
ND
0.5
Trichlorofluoromethane
ND
0.5
ert -Butyl Benzene
ND
0.5
4- Chlorotoluene
ND
0.5
etrachloroethylene
ND
0.5
Benzene -
ND
0.5
oluene
ND
0.5
Bromo Dichloromethane
ND
0.5
richloroethylene
ND
0.5
Bromo Benzene
ND
0.5
inyl Chloride
ND
0.5
Bromochloromethane
ND
0.5
p- Xylene
ND
0.5
Bromomethane
ND
0.5
ethyl tert-Butyl Ether
ND
5.0
ND - None Detected
Results based on sample(s) submitted:7/16/99
*The MCL for Total Trihalomethanes (TTHM) is 100.0 mg/L, this is the sum of the four (4) constituent Trihalometbanes.
•
Laboratory Director .
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 . OUTSIDE CT: 800- 6541230
PUTNAM COUNTY DEPARTMENT OF HEALTH '
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION -FOR-. - PPR,0V _4F_PLANS.FOR_ -
•li...C+.GY_.. 9...�YA�J :.7••LV�a• )7�T'. /'.... .�'V .... t�.- f. — °�.• a4. ..... T.. .�.: 1...M M s�'Yq
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: 37 Croton Dam Road Corp.
37. Croton Dam Road
Ossining, NY-10562
2. Name of project: Putnam Chase - Lot # T 3. Location TN.: Putnam Valley
4.. Design Professional: Timothy L. Cronin 111 '5. Address:
2 John Walsh Blvd.
6. Drainage Basin: Peekskill Hollow Brook Peekskill, NY .10566
7. Type of Project:
X. Private/Residential Food Service', Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ...................... ..............:..::............ Type I Exempt
Tvpe.II _ Unlisted • X
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No
10. Has DEIS been completed and found acceptable by Lead Agency? ............... N/A
11. Name,of Lead Agency Town of Putnam Valley Planning Board
12. ,.Is this project in an area under the control of local planning, zoning, or other
.. ..y• .. �... ... • • r :... .. .. ._y.. ..
_... . officials, :ordmatiaes`' ...... .....:. _ .: _ . _ . ...........- ..:............. ES . _ ...:...... .
13. If so, have.plans been submitted to such authorities? YES
14. Has preliminary approval been granted by such authorities? YES Date granted: 08/02/99
15. Type of Sewage Treatment System Discharge ..........:...... surface water X groundwater
16. If surface water discharge, what is the stream class designation? ..............
17. Waters index number (surface) ........................................... ............................... N/A
18. Is project located near a public water supply system? ....... ............................... No
19. If yes, name of water supply N/A Distance to water supply N/A
20. Is project site near a public sewage collection or treatment system? ................ No
2 L Name of sewage system N/A Distance to sewage system N/A
V
22. Date test holes observed 03/29/99 23. Name of Health Inspector Adam stiebeling
24. Project design flow (gallons per day) .:...... ............ ..... ............................... 800 GAL /DAY
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... No
26. Has SPDES Application been submitted to local DEC office? ......................... NO
Form PC -97
-_a
.j
2
2.7... ,Is. any - portion -.of this- ;project located within a designated Tow. n or State wetland- -
28. Wetlands.ID Number...." ....................................................... ............................... N/A
29. Is Wetlands Permit required? .............................................. ............................... NO
Has application been made to Town or Local DEC office? ............................... NO
30. Does project require a DEC Stream Disturbance Permit? .. ............................... NO
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 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 YES
DESCRIBE: Property adjacent to the west was the former Orlando Landfill.
33. Is there a local master plan on file with the Town or Village? ......................... YES
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ............. ...............................
5.. Are any sewage treatment areas in excess of 15% slope? . ............................... N
36. Tax Map ID Number .......................... ............................... Map 84 Block 1 Lot _V,5 i
37. : Approved :plans.- are_to.bt.rettimed.to ... _ _ ,Applicant._ 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 stonnwater.plans or the creation of
impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from
DEP and submit those forms to DEP for review and approval.
