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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 1 -1 -80.4 BOX 1 I4 '- NM rr ■ PL 00047 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P I`� - 0 Located at � biILplL�— kAD Town or Village Owner /Applicant Name Formerly ` tkw-k" t'ANH Tax Map Subdivision Name Subd. Lot # Block 1 Lot 1011 ml t, 4 Mailing Address . ► S -oa�' LLn`")� �'� Zip � � Q Date Construction Permit Issued by PCHD �a- Separate Sewerage System built by Consisting of I Other Requirements: Water Supply: 1JNME,5 aftkiL AA"I Gallon Septic Tank and �-,0: b, V(t l Public Supply From DO Lr or: Private Supply Drilled by MI L U V �I l�L N LI3 , 11 -tL % Building Type Address AJIuAw �S- qj�J c A Pte, rP-F_ HL, (A Address Address W l VPM AVE, '� _,9 Win Has erosion control been completed? 1�i�5 Number of Bedrooms OD Has garbage grinder been installed? 14 t' I ce dfy that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- builtplans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plan's-'and the standards, rules and regulations of the Putnam County Pepartment of Health. Date: o 1 ) �-1 I ') Certified by Address 1_050 K 1�4_ P.E. A R.A. License # '55 Cl/A 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 ar subject to modification or change when, in the judgment of the Public Health Director, such revocation; mo ificatio or change is necessary. By:. Title Date: xa2 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Lot #4 Burdick Rd. Town/Village: Patterson Tax Grid # Map Block i Lot() '4 Well Owner: Name: Alan Finn Address: 15 Solomons Hollow Road - Brevister, NY 10509 Use of Well: 1- primary 2- secondary X Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment 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 42 ft. Length below grade 40 ft. Diameter 6 in. Weight per foot __]J_Ib /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded ___)L Threaded _ Other Seal: Cement grout X Bentonite Other Drive shoe: X 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 _X_ Compressed Air Hours f)__ Yield _L0 Depth Data ' Measure from land surface- static (specify ft) 10 feet During yield test(ft) 265 Depth of completed well in feet 365 Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 6 Sandy Soil 7 365 Limestone If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 365 100 Pump Type � Capacity r 215"1 /Z Depth 00.1 Model 7EH Voltages -3 Other 1 Tank Type t -3o.Z. Volume 06Z Date Well Completed 12/31/02 Putnam County Certification No. 2 Date of Report 12/13/02 Welt -D-i n NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan( Well Driller's Mij I Address: 75 Putnam Ave, , Brewster, NY Signature: Date: 12/31/02 White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 / 4� •C BRUCE R. FOLEY. ti LORMA"- MOLINM RN., M.S.N. ?w6lic Health Dlreeta Mtoetau Public Health Director D(notor of Pattent Servtca - D_ EP_AR'1'MENT OF HEALTH .. _ 1 Geneva Road Brew3ter, New York 10509 EovlroomeaW Health (911)271.61)0 F"(914)271-7921 - Nun4a5 S0lca (91{) 211, 6551 WIC(914)279-6671 .F"(914)-M-600 Lariy'io'tcrvio600'(R14)11f • 6011 Pradool (91j) 37W92 F"(914)171'.6641 - — E9 11 ADDRESS VERIFICATION FORM OWNERS NAME; A A H r-1Mi4 TAX MAP NUMBER; E911 ADDRESS: 2�J f�jpI Gv. ^J) TOWN:{rrEl�- �J�i -� AUTHORIZED TOWN OFMCIAL: (Stgnature) - DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed; -Le., 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. - - (E91 I VERFW- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Ai-,AH r-� N)-A Owner or Purchaser of Building ALAH Building Constructed by Location - Street 1 c6a'� Tax Map Block Lot TownNillage Subdivision Name 4 Building Type 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 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 system. ted: Month J�� Day Year Signature: Title: F f C a Nr-- r7 aof is :tor wne e - Corporation Name (if corporation) Corporation Name (if corporation) Address: I Lo 14OLl-0`,J R R96�j Address: W4 Ngt_fij State Zip 5709 State Zip Form GS -97 )MS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET STAMFORD, CONNECTICUT o6905 Mailing Information: Name: Mill Drilling Co. Address: 75 Putnam Ave City: Brewster State: NY Telephone: Sample's Information: Client: Al Finn Zip: 10509 Fax: 845 - 279 -5075 Site: water tank Date Collected: 1/20/03 Preservative: N/A Time Collected: 16:30 Temperature: <4C NELAC, CT and NY State Certified Environmental Laboratory Collector's Information: Name: Russ Address of site: lot 4 Burdick Rd City: Patterson State: NY Zip: Telephone: Date Received: 1/21/03 Time Received: 14:45 Lab No.: J030298 Date Analyzed Test Name Result MCL Method 1/21/03 15:00 Total Coliform Absent Absent SMWW 9222B 1/21/03 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 1/22/2003 Color ND 15 Units SMWW 2120 B 1/22/2003 Odor ND 3 TONs SMWW 2150 B 1/22/2003 Iron 0.066 mg /L 0.3 mg /L SMWW 3111B 1/22/2003 Manganese 0.012 mg /L 0.3 mg /L SMWW 31118 1/22/2003 Sodium 4.77 mg /L N/A SMWW 3111B 1/22/2003 Chloride . 