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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # -- 5-7-
Located at; / 4 � /Q ((�r Village
Owner /Applicant NameLLA.SS ;; _ ii`S,Q Tax Map 13 Block Z, Lot
Formerly ' llw4 Subdivision Name i� h5cyri(/1�
Subd. Lot # 6.1
Mailing Address / W �s T 4ycun ,61 Be,
Date Construction Permit Issued by PCHD
Zip Imo- M
Separate Sewerage ystem built by �'1(_ L� a Address �� VVjP�T 1-6_Lnw L&
Consisting of Gallon Septic Tank and Z. i (D' � J %EJ6 sV,}
Other Requirements:_
Water Supply: Public Supply From Address
®r: Private Supply Drilled b 7 ��� �4
— pP Y y NIa�L. ��LI 1. L 1�1��Gi �nY - Address u�2.F,vJ�s r"� , .
Building Type Q�61& Has erosion control been completed?
Number of Bedrooms Has garbage grinder been installed? TV0
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Per7and ved
plans and the s dards, rules and regulations of the Putnam County' Department of Health.
Date: Z Certified by // �D � . i " A / P.E. R.A.
Address 1 ,o. A ,.►-
License #
Any person occupying premises served by the above system(s) shkf promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject ,to modification or change when, in. the judgment of the Public Health Director, such
revocation,, dificatio r change is necessary.
r //
By: / Title: / Date: V
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
. Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building
Building Constructed by
Tax Map Block Lot
Tow illage
- 4 V, Gvt pe O' �AA Sc 7 i3D t u ►Slot J T
Location - Street Subdivision Name
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 occupa of the ilding utilizing the
system.
7'Wnth 1 �Day Y5' Year 9
Coni factoA,(gwner) -
Corporation Name (if corporation)
Address:
State Zip
Signature:
Title: 6�
hr
Corporation Name (it corporation)
Address:
State
Zip
Form GS -97
• PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
Ridge View Road
Town/Village:
Patterson, NY
Tax Grid #
Map Block Lot(s) 36
Well Owner:
Name: Address:
Classic Homes & Development, Brewster, NY -Alan Finn
Use of Well:
1- primary
2- secondary
xxx Residential Public Supply Air cond/heat pump Irrigation
Business,' Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion XXX Compressed air percussion Other (specify)
Well Type
Screened Open end casing xxx Open hole in bedrock _ Other
Casing Details
Total length 45 ft.
Length below grade 44 ft.
Diameter 6 in.
Weight per foot 19 lb /ft.
Materials:xxx Steel _ Plastic _ Other
Joints: _ Welded xxx Threaded _ Other
Seal: xxx Cement grout _ Bentonite Other
Drive shoe: xx 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 xx Compressed Air
Hours 6
T Yield6 e 5 gpm
Depth Data
Measure from land surface- static (specify ft)
Overflow
During yield test(ft)
200
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
10
Soft limestone
10
365
Medium to hard white limestone
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
220.
2
Pump Types ubmersi Oapacity 5
Depth 200 Model 5GS05
Voltage 230 HP •1' /,Z
r
Tank Type aiaoragmVolume 62
inn
3
365
.6,5
Date Well Completed
1.1/1.0/98
Putnam County Certification No.
2
Date of Report
1.1/12/98 1Z471
Well
1 "1
NOTE: Exact location of well with distances to at least two permanent landmarks to be Vovid6d on a ftfi V Sheet/plan.
Well Driller' me M L RILLING, INC. Address75 Putnam ,.Avenue, Brewster, NY
Signature: f%. Date: 1.11y2198
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
.�
NORTHEAST LABORATORY OF DANBURY
CT Cert: PH -0404
39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471
LAW (203) 748 -7903 - FAX (203) 748 -0652
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC. DATE SAMPLE COLLECTED: 11/10/98
75 PUTNAM AVENUE TIME COLLECTED: 1:30 P.M.
BRESTER, N.Y. 10509 COLLECTED BY: ROB MILL
DATE RECEIVED @ LAB: 11/10/98
TESTED BY: LAB #11471 & 11301
REPORT DATE: 11 /17/98
SAMPLE SITE: AL FINN - CLASSIC HOMES, LOT #36, RIDGEVIEW RD,. PATTERSON, N.Y.
