Loading...
HomeMy WebLinkAbout0559DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -23 BOX 7 00559 . j �. �� - F . ` 10� 1 . ._ r T_ �. � ' :1 �i4. r , 00559 PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. ' 3/86 Division of Environmental Health Services Carmel N Y.10512 Engineer to.Provide Permk q on CERTIFICATE OF COMPLIANCE 'Permit CONSTRIICTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Located at C A i2 W WA LL "ILL 9-0.A D Town Sgbdivision Name Co R N WALL 1� 11D Ca it crii Lot N - 4.3 Tax Map ' Block Renewal-0 Revision owner /Applicant Name C-0 12 ti wAL L 14 I t_ L - Dete of Previous Approval Z 3 MaWng Address 'Z 2 3 LC A�'o 1a l� H A y C Town K ATI0 NA H NT— ZIP Building -_Type G Lot Area ' Flll Sectlon Only L. J Depth Volume Nnmber of Bedrooms 4 Design Flow G/P/D PCHD Notl6cation is Regaleed When FiR is completed Separate Sewerage System to consist of ) Z 5 0 Gallon Septic Tank and 4-6(- 1350 lZ B7" Ink :j - R IE 1 1 C, TE To be oonatraeted by TAMTO I y IMI Address water Sapp!): Pubpc.Sapply From Address or: x .._... Private Sapply-Drilled by-' T � , � .. . Address ; Other !Requirements 1 represent that .1. am wholly and completely responsible for the'design and location of the proposed, system(s); 1 that the separate,sewage disposal .system above described: will to constructed as shown on the approLed amendment there to and in accordance with the standards; rules an ►egu a, ions o , e ,u nam y ounty ;Department of Health, and that on completion thereof, a " Certificate of Construction Compliance" satisfactory ;to the Commissioner of Healthwill be. wbmitted to the Department, •and a written guarantee will De,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 ,disposal. system during the. period of two (2) years immediately'4ollowing the date of the issu- ance of the approval of the Certificate of Construction Compliance, -of the, original system or any repairs thereto; 2) that the drilled well described above will be located as shown,on the approved plan'and that said well will be ins a ed in accordance with the a rds, rules and regulations of the' Putnam ..9ounty', Department of Health. iz". Ol,; H w , Date t��Q PGS�9ned. .. P.E R.A. • Address' 7 zhigr= _ 'license No ' - APPROVED.FOR CONSTRUCTION. This= aoproJal expires on - ear from a da ued unless construction .of. the building has been. undertaken and. is revocable for ca se or may be 'amended'. or modified when con 1 nace y b- Commissioner f Health. Any change or alteration of construction t requires a new perm . Approved for ;disposal of domesti• ary -ge, or rivate ater. pNy only. Date BY Title �,� — '- - - "" r' ! W LLL, lj U 1V1 r LL 1 1 U li 1 1 l_.l U l l 1 r DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM "COUNTY .DEPARTMENT OF HEALTH — — - SIREET ADURESS: 10wNwILLAGE101Y fAX GRIO NUMEIER: Co Rcv AI --t-• N kt-L- (P X17ER50r-1 . YELL LOCATION WELL OWNER NAME: ADDRESS: KATO N l\ (-{ t4 k -pj-or kAA Gaus%RUc-TION co. az3 KA-r-oNA H AqF PBIVA t I UEUC USE OF WELL 1 - primary 2 -. secondary ]K ESIOENTIAL ❑ PUBLIC SUPPLY. ❑ AIR /CONO• /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ .MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED 5 / EST. OF DAILY USAGE cal. REASON. FOR DRILLING '�kfiEW SUPPLY = ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH c2 rd ft. STATIC