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The Sum Of "`
❑„ Cash......;,. Check
X%,__101'.
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a
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WELL UUrirLL t 1UV tulruml
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: WN/vt I TAX GRIO NUMBER:
F � , (IVY CD C ;-� i tc �i'c,
WELL OWNER
NAME: ADDRESS:
-- a
c;i CA
❑ PBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED ,2 / EST. OF DAILY USAGE l2 gal.
REASON FOR
DRILLING
NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
0 REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH % A5' ft.
STATIC WATER LEVEL � _f
GATE MEASURED 1 - 1 'mil S
DRILLING
EQUIPMENT
O ROTARY M COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER. (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. C� OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 8— ft.
MATERIALS: 51 STEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED O THREADED ❑ OTHER
DIAMETER in.
SEAL: q CEMENT GROUT 0 BENTONITE 0 OTHER
WEIGHT
PER FOOT /!I lb./ft.
DRIVE SHOE O YES ❑ NO
LINER: ❑ YES ❑ NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GKAVEL PACK
O YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK In
TOP
DEPTH ft-
BOTTOM
I DEPTH ft.
WELL YIELD TEST It detailed pumping
METHOD: 0 PUMPED 1 tests were done is in-
f
COMPRESSED AIR formation attached.
BAILED O OTHER :OYES 0 NO
WELL LOG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Pear-
ing
Well
Oia-
Meter
r-
9
FORMATION DESCRIPTION CODE
tt.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gym.
Land
I
fV
WATER CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
❑ COLORED ANALYZED? BYES O NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK : TYPE U)X ;.I (D {
CAPACITY (9a GAL. (9 61
PUMP INFORMATION
TYPE 4U 11��`� I RAPACITY
MAKER i_1 DEPTH 0 ,
MODEL I VOLTAGE. t; HP
qa-
WELL DRILLER NAME ��i� -�, , uo _ DATE
AooRESS �, j�p) ` ,� v , StGrnfTURE 'C" r
it
PUTNAM CDUYfY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or ,Purchaser of Building Section Block Lot
Building Constructed by
Aled
Location - Street
41 -lee Y m Lart.
Municipality
Building Type
Subdivision Name
Subdivision Lot #
/0 _ 7 � -Z3
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTU4
I represent that I am wholly and completely responsible for the location,
work=ship, 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 DeFaranent 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 inmediately following the date of approval of the
"Certificate of Construction Compliance" for the saiage disposal 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- Director of the Division of Environirental Health Services of the Putnam County
ti,i 1.rc�gt uucul, vL 11cCL11.11 CLZ) t.v wuculc.L WL 11v�. 1.110 1.CL1. -LULC V1 111C JYJL IL l.V VjjC.Ld IC WCL
Caused by the willful or negligent act of the occupant of the bui;4ng utilizing
day of 7 1917-6 Signature
Title
ier"a1�Contractor (Owner) - Signature
o. .
Corporation Name (if Corp.)
_� lVa ,ill fid
Address Pa-tel-5oa, /V Y, 12,5-&3,
rev. 9/65
mk
Address
r
Corp.)
NORTH AMERICAN
nATMRIES31K,
L zmna
LABORATORY REPORT
TYPE: P
LAB ID NUMBER: 95-3625
CLIENT: Paul Talamo
3504 Gomer St
Yorktown Heights NY 10598
SAMPLING LOCATION:
COLLECTED BY:
DATE COLLECTED:
DATE RECEIVED:
DATE OF REPORT:
Upstairs Bathroom Sink: Bridle Ridge Rd, Lot 12
P. Talamo
07/10/95 TIME COLLECTED: 2:00 PM
07/10/95
07/17/95
y_
ANALYTE
RESULT
UNITS METHOD
ANALYZED
Total Coliform
Absent
Colilert
07/10/95
E. Coli
Absent
Colilert
07/10/95
This sample, as submitted to the laboratory, and as compared to the New York State limits
for drinking water quality for the tests performed, was:
✓ 'ACCEPTABLE. . NOT ACCEPTABLE.
447W1
0 u7:141-OmAr.
Laboratory Director
NYSDOH ELAP #11218
CT Lab Approval #PH-0171
Fax
A
!UTNAM COUNTY DEPAMMERr OF MALTS
Dmdm 1 sod& S lo Caal, N.Y.14S12 Blighs. Ir b pa 14- Pall
w CEi1S+ICATE OF CDC
PEtt1101t FOE =WAGE MWOSAL SYST=
o.:esTiA�.e m..e a L�vr+. MA I-to
,,►ate...
nat-c QrihtHvi -,I Annrnved z-. Z-i \�9�
-7 4 93
Town :dry[oh
Tax Mill S 3191 i lat
ReuvwaL—O—Revkhe o
Date d Previous Approval
Town °ter V :.� : a (L'.
