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Home My WebLink About4419DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS; INC. www.scanyourdocs.com 631- 589 -8100 84.11 -1 -24 BOX 33 04419 ti � If r ek 1 , i. ,l, T. I , r - +� 1 ,� 04419 • 7. ev 3186 PUTNAM COUNTY DEPARTMENT OF HEALTH, Engineer Must Pi6vide P'C.H.D. Permit q— KhTEOE.CLN$TRUCRON.C-.OYRLIANCE-FOP,-,SEWAGE DISPOSAL SYSTEM B %X140. V -V 0" 4t Tillaw at el ev'15 Tax -Map-, Av. B,lo;ck Lot .2- op e Owner/applicant Name er 'la!!!eForme S".vIsIou NameJz, e-. ubdv. Lot Mailing Address 0- _zip -Y.& -4 Dati. Permit Issued Separate Sewerage System built by 1JAddress Consisting of I gk D —Gallon Septli Water Supply: Public Supply From Address or: Y Private Supply Drilled by A' Address 2%A-7,WW7 Building Type r Has Erosion C . ontrol Been CompletedT Number of Bedrooms Has Garbage Grinder Been Installed? Other Requirements I certify that the system(s) as listed serving the above premises were construc wn on the plans of the' completed work copies of which are attached), and in accordance with the standards, rules and regula acco the file plan, and the permit issued by the Putnam County Departrent Of Health. k� Date Co. P.E.P . E. — R.A.— Address r License NOAI-7 Any person occupying promises served by the above system(s) shall promptly t saary to secure the correction of any unsanitary conditions resulting 'from. such usage. Approval of the separate sewerage star" sh void as soon as a publ,- Unitary sower becomes availalbi ..r no thn ova . f, he private water sup . ply shall'tiecome null i in . supply becomes available. Such qpprovals are change va 6 a J=/ oche when, in the judgment of the Com Is Health,, su Inodiftcation or subject to r Change Is Y. By Title Date —Pe 7Z.. zo"_� An, WbLL UVr1rLJ111VV Am"AL office Use Only DEPARTMENT OF HEALTH "DIV bii�"Eniv' irc, ti'm"en' 7 PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADOW S: `TtAW_tW ILIAMCI[Y TAX (;Rio mumBEA• WELL LOCATION F�,,/e WELL OWNER AOORESS: J�M � PRIVATE n PUBLIC USE`OF WELL tr 1 - primary 2 - secondary g RESIDENT IR 0 PUBLIC SUPPLY '' O'AIRI COND. /HEAT PUMP 0 ABANDONED ❑ BUSINESS ❑ FARM 0 TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY []TEST/OBSERVATION [:]ADDITIONAL SUPPLY NEW SUPPLY (NEW DWELLING) [3DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. I STATIC WATER LEVEL ft. DDATE MEASURED DRILLING EQUIPMENT ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT 0 CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED 0 OPEN END CASING 123-OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH ft MATERIALS: STEEL 0 PLASTIC ❑ OTHER LENGTH BELOW GRADE ft. JOINTS:- 0 WELDED J54HREADED 0 OTHER DIAMETER in. SEAL: XCEMENT GROUT OBENTONITE 00THER, WEIGHT PER FOOT ZI- Ib.1ft. DRIVE SHOE: M ONO I LINER:0 YES SNO SCREEN _- .,DETAILS.. DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (it) DEVELOPED? FIRST 0 YES 0 NO :.'HOURS • GRAVEL PACK 11 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK -In. TOP DEPTH tL BOTTOM DEPTH — It. WELL YIELD TEST If detailed pumping 9 METHOD: 0 PUMPED tests were done is in- ? 0 COMPRESSED AIR ormation attached? 0 BAILED 0 OTHER 0 YES 0 NO I It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE *n�d Water Bear- ing Well Oia- meter In, FORMATION DESCRIPTION CODE WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD 0M. Surface Surface .0v 7 WATER REAR . TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES ONO I ANALYSIS ATTACHED? 0 YES ONO STORAGE TANK: TLYPE CAPACITY WELL DRILLER NAME rTE fzmfe ADDRESS IIINATURIE PUMP INFRMATION TYPE 61d& CAPACITY MAK 1341T '51 �_j 2 DEPTH MOD01 VOLTAG910— HP J/dv PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIROV1 0TI'AL HEALTH SERVICES - +��Y�• -, •s - ^ _•. vc p~..