SAMPLING POINT: TOP OF WELL
SOURCE: WELL -NEW
TREATMENT: NONE
TEST PERFORMED RESULT: MAXIMUM CONTAMINANT LEVEL
BACTERIAL:
Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml
PHYSICALS:
pH 8.06 no designated, limit
Turbidity 18.0 NTUs 5 NTUs
CHEMISTRY:
Nitrite N 0.07 mg/L as N l mg/L as N
11301 - 'Nitrate N 0.03 mg/L as N 10 mg/L as N
Alkalinity 84.0 mg/L no designated limits
Hardness 86.0 mg/L no designated limits
Iron 0.666 mg/L 0.30 mg/L
Manganese 0.048 mg /L 0.30 mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
Sodium 7.6 mg/L 20 mg/L **
Lead <0.005 mg/L 0.015 * **
m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units
* *Notification Level ** *Action Level
RESULTS BASED ON SAMPLES SUBMITTED: 11/10/98
SAMPLE, AS TESTED ABOVE: ❑ or CkOT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105. OUTSIDE CT: 800 - 654 -1230
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Street Location `tT.>,-,- Vj C tA1 '[jjztvE
Torn
TMr_
Date: Qg
Inspected by: e
ONvner 19',0A 12.A
Permit# F— 6-7-13
Subdivision Loth
L Sewage System Area
a. STS area located as per approved plans ...........................
b.' Fill section - date of placement
3:1 barrier Lgth. Width Avg.Dptli
c. Natural soil not stripped ................... ...............................
d. Stone, brush, etc., greater than 15' from STS area..........
e. -100' from water course / wetlands ...... ...............................
II. Sew- 0'e Svstem -
a. peptic tank—size - 1,000 ...... ;:.1, 250 .! ...... other ................
b. Septic tank installed level....`,,......
..........................
c. 10' minimum from foundation .......... ...............................
d. Distribtuion Box
1A� oufl utlets at same elevation -water tested .................
2. Protected below frost .................. ...............................
3. Minimum 2 ft.Original soil between box & trenches
Junction Box - properly set ..................... ...............................
ength required 7 Length installed s
2. Distance to watercourse measured+ZGo Ft..........
3. Installed according to plan ......... ...............................
'4. Slope of trench acceptable 1116 -1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface..................
7. Room allowed for expansion, 100% ..........................
8. Size of gravel 3/4 - 1 %" diameter clean ....................
9.. Depth of gravel in trench 12" minimum ...................
10. Pipe ends capped ........ ...............................
................
g. PUMD or Dosed S :stems
1. Size ot 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. House/Building
a. ouse locatEd per approved plans ... ...............................
b. Number of bedrooms ... .................. .q... ........
IV. Well xu up-modfr
a: Well located as per approved plans . ...............................
b. Distance from STS area measured t lo o ft..:........
c. Casing 18" above grade .................. ...............................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box ... ...............................
d. Backfill material contains stones <4" diameter ..............
e. Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dir.to exist watercoursf
g. Footing drains discharge away from STS area...........
h. Surface water protection adequate ..............................
ig
i. Erosion control provided ................................................
YES
NO
COMMENTS
X
LOW
X
�C
X
d--
DMSION OF ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION C,OMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # /0— 57
Located at --T-� C � To or Village Rn-EMSOA) � & Al I ,
Owner/Applicant ant Nam -- Tax Map Block Lot
i r
Formerly_ /� Subdivision Name
Subd. Lot # —3%
Mailing Address
Date Construction Permit Issued by PCHD ..5-
Zip
Separate Sewerage system built byj�_ dry �f /il,� Address foAD h2&
Consisting of L J Gallon Septic Tank and 57 -- Z-, g Z7 Z Z2go, % e,y
Other Requirements:
Water SuVI14: Public Supply From Address
or: Private Supply Drilled by Address 715 5� �
J
Building Type 2-455 i jor.611�. Has erosion control been completed? _
Number of Bedrooms Has garbage grinder been installed?
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the st#ndar(J9, rules and regulations of the Putnam County BWaoi pnt of Health.
Date: L �1Certified by
Address �f% 130 � 1Y �/�6
Any person occupying premises served by the
P:E. l
License #
4-5-5-
s) sW 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 ai ubject to modification or change when, in the judgment of the Public Health Director, such
revocation, mo 'ficatim hange is necessary. A 111f� 2B °'u/�-� Title: ' � G�CL Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
v PUTNAM COUNTY DEPARTMENT OF HEALTH'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
Ridge View. Road
Town/Village:
Patterson, NY
Tax Grid #
Map Block Lots) 36
Well Owner:
Name: Address:
Classic Homes & Development, Brewster, NY -Alan Finn
Use of Well;
1- primary
2- secondary
XXx Residential Public Supply Air cond/heat pump I.rrigation
Business Farm Test/monitoring Other(specify)-
Industrial Institutional Standby
Drilling Equipment' .
Rotary Cable percussion XXX Compressed air percussion Other (specify)
Well Type
Screened; Open end casing xxx Open hole in bedrock . Other
Casing Details '
Total length 45 ft.
Length below grade 44 ft.
Diameter 6 in.
Weight per foot 19 lb /ft.