25.0 mg /L 250 mg /L SMWW 4500 Cl C 1/22/2003 Hardness 188 mg /L N/A SMWW 2340 C 1/22/2003 Nitrate 3.19 mg /L 10 mg /L SMWW 4500 NO3E 1/22/2003 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 1/21/2003 pH 7.46 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 1/22/2003 Sulfate 36.9 mg /L 250 mg /L SMWW 4500 SO4F 1/22/2003 Turbidity 1.34 NTU 5 NTUs SMWW 2130 B 1/22/2003 Lead 1.10 ug /L 15 ug /L SMWW 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Signature: State #: PH -0218 Michael Lapman ELAP #: 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com 3 �n 0 I 1 e N , 380 } O n i �' V1 Z _0 �. o 'n ttu ~ o 0. Q ? k � W m m a w J Q �FLIOOD GAL SEPTIC TANK B EXISTING 3 BR. RESIDEMCE btST. goy SOL'o. Pvc $p2 35 X► T. WELL 'W �o M DIMENSION CHART -(in feet) Number A 1 39 23 2 83 85 3 123 131 4 127 138 5 128 136 6 129 135 7 130 134 8 132 133 9 134 132 10 182 183 1 1 181 183 12 DSO 183 13 ITS 184 14 177 185 15 07 186 C e PUTNAM.COUNTY DEPARTMENT OF HEALTH X131 ®3 ,DIVISION OF ENVIRONMENTAL HEALTH SERVICES 3 FINAL SITE INSPECTION + � Z ,�S�o- + b r Date: /,.Z Inspected by: Street Location 2. -Bvg_Dt6k° -Zj_ Owner JSfA/,y Town &; T Al Permit # TM # _ ?, — 1, Subdivision Lot # 1. Sewage Svstem 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.......: .......................................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System --r -- a. Septic tank size�1;600 : � ....:1, 250 .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from ; foundation .......... ............................... d. Distribtuion Bo-�- z 47 dut ets at,8ame elevation' water_tested ......:.. 2 Pr t cted below frost............................................ ..... . 3. Minimum 2 ft.Original soil.between box &..trenches Junction Box - properly set .................... ...:........................... 1. ength required `3 f� Length installed 2. Distance to watercourse measured -;- ie�w v Ft.......... 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 - 11 /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ......................... ............................... g. Pum p or Dosed Systems . Size o pump chamber ................ ............................... 2. Overflow tank ....................... ............................... _..... 3. Alarm, visual/ audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. Ho se/Bu ildin . a. house located per approved plans... ...., .......... .. u.° lvutuucr ui.ucurvvui� 1V. We..� 4 w V. a�i�ell located as per approved plans ............................. b. Distance from STS area measured ? . ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable .....................' 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 & dinto exist g Footing drauzs discharge Awayfrom STS are h:-- Sur& -dP= "titer protection'adequate ... .. i. �: Msion- control provided _ _ Rev. - 11/97- — - - - - -- _ -- Guy >i�C 1Pd� ma�73,;�;2 yr '�`v T l 7�Ci ?e 44 ' I7 G' %G lee-G:C �f f YES, ' 'NO C COMMENTS sue , , 2 2e e. t r` = 'A r %f, E--t' /� .f, f . . i :- a I DEC-13-2002 11:48 AM HARRY W NICHOLS 914 279 4567 P.01 C )_"0141 at PUTNAM COUNTY DEPARTMENT OF HEALTH DPISION 'OF ENVIRONMENTAL HEALTH SERVICES RPQT MST FOR FINAT . MSPP_C!nQN For: Fill Date-,. 11-11-01- ..Trenches �/ PCHD Construction permit # Located: 2a. fig (T) (IV) Owner /Applicant Name: AiA .;-Vt ja Q TM I Block I Lot -10--.5 Formerly: Subdivision Name: tiiILL z�6UWJ. Subdivision Lot# Is'system fill completed? Date: I's system complete? Date: Is system constructed as per plans ? - -gig Is well drilled? Xis Date: 12 -12-0 z -Is well located as per plans? Are erosion control measures in place? certify that the system(s), as listed, at the above, pre.mise3 has been constructed and I have inspected and -verified -their completion in accordance with the issued PCHD Construction..Permit and approved plans'atd the Standards, Rules and Regulations of the Putnam County. Department of Date: L Ce*rded,by. A A PE RA Desiai Professional )v V- Address- Z050 gai"PT 22 1512,josRz 0 y LicV. - 561 xA Comments:, FOR: CO ADAM GENE 0 - (NAW) Form FIR-99 BRUCE R FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director 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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 December 16, 2002 Alan Finn 15 West Hollow Road Brewster, New York 10509 Re: Field Inspection - Finn 23 Burdick Road, (T) Patterson Lot # 4, TM# 3. -1 -80.4 Dear Mr. Nichols: The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: • Erosion control measures have not been maintained below the well construction area. This violation may lead to an enforcement hearing and subsequent fines. The violation is to be immediately corrected to minimize the number of days you are out of compliance. Please note that fines may be issued for every day the violation is not corrected. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj BRUCE R. FOLEY. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 December 16, 2002 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Finn 23 Burdick Road, (T) Patterson Lot # 4, TM# 3. -1 -80.4 Dear Mr, Nichols: The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: • Erosion control measures have not been maintained below the well construction area. This violation may lead to an enforcement hearing and subsequent fines. The violation is to be immediately corrected to minimize the number of days you are out of compliance. Please note that fines may be issued for every day the violation is not corrected. Sincerely, 4� V 4,0/ Gene D. Reed Environmental Health Engineering Aide GDR: cj BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORET TA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services . Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 December 16, 2002 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection. - Finn 23 Burdick Road, (T) Patterson Lot # 4, TM# 1-1 -80.4 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The distribution box needs to be water tested.. 2. A bedroom count needs to be performed by this Department ;upon construction completion. 3. Erosion control measures must be re- installed and maintained below the well construction area. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed &4e GDR: cj Environmental Health Engineering Aide LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services February 13, 2003 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC(845)278-6678 Fax(845)278-6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: This office is in receipt of compliance for sewage treatment systems as submitted by your office for the following projects. a. Reilly Construction, Fields Corners Road, Lot 14. b. Reilly Construction, Fields Corners Road, Lot 15. c. Finn, Burdick Road, Lot 4. At this time, the above noted projects currently have open comments that still need to be addressed. Copies of the original comment letters have been submitted for your review. Please call me at the number below when all comments have been addressed and ready for re- inspection. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR: cj Environmental Health Engineering Aide LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services March 3, 2003 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax(845)278-6648 Harry Nichols, PE Patterson Park, Suite106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Finn 23 Burdick Road, (T) Patterson Lot # 4, TM# 3. -1 -80.4 Dear Mr. Nichols: A re- inspection at the above referenced project has been completed. There are not further comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR: cj Environmental Health Engineering Aide . 0�1 . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE THE T PERIMIIT# P11-O2 Located at 'L :3 B 0 9_1� i e- V_ 9-y A I Town or V illage ?A f Ztc-5 V 1 Subdivision name V3 r LX- Subd. Lot # /j_ Tax Map 3, Block 1 Lot V O -y Date Subdivision Approved 9 12 9 /01 Renewal Revision Owner /Applicant Name A LA is V I N N Date of Previous Approval OS ho oL Mailing Address t5 OtSS- NOLLva f4VA1,, b4mi, si5 Ey- P y Zip -%05Oq Amount of Fee Enclosed Building Type Lot Area 1.2 2 No. of Bedrooms 3 Design Flow GPD -a 0 p Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S stem to consist of i ©O� gallon septic tank and 300 L F A 81&. TgZPC:�A OtherlZequirements: 2 -3 ;FILL To beconstructed by Address water-sun-111. Public Supply From Address or-. Y _ Private Supply Drilled by `M!�i, Address I reprsent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the sepa�}e sewage treatments stem described above will be constructed as shown on the approved amendment thereto and in accorance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion theref a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Depasent, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builds will place in good operating condition any part of said sewage treatment system during the period of two (2) years irnrndiately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original systea or any repairs thereto. Sigxl: Add;ss R.A. Date f 2- -,02 -- CJZ License # M/ 2- -11 A-IF"ItOVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sevvp treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or m died wh nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a 1X4z perrni . proved discharge of domestic sanitary sewa B y ; Title: Date: 11k1_0 2_ WTj; copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # 11b �� Map Block Lot(s) Well Owner: Name: Address: NLA HH iS Wes., 1-��t l,��r► plain � Si -N (caS��i Use of Well: Y, Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5+ gpm # People Served /6 Est. of Daily Usage 6 �gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes- / No Name of subdivision ym\-'1. Lot No. Water Well Contractor: 11D Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: --- Town/Village ` Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate shee plan. Date: WhAi l/ Applicant 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 riller certified by Putnam County. ".f 11A Date of Issue J Date of Expiration _ Permit is Non- Transferr. ble Permit Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 — � `- Q O' 1� 1 l fDCC 6AUG STMP)I I S C 1 \ 1 •i t I 1 \ \ \ I r ® p6 470) /f j 1060 6 A I 1`SEVTIC TA K 594 \ _ _ 1 1 1 \ 1 1 1 a WELL q60 11 \PROP. 3�SEDR00 \\ \\ \RESIDENCE- -- " " - - - -- __ \\ FF. e 458>CLQ' _ -- ---------- - = 454.5\- ------------ ---------- _ - -- --------- 1----------- - - - - 1 _ - ` - -- - - -T - -� - - -- -- -- ------------ N / --- ------- - - - --" Y - - / 1/ -------------- - - -- -- 6"05 °30' 00" W ��- - -� � ® - - - - -- - -- - - - -- — 1 tB0.S0�� --------------------------- I EXIST. — � `- Q O' 1� 1 l fDCC 6AUG STMP)I I S C 1 \ 1 •i t I 1 \ \ \ I r ® p6 470) /f j 1060 6 A I 1`SEVTIC TA K 594 \ _ _ 1 1 1 \ 1 1 1 a WELL q60 11 \PROP. 3�SEDR00 \\ \\ \RESIDENCE- -- " " - - - -- __ \\ FF. e 458>CLQ' _ -- ---------- - = 454.5\- ------------ ---------- _ - -- --------- 1----------- - - - - 1 _ - ` - -- - - -T - -� - - -- -- -- ------------ N / --- ------- - - - --" Y - - / 1/ -------------- - - -- -- 6"05 °30' 00" W ��- - -� � ® - - - - -- - -- - - - -- — 1 tB0.S0�� --------------------------- I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMI GE TREATMENT SYSTEM 'w PERMIT # /r Located at V� kAD Town or Village I ATTt D0 Subdivision name Subd. Lot # + Tax Map 97 Block 1 Lot �0 Date Subdivision Approved %41 b 1 Renewal Revision Owner /Applicant Name ALAO FA H H Date of Previous Approval Mailing Address 15 W e� 491 -LD'nj PLO PO �J �W 6jeL 1 j Amount of Fee Enclosed ��So ae Building Type S('tl-1162 Zip to �-O j Lot Area 1 111— No. of Bedrooms � Design Flow GPD 6 ©© Fill Section Only X Depth 