WATER LEVEL � ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑SCREENED D OPEN END CASING. Q`DPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH ;Z -ft MATERIALS: �TEEL ❑ PLASTIC ❑ OTHER CASING LENGTH.BELOW GRADE ft. JOINTS: O WELDED WHREADED ❑ OTHER DETAILS DIAMETER in. SEAL:,P<EMENTGROUT ❑BENTONITE DOTHER WEIGHT PER FOOT d 1b./ft. I DRIVESHOE:,INffES ❑ NO i UNER:OYES* ,10 SCREEN DETAILS AILS DIAMETER (in) • SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES 0 NO HOURS SECOND GRAVEL PACK O YES O NO GRAVEL SIZE. DIAMETER OF PACK in. TOP DEPTH ft. 60iI0111 DE.M It. HELL YIELD TEST I If detailed pumping AETHOO: O PUMPED ; tests were done La ln- y5OMPP.ESSED AIR , formation attached? •�= ] BAILED ❑ OTHER ; ❑ YES ONO If more detailed formation descriptions or sieve analyses I WELL LOG are available, please attach. DEPTH FRUI suRFACE Water Hear- ing W01 . Oia- meter FORMATION DESCRIPTION COE tt. it. 'ELL OEM It. DURATION hr- min. ' ORAWOOWN It. YIELD gpm. Surface 0 I I. 'ATER ❑ CLEAR TEMP, JAUTY O CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? O YES O NO I STORAGE . TANK : .TYPE - CAPACITY ' ' " GAL. JMP INFORMATION 'PE CAPACITY aKER DEPTH )DEL VOLTAGE HP WELL DRILLER NAME �Q�� ���o j �y� DAT d. Y- E ��� / 0.5 /02_/ : -- ,� s•- ,^=s�°-�...-- .+u. e# ^s+- .�.+r --• ;z,�'�' - =n w- '�,�...: ° ^� .,�^�•�- ^°.r-..:w�1�3�1 ''�- 5-°°�^ � -- f s� rtn-• ss� � 'ars��.7 X33-: �y .f �-•. "' -' +� .. t ., -- . - •. ... ` }+ U's � uK, � `i t r is '•`} t Rev. 3/86 PUTNAM COUNTY DEPARTMENT OF, HEALTH Dl eion of Environmental Health Services, Cat�el, N ?:10512 t- Engineer, Meet Provide` ��ej Y _ P H D Permit CERTII IGATE .OF -EONS U ON COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Town or V e Located at C�dJ2iV 1rL'� �-IGG �F%�Q Ta=MapBlock Lot' CoRNW Owner /applicant Name cr6RNWJJtL ll1lL SST. %NrrFormerly Subdlvision Namel��nSabdv /Lot N Ni[ailing Addrose CaF'A/ IrCIALG NIL' L S T�j7 oQU7 /A <Zip -� �✓a`v Date: Permit issued 043: 3 1fA7v A1,4lW , , /fia7WAI/ A/y Separate Sewerage System built by,a A/ F`�RN dsY �vN P Address rA % V,� �A 9aA/AN /V /� G ; �i �- St`s < %C% ��✓ >%��iiif:%ff t <' T3G Consisting of %Z -s�' Gallon Septic`Tsnli and Water Supply. - Pn6llc Supply From Addross �vW ARI S44,y RTC S"7 :CARM91, AIV �DS"IZ or Private Supply Dv*0 by w dress Ballding Type J %%J "AMC Has Erosion Control Been Completed? - C a/0PL IC rE N=6 if Bedrooms Has Garbage Grinder Been Installed ?; . Wo z Other Requirements I certify that, the sysieia(s) as listed serving the above,premises were constructed essentially as ppgwn on the plans of the completed work ( copies of. which. are attached)" and in "accordance with..the standards rules a regulation accordanc the filed plan, and the permit issued by the Putnam County DepBrtmenCpE9Of Health Date s O. Certified by P.E. ZR.A. Aed ►e :: 73 "/�.41/?FIgG OR IPAi T'IL "/ZSJR/ Al �.2 f(p icense No. 7i��7�1 Any person occupying prem,sss served by. the above'.system(ii shall'promptly, take sucn,actioii,as"may:be necessary to secure the correction of any unsanitary conditions resulting from such usage - Approval of the separate sewerage syftsm, shall become null and void as soon as .a pub•' sanitary awes; becomes . .. avaNable and the approJal, of the..private °water supply shalt tiacome null andtpdid when a public water' wpD1Y