Materials:xxx Steel Plastic Other
Joints: _ Welded xxx Threaded Other
Seal: xxx Cement grout _ Bentonite Other
Drive shoe: xx Yes _ No
Liner _ _ Yes _ No
9
:}
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
Bailed Pumped xx Compressed Air
Hours 6
Yield6.5 gpm
Depth Data
Measure from land surface -static (specify ft)
Overflow
During yield test(ft)
200
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
10
Soft limestone
10
365
Medium to hard white limestone
If yield was tested
at different depths
during drilling,
list:
Feet.
Gallons Per Minute
Pump /Storage Tank Information
220
2
Pump Types bmers i KNpacity 5
Depth 200 Model 5GS05
Voltage 230 HP 1/2
Tank Type Dia-phragmVolume _ 2
ion
3
365
6. 5,
Date Well Completed
11/10/98
Putnam County Certification No.
2
Date of Report" . ..
1,1 /1:2/,98
Well
i,%v i r.: cxact <ocanion of wen with atstances to at Least two permanent landmarks to ne provtaeu on a separate sneevplan... .
Well Driller' 1441- BILLING, INC, Address75 Putnam Avenue Brewster NY
Signature: f, Date: 1111219
/ F 8
White copy: HID File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
s
1
i
NSA
4VIV
NORTHEAST LABORATORY OF DANBURY
CT Cert: PH -0404
39 -3 MILL PLAIN ROAD DANBURY, CT 06811 NY Cert: 11471
LAW 1 (203) 748 -7903 - FAX (203) 748 -0652
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING,` INC. DATE SAMPLE COLLECTED; 11/10/98 & 12/16/98
75 PUTNAM AVENUE TIME COLLECTED: 1:30 P.M.
BRESTER, N.Y. 10509 COLLECTED BY: ROB MILL
DATE RECEIVED @ LAB: 12 /15/98
TESTED BY: LAB# 11471 & 11301
REPORT DATE: 12 /16/98
SAMPLE SITE:
AL FINN - CLASSIC HOMES, LOT #36, RIDGEVIEW RD,. PATTERSON, N.Y.
SAMPLING POINT:
TOP OF WELL
SOURCE:
WELL -NEW
TREATMENT:
NONE
TEST PERFORMED
RESULT:
MAXIMUM CONTAMINANT LEVEL
BACTERIAL:
Total Coliform (Bacteria)
0
per 100 ml
0 per 100 ml
PHYSICALS:
pH
8.06
no designated limit
12/16/98 Turbidity
0.46
NTUs
5 NTUs
CHEMISTRY:
Nitrite N
0.07
mg/L as N
1 mg/L as N
113 01;- Nitrate N
" 0.03
mg/L as N
10 mg/L as N
Alkalinity
84.0
mg/L
no designated limits
Hardness
86.0
mg/L
no designated limits
12/16/98 Iron
<0.03
mg/L
0.30 mg/L
Manganese
0.048
mg/L
0.30,mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
Sodium
7.6
mg/L
20 mg/L**
Lead
<0.005
mg/L
0.0151***
m1= milliliter mg/L = milligrams per Liter
ND = none detected NTU =Units
* *Notification Level
** *Action Level
RESULTS BASED ON SAMPLES SUBMITTED: 11/10/98
SAMPLE, AS TESTED ABOVE: MOTABLE or AMNOT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
-NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
i n
Owner or Purchaser of Building
r
0 Ah
Building Constructed by
Locate n - Street
l3 1 21
Tax Map Block Lot
A,�64 (-< 6-VN
Town/Village
Subdivision Name
PCs: 11CL11d
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 dct 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 occupagt -Gkhe building utilizing the
system. . •� 2�.�,
Dated: Month 10 / 6� Year
General Contractor (Owner) - Sigria e
Corporation Name (if corporation)
Address:
State 4 Zip _ /o
Signature:
Title:
Corporation Name (if corporation)
Address: Iva
State Zip 10 S701
Form GS -97
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.Date ",2
Re: Property of zqG 6J.5 0
Located at <D��' j/���.✓ ��i�E
Tom/.
(T) /�.¢77�.�So -✓ Seri -ems l 3 Block Lot g
Subdivision of Q
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize S%�'✓ °s�� ��'9�%
a duly licensed professional engineer for r
(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 Code.
Very truly yours,
Signed
Countersigned: ��'I Owner Property
P.E. , R.A. , # ;711 lr_93S, 7
Address
RO, 13&-,-e- 2-V3
Address Town
��..