2-, ar Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1 Q Q 0 gallon septic tank and Other Requirements: .1, 5 �i 1L To be constructed by 80 Address Water Sup&: Public Supply From or: �_ Private Supply Drilled by 6D Address 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: Address R.A. Date I a 11.5 J 013- License # 6 L (1-' 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 w o idered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit' roved f 'scharge of domestic sanitary sewage only.. U G" �- By; Title: Date: y White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 d Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -1003 Fax (845) 274 -4567 October.25, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Mill Subdivision, Lot #4 23 Burdick Road Town of Patterson T.M. #3. -1 -80.4 Dear Robert: Enclosed are the following: 1. Four (4) prints of Drawing SF -4, "Preliminary Design For Fill Placement Only," dated 10- 25 -02. 2. Two (2) prints of Drawing SS -4, "Proposed SSTS," dated 10- 25 -02. 3. Short EAF. 4. `.`Application for Approval of Plans for a Wastewater Disposal System," dated 10-25 - 02. 5. "Application to Construct a Water Well," dated 10- 25 -02. . 6. "Design Data Sheet." 7. "Letter of Authorization." .8. Review Fee in the amount of $150.00. The Residence floor plan(s) were previously submitted and approved. If there are any questions concerning the enclosed, please call. Very truly yours, Harry 'W Nichols Jr., P.E. HWN:JM jmm .02- 094.00 14.16 -4 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 - SEOR Appendix C __.... State Environmental Quality Review ..SHORT ENVIRONMENTAL ASSESSMENT..F.ORM. For UNLISTED ACTIONS Only —_ PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT lSPONSOR A1 H FiM� 2. PROJECT Q E 4 y _ r,5 3. PROJECT LOCATION: ��N � M G Municipality County 4. PRECISE LOCATION (Street address and road InterseCtlons, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: . 9 New ❑ Expansion .❑ Modlflcation/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED:- I `� ' `� Initially Initially acres Ultimately +� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? Myes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF. PROJECT? ®,Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES - ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY- FROM ANY OTHER GOVERNMENTAL AGENCY.4I=EDERAL, ; STATE OR LOCAL)? ❑ Yes ;iLNo if yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ((Jo 'If yes;' list agency name and permlUapproval • _ 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes [6No .. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE VV App I lean Usponsor name: + Date: Signature: - If the action Is In the Coastal Area, and you` are a state agency, complete the . Coastal Assessment Form before proceeding with this assessment OVER —.. .PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR - A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: A LAH (✓I H j-1 = 5 irL O�T m—Q AD. L-07 �-JTS 3. Location T/V: 2. Name of project: � 4. Design Professional: t4*W W. JUIC, � , rLPc 5. Address: IZT-..�'Z- . 6. Drainage Basin: ��iT' $2AJ4a� . � ��-�. .._.t 7o 7. Type of Project: K Private/Residential Apartments Office Building Food Service Commercial Institutional Mobile Home Park Realty Subdivision __.. Other (specify) 8. Is this project- subject to State Environmental Quality Review (SEQR)? Type Status. (check one) ....................... ............................... Type I :Exempt ype-II ..Unlisted.:.;. ,. 9. Is a Draft Environmental-Impact Statement (DEIS) required? _ 10. Has DEIS been completed and found acceptable by Lead Agency? .............. N;A. 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials; ordinances? ........................................................... .............................i. 13. If so, have plans been submitted to such authorities? ........ ............................... �b 14. Has preliminary approval been - granted by such authorities? �O Date-granted: N�... 15.. Type of Sewage Treatment System Discharge ................. surface water K groundwater 16: If surface water discharge, what is the.stream class designation? NA 17. Waters index number (surface) .. � Nr4 18. Is project located near a public water supply system? ....... ............................... �Jb 19. If yes, name of water supply Distance to waver: supply ::14 - Is project site near a public sewage collection or treatment system? ::...:.'..::..:: 21. Name of sewage system- rJ A Distance to sewage system ..NA 22. Date test holes observed l�l5i�� rltitii�� 23. Name of Health Inspector 24.. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 416 26. Has SPDES Application been submitted to local DEC office? ......................... Nh Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? Na 28. Wetlands ID Number ........................................................... ............................... p.A 29. Is Wetlands Permit required? ............................................... ............................... Has application been made to Town or Local DEC office? N� 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/No'- 4 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 r' 0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ty9 34. Are community water and/or sewer facilities planned to be developed within C, rn 15 years in or adjacent to project site? ................................ ..........................I.... _ M N o,= C--) z 35 Are any sewage treatment areas in excess of 15% slope? 