� ^{.�01�::b�a:. ;�'r' ,�...�.;s..iv:•_: �.a � : ve :7' ; a . w<:jii•p..: -_ . o.�� _ten. -r., • . - 'tom -�. •war. •�n.±.. .��= ::'ti;��•.+.c^ — . +.ev C.:rv.' �� .`1.' •, -i� Owner or Purc of Building Section Block Lot We%Icke Jut a Building Constructed by Location - Street ., iv Municipality ' co IU/.,lwl Building Type ,La ✓C jlu K AtR t Subdivision Name 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 - "Certificate., of .Construction Compliance" for the sewage disposal system, or any -fepaYrs- Made'-by -irk ta- -smach -system,. except_ where, the Tailure 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 Director of the Division of Environinental Health Services of the Putnam County Department of Health as to whether or not the failure of the caused by the willful or negligent act of the occupant of th e the system. Dated this day of 4"_ 19 put� &,�� I I General Contra or (Owner) - Signature Corporation Name (if Corp.) tybjo "s Address rev. 9/85 mk Signatur Title system to operate was building utilizing �rN Address 1/ r � ,/n- ENVIRONMENTAL ocnvICcc` / | --- ''^— ~^'^^^ ' York6wn Heights, N.Y. 10598 (914) 20-2800 Alb t H NOYER, PETER DATE/TIME TAKEN: 09/17/96 09:00 68 LOVERS LANE DATE/TIMEREC'D: 09/17/96 09:45 PUTNAM VALLEY, NY 10579 REPORT DATE: 09/18/96 PHONEt (214)-528-7019 SAMPLING SITE: 68 LOVERS LANE SAMPLE TYPE..: POTABLE : PUTNAM VALLEY PREARVATlVES: NONE. COL'D BY: PETER NOYER ` TEMPERATURE..: { 4C NOTES...: KITCHEN TAP COLIFORM METH:`MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 09/17/96 MF T. COLIFORM / ABSENT /100 ML ABSENT COMMENTS: ` BACT THESE RESULTS INDICATE THAT THE WATER (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE . AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. ' . ' ' . ` ' SUBMITTED BY:_______________ ______ ' 'Albert H. Padovani, M.T.(ASCP) D i re ctor ' ELAP# 10323 CO N PUTNAM COUNTY DEPARTNIENT OF HBALTH Dlwld= eQ 2tvbmnwuW Hedtb Swwima. Caned. N.Y. 10512 anshmm to Ptovlde Fell 0 SRWAGE DUOS" SYSTEM g4e+rt! - = _ Stl6drvWad Name �v f' Y.- Vic- /'i Stilled W i = CZR'MCATE OF CO Petml! / ,% tetra 177 '7777.4 To, Mp Ow /AppBNW Nonna 'j >/d i7: +P /die ! iC -r w�— ❑ Sevlaba ❑ Date of Pee Approval Mdbg Atldteaa Town .� ZIP G? --f2:2 natP Stihdivision Annroved Fee Enclosed M1111Mk8 T9W / &— �tii9 G t let Am / 4r Jt FM Section Only LJ D.P& yhm - Ntn betr of Bed o Doaiv Flow G P D S�Dd PCHD Notfim" b Reaaleed When FM Is conoOMW sworabe ame new Syd m to candid e8 %252 Gomon Sept. Tank and 4� !' •�� !� . !%%% S To be aonobvited by d 4-1,/2 Y,&= . Afldeeae Willer Supply: PsbRc Sw* on pli late Supt Otber Reoahemeate r ��- 1represent that 1 am wholly and completely responsible for the desig end location of the oposed system(s)i 1) that the separate sewage dos sal s stem above described will be constructed as shown on the approved amendment there to and in ccordance with the standards. rules anZ regulations .1 Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Health will be submitted to the Department, and a written guarantee will be furnished the owner, his successor assigns by the builder, that sold builder will Place in good operating condition any part of said sewage disposal system during the period o $;immediately following the•date of the Issu- ance of the approval of the Certificate of Construction Compliance of the original system w r W ' hereto g) that the drilled well described above will be located as sheen on the approved plan and that said well will be Installed on tFda s, fulilif a d ropu a�Titoni of the Putnam County Department of Health. � ! Date ! Signed 1� a P.E. ✓ R.A. Atltlroa License No � � -2 APPROVED FOR CONSTRUCTION: This approval expires two year ro the date ' d u A nstr6"n of/ ilding has been undertaken and is revocable for auto or may lea amended or modified when consider ry by the m °C9 `ofy lth.' ", hange or alteration of Construction "quit" a ngyil. er it. Approved for disposal of domestic rani ar a and /or r' to r supply "O ty� Rev. S Gl.