Telephone
I/ c/ - g;, ?K- y-� sy
Telephone
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! \71 1.87 AC. 9 Z!u+�� ,11.1e 30 44; ery 661.76 a At
1p. T 2 y ' • >'
12 'N Qe 11 !�v �0 ti°°9° $4 i ii aAC:cpttiaw ` �.� ,6' t • 1.26 ' " p 12 n
13 - ' -3r� i j t° 92 coat ° 78 AC. 6
Is.2 3.36 A 2.06 AC. "egt . ?�5.0�9'AC, v° 06� � 1. J 79 1.6e
zo2AC• ;5.41 AC. 5 r5 30°. o ,, j9: 54 P 26.75 AC.'
Il r 2` sz9 z6 y • >� laze /� m 55 7 6.21 AC. CAL. A
• `96 0. 1.71 Ac.
8 3:° �C AC. I
6 88 AC. v
is, 409? 61456 ` i , Aq 2.45 AC. CAS. 290.65 ¢ 2j1,p0 �... I _
366.56•' i tern
5.24 AC'' • o^ •1.4` A 9 d
15.4 10.3 B0T.94 •- 2 a 57 Q '� 23 I f
L93AC 2.oeaC ° 5.59 AC. 1� ?' \1 °` '
622.89 1- a� ,/. W
\,04.69 AC. t�s �`o 27.52 ACl uz.sp Zb:�4,r" e
25 a 1.49 A6. 9 3
J • f �\ 4.95 AC, j50' 59 X ':1 01.1%
/ �g001 .96 AC 15 2 \ " g
,9 24 '
CA 611. c './ ,h I a 600.00
�• / �a 13
5.35 AC. CAL. a \ 57 5
a
/ 171.04 e
/ / \ v ¢ sip.i•612 o O 58 6.49 AC.
2.0 AC. O ` I N t �i wl3 1, 163 .;
163.20 V
/ / y 61,1 O JAW 41x6) I
167.0 ^
7.47 AC. Mu.n _ 59
19x.1 e
•T• 40NF -
5 • � 1s l 21 � I � 21.97 AC.
AC CAL. � 93.45 is
IC3.86 . ° S Z 150
150 m 6�
1
20.e9AC. 20 '
, ' 1. C I ti e
/ J \ 4.73 AC.
)4x..7 I
/..� •-- �.../' .� N4` ' 665.00 402.35 -•� .
90662 � I
\ 19.86 AC. 18
I r \ 19 2.06'AC.
I I •` . � txn 217,02 ' / ? •
I.00 r
I I 1 1 ID 18.92 16.64 AC. 'ts9faAC. - 1.00 actl I ` 63 �e3m6
4 ` �,�' �'o, ACAL. N"o 16 19 6 I 115.71 A aMal 05.
11 , ` d 1/73 101 G •t G- { a tue
\ 83.92 AC. CAL. 4x4 zz F
I l / \ 63 /�° 1.77 ACS t eer 0 ✓'`,1
11,10 AC. CAL. ) 14
1.831 AC. 1
1 1 .85 AC. 64 t3l 3 ACC 1'Rc
1 �a �
10, 58 AC. CAL 1.59 AC.
11 1116.fit) Q 1068
e .✓ 12 1
st
1
2.35
3.1 �0 9.78 AC. MI-11' 12S $ I
11
18.88 ac. \ J 66 2 AC.
35 6610
11 \ 3°9.42 r"•+ N e QC•, \ !•�
6.82 AC. CAL.
11 1. 31.73
/ �. i / I ' • teiC% zid 66C. 2.1 AG 8 °
/ . y, I• 41.2 AC. r 377.30 � ,L' t/
\ 14.57 AC. CAL. 5 'c �. P tai. 8 t, y a� ^1 r. ii At.
'& 2. I A.C. r,2, ff� 1.15 AC. ;' I
- �
Ado@
BRUCE R. FOLEY
Public Health Director
DEPARTMENT OF HEALTH
Division of. Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
December 16, 1998
Shawn Daly
P.O. Box 418
Shenorock NY 10587
Re: Proposed SSTS:
Classic Homes
Ridge View Drive, Lot #36
(T) Patterson
Dear Mr. Daly:
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) Water analysis indicates turbidity and iron exceeds States standards. It is
advised that the system is flushed and the water re- sampled.
3) Property metes and bounds are to be provided.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Ve ly yours,
Robert Morris, P.E.
Public Health Engineer
RM:tn
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278 - 7921
Sean Daly_
Box 243
Shenorock, INew York 10587
Dear N.-Ir. Daly:
BRUCE R FOLEY
Acting Public Health Director
November. 3, 1997
Re: Proposed SSDS: O'Hara
Lot 36
(T) Patterson
Review of plans and other supporting documents submitted at this time relative to the above -
captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard."
"You are referred to Article 128.1 of the official compilation of Codes, Rules and regulations of
the State of New York, Title 10, relative to'the need for approval of individual sewage disposal
systems by the City of New York. You should contact city Officials in this regard."