If the application is signed by a person other than the applicant shown in Item l .,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
1 hrereby affirm, under penalty of perjury, that information provided on this Dorm is trace
to the best of my knowledge and belief. pals Cements made herein are punishable as
a Qasi'l misdemeanor pursuant to Sect' n 2 0.45 o flee Pe
Sd�N� MVP � ®F'1FICIAL TITLES:
C3
Mai -1 t d=A ftss :.... ............................... Cronin Engineering, P . E . , P . C .
John Walsh Blvd,. Peekskill, NY 10566
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
6ESIGN SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner 37 C-J?oTDAJ (gym &A p - wi-Z.P Address 32 CIZOVAJ Dim - aQ 11 4055wAJ4. AJ.
Located at (Street) tUy-4 iw-�;o Tax Map 491 Block Lot
zq
(indicate nearest cross street)
MunicipalityC-rj 8,tAIA "OLI Drainage Basin ft-gK!5gj u hbup W Cg Mg
ffiV0!WJ AlUcM
SOIL PERCOLATION TEST DATA
Date of Pre-soaking y4-c,1sq49 Date of Percolation'Test 04 =gq --I q
a
Role No.'
'Run No.
Time
Start - Stop
lbaNe Time
I in.)
D " to Water
Vrom Ground
Surface (Inches)
Start Stop
Water
Level
D in
ro
ncles
Percolation
Rate
Mwinch
13
.15
-7-1
3.
.2
q -101.1
1 e—L 1
3
7
3
l0 "1— 10",
-7
4
............
2
Sr, 1010x.
If
S7- —7-
3
4
5
2
.3'
4
5
N UIES: 1. Tests to be repeated at same depth until approximately equal percolation rates, are obtained at e=
percolation test hole. (i.e. s I min :for 1,30 minfinch, 12 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
2
TEST PIT DAT'A
..-PE PT 101 J0F' 1 - -PMC UiT E' RE6 Rq TEST HOLES
DEPTH HOLE NO. ��� HOLE NO. WA DOLE INTO..1-4 A
G.L. 10A so s
0.5'
lip
1.0'
dt9e.
1.5 LO ta4o" .4
2.0' _
2.5'
3.0' g V3 er
Indicate level at which ground`vater is encountered a"a,E ggCa� . meet
Indicate level at which mottling is observed:
Indicate level to which water level-rises after being encountered A
Deep hole observations made by: an4w ED 1-96n& Date
Oesign,PrPOssional Name: TjmQn V j— c
Addc�s• �vC `ter
J y `ray l . ��
�flgnture
u cr�JF 62980 �`C9
Design Professional's SeaD
VFESS�O
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of 37 Croton Dam Road Corp.
Located at Sassinoro Drive /Kramers Pond Road
T/ Putnam valley Tax Map# 84 Block 1 Lot S)
Subdivision of "Putnam Chase. Subdivision"
Subdivision Lot # -7 Filed Map # 2-e32- Date Filed 0 7 -7- i Od
Gentlemen:
This letter is to authorize Timothy L. Cronin III
a duly licensed Professional Engineer X 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 th of said wastewater treatme and/ water supply systems
in conformity with the 4 A R c 45: and/or-.147 of:the d atio w, the Public.-Health
Sani ' �de. - s
. s + .. Very trul our
W
Countersigned: < �,� Signed: Alk
` Pres .
` v., 2 � . 9so
06298 \�u r1n . �' ( )
0 er o P e
Mailing Address 2 John Walsh Blvd. #200
Peekskill
.State NY Zip 10566
Mailing Address: 37 Croton Dam Road Corp
37 Croton Dam Road, Ossining
State NY
Telephone: (914) 736 -3664 Telephone: (914) 739 -7362
Zip 10562
Form LA -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVMION OF ENVIRONMENTAL HEALTH SERVICES
AFFIIDAVIT -- CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT
To: Public Health Director
In the matter of application for:. Construction of SSTs and Water Supply
j Val Santucci
represent that.I am an officer or employee of the corporation and am authorized to act for:
Name of Corporation:
37
Croton
Dam
Road
Corp.