�aa F.nr1 nGart ❑ k,..,: —+- ..: > - �
onefts Type Lot Am i .X1.3 • Fm section oab, Dept vala.e
mombw d Bed' Den1Ee Fbw G P D CEO PC® NolMleatiea Is Eegdeed Wheel Fm d a�pided
Selpaea/e SewenW System a con" et [CV0 c.ao. Sepa Talk Jim - Coo t,�F. ors emi oxi
To be o by —ry . (3 V— h diireee
Water swflr. Pedelic Supply Fees• Addnm
ere _PlIvate Supply DOW by C' 91;- I%E �j'eee
Odwr iEaq�be�wta
1 represent that 1 am wholly and. completely responsible for the design and location of the proposed system(s); 1) that the sa rate ,saw di aal' stem
above described will be constructed as shown on the approved amendment there to and in accordance With the standards, rules a squ ions O nam
County Ospartment of l+..ltn, and that on completion thereof a "C"fIII of Construction Compliance" satisfactory to the Commissioner of Hulthwill
be suOmitted to the Departnnnt, and a, written guarantee, Will be furnished the owner, his sltcesiews, heirs or aaiflns by the puilde►, that aid builder will
plece in flood .operating - "Rion any part of said sewage .disposal system during the period of two (2) yeas Immediately following thedate of the iau-
ence of the approval of the Cartilkate• Of Construction Compliance of the Original slam any r M►et0; 2) that the drilled well dps►Iped above
will be located a$ shown on the approved plan and that Paid well l will M' ltA t sta rds, rules and ree—UN o-f Of the Putnam
County' Oafart o wealth.
Date t O�C� ` Signed P.E.'Rr.A. —
' `7p& Addna S" � License No
APPROVED FOR CONSTRUCTION: This approval expires two yeas from the date issued unless construction of the build, inq .has been undertaken and is
revocable for cause or may 'be'amended 'or modified'whon'considered n cesary-b the . Commissioner of Health. Any Charge Or alteration of construction
"Quires anew permit VW2Mpd for disposal of domestic sanitary e, w �ri�r to water wpply only.
Ran.��
10/88 "a- 0Y — Title s
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner } 1..lsvrui. Address 3So �E Ceti- �-�2 55r,
T31Lr x-Le- lZh7 ZO q 1 vS4
Located at (Street) 'IQ rrzc l� W L t_ Mr, _ (jviv \ Sec Block Lot I �o
(indicate nearest. cross street)
Municipality Watershed K --e7V �
Date of Pre - Soaking C I' Ice
Date of Percolation Test e i "-{
HOLE
�iZ
1S
NUMBER
CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water From
Water Level
We
No.
Time
Ground
Surface
In Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop In
Min /In.Drop.
Inches
Inches
Inches
1
.4 -���
r
26 ��
Z
i
2
Iv�3R ii L�q ��
Z4 i�ti
- .�f ���
j,'?S
F7
3
lido II •L!o 3y
,l
Z4
_ zG
1. 7f
1.7
4
30
Z4
- 2�
5
1 to:y� IAA 3`1 3
7-
�iZ
1S
^j
3 1013
4
We
5
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 suimitted
for review.
2. Depth measurements to be made fran top of hole. .
P TNAM COUNTY DEPARTMENT OF EMALTD _
Dldira d Dawkouniatald Hedlh Saltless. Camel. N.Y. low to Pwvl� Ia�ll.