1) Engineer's Authorization has not be signe�by e
Trench cover is to be noted as geotextlte
-/3) Erosion control measures are to be shown and detailed for the house well and SSDS.
,/Furthermore, a note is to be added stating all erosion control measures are to be installed prior
to the start of any construction.
✓) Plan has not been signed and sealed by the design engineer.
✓5). The location of the SSDS and the proposed well on Lot 37 is to be staked by a Licensed
Surveyor prior to the installation of the SSDS. This is to be noted on the plan.
Upon receipt of a submission, revised to reflect the above, this application will be considered
further.
Very truly yours,
�h,vll /&W
Robert Morris, P. E.
Public Health Engineer
>;Livmh
watershed
i%
-v VI J;C
Slttbdhlra� Nine O Let
OwedA�ierrt NOM � � 1 ;l '
1y�e '.Lot ,fie, kC= pip Sedlou peg Vaame
Nober d Heioems DealSb Flow G P D 0 �J FCHD NoMidled b l:agdhed When FM Is esmpleled
«*' S"Waf Senerep $yme m to bas" d :(m, o
- T� be oer4taebd • F�'a � .
Witter SplJt. Ftdllk SepI±tie� „ - .. Addssaa
des' � ifFeh�'s �:De®ed by �• � t �� — Addlew: ,
Ober Retemaltb
f rtp►eant that 1 am wholl and.eomDNtHy responsible for the dasgn and location of `the P►ot►ot�d systems) 1�, that the separate saw di tai s Item
i
above desrcritMA will be'eonstruetad at shown on the jipproved amendment then to and in, accordance wiWthe standards, rules a rpu of o nine
county. DepiftTMt of Nrllt, and thaf_ on compNtion thereof a 'Catificat or Coestruction Comolianu Ytisfactwy to Ma''Commiuione► of MwKhwill
a apbrnitted ao .thh. Depar raw irid r wiitten,•,ouaranti will be, furnished ,tM owner hif.succe, - heNS or as q.iy the butWa►. that said builder will
olaee in .gooe Operitinp Condition any!oart of ,raid »vra4e dispowl sy8!!u durirp A 0 perioA: of tvvo (2) yeais,l" ateiy'followinq the date of the Isatl-
f t11i epprovil of the.iCertifkate "of Coni iiiction.:como4iice o /.tha agmaP,'fysteioor an r Mains ther o the Aihied well'desciibed above
win be located as shat- on the aOproved; pMn and.tMt. said well wi11,M.lnstal in 'atco p: wit M sta Y N nd rqY a�iiOnf 'Of the Putnam
county Oegit of; Ith.
F � .
Date ,.A !�; y� n
Sid P.E.
Address T� license No
APPROVED FOR CONSTRUCTION This appioval expires two years :from the date isfued unNSS construdIon of he building .has been' undertaken and is
revocable foi,au", w may Oe:aenende0 of mOdifiod 'whenconsideied;necessary,by tha' :Commissioner of MNlth. Any change or alteration of construction
re0uhes a new per it: Approved for dit�po-s I*of domestic sanitary se —w r only." ,
REV. OaN� ^'� By .• / Titli?�i
10/88" �''
-s.
M1}n�3.�� ^..- ^-�.ik
•� —.' -f ,�.. ,. i.\
.fi:-.. : -•_. . }S�{ >.: ti„ly ^•4L» - '�'+,'�.��sm F. - _ ''"�f T' � ..
w IDTNM[OEPA�lH
DbYCDY DO'
dDtn[twraa�W Ha�Ih Salr�ba. Ca�1. N.Y 1�SU,�a� C �GTB OF 00�l�ANCS
FOIR SNWAGE.01 IOSAL SYSTM
-
-v VI J;C
Slttbdhlra� Nine O Let
OwedA�ierrt NOM � � 1 ;l '
1y�e '.Lot ,fie, kC= pip Sedlou peg Vaame
Nober d Heioems DealSb Flow G P D 0 �J FCHD NoMidled b l:agdhed When FM Is esmpleled
«*' S"Waf Senerep $yme m to bas" d :(m, o
- T� be oer4taebd • F�'a � .
