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Home My WebLink About0496DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 14.19 -1 -8 BOX 6 YOM !7- ., IN a To i 'o L :r ILL I 00305 i PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVIC YES , Internal Use Only ❑ D Repair Permit issued in last 5 years ❑ . ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION VJpale� } Its Ate TOWN Pa+rscn OWNER'S NAME MAILING ADC APPLICANT \Cr V _'��' LJ Not in Watershed ❑ Delegated ❑ Joint Review TM #14eiq._l---�g NFM Name & Relationship (i.e., owner, tenant, contractor) DATE 6 -1?:�- I I FACILITY TYPE PCHD COMPLAINT # /db- /) -/ PROPOSED INSTALLER mml r or) _PHONE # '?h3- 3yt -ZZW ADDRESS REGISTRATI N /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree to the conditions stated on this form SIGNATURE ../ TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (Installer) Proposal approved with the following conditions: , 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ 7h9 /i, Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes Er_ No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION (17 ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM QTR YM No Internal Uss Ordy PEFW f 0 L1 Rep* Pemac awed M 40 a Vets El Not In Wainehad ❑ ❑ RW* wNNn Boyd'a CWrron, W. INWOh or Cmton Fab Res. ❑ Da1a-ats0 ❑ ❑ Repair wift Wo t of A wwroWUss or oEC4mWW as ❑ JO RWIBW SITE LOCATION Jel /i �N an Hi e4 so n TM # /y r9 -/- ?- OWNER'S NAME CAA,0erI IkVnLS G- ,7VVX1 /*�,eelZ PHONE #' S-1 —377-- l:E MAILING ADDRESS 25 S°/- S /,wnrc> Ij C APPLICANT ee9 /oi1/4/ No 0 & PAWWriaw p.e., owrw. UW" ooh DATE G� / 3 e %I FACILITY TYPE PCHD COMPLAINT r PROPOSED INSTALLER. PHONE f ADDRESS REGISTRATION IUCENSE N Pro=W (Include • separate skeb h locating the house, propwty Nns% aN - jq o t wdle wWO 200 het of repair and Ilte Iocatlon of @add rp end Proposed sys0m) NOTE: The Department may require submittal of propoeal from licensed pohrelion.l depsrtd - on tits nahlre and extent of the repair. /% _ i_ _ ) Jam. /.•.� �d1 !✓ ,��n n . r. . 11 . i �/ n �, _ n r- I, as owner.Wee to the condkions stated on this form SIGNATURE TITLE DATE (owner) I, the septic IrtSWW, spree to comply with the cortdkions of title permk for IN ssplic eyeto - repair SIGNATURE TITLE DATE boom MAINIUM go do No" emdom l 1. Pmar ema t of arty Town Pea, It applicable. 2. Submission of as built repair sketch by the saplk system baaW w1M* n 30 days of firs repair, in dupkeft a0 k, f a. OwrwIs name. Sib 96" Name. Town and Tax 111ip mm*w b. LooiOn d iralered a a v a a to tied to two And pokft c. SyMp sea 1 IVORrt (@.g,, 1250 WL Concrete septic Wj*. air.) d. Iratelers' Warne and phone number 8. Syele n repair to bs performed In a000rderve wNh the above propoas and oorxtglo .8 4. The proposed SSTS repair Is oortsideo+ed a beat tit daipn and than b no p Kenlea b the dx0m at whfoh 1lte oonpNtsd SSTS repair will luncllon. !T. No oompsled work b to be baddM@d until aufthadon to do so has been ablsnad A+orn the Dspwbvwm INTERNAL t= OILY Proposal Approved ❑ Proposal Denied ❑ Inspectors Signature & Title Date Date Is In corn wkh codes Yes O No D COPIES: PCHD; Owner; IneWler PC-RP 99ML Rev. 2W -- _. • ?�t��6 .. r*.�, ",' .:' : a.,; . s w ;, .a.- '"Je.;�hr� at *tk'`z�� L20;-2- - ELEC. ME7Ef? C3px -- JUNr- WAY . of 2 8` .. 5HQMErAL UZ/ n 7.71 t I 51-fn MErAL 5HF-P. PRICK T�All o PATIO � �¢: , � MCK 22,09 , . I �f WOOt? `fl 506 • p5' p8 "� 103.75' N827:55' 02 "E l 51-fn col?, ONLINE f'.L. Sf t7 COR, OVER I ,62' GARDEN HOMES MANAGEMENT CORPORATION 29 Knapp Street, P.O. Box 4401 Stamford, Connecticut 06907 (203) 348 -2200 o Fax (203) 967 -8372 www.gardenhomesmanagement.com July 5, 2011 Putnam County Dept. of Health 1 Geneva Road Brewster, NY 10509 Attn: Chris Walsh Dear Ms. Walsh: Please find enclosed per your June 27, 2011 letter a bank check #1324432 for $150.00 representing the fee for the enclosed sewer repair application. Please note that Garden Homes staff members completed the repair as outlinged in the application. If you have any questions, please feel free to contact the undersigned. Thank you. Very truly yours, GARDEN HOMES MANAGEMENT CORP. By: 010'z� Diane Adamis ext. 2496 Investors /Managers /Developers since 1962. Serving 7,000 families in 110 affiliated Apartment & Manufactured Housing Communities throughout Connecticut, New York, New Jersey & New England R: Sheet —l— of _1 Putnam County Department of Health • Division of Environmental Health Services Field Activity Report Name: Wooded Hills MHP Address: 29 Knapp St. Stanford CT 06907 Street Person in Charge or Interviewed: Telephone: 203-348-2200 Town State Zip Name and Title Date: Findings: Permit # R- 118 -11, Complaint 120-11-19, As per Mike Luke this was seen and done immediately form time it happened by Management Company. As build was sent in and completed. Inspector: / Telephone: Signature and Title Report Received by: I acknowledge receipt of this report: Signature: Title: Field Activity Report: cw Date: Property Details - Image Mate Online Putnam County *6G, Image Mate Online Page 1 of 2 Navigation GIS Map I Tax Maps 11 ORPS Links Assessment Info Help Log In Commercial Property_ Info Owner /Sales Inventory Improyements, Tax Info Report ,y,1 Comparables Com. Sites E1E Municipality of Patterson, Town of SWIS: 372400 Tax ID: 14.19 -1 -8 Tax Map ID / Property Data Status: Active Roll Section: Taxable Address: 1 -37 Wooded Hills Park Ln Property 416 _ Mfg Site Property 416 - Mfg Class: hsing pk Class: hsing pk Site: Corn 1 In Ag. No District: Zoning Code: Bldg. Style: Commercial Applicable Neighborhood: 00222- School Carmel District: Legal Property 01600000010060000000 Description: 000200000000000000320 16 -1 -6 Total 4.72 Equalization - - -- Acreage /Size: Rate: 2011'- 2011- Land Tentative Total Tentative Assessment: $426,400 Assessment: $1,455,000 2010 - 2010- $426,400 $1,484,700 2011- Full Market Tentative Market Value: $1,455,000 Value /sqft: N/A 2010- $1,484,700 Deed Book: 1744 Deed Page: 176 Grid East: 744224 Grid North: 969505 ra No Photo Available Ma View Tax Map Pin Property on GIS Map View in Google Maps View in Yahoo! Maps View in Bing Maps Map Disclaimer http:// putnam .sdgnys.comlpropdetail.aspx ?swis= 372400 &printkey = 01401900010080000000 7/11/2011 Property Details - Image Mate Online Special Districts for 2011 (Tentative) Description Units Percent Type Value Fire #1 0 0 0 Park district 0 0 0 Garbage dist 137 10 1 10 Special Districts for 2010 Description Units Percent Type Value Garbage dist 37 0 0 Park district 0 0 0 Fire #1 0 0 0 Land Types Type Size Residual 2.01 acres Primary 118,400 sq ft Page 2 of 2 http:// putnam .sdgnys.comlpropdetail.aspx ?swis= 372400 &printkey = 01401900010080000000 7/11/2011 Property Details - Image Mate Online Putnam County *bG Image Mate Online Page 1 of 1 Navigation GIS Map Fx Maps I OR PS Links Assessment Info Help Log In Commercial Property_Info__ Owner /Sales Inventory Improvements Tax Info .Report _ Comparables Com. Sites Fl 1U http: / /putnam. Municipality of Patterson, Town of SWIS: 372400 Tax ID: 1 14.19 -1 -8 Ownership Information Name Address Partnership Third Garden Park Limited P.O. Box 4401 T Stamford CT 06907 Sale Information Sale Date Price Property Class Sale Type Prior Owner 5/12/2006 $800,000 416- Mfg hsing pk Land & Building Wooded Hills Inc Price per sqft Value Usable Arms Length Deed Book Deed Page N/A No No 1744 176 Additional Parcels Involved in Sale 14. -1 -13 in Patterson, Town of 14. -1 -14 in Patterson, Town of Photogeaphs No Photo Available M View Tax Map Pin Property on GIS Map View in Google Maps View in Yahoo! Maps View in Bing Maps Map Disclaimer 72400 &printkey = 01401900010080000000 7/11/2011 t_ . PUTNAM COUNTY DEPARTMENT OF HEALTH,.. DIVISION OF ENVIRONMENTAL HEALTH •SERVICES.:., ::.,:. "' ........ ....._.. LETTER OF AUTHORIZATION Property of o i� y�� l,� - _--------- Located atZ T/V �' ,arse Tax Map # tl,17 Block 1 _ _Lot Subdivision of Subdivision Lot # Gentlemen: ..4 ,y Filed Map # Date Filed This letter is to authorize A:',& r r ii h1 . � ,,,1. Jr a duly licensed Professional Engineer" for Registered Architect to apply for the. required wastewater treatment and/or water supply permit(s) to serve the above- noted•property in:accordai ce ,.;,. • with the standards, rules or regulations as promulgated by the Public Health Director of.tlie Nffiain :!' ;, 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 tretment 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. - - -Counters igned. P.E., R.A., # 5 �- Mailing Address 5 State / Zip to 30 Telephone: oG Very truly yours, Signed: (Owner of Property) Mailin g �o Address: 4 State —zip Telephone: ! L °' 14 3 Form-LA-97 NEW CLASSIC V1�OQt�D � ice, �t�C .J R_• f C/QE227� /loAr&s uric= p�cgi�cru7� r��Or� Diu j, �.