N PSUOT FOR SRWAOE DISPOSAL SYSTMyI[�
,� �i'zl nlar �i (»s K- ell�t7
S.eavw. N�io a'. i D1 c 2 i nL;� r:S MTeS Subd. rot / I
1
Ownof/Ap OkWA Nlaffs Piau1 LAUeA i A Lea V4 0
Tema on:
Tax 11LP 45> Itaotl< ' f.r 1 (19
Rawwa_❑ Rovidw -a
Daft of Pirevba Approval
Town �(c� lZ iCi?Si_:i�� (�TS . zip t v `1b
CC)
Dies Type 9 LL-1 1VA' l t Ara A G - F)R Sectlea OBIT Depth' r V.Ww Z-5 '
Nombot d Ded� DWp Flow G P D Required Whm FM Is aNpbobd
Sopfrala Sew+egp 8�� a oatlalat d .tiC>ti U C.aBon SoPtk Took and � vz.3 L F, n "F l� T5 ���P`ri vu . ) 9v�e�
Te ba,00exlIi%i ad by 1 J29- 12�1- 4111)12 -2 Addwas
WatR Sqppb: Ptiilli Sopi* Fto Ad&m
Other Regdeareanla
1 reprennt -that I am.wholly and Completely responsible for the design and location of the proposed system(s); 1) that the u sate sew di cal s stem
above descritiid will be constructed as shown on the approved amendment there to and in accordance with the standards. rules on*
rpu anf ream
County, DSpsitment " of leulth, and that on completkfn. thereof a .,Cartiflute of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and' a, written guarantee will be furnished the owner, his successors, heirs or assigns by the bulkier, that said bulkier will
gAae.. in food .operating "Man goy, part of said sewage .disposal system during th kxll of ears immediately following the "to of the luu-
ar4o of the approval of the Certificate of Construction Compliance of the origi st W y repairs t o; 2) that the drilled well.described;ebom
w1a be Muted as showw on the approved plan and that islet welt will -0o 1 rda he standards, rules and rpu aliions of tM 1, outnam
County Depart of Ifaaltei.
Date q -1 Signed P.E. R A ,
.
Address ,4 ) 1 ��rL . Z— License No 67
APPROVED FOR CONSTRUCTIONe Thee " approal expires two years from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
requires w permit. Approved for.dispoul of domestic unitary iw !%§N WA private water supply only.
?ev. oae• 2G l er/ /�� /� Title
V/ 00
3Y� 4
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Geneva Road, Brewster, New York 10509
(914) 278 -6130
December 14, 1993
Paul Lynch
103 Fair Street
Carmel, NY 10512
Re: Talamo
Bridal Ridge Road
Patterson
Dear Mr. Lynch:
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Your application has been received by this department on 11/16/93
The application is considered incomplete and the following items must be
submitted.
( Fee should be paid by Certified Check or Money Order only.
( ) Fee is not enclosed or incorrect amount.
Fee due is:
( ) New Tax Map designation should be provided.
( ) Other:
If you have any questions, please contact Robert Morris, ext. 166 or
William Hedges, ext. 168 of this office.
Thank you for your cooperation.
Very truly yours,
Christine Johnson
Intermediate Clerk
Note: Your application has been approved, upon receipt of a Certified Check
or Money Order you can pick up your application.
0
Paul Lynch
103 Fair Street
Carmel, NY 10512
Dear Mr. Lynch:
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Geneva Road, Brewster. New York 10509
(91;, 2 73 -0130
December 14, 1993
Re: Talamo
Bridal Ridge Road
Patterson
.;OHN -(ARE!-I _ _ .. PE.. M.S.
PCo::c Heai :n Jirec :or
Your application has been received by this department on 11/16/93
The application is considered incomplete and the following items must be
submitted.
should be paid by Cartified Check or Money Order only.
( ) Fee is not enclosed or incorrect amount.
Fee due is:
( ) New Tax Map designation should be provided.
( ) Other:
If you have any questions, please contact Robert Morris, ext. 166 or
William Hedges, ext. ?9.8 of this office.
Thank ycu for your ccoperation.
Ilery truly yours,
Christine Johnson
Intermediate Clerk
Note: Your application has been approved, upon receipt of a Certified Check
or Money Order you can pick up your application.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # v
WELL LOCATION
Street Address
t32it� 21D6C
Town V+k
7a y>
Tax Grid Number
zc�+.S S - t - t
WELL OWNER
Name
Mailing Address
'35v 4 6,044VW-
Private
0 Public
USE OF WELL
- primary.
- secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY
O FARM
C3INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
0 ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED 4- /EST. OF DAILY USAGE (.C:t.) gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION 12-ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
DUG
GRAVEL
C]
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL' IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: TS21DL�_ 1p c_F_-f
Lot No. i7_
WATER WELL CONTRACTOR: Name 'r, �• Address:
1 17
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ NO
NAME OF PUBLIC WATER SUPPLY: u A TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: A ,
LOCATION SKETC SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(da e) (signat re)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or grou ater.
Date of Issue: 19—
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
ti
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date �•.� c3v � a�_ Y} Ic(ci7
Re: Property of��� L,�ti,- jjL,Lc�
Located at C3 t&z o _
(T) �j�,�ZLJr?�SC,�j Section S Block Lot C:1
Subdivision of Ra cot,,i_ `R'cP
Subdv. Lot # .Z Filed Map # ate "Z Z -I
Gentlemen:
This letter is to authorize I � �u t- ��'1 _ � rW-C"�
a duly licensed professional engineer 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
system or systems in conformity with the provisions of Article 145'or.