Witter SplJt. Ftdllk SepI±tie� „ - .. Addssaa
des' � ifFeh�'s �:De®ed by �• � t �� — Addlew: ,
Ober Retemaltb
f rtp►eant that 1 am wholl and.eomDNtHy responsible for the dasgn and location of `the P►ot►ot�d systems) 1�, that the separate saw di tai s Item
i
above desrcritMA will be'eonstruetad at shown on the jipproved amendment then to and in, accordance wiWthe standards, rules a rpu of o nine
county. DepiftTMt of Nrllt, and thaf_ on compNtion thereof a 'Catificat or Coestruction Comolianu Ytisfactwy to Ma''Commiuione► of MwKhwill
a apbrnitted ao .thh. Depar raw irid r wiitten,•,ouaranti will be, furnished ,tM owner hif.succe, - heNS or as q.iy the butWa►. that said builder will
olaee in .gooe Operitinp Condition any!oart of ,raid »vra4e dispowl sy8!!u durirp A 0 perioA: of tvvo (2) yeais,l" ateiy'followinq the date of the Isatl-
f t11i epprovil of the.iCertifkate "of Coni iiiction.:como4iice o /.tha agmaP,'fysteioor an r Mains ther o the Aihied well'desciibed above
win be located as shat- on the aOproved; pMn and.tMt. said well wi11,M.lnstal in 'atco p: wit M sta Y N nd rqY a�iiOnf 'Of the Putnam
county Oegit of; Ith.
F � .
Date ,.A !�; y� n
Sid P.E.
Address T� license No
APPROVED FOR CONSTRUCTION This appioval expires two years :from the date isfued unNSS construdIon of he building .has been' undertaken and is
revocable foi,au", w may Oe:aenende0 of mOdifiod 'whenconsideied;necessary,by tha' :Commissioner of MNlth. Any change or alteration of construction
re0uhes a new per it: Approved for dit�po-s I*of domestic sanitary se —w r only." ,
REV. OaN� ^'� By .• / Titli?�i
10/88" �''
-s.
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 -�
WELL LOCATION
Street Address
, — VQ
To Village City Tax Grid Number
i_qz_;- . - 1- -A,-i 7 a oz--,�- ' i';�7 -
WELL OWNER
Name -
Mailing Address private
D Public
U E OF WELL
1 primary
- secondary
QJ�IDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION 0 OTHER (specify
C3 INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT !�F___gpm /4i PEOPLE SERVED_ /EST. OF DAILY USAGE L&13 Sal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY
&NEW SUPIPLY (NEW W LLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
[3.DeILLED
DRIVEN DDUG 0GRAVEL 0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES �N0
WELL IS LOCATED,IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name ""�v Pte. (_ Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES C._iO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
EDARATE SHEET
(date) s
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 anner as not to degrader otherwise contamin a surface or groundwater.
Date of Issue: 19_�'�
Date of Expiration 19j� ' Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
LOT 36 MI-I -1 COUt11'Y INTARU• EM of HEAL111
'SECT I,ON 27 DIVISION OF I.11V.I11QI•1CNM 11111L'111 SUIVIM
DGSIGu
U11rA SIIEEr- SUQSUEACC
SEWAGE DISPOSAI, SYS TH
FMC 110.
Owner
PETER 0' HARA
Address. P.O.
BOX 282, PATTERSON, NY
Located at (Street) _ B.OUTE 311 /CROSS ROAD See. _10 Block 2 Lot 11
(indicate nearest cross street)
I-Ulicipality PATTERSON Watershed - CROTON
SOIL PEIMLAnCN MT DATA PBOUIM TO BE SU 3UIIFD Wl1II APPL ICKCIONS
Date of'Pre- Soaking 9/14/88' Date of Percolation Test 9/14/88
MOLE
11:28- 11:46
18
Ilt MER CLOCK TIME
PEROOLTMON
FF1100LATIM
Run Elapse
Depth to Water Fran
Water Level
No. Tine
Ground Surface
In Inches Soil Rate
Start -Stop Min.
Start Stop
Drop In Hin /In Drop
24
Inches Inches
Inches
1) 1 11:, 29 -11:59 30 24 '26 2 15
2 11:59 -12:29 30 24 26 2 15
3 12:29 -12:59 30 24 26 2 15
A
5
2) ],
11:28- 11:46
18
24
27
3
6
2
11:47 - 12:05'
18
24
27
3
6
3 12:05 -12:23 18 24 27 3 6
4
1 r1, LES 1 16
2.
t.�v. 9/05
Tests to be repoabA at same depUs until approximztely egttil coil rtes
are obtaino3 at eadi percolatim tr_.rt Dole. All data to' Ir_ subRittecl
for review.
Depth nr_a.surumnts to be mx3e Fran lop of bole.
1 ,
E
8
E
�
n
Q!�
/ lib,
3
/'f'c VAA.
C 3
A
1 r1, LES 1 16
2.
t.�v. 9/05
Tests to be repoabA at same depUs until approximztely egttil coil rtes
are obtaino3 at eadi percolatim tr_.rt Dole. All data to' Ir_ subRittecl
for review.
Depth nr_a.surumnts to be mx3e Fran lop of bole.