% '� App 10/88 veto_- ev Title I z cv J-3, f r z anE 5 UZ All S:-_M_= El ......... . far - - Dc to - cl =-a 20 e t 7-. ca S to ZM-7 Car 4=7C 1-17. F EZ 'Cer as TZ= cf C_ with cnez- < 4" C=ta Ei`- tO S a_raa C_ r-ct inc cr_� aWav 1:::C" S2 WE-=- DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICAT- ICON._, TO;. COi�TST .RUCT-_A:_WATER-�WEL-L� ~::�..~ --��ff PCHD PERMIT `X11 �� + WELL LOCATION Street Address Townn -Village Cit% Tax Grid Numb r WELL OWNER Name , ,tom d /�odr� n Mailing Address d ! e'�/ U �a.'� /� ��r c /" t >�4�,�� / r'.4? Mrivate O Public USE OF WELL 1 - primary 2- secondary ARESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT UMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT 4_-r gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 0'a gal ❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION LIADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN , DDUG GRAVEL. 0 OTHER 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 iji' �i i� %��[rry Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES !/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE ,TO. PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE G gON SEPARATE SHEET (d te) (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 thirt,• (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 dril ng operations be contained on this property and in such a manner as not to degrade or othErWOLse cont am' ate surface or groundwater. Date of Issue: 19q 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES q"°' -_ _ a . •- _.i .- � e- -.v .- .. - _ a f j d . f � ., I ._. _r. Y C • _ Date ` r Re : Property of %�Pi/"�/ %3d7-h %d dv y y �� Located at ®fie, .G (T)'114, ,0,77 of e- Section Block ! Lot 2X Subdivision of �v ✓G �� Cr�i Subdve Lot # // Filed Map # Date �� / -g6 Gentlemen:. This letter is to authorize .'S� a duly licensed professional engineer .4� or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said - "- -Eyste aor systems in -c•onformity -with -thz prowis'ions �of`Ar`t le 14j or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary - Code. Very truly yours, Signed Countersigned: P.E.,'�Aa, 7 a- Address 461-.r Telephone Owner of roperty Address Town y) S:tf 7C/T Telephone r• WO—LOAR 0 WAI DO W• r I R 0 We) DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. _•`G `I i1.! Y• Ti i.. � �.e , .p -. .: `.,,M_ �� i�wa .' .. � +• .Y. ". """i Gf •. �i8•r. �.V .. ..' Ofi•.. u�.. j • - +1 r..; u. a .:._.. � •_ LL� e..... � :, aw ii • n.. Owner �� / Q Z ��a>'Ore e,O Address 1� v �� y �rS .� a Sec. e- Located at (street) a ��5 d"y e- gr¢ Jl Block Lot �_ (indicate nearest cross street) Municipality Ua //e-V Watershed . Date of Pre - Soaking p G Date of Percolation Test _3j p T HOLE NUEM CLOCK 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 2, %_ /L2-7 332 4 5 4 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submittiad for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 .TEST PTT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES. MLE = NOa 29 3' 4' 5' 6' V 81 9' 10° 11° 12' 13' 14° INDICATE LEVEL AT WHICH GROUNMTER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 41d,�7 e, DEEP HOLE OBSERVATIONS MADE BY: DATE - DESIGN - Soil Rate Used Min /1" Drop: S.D. Usable Area Provided Septic Tank Capacity gals. Type Absorption Area Provided By L.F. x 24" width trench / Other 1f/ale 2� r,,l Name Signat �✓ o r Address �� P �� C" �"�� .