�c -P'1DUE FAiU .. 1 .. i ( I 'd 1 1 ; i•TSK• E E. l.. , 1 New � i9 L ' _ SECOIUO .j EDROOM 5' S 3W 2(IA, 'rA'O FROM BEDROOMS MW147011 #OUSE PL)LS APPROVED FOR EDrtG[3 �f COUNT ONILY; ooimts & Title uJ /1r /taus ud:Y1 7185430941 M & J CHARRY PAGE 02 ,) 7 f 1:!_',E1 L;..J .'1).. P11 7H _ -HLI I *WbEb HILLS M08Il.E H 11AE PARK ,40t11'"E 22, PAiTER5ON ITS PLAN Cottage Unit 38 r Unit 2 Unit 3 unit 1 Unit T Unit 8 Unit 8 • ,nn is Unit 17 tJnQ 17A unit 1a 1JtUA) WAY Unit 24 Unit 26 Unit 2s WAY Unit 34 Unit 35 Unit 38 t4 • RIDGE LANE i 2-Family House Units S9 & 40 Unit 4 Unit 8 • Unit 6 Unit 10 i nit 11 Unit 12 Unit 13 Unit 14 Unit VAY yea; •. 61`Jz Unit 20 Unit 21 Unit 22 Unit 23' Unit 19 e�� Unit 2T Unit 28 Unk 30 Unit 31 Unit 29 •k. • <=) Witty Tank Unit 32 Unit 33 _OWNED BY Un it 37 � � s WOODED NilL3 `%, 1 • ent of NeWth +3 Dlbision 4 En ealth Service a -- SEPTIC WAMPUS ROAD "'r; LOg rov1 as too Vw� TI ON ,.. 'pllcablo R t f) Putnam a nt. Z � Signature & 'NO 5�.. . 05/27/2003 08:21 7185430941 M & J CHARRY PAGE 01 Wooded Bills, Inc. c/o Mkhael Charry 2500 Johnson Avenue, 17A Riverdale, NY 10463 Tel/Fam (718) 543 -0941 Email: michaelcharry@bagplaneLcom 27 May 2003 Barry Nichols, PE Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Via Fax: 845- 279 -4567 Number of Pages: 3 including this one Dear Mr. Nichols: Wooded Hills Mobile Home Park is buying a new 14'x70' to replace a home in the park. The old home now shares a septic system with the adjacent home. We want the new home to have its own septic field and tank. Wa)me Sniffen, who is our contractor, suggested I ask you to design a septic system for the new home. Along with this letter I am sending a floor plan of the new home and a map of Wooded Hills. The new home will be on site number 19. If you can do this job please let me know when you can do it and how much you will charge. I understand that the design must be approved by the Putnam County Department of Health before Wayne can begin work. Am I also correct that you would apply for the appropriate permits? I will telephone you today but wanted you to have this material before we talked. Thank you. Sincerely yours, Michael Charry, Vice President Wooded Hills, Inc. copy: tjarh a fyi fieh Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 'AA Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 August 12, 2003 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Att: Mr. William Hedges RE: Wooded Hills Mobile Home Park Route 22 Patterson, NY Dear Mr. Hedges: The owner of the above noted facility proposes to replace an aging two (2) bedroom mobile home with a new three (3) bedroom unit on Lot #19. Currently, Lot's #19 and #20 are served by a common SSDS consisting of a leaching pit. We propose to leave Lot #20 on the existing system and to install a new system to serve Lot #19. The proposed new system will be based on current required application rates. Percolation Tests performed at the site are in the 3 -7 min. range. The fifteen . (15) foot deep hole was dry and contained sand and gravel. Accordingly, a three (3) bedroom home will generate 600 gpd and require 600 s.f. of absorption area. Twenty (20) vertical feet of 8' 0 leaching rings with 1" of gravel provide an absorption area of 628 s.f. (31.4'x 20'= 628) Reflecting the above, we are enclosing the following: 1. "Construction Permit ", dated 08- 12 -03. 2. E.A.F. Short Form, dated 08- 12 -03. 3. Design Data Sheet. 4. Letter of Authorization. 5. Mobile Park Layout Plan. 6. Three (3) copies of Home Floor Plan. 7. Application Fee, $100.00. 8. Copy of 05/27/03 letter from applicant to engineer. Kindly process the enclosed at your earliest convenience. Very truly yours, Harry W. Nich s Jr., P.E. HWN:gav 03- 064.