1 ,
E
8
O'NARA SUBDIVISIOt
'1'E �'1' 1'1'1'_UlYl!A Itt)JU.l ll11) 'lU 13C sunt- J -ma) 111'111 11l'l'Ll(W1'1.Ut l
SECTION 2
L)ESCIUl1r.10N OF SU1l.S 114COU1J1'1's ul) Im 'l.mr flour
1ka'll l How. t40. 3 6 A I IOLC 140. 36-8 110111; I )J .
36"
42"
/4811
54"
60"
66"
72"
78"
04"
TOPS IL
BROWN
GRAVELLY
'LOAM
w /SILT
f
11 1DICA1m LEVEL AT WuIQt GEZOUNUA I m IS Er1000w=FD None
111UICAIE LEVEL m wuat WATER IMM RISES AFM DEM FNJL7UNMMEO N/A
DEEP DOGE 00SMMTICUS WE 8Y: J. F. E 8 E R L E DATE: 916188
DESIGN 75D0
Soil Rata Used 16 HUVJL" Drop: S.O. Usable Area Provided
._.+..�� P. M I C!y 1-
t lo. of Dedrocm ; 4 Septic Tank Capacity 1:288 - . gals. M
Absorption Area .Provided Dy 571 L.F. x 24" width trends
Outer Alt. 'Design or Dosing Required
li A.
tlauk3 BALDWIN & CORNELIUS, P.C. Signatu%ef � -.
:a:
ft
10dress R0 5 . Route 22 _ SCAG °° ' ,1980
• Brewster. New York 10509 �OfESSi0N���
11115 SPACE LUII USE DY 11 AM11 DEPAtil1•IMIr ONLY:
0.
Soil Rate Approved sq.fk;/gal. Checked by Ual.•e
6"
TOPSOIL
12"
113"
BROWN,
24"
STONY
30"
LOAM
36"
42"
/4811
54"
60"
66"
72"
78"
04"
TOPS IL
BROWN
GRAVELLY
'LOAM
w /SILT
f
11 1DICA1m LEVEL AT WuIQt GEZOUNUA I m IS Er1000w=FD None
111UICAIE LEVEL m wuat WATER IMM RISES AFM DEM FNJL7UNMMEO N/A
DEEP DOGE 00SMMTICUS WE 8Y: J. F. E 8 E R L E DATE: 916188
DESIGN 75D0
Soil Rata Used 16 HUVJL" Drop: S.O. Usable Area Provided
._.+..�� P. M I C!y 1-
t lo. of Dedrocm ; 4 Septic Tank Capacity 1:288 - . gals. M
Absorption Area .Provided Dy 571 L.F. x 24" width trends
Outer Alt. 'Design or Dosing Required
li A.
tlauk3 BALDWIN & CORNELIUS, P.C. Signatu%ef � -.
:a:
ft
10dress R0 5 . Route 22 _ SCAG °° ' ,1980
• Brewster. New York 10509 �OfESSi0N���
11115 SPACE LUII USE DY 11 AM11 DEPAtil1•IMIr ONLY:
0.
Soil Rate Approved sq.fk;/gal. Checked by Ual.•e
��r> st�.. ° i7.: ai ,�• rxx^ °n�`^ �,i._ _ <zrnr> 2' :" i,t, =,^- n. r^^a• a t 9' .. fi.: m. ry•�- f t� K `-•. .M.
�• _ �T .,
�' Q 1pTNAM 00DlR'11' DEPARTAUM OF HEALTH a y
T . /a.l �G ` DNIi� d BnYrssN�l Sa�loeo. Gitel. llY 14612 .� Fwvidi lw�lt 1
^ J/'
as CEaTHaCATB OF
Rev.
10/88
S�nM $ewer S7�.ta;owit d�GoBara,S�pAc Y'oek � - = Z � �' 1 i Gtr•,[ -i'l
Te, be enpftwoeod by Address
WSW S"Ors ✓Fite S Iy Addren
n a..e. saippitr DdRed by adirew
County
be, VAM
Dim in
ance of
WHO be k
APPROVED FOR COI
revouble for cause, or
requires a new ;permil
that ,the separate uw di sal t stern
rdt; rules a rpu n} o na
Ktory to the Commis"ner of Health will
signs by, thra builder, that Yid. builder will
inma0ia t•hy following thedete of the taw-
o; ) that the drilled we 11 g wit" 06-
s and rqu slalomof 1M Putnam
e% . P.E. _ R.A.
of the building .has been undertaken and is
Ith. Any change or alteration of Construction
only.
.Title .