�ri /'� S ��`` _ �, s� THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY :�'' Soil Rate Approved sgeft /gale Checked Date r 2. 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. d �y:. i� :. V+.. T�..-as' �!W' .� i� N•', �n1.''f• V ... 25. Has SPDES Application been submi ttedto local DEC Off— ce`?� ....... ... r . :: 26. Is any portion of this project located within a designated Town or State ./ wetland? ................. ............................... . o 27. Wetland ID Number ....................... ............................... 28. Is Wetland Permit required? .............. ............................... �d Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... Ala 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial- activity? ........ YES or NO a 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or Ala any other potential known source of contamination? ...............YES or NO DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ 35. Tax Map ID Number .. .. 36. 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. SIGNATURES & OFFICIAL TITLES: a MAILING ADDRESS: YM' r, PC -1 .1=1vVIr�TAlm Cp1L7rI�F °Y 1��1PAk��Y✓��i� "�° C: EEp ra=.^-T'Q'rM :, : :; :.� .,:..�.•: -;:.,, A1�?CriIDATFOd' `:FOR APPROUkL' OF,, -,PLANS FOR `�+:WAStTiWiTER' DI,^S��?��OSaL_:SYSTEM, 1. Name and Address of Applicant: 2. Name of Project: 3. Location T /V /C :� 4. Project Engineer: �� / /�`� 5. Address: License Number: Phone: 2- ya %� 6. Tyne of Project: 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)? Ale Type Status (Check One.) Type I.. Exempt Type IL. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. A/o 9. Has DEIS been completed and found acceptable by Lead Agency? .........o. 10. Name of Lead Agency 11 Is this project in an area under the control of local planning, zoning, ...r- - �or-- othar�offi eial•s or- d�icianc�s-? a.o . e ..- e o ; -. .. e :..tee : o- �� -y�= e . e e e . b � =e .•.= ::�= .:_.:� �..�- �-�: = ' �- - - - -•- 12. If so, have plans been submitted to such authorities? .................. 4� 13. Has preliminary approval been granted by such authorities?-/ Date Granted: 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) o. ...................��....... 17. Is project located near a public water supply system? .....o. Al 18. If yes, name of water. supply Distance to water supply ;9. Is prcJect site near a public sewage collection or disposal system ?..... Ala ?0. Name of sewage system Distance to sewage system ?1. Date observed: 23. Name of Health Inspector: 24. Project design flow (gallons per day).........Q.v ...................... PC -1 PUTNAM c,-Oi?NTY DEPARTMENT OF HEALTH APPI CAI ION EG1R- •APPROVAL OF-.,PLANS , -FOR A-, WASLEWAT ,ER._.DISPO,S�1L..-SYSTEM,._... a }7. z n \ b � yA + -. ^ •e• a w•. _.D S 9_ , R .•w .. 1. Name and Address of Applicant: �� e-1- of -., a 4o V6!�o A e Al 2. Name of Project: $ .S __ 3. Location T /V /C: �.� 0&71� 4. Project Engineer: °�!� y 41 1 ✓,,A 5. Address: License Number. Zy �� Phone:�d��/Z6 6. Type of Project: _;Z 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 (SEOR) ?: 4/0, Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ...,.....'..... 9. Has DEIS been completed And found acceptable by`Lead Agency? ............ 10. Name of Lead Agency. Al 11. Is this project in aw area `under the control of -local planning, zoning, .