36. Tak Map ID Number .......................... ............................... Map °� Block I of 37. Approved plans are to be returned to ..... Applicant Y` Design Mfes�o al NOTE: All applications for review and approval of a new SSTS to be located within the NYC Wa%sh6d shk.1 1 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 appro.val.by the Department. Projects within the watershed may also require DEP review and approval -of other aspects of a project; such as stormwater plans -or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 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. I hereby affirm, under penalty of perjury, that information provided on this form is trite 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: Mailing Address: ....................... ...... 20 50 af e r4 e0 I-, yr ( re k-1 '17 je- eAs e- am rio t4 If C-p NOV -17 -2002 10:02 AM HARRY W NICHOLS 914 279 4567 ?UTNAM COUNTY DEPARTMENT OF HEAL'T'H DrmION OF ENVIRONMENTAL HEALTH SERVICES For: Fill Trenches P.01 PCHD Construction Permit # /_7 `Q 2-- Located; 2-3 a (T) / "ors ati Owner /Applicant Name: Ia.� L% TM 3, Block 1 Lot �3oft- Formerly: _ Subdivision Name: - Subdivision Lot # Is'system fill completed ?�S Is system complete? Is system constructed as per plans?..... -- Is well drilled? - - - e Is well located as per plans? Are erosion control measures in place? Date: Date: Date: 1 certify that the system(s), as listed, at the above premises has been constructed and I have inspected and .verified their compledon in 'accordance with the issued PCHD Construction permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. We: -7-6 L. Certified by PE yr RA ,rr De ' Professional Address: �� J& WU AYe...,C)L Lic, # T4,t2--f Comments:. FOR: ❑ ADAM GENE ❑ (NAME) . Form FIR -99 K 1nMC• I1TA,t]M f'fi11A1TV MCMn0TMCAIT fiC M 4 d BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director 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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 November 20, 2002 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Finn, 23 Burdick Road, (T) Patterson Lot # 4, TM# 1-1 -80.4 Dear Mr. Nichols: An inspection of the fill pad at the above referenced project has been completed. Comments are as offered. 1. Deep test holes are requested in .order to determine fill depth. Please call me at the . number below for an appointment. 2. The clay barrier needs to be installed. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at (845)- 278. -6130 ext. 2261. Sincerely, V9 Gene D. Reed Environmental Health Engineering Aide GDR: cj Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 EM 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 December 2, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: SSTS Trench Permit Lot # 4 Burdick Road Patterson, NY Dear Robert: In regards to the above referenced project we are enclosing the following: 1. Five (5) prints of Drawing SS-4, "Proposed SSTS," dated 12/2/02. 2. Percolation Test Results. 3. "Trench Permit Application," dated 12/2/02. Kindly, process the enclosed application at your earliest convenience. Very truly yours, Harry W. Nic Is Jr., P.E. HWN:JM:jmm 02 -099.00 FUTNAM COUNTY DEPARTMENT OF HEALTH., DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner NAW F-k0 l" Address is 146�r R0110v i o ,i 41vol Located at (Street) "1 Pr 9)1 Tax Map � � Block Lot 06014 (indicate nearest cross street) Municipality Watershed -- SOIL PERCOLATION TEST DATA - - Date of -Pre- soaking Date of Percolation Test T i nl Hole No. :...:: R,un.No::::;:.; <Tme: >:Sti rt;':;;Sjop..:; :>Ela se Time Min.) De th to' Water From Ground S.urface (Inches) Start Stop Water; Level Drop In °Inches Percolation Rate Min/Inch: _l04' 2 ._....... u1 .. t"11 a I� 9 3 4 OK' �< Z�i`�2 2�1��, 4h 3 Q -0"" 4 2 ... 4 5 _ ... L . 1 VZOL, kv , Vpuamu at barns ucptn unui approximately equal percolation rates are obtained at each percolation test hole. (i,e. s 1 min for 1 -30 miMnch, 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. --------------- ZZ- Indicate level -at-which -kioundwateris encountered Indicate level at which mottling is observed Indicate'level-to which water level rises after being encountered Deep hole observations made by: T� A AWH Date I . iliqlll Design Professional Name: RLJJ i �t(,Aa.;Jpf Address: UT-P' Signature Design Professional's Seal J, _X TEST PIT DATA_- 2 DESCRIPTION OF'SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO.' 2- HOLE NO. TO "I TOPAIL 0. 5' fir 1.01 LG An . -1.51 60 �OPVA\ 2.51 3.5 4.5 - --------- 5.5' . ...... C.7 6.5 1,01 7,51 8.01 8..5' AT� 9.01 10.01.. --------------- ZZ- Indicate level -at-which -kioundwateris encountered Indicate level at which mottling is observed Indicate'level-to which water level rises after being encountered Deep hole observations made by: T� A AWH Date I . iliqlll Design Professional Name: RLJJ i �t(,Aa.;Jpf Address: UT-P' Signature Design Professional's Seal J, _X Subdivision of Subdivision Lot # Filed Map # Date Filed_ Gentlemen: This letter is to authorize Ws NtGMV___) a duly licensed Professional Engineer or Registered Architect tor-apply for the. ;eqpired wastewater treatment and/or water supply permit(s) to serve the above- noted-property in.a6c6r1i 66,:.; with the standards, rules or regulations as promulgated by the Public Health Director of the. County Health Department, and to sign all necessary papers on my behalf in connecti 6nN,ith-this matter and to supervise the construction of said wastewater tretment and/or water supply systeniS M' conformity with the provisions of Article 145 and/or. 147 of the Education. Law, the Public Health Law, and the Putnam,.j-C-ouri�V-,�4ilitary Code. -Countersigned: P.E., R.A.3, # — Mailing Address State Zip Telephone: Aloo/V Very truY\7 Sighed:. (Owner Mailing Address: State 1 Z' 1 U Telephone: Form LA-97 c�. �� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT 1SEWAGE TREATMENT SYSTEM PERMIT # �,as /per Located at 23 7iW2DIO:C 9-0 Ao Town or Village -PA, - FM1Z5,0A) Subdivision name MILL GUBDiV►S • Subd. Lot # Tax Map Block ( Lot 00. Date Subdivision Approved Qq -A - 20,01 Renewal Revision Owner /Applicant Name ?603t� Hi L l- Date of Previous Approval Mailing Address Z 12 -dCCo J6.