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary C,
Counter
P.E. , ]
Address
Very truly yours,
����Lt�C
�Cl
Signed`
Owner
of Properrt�y
X35 S/ 414,
A/ ee ,k
Address
��FX` ��TOc✓t�
� bti � /(O
Town
Te lephone Telephone
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEK FILE NO.
C weer } Address 'W<3 4
Located at (Street) ALL n r? (�,�t ;s1 Sec. .Block 1 Lot. i
(indicate nearest. cross street)
Municipality Watershed
• • • 71• •• • Y� t • Y• - 9• P �t • XIMU Yet •I •
Date of Pre - Soaking
Date of Percolation Test
HOLE
NL74BM CL=
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
2t_
3
14o&-is-
3
4
5
1. Tests to be repeated
are obtained.at each
for review.
2. Depth measurements to
_, o /Q [
at same depth until approximately equal soil rates
percolation test hole. All.data-to'be submitted
be made from top of hole. .
TEST PIT DATA P3QUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN .TEST HOLES
DEP'T'H HOLE NO. HOLE NO. HOLE NO.
G.L.
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROONDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: <>u ,, n t V 5 r oy DATE:
/ Lii71Vt`1
1" Drop: S
Soil .Rat ed 2 -1 -13 v / P= .D. Usable Area Provided
No. -6f Bedr Septic Tank Capacity UU Zj g Type
Absorption Area Provided By SQL L.F. x 24" width trench
Other ! U. CS l 1 R-�- 5 ��1CHAE((Y 9f
Name- �v� 1 `ft✓c �� Signature
Address ko'3 -7-7109 S-,— SEAL
Fpm 06744
Ivy 4 Z
THIS SPACE FOR USE BY HEALTH DEPARIiENP ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
PC -1
P UT NAM
C OUN TY D E PART M EN T O F H EAL TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: _ -P&ui t., c, & i--C
3 Cc ZA 6 —cl a'Pl S�
2. Name of Project: 3. Location T /VV-e:-
4. Project Engineer: Ps -vim L �wzf� �� -1 5. Address: 0,3 47:'- ►e-
Si
License Number: (a-1 4 rk( Phone: Z2 -S" o�rEA
6. Type of Project:
7 — 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)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted -�K
8. Is a Draft Environmental Impact Statement (DEIS) required? .............
9. Has DEIS been completed and found acceptable by Lead Agency? YL ............L- l \
10. Name of Lead Agency �i�rr►j�s � 4�.utr RD. SugDwtsco
11. Is this project in an area under the control of local planning, zoning,
or other officials, ordinances? ......... ............................:..
12. If so, have plans been submitted to such authorities? ..................
13. Has p•�iaa.ry approval been granted by such authorities? Xf-Ff Date Granted: Z. Z
14. Type of Sewage Disposal System Discharge...... Surface Water Ground Waters
15. If surface water discharge, what is the stream class designat ion ?........ 1)
16. Waters index number (surface) ..... ................ ! l
!7. Is project located near a public water supply system?
8. If yes, name of water supply Distance to water supply
9..Is project site near a public sewage collection or disposal.. system ?.....
0. Name of sewage system Distance to sewage system
,1. Date observed: 17,1D4M23. Name of Health Inspector:
4. Project design flow (gallons per day) ....... . ..............................
('w
W
25. Is State Pollutant Discharge Elimination System (SPOES) Permit required ?..
26. Has'SPDES Application been submitted to local DEC Office? ............... LJ-7111
2T. Is any portion of this project located within a designated- Town or State
wetland ? ............................. t�3Z�
28. Wetland ID Number ......................... ........................ ........ 07Z,
29. Is Wetland Permit required? .............. ...............................
Has application been
made
to Town
or Local DEC Office? ..................
30. Does project require
a DEC
Stream
Disturbance Permit? ...................
31. Is or was project site used for agricultural activity involving application
.of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ........ YES 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:
. kj--u
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? 1�
35. Are any sewage disposal areas in excess of 15% slope? ........................ U-7)
36. Tax Map ID Number ......................... ...............................
37. Approved Plans are to be returned to: ................ Applicant _Engineer
If the application is signed by a person other than the applicant shown in Item 1, the
application must be accompanied by a Letter of Authorization. Failure to comply with this
provision may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this
....form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A. Hisdpoeanor pursdant to Section 210.45 f
the Penal Law.
SIGNATURES & OFFICIAL TITLES: 1`i���+— I�l • �-! (1.�Z -�i{ )� ^ —�.
1 u3- .fit(!? Si V
MAILING ADDRESS:
,�,... •�
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