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130 _
APPLICATION TO CONSTRUCT A WATER WELL �f
PCHD PERMIT #/
WELL LOCATION
_ Streetli&ddress
'— VjnA
Qtawh
4E
7Village/City Tax Grid Num er
�J '
WELL OWNER
Nam;
d
Mailing
, ID-2P_>oX Z,6
Addre ivate
O Public
U, E OF WELL
1 L primary
- secondary
G 4dfiDEN,TIAL
D BUSINESS
D INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT t.— gpm /f/
13 RgPL ACE EXISTING SUPPLY
LI'1fEW SUPPLY DWELLING )
PEOPLE SERVED & /EST. OF DAILY USAGE &oo Sal
O TEST /OBSERVATION GI ADDITIONAL SUPPLY
D DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DMILLED
DRIVEN
[]DUG
[3GRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES C-90
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:. d::
Lot No.
WATER WELL CONTRACTOR: Name �";'�3 a'� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES '--"CIO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
SEPARATE SHEET
(date) (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
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 contami ate surface or groundwater.
Date of Issue • �� 19
Date of Expiration 19 5 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
Date 1 I �!f I g-,t>
Property of
Located at
(T)G�- t•Tj�. Sege Block p .
Lo,t
Subdivision of
Subdv. Lot # _Filed Map., # i ?jZPC> E Date
„,t:.
T. MICHAEL DA�.Y, P.E.
X.
Gentlemen: .`'`�• ..,.
CONSULTING ENGINEER
P. 0. BOX 243
This letter is to authorize SHENnR(1('K. N y 1(1587
a duly licensed professional engineer '✓ or
(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_pnd to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
s .
147, Education Law, the Public Health•Law; and.ttie Putnam. County Sani-
tary Code.
Very truly yours,
n e d <�r
Countersignes�* Owner of Property
P.E., R. A. # `Z Address
T. MICHAEL DALY, P.E.
Address Town
P. 0. BOX 243
SHENOROCK, N. Y. 10587
Telephone —
Telephone
r1---L
PUTNAM COUNTY DEPARTMENT OF HEAY.TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: C)% NA A.
2. Name of Project:
4. Project Engineer:
6.
7.
License Number:_
Igoe of Project:
Private /Resident
Apartments
Office Building
Is this project subject
Type Status (Check One)
•
r�
t., LocatAondVV /C
*ddres; VDC Y,
7 F-1 C�il.l lU:
-o5-o-
ial Food Service Commercial ,
Institutional Mobile Home. Park
Realty Subdivision O.t'Ker (specify) _
to State Environmental Quality Review (SEAR)?
Type I.. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? ................ KIA
9. Has DEIS been completed and found acceptable by Lead Agency? •.........�r, JAN
10. Name of Lead Agency
1 11.
112.
Is this project in an area under the control of local planning, zoning;
or other officjal's, ordinances? ........... ..............
If so, have plans been submitted to such authorities ?. ...:.:. o
13. Has preliminary approval been granted by such. authorities? Date Granted:
14. Type of Sewage Disposal System Discharge.'�YYF> 6yOF, Surface Water Ground Waters
15. If surface water discharge, what is the stream class designation ?........ _
16. Waters index number (surface) ..
7. Is project located near a public water supply system? ..................
8. If yes, name of water supply — Distance to water supply
x ,
9. Is project site near a public sewage collection or dlspo.pal system ?.....
0. Name of sewage system Distance to sewage system _
1. Date observed: 23. Name of Health Inspector:
4. Project design flow (gallons per day) .......... ...............•••••
2.
25. Is State Pollutant Discharge ElirRinati,on System (SPDES) Permit required ?.. �
26. Has SPDES Application been submitted to local DEC Office? ...............
27. Is any portion of this project located within a designated Town or State ,` U
wetland ? ......................... ... �1
28. Wetland ID Number ...........::.. .:.� :.,,... '
29. Is Wetland Permit required? ......................... ....... .
Has application been made to Town or Local DEC.Office?
b
30.' Does project require a DEC Stream Disturbance Permit? .................
31. Is or was project site used for agricultural activity involvingg'application
of pesticides to orchards or other crops, solid or hazardous waste disposal, +,
landfilling, sludge application or industrial activity? ......... YES -or NO 1J
32. Is project located within 1,000 feet of existence of abandoned landfill l,
hazardous waste site, salt stockpile, landfill, sludge disposal site °or
any other potential known source of contamination? ..............YES'or NO Nell
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ...........
34. Are community water, sewer facilities planned to be deve:lopeo within 15.years? b
35. Are any sewage' disposal areas in excess of 15% slope? .:......................
36. Tax Map ID Number ......................................
37. Approved Plans are to be returned to: ................ Applicant '_Enginee`ir
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 informat ton provided on this
form is true to the best of my know ledge and be 1 ief. Fa Ise statements made
herein are punishable as a Class A Misdemeanor pursuant_. o Section 214.45 of
the Pena 1 Law.
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS:
1 24'
T. MICHAEL DALY, P.E.
BOX 243 SHENOROCK, N.Y.
4 BEDROOM COLONIAL
5 I NGLE FAMILY RESIDENCE
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