( \k, 12i✓U! Si �i� ► �/ Zip ,09L Amount of Fee Enclosed . 00 Building Type Lot Area L . Z2/rcNo. of Bedrooms ¢ Design Flow GPD_S� Fill Section Only -- Depth 2.5 Volume q64,29 Cy PCHD NOTIFICATION iS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of , -2 So gallon septic tank and 4-0,o JF A 1 Ai G46c, ( P i2i MA P,1) A iy b 40-- LF x Z4' W Di T( tt% S i fLr-St P-Vb Other Requirements: 2 ' �' D r -j i..,L- To be constructed by $ Address Water Supply: Public Supply From Address or: /X Private Supply Drilled by h I LL- Y'�.i I.L1 W6 Address Pik i NA 01 /tut 1I 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 Aaccordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 2- 15-02— License # d ` o, 5 k6 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 whe on idered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit' p oved fo ischarge of OQmestic sanitary sews e n y. % / Date: �— )3y: vV Title: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 1--- - i r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: ;2 R -©c'c� DQ-LU 2. Name ofproject: I►MiLL 5oPTI(- kGT 3. Location TN: �� ► t -�� 5 c�•� 4. Design Professional: P. t-J • s co-rr -Qj 4 �` 5. Address: 3 i '7 I P--cur i 6 6. Drainage Basin: FAQ -�52Agcw Mjeedc; i x G3 P r, s�2 , N y [0,576c] 7. Tyne of Project: _ 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 X 9 - Is a Draft Environmental Impact Statement (DEIS) required? ......................... �Ao 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency . P4 &t3 (b o. 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... C- -5 13. If so, have plans been submitted to such authorities? 14. Has preliminary approval been granted by such authorities? t� Date granted: $ 20W'o 15. Type of Sewage Treatment System Discharge................. surface water 41-1 groundwater 16. If surface water discharge, what is the stream class designation? .................... _ 17. Waters index number (surface) ........................................... ............................... 1J A 18. Is project located near a public water supply system? ....... ............................... M o 19. If yes, name of water supply ! Distance to water supply _ 20. Is project site near a public sewage collection or treatment system? ................ 1� 0 21. Name of sewage system W ,A- Distance to sewage system,¢ 22. Date test holes observed j 2 9 23. Name of Health Inspector, 24. Project design flow (gallons per day) .......... K:' ............. ............................... gwo 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? N/,�k ......................... Form PC -97 8/99 2 27. Is any portion of this project located within a designated Town or State wetland? f o 28. Wetlands ID Number ........................................................... ............................... PA 29. Is Wetlands Permit required? .............................................. ............................... J C, Has application been made to Town or Local DEC office? ............................... P /{< 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 13 u- -- 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landf lling, sludge application or industrial activity? ............................ Yes/No 40 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 .90 DESCRIBE: 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 protect site? ................................... ............................... 40 -.. 35. Are any sewage treatment areas in excess of 15% slope? ... ..............................� 36. Tax Map ID Number .......................... ............................... Mapes Block I. Lot 80 37. Approved plans are to be returned 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 stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 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. 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 Seg*n 210.45 of the„Penal Law. SIGNATURES & OFFICIAL TITLES. S0 :6 WV 02 03J Z0 J-Tt ]H Ar'g3 Mailing r� 'ul$ft� .................... 3 7 i 20 C)TC � r�. r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Located at (Street) Z,; Ougple -k Tax Map �_ Block _� Lot o, j0,+ (indicate nearest cross street) Municipality P.4- rrEp-,IV Drainage Basin --139m-VC4 Orr SOIL PERCOLATION TEST DATA Date of Pre - soaking /�/ l�— Date of Percolation Test /Z--- � % Hole No. Run No. Time Start - Stop Ela se Time �I41in.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Dro In Inc %es Percolation Rate Min/Inch ,. d _3 ... ,�. 4 1 _ Z / 3 3 3v 4 1 3 " 4 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min /inch, < 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 MILL SUi3�IVI5tOl T� ST PIT DATA REP= TO BE SMMj:TT.L•E 'NITH APPLICIATTON .ON OF SOILS TiJC UN'TEttETJ IN 'MST HOLES DL.'°' H HOLE NO. EOLE- N0. y Z .air o�c:� HOLE NO. G.L. I yi►M - Tp Ps �� �oACq — ra psa t L 1 i La�MY S 2, 4' 5' 4 A" RoG�c R'f'Co �'t 7' r at 9' 10' 12' 14' ZyDICATE LL•'VSL AT WEICE CRCCM -12 Z IS ENCOUNTERED _�- .