�( ar.: other �off.i.ca.a ls; . "o'dinaxtce? -: �............: :..,;.:T. ::.. �2... a a..4 2 1L h, .. 4u .� 12. If so, have plans been"subm'itted to such authorities? .................. e, 13. Has preliminary approval been granted by such authorities? ✓o Date Granted: / 9 14. Type of Sewage Disposal System Discharge...... Surface Water _Ground Waters 15. If surface water discharge, what is the stream class designation ?........ lyi* 16. Waters index number (surface) ............ ............................... d A- 17. Is project located near a public water supply system? .................. No 18. If yes, name of water supply:' Distance to water supply 19. Is project site near a public sewage collection or disposal system ? .....a 20. Name of sewage system Distance to sewage system/ 21. Date observed: 23. Name of Health Inspector: 24. Project design flow (gallons per day) ..................................... :.. X25.:: I St. P .lzlt;Wer t- DI s El i :n ti n= ysm iS DDS)e M 4qui �L ? re 26. Has SPDES Application been submitted to local DEC Office? ............... 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 application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? ................... �G 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, A/e/ landfilling, sludge application or industrial activity ?......... YES. or NO 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 DESCRIBE: 2. 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:. di.�pAs-al:,areas —i-n .ezce s- of y5 0p e?- 36. Tax Map ID Number ..... .....� F., 9. -.// : I . e-.V—.y ............................ . 37. Approved Plans are to be returned to: ................ Applicant le' 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. % 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 Nisdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: NO FIED TO: )RDANCE WITH THE EXISTING CODE OF PRACTICE ID SURVEYS ADOPTED BY THE NEW YORK STATE %TION OF PROFESSIONAL LAND SURVEYORS. MONS SHALL RUN ONLY TO THOSE INDIVIDUALS TITUTIONS SHOWN HEREON UNDER THE TITLE POLICY SHOWN ABOVE. SAID CERTIFICATIONS ARE NOT RABLE. LOT I I AREA= 45, 764 S_. F = 1.. 051 AC. I N•Lr; 1 m� II I jml II- 11� Irl E IAA Im I I� PREMISES -,WN HEREON BEING LOT 11 ` A5 51-i'OWN ON MAP ENTITLED "LOVE - PEEK ACRE$," FILED I" T}-{E PL}T�1AM COUNTY CLERK5 OFFICE On! NO-/. 11, 1986 AS MAP °NO. 21 8Co • "•' tr MAP OF LOT L /NE CHANGE. rtifications hereon are —lid for the map and copies SITUATE IN THE I only if said • map or copies bear the impressed n. (' of she surveyor whose signature appears hereon. t 'r TOWN OF PUTNAM VALL SURVEYED & PREPARED BY 1+ PUTNAM COUNTY, N EW YORK BUNNEY ASSOCIATES �: LAND SURVEYORS SCALE 1 "= 50 DATE:APSLI L 4AL ROUTE 42 FIELDS LANE REVISED: MA NORTH SALEM. NEW YORK 10560 t y,• I. i. 4 t K 9 T7;> A - 43 ,� .. ., r •J,.,.f ..,�- ,. _:.. i.. . a .. i... . .. '.4, t :';'_. ;-.: �; �`�. -. -�'w :cC ✓: 'rt `.':�,+.- - ` -�`; _.•_�:: --.c. =,. .. .: __ __. ._.... ,. :r ,.. �.. ..`*t _ -. -� � 4 - � "r��. .f a. -_r'.. ...:°h4:.�; mod•^. ,n. ...2 -!. .a; • ;. ag _ ev #. .. '_�.` -.r ., o-._., '.....y y .. . -:.r v ._ _ .: !t � _ C ~'FY f _ � _ "`-� -4 ♦ I.. ..• ,r .'.'.... .rte, -u ,- ss. al S. -;4" �` ;I .l 1'o`...fT- v'�'.?'_ .-}, .= 3"W'+ +. -.-'^1 ,..,;. ... .x �, ,,f c,., ..Jx. ,.,... +.... ,�Y,,,�'• -..'•: ,. .. .. -.:r ....,, R�_;:. -,4. s., �' -� �. -•x. `i _ - '�s" 'I J F�i"Y- ,.(, of JK'i'..ls- ':x �S. i� S .ii• T. F- 1 t C .,x�.E� . i� ,3' 't.C:i) � �S -Q ",� 6�• , � �� H ,� . !M�' � t y: �' (�y iii 7�f �` �� - i l �� ' _• � � .. {�'' of � ": � ``-� �%�` I � •. """ r ' t . off ._ i •