Having offices at:
37
Croton
Dam
Road,
Ossining, NY 10562
Whose Officers Are:
President - Name: Val Santucci
Address: (Same as above)
Vice President - Name: Same as President
Address: (Same as above)
Secretary - Name'. Michelle Santucci
. Address: _(Same .as above),.
Treasurer - Name: same as Secretary
Address: (Same as above)
and that I am and will be individually responsible for any
to the approval requested and all subsequent acts relating
Si-aned:
Title:
Sw rn to befo e me this day of
( onth) 20o ear)
Notary Public ,
KELLY M. LENT
Notary.Public, State of New York Corporate Seal
No. OI LE6026834
Qualified in Westchester Count
Commission Expires June 21,-W
Form CA -97
t
ion with respect
0
617.20 SEAR
Appendix C
State Environmental Quality Review.
SHORT ENVIRONMENTAL ASSESSMENT FORM
�; o? s a.= w� "r.: . «-tips• -. •..�; ':fin:_ _, .t,r 'v... :: v .. i.: 7, _. -.:d .. - ...yr •o .. •... .,a.: ir:. ._ ...
tFor i�NLISTED;A�°ffON3 fliilq`
Part 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. .APPLICANT /SPONSOR:
2. PROJECT NAME:
37 Croton Dam Road Corp.
Putnam Chase Subdivision, lot #
3. PROJECT LOCATION:
Municipality Town of Putnam Valley County Putnam County
4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map)
Kramers Pond Road/ Sassinoro Drive
5. PROPOSED ACTION IS:
lNew ❑Expansion ❑Modification /afteration
6. DESCRIBE PROJECT BRIEFLY:
construction of subsurface sewage treatment system and individual well water supply
7. AMOUNT OF LAND AFFECTED:
Initially 6 8. acres Ultimately. 6 8 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
®Yes ❑No . If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
Residential ❑Industrial ❑Commercial ❑Agricultural ❑Park/Forest/Open space ❑Other
Suir un&igylands are zoned single fsvnrf r dents!
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (FEDERAL,'STATE OR LOCAL)?
®Yes ❑No If yes, list agency(s) name and permillapprovals
Town of Putnam Valley— Building Permit
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
®Yes ❑No if yes, list agency(s) name and permil/approval
Subdivision Plat Approval — `Putnam Chase Subdivision"
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑Yes 80
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant/Sponsor nam P.C. l Keith Staudohar date: 04 -19 -00
Signature:
r
N the action is in a Coastal Area, and you are a state agency, complete a
Coastal Assessment Form before proceeding with this assessment
OVER
1
A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? if yes, coordinate the review process use the FULL EAF
OYes ONo
B. WILL ACTION RECEIVE COORDINATED REVIEW, AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6 ?.. If No,_a
negative declaration maybe superseded tiy7another involved agency.-`=- •-- ' - - - �- -
OYes ONo
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: Answers may be handwritten, if legible.
C 1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or
disposal, potential for erosion, drainage or flooding problems? Explain briefly.
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood
character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural
resources? Explain briefly:
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly:
C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly:
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly:
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT
OF A CRITICAL ENVIRONMENTAL AREA (CEA)? OYes ONo If Yes, explain briefly:
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
OYes ONo If Yes, explain briefly.
..f, it lll— DE f Et M[NAT11,0 � -OF SIGI' J ICAWM -�TU t G °i c n4lPtecl•.by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question
D of Part If was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the
environmental
UF-A.
O Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then
proceed directly to the FULL EAF and /or prepare a positive declaration.
O Check this box if you have determined, based on the information and analysis above and any supporting documentation, that
the proposed action WILL NOT result in any significant adverse environmental impacts AN D.provide on attachments as
necessary, the reasons supporting this determination:
Name of Lead Agency
Print or Type Name of Responsible Officer in Lead Agency
c�
Signatdii'of Responsble.0fficer in Lead Agency
cv date
r;'
Title of Responsible Officer
Signature of Preparer (If different from responsible officer)
wvr
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s� .:�' � P20405 BULOW ti
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