^ _._....... _.......... _.._ ..., __.... =j:C= I.h'VEL TO WHICH WA= LBPEL RISES AE'TER BELNG E=NT= DEEP HOLE OBSERVATIONS MADE BY: M SUnztrNeil -1 DATE: DESIGN Soil Rate Used M.in/l" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity / gals. Type C _ Absorption Area Provided By L.F. x 24" width trench Other Name �nf� (.✓� �.,� Signature aD S ,�i'G? Address j't�= �cir. -rte' �i�C.iNE- %�' /� /C �.�?C /� /7G�'Tlir'� S�iL Aq0FFSSl�l��• THIS SPACE FOR USE BY HEALTH DEPAEM= ONLY: . Soil Rate Approved - sq:ft /gal.. ' C heckcd by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of Located at LETTER OF AUTHORIZATION T/V T'4fl- _ Tax Map # Block _�_ Lot (� Subdivision of Subdivision Lot # Filed Map # 2990 Date Filed 091 Z? o Gentlemen: This letter is to authorizeC��` a duly licensed Professional Engineer ._,,N:"' or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance r 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 Code. Very truly your , Countersigned: Signed: P.E., R.A., # (Owner of Property) Mailing Address `�� -}� Mailing Address: �� GCt� 1J(�lf "�' �Ij 71�a u j skc State Zip State_ Zip (� Telephone: ��'� _C219_9111 C) Telephone: Form LA -97 P. W. yCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (845) 278 -21j10 FAX (845) 278 -2166 TO - -� A WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via • Shop drawings ❑ Prints XPlans • Copy of letter ❑ Change order ❑ DATE JOB NO. ATTENTION RE: 'OU1S w ❑ Samples COPIES DATE NO. DESCRIPTION T SQ 5P THESE ARE TRANSMITTED as checked below: For approval ❑ r your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE [V 21ITA /_1V&r1 COPY TO s SL itted ❑ Resubmit ❑ Approved as noted ❑ Submit _ ❑ Returned for corrections ❑ Return _ (DO the following items: ❑ Specifications —copies for approval _ copies for distribution corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US 6—(— �C_A C,, ( c (ti Z� if enclosures are not as noted, kindly notify us at once. t v BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services 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 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 March 6, 2002 Peder Scott, P.E. PW Scott Engineering 3 871 Route 6 Brewster, NY 10509 Re: Mill 23 Burdick Road, Lot #4 (T) Patterson, TM# 3 -1 -80.4 Reservoir Basin Dear Mr..Scott: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on February 21, 2002 is complete. The Department will notify you by March 26, 2002 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. El Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your. name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised, that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of aproject, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Letter to: Peder Scott, P.E. - March 6, 2002 -2- Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Very truly yours, �g-e-kx /V W-&- Robert Morris, PE Senior Public Health Engineer BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services 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 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Peder Scott, P.E. PW Scott Engineering 3871 Route 6 Brewster, NY 10509 Re: Proposed SSTS: Mill 23 Burdick Road, Lot #4 (T) Patterson, TM# 3 -1 -80.4 Dear Mr. Scott: March 6, 2002 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. All boundary separation distances are to be taken from the toe of the fill slope. Therefore, all of the fill pad must be 100 feet from the existing adjacent well. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Robert Morris, P.E. Senior Public Health Engineer I.AUT041 PUTNAM COUNTY DEPARTZIENT OF HEALTH .. DIVISION OF ENVIRONMENTAL HEALTH INDMDUALWATERSUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEbIS REVIEW SHEET FOR CONSTRUCTION PERMIT VAIAE OF OWNER: STREET LOCATION: REVIEWED BY: RIM, GP, AS, SRDATE: DOCUMENTS PER -MIT APPLICATION `TILL PERMIT OR PWS LETTER TC -97 LETTER OF AUTHORIZATION U)DESIGN DATA SHEET (DDS) L)CORPORATE RESOLUTION U�SHORT EAF PLANS -THREE SETS HOUSE PLANS -TWO SETS U) VARIANCE REQUEST SUBDIVISION �LEGAL SUBDMSION SUBDMSIO`i APPROVAL CHECKED UPERC RATE r- L)LUFILL QUIRED (DEPTH CURTAIN DRAIN REQUIRED GENERAL LOCATED IN NYC WATERSHED ��PLANS SUBMITTED TO DEP LEGATED TO PCHD ( DEP APPROVAL, IF REQ'D !_ )DEEP TEST HOLES OBSERVED �EX.APPROVAL PERCS TO BE WITNESSE SSDS ADJ, LOTS CU.,�I,L)WETLANDS (TOWN/DEC PERMIT RE.Q'D ?) I__,,dTUDATA ON DDS PLANS & PERMrr SAME �',UPRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA i 1100 YR. FLOOD ELEVATION W/I200' (- f . 1SOIL TESTING LOTS >10 YEARS OLD ;EWAGE SYSTEM PLAN - (NORTH ARROW) ;SDS HYDRAULIC PROFILE 3RAVITY FLOW ,CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS Z' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT . FOOTING /GUTTER/CURTALY DRAINS USDA SOIL TYPE BOUNDARIES (TITLE BLOCK; OWNERS NAME ADDRESS TNW, PE/RA; NAME, ADDRESS, PHONES )DATE OF DRAWING/REVISION )DATUM REFERENCE )LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS )WELLS & SSDS'S WAN 200' OF SSTS )PROPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROLNOTE . 'r,N iY1ENTS: {VSHEET)09 101 100 T.4X 14V=: (CONFIRMED) Y ,cam' l (REQUIRED DETAILS ON PLANNS CO \ ?'Dl (� / HOUSE SEWER -' / ;' FT. 4"0'; TYPE PIPE CAST IRON UU \0 NDS; DIA.X BENDS 45° NV /CLEANOUT RENEWALS _)SITE NOTE (NO CHANGE) FILL SYSTEMS ((�10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE U/ ILL SPECS' FILL NOTES 1 -5 ILL PROFILE & DIMENSIONS FILL LX EXPANSION AREA FILL GREATER 7N4 V 2 FEET C� CLAY BARRIER l FILL CERTIFICaTI ON, NOTE. DEPTH GAUGES ( 1� )VOL. ON PLAN FOR R. O.B., UNCLASSIFIED & IMPERVIOUS U! )SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH �LF TRENCH PROVIDED GOFT bIAX. . PARALLEL TO CONTOURS )100% EXPANSION PROVIDED �DETAILIDUST FREE CRUSHED STONE OR WASHED GRAVEL GEOTEXTFLE COVER SEPARATION DTSTANCES ON PLAN - FROM SSTS �10'TO Y.L. DRIVEWAY, LARGE TREES, TOP OF FILL 30' TO FOUNDATION WALLS U 100' TO WELL, 200' IN DLOD,150' TO PITS U f 100* TO STREAM, WATERCOURSE, LAKE (inc. espau) 50' TO CATCH BASIN, 35' STORtiID)tALN, PIPED WATER 10' TO WATER LINE (pits -20') (50' (INTERMITTENT DRAINAGE COURSE RESERVOIR, ETC. _ 150' GALLEY SYSTEMS U(_J10' MIN TO LEDGE OUTCROP SEPTIC TANK LX�10' FROM FOUNDATION; 50' TO WELL WELL DI`IENSIONS TO PROPERTY LINES - - -- -- - - -.._ -- - - LOCATION OF SERVICE CONNECTION *Ljti1LN 15' TO PROPERTY LINE / SLOPE )S OPE IN SSTS AREA (S20 %) t (`) EGRADED TO 15 %, IF REQUIRED DOSE/PUbiP SYSTEMS ( PUJIP NOTES DOSE 75% OF PIPE VOLUINIE/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED ZUI DAY STORAGE ABOVE ALARM CURTA X_DRAiN STANDPIPES, 5' BOTH SIDES, DETAIL 15' bILN to CDS = >5 %, 20'4%,25'-3%,35'-l%, 100%-<l% . UU20' b1IN to CD DISCHARGE 1100' with 182 cons day discharge U( _J10' N0 to NON - PERFORATED PIPE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address: TownNillage Tax Grid # o� 3 160a iDi oc R-'J w—c1f,50-"J Map -2-3, Block Lot(s) ?. Well Owner: Name: Address: Vf')f(boXz..- Vv,- l i l- a. R-oc10 ID 9-1 Ve') i3 �Z S`Te) tJ (3"5-0 Use of Well: Residential Public Supply Air/Cond./Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served �_ Est. of Daily Usage vJ]W Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason 0 1 .. ` S 0 e P LW for Drilling Well Type_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes__ No Name of subdivision M i LL 6UZ D1 Vi-S., o nl Lot No. Water Well Contractor: &lu_ 17!? 1 `44 ed Address: WWA S Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: 0 TownNillage Distance to property from nearest water main: 7 _ Proposed well location & sources of contamination rovided on separate sheet/plan. Date: ?/ Applicant 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 wat w 1 driller certified by Putnam County. Date of Issue Permit Issuing 1 1: Date of Expiration v d Title: Permit is Non- Transferr ble . White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 P. W. SCOTT Engineering & Architecture, P.C. 3871 Route 6 BREWSTER, NY 10509 E -Mail: pws @bestweb.net (845) 278 -2110 FAX (845),278 -2166 TO sic.- WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ LlIl�,lb`a �oI _ V ?� dGVvlg 3 @I F U ° a GJMOVULM DATE l ^ 4 JOB NO. ATTENTIO U/ RE: ` ❑ Samples the following items: ❑ Specifications I I THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS • Approved as submitted • Approved as noted • Returned for corrections ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO I «r k y 't i P.4 03�� $JGNED: H enclosures are not as noted kindly notify us at once. DESCRIPTION ��7�� tom.. .. � .. . .:• .. - _ �C?�1��- fit, .. _ .�r_.._ - A;.s. -_ - _sir =s_ •� -�. � -_ I I THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS • Approved as submitted • Approved as noted • Returned for corrections ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO I «r k y 't i P.4 03�� $JGNED: H enclosures are not as noted kindly notify us at once. 14.16 -4 (2/87) —Text 12 PROJECT I.D. NUMBER 617.21 SEOR Appendix C State Environmental Duality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME u 13 t'b2 -1 tYt 3. PROJECT LOCATION: Municipality -P/k—, -�ra et l_s0-11-i County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 2 3 a �. �z.� (c,�� t2v i� c� P� TCL�Y2•- S e1✓� 4�= . � . i j I 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 7A-0K- A-iJD 4-00 (I ?" Z*° w1,Dc — ,pet4COBS 2. 5` 1;1(.li 7. AMOUNT OF LAND AFFECTED: Initially ��� acres Ultimately �. 3� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ttxYes ❑ No It No, describe briefly t f/ 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? S Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other N � Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY DER STATE OR LOCAL)? Ti C ❑ Yes �No If yes, list agency(s) and permitlapprovals t Z G:s 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yes, list agency name and permitlapproval 5vr'��7�J�S�Cru� �at2�vik� - iT7rZa 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes ONO I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Signature: Date: 2--15-07— - I If the action is in the Coastal Area, and you are a state agency, complete' the I Coastal Assessment Form before proceeding with this assessment OVER 1 CD PART II— ENVIRONMENTAL ASSESSMENT (To be completed by agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) C1. 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. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed 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 (I) 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. ❑ 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 andlor prepare a positive declaration. ❑ 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 AND provide on` attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in LeR Agency Signature of Preparer (if different from responsible officer) Date 2 / — 38e 1 1 1\ � � I i, 1 ♦/ i 1 I // / 1 � •�� {� l \ t r lo, / / / // / i ♦ / ' /'' / (A70) EOTIC TA I \ EX15T. _� - - -- / WELL I I 1 1 c q6 \PROP. \RESIDENCE— _ — -- _ - - -- -- / / ♦ FF.: 458�gp� i 1 F. _ 454.75T� _ -__ -- i i 1---- - - - --- \ (45 ) / 180. SO -1-1 '40) 9 URA /C1 1 , I 1 / /