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION .OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # R ASE - Q 3 Located at tvavj 1 5 1 w� r /��. �IYS%� c Town or Village teQ tey5e S Subdivision name Subd. Lot # Date Subdivision Approved Owner /Applicant Name .A G L 4 ,G ( C Mailing Address a.S'OO ILSV� AVC e.f—, ' Amount of Fee Enclosed jr611 '' Building Type Lot Area Tax Map 14, 11 Block __ Lot?_ Renewal Revision Date of Previous Approval y�rd rL 1 _ Zip /0 1;(�3 No. of Bedrooms 3 Design Flow GPD 640 4 Fill Section Only Depth Volume Separate Sewerage System to consist of d UD d Other Requirements: To be constructed by Water Supply: V Public Supply From or: Private Supply Drilled by _ gallon septic tank and Address Address Address altee-+ 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. A Signed: Address R.A. Date �g -/,1 --0 3 License # � -Lj 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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approv anitary sewage only. By: Title: Date: � �_ White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design P fessio Form CP -97 50 PUTNA4&COUT P E P n TME,OF:HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET SUBSURFACE SEWAGE. TREATMENT SYSTEM J-01 .e, Owner':AL& Address' 4504' - Ay im 1 J�, ,.�.�% i Located at ( Street) 2-7) Tax Map ck icate nearest* cross street) Municipality.. Watershdd SO11L, PERCOLATION TEST DATA 7 Jog Date of-Perc . olation Test . ..... . Date of Pre - soaking -7 -7 to ................ ..... e th .to 111be- rom .9 u 'aches .. .- V to,Zo, zi 3 3 ;2-d t0- .' -f7.. 11! 1 01 1 2-0 3!r io.1-4 i .2 3- 0.6 3 `2 s 6 5 -4. 2 3 51, NOTES: 1. Tests to be repeated'at same depth until approximately equal percolation rates are obtained at each percolation test hole. (he-;.s I min for 1-30 min/inch, :5 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 DEPTH G.L. 0.51 1.01 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0. 1 5.51 6.0' 6.5' 7.0' 7.5. 1 8.01 8.51 9.01 9.5' 10.01 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED .IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. Indicate level at which' groundwate'fis encountered — No" e., Indicate level at which.mottling..is observed Indicate level to which water level rises, after be.ing.enc.oun.tered Deep hole observ'iti6'n'_s_made by: Date Design -Professional Name:-. Address: ;).oti v In Signature: Design Professional's Seal W Igo. 5612 14 =164 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix C State 'Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be conipleted by Applicant or Project sponsor) 1. APPLICANT SPONSO T �a.�- 2. PRO ECT NAME �i�d �d� t� E , �+s 5 . 3. PROJECT LOCATION: AV4.oy4 "A14 44N Municipality County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, aettc., or provide map) We.5+_ J, 9 P • ii$ ✓t �� /77�"d� 1'�o +adr ch ��rS�t%�"jt�`i 5. IS PROPOSED ACTION: D New D Expansion odlflcatlon/alteration 6. DESCRIBE PROJECT BRIEFLY: '4 4 99 7. AMOUNT OF LAND AFFECTED: Initially n D acres Ultimately + to acres 8. WILL P OPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? axes ❑ No If No, describe briefly 9. WHATA PRESENT LAND USE IN VICINITY OF PROJECT? Residential D Industrial D Commercial D Agriculture D Park/Forest/Open space D Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ to list Yes It yes, agency(s) and permit/approvals 11. ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ��,D�/OOES IffSYes ❑ No If yes, list agency name and permitlapproval 12. AS A RESULT OF P�gQPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? D Yes o. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor ame: IL IL eA( CL 4 Iry 14 Date:.��a� Signature: 1/ v 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 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAR ❑ 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 CI-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART 111 — 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 (f) magnitude: If necessary; add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part 11 was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ 'Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ 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.Lead Agency Signature of Preparer (If different from responsible officer) Date 2