becomes available. Such approvals are subject tb odifieation or, change when; )n the Judgment `ot the Commissioner of Health, wcA revocation, modification or change is necetaory. — Titt Date / try PUnMM COUN'T'Y DEPAR7I� OF HEAL-111 DIVISION OF ENVIROirAL HEALTH SERVICES Cornwall Hill Estates, Inc. Owner or Purchaser of Building Building Constructed by Cornwall Hill Road Location - Street Patterson Municipality Single - Family Residence Building Type C. 15 6 2.1 Section Block Lot Cornwall Ridge Subdivision Name 43 Subdivision Lot # GUAPARM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shoran on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any 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 Environmental Health Services 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 utiliviInq , the system. Dated this _ day of �0 J • 19SSIL Signature Title Ggner 1 n acto (Own -'Signatute Katon h Close Construction Co.. Inc. Corporation Name (if Corp.); • 223 Katonah Avenue, Katonah, N.Y. 10536 Address rev. 9/85 mk ryo Corporation Name (if Corp.) � UP A&iress ko6ono h1' - z s � 0 O L z /5 29 °Ir 3SyEi 1 �-. 1 ► /� ol I l ,, 1 i 1 1 '' 1 ► r' p ZOD l I l / r / // / % ♦� / le zit r r/ �/ 'If I I 1 I 1 I I by ,' / XX it / / '6) / / r' ,/i ' / ' / r' \ /� 1 IN, \ IN 1 \\11 1 1 \ \ \ \�\ \� \ / / , 1 1 1 i \ \I 11 \ \\ \ 1 1 I 1 1 N \ `11'1 I 111/1111 \ \ 1 \ \ \ `1 \ ; �j �. l /' /' /',' 1 I I t 111 11 \ \ 1 1 1 1.11 \ I ► / �� /// - �� / ♦ / �,'�.' �, %I\ 1\ 1 1 j I \ 1 \ ► 11 11 \ I I / / / / 1 1 I 1 11 11 1 � 1 11 I I 11 ► / / , / /./ 1 / / 0 1 it 1 11 11 1 11 \\ 1 II It ;11 I I 1, 1 In I I I 1 11 1 %' ► U► ' i 111 I' nliil 1\ 1 I 1 Ili 1 III ��► I 1 I 1 III I`'1 1 ` 1� � / �r--i 1 1 �p l I I 1\ 1 , 1► 1 1 I I I \\ 1 I I N 1 l 1 1 u 1 ► 1 It ✓ 1 11 I 1 1 \ 1 1 \1 1 1 ► 11 II 1\ 1\ 11 \ ► 1 1 \ \ \ `� 11 I 11 1 11 111 j II 1 \ 1 .I 1 1 \ 11 1 1 III 1 1 1 \ \ 1111 1 III i I 1 \I I I' 1 111 1 111 1 1 \\ \` 1 \� 11 1 1 1 1 1 1 � 1 1` 1 1 11 1 1 11 1 11 1 \1 ` \ \ 1 \ 111 1 II 1 1 1 \ 1 I ► \1 1 1 1 \ \ \\ \ \ \ \ \ � 1 11 I 1 ► 1 1 1 \ ► 1 1 1 1 \ 1 1 1 \ 1 \ \ 1' \\ 1 1 1� 1 1 1 1 i 1 \\ 1 1 1 IN rU11VtW1 %-lV UI 1Jr JUCJZ1rAV1' Vi'' J:jj*A 121 DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Cco1.� 1Alu- XW, Address Located at (Street) 'A R..-G g A Sec. 1—�5 Block G Lot 2. (indicate nearest cross street) Municipality Watershed�~,�� f Date of Pre - Soakings -o Date of Percolation Test ---1 HOLE NUMBER mam 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 1 S -- 3 :5d A a Z4 2x'.55 - : IQ lq Z4 Z77 �, 3 3 16 - A : M IC( ZA 2-7 4 5 1 3 :Ao-- 3: s4 t q zA 2 Q: w -- A : Eg 20 ZA Z2 3t 3.1- 4: /4d is 2A -L-7 3" 4 5 �1 2 3 ,c 4 5 :'�• L. Tests to., be repeated• at same depth until apprmiz ately equal s iil rates are cbtained.at each percolation test hole. All data to'be submitted for review. 2: Depth ii6asurements to be made fran top of hole. mv. 9/85 DEPTH G.L. 1' 2' 3' 4' 5' 6' TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS E[N]COUNTERED IN TEST HOLES HOLE NO. G_ HOLE NO. �j HOLE NO. LAN" 7' 8' 9' 10' 11' 12° 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER .LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: 1Z. C DATE: _ -- DESIGN Soil Rate Used G--7 Min/1" Drop: S.D. Usable Area Provided 6J= No. of Bedrooms Q Septic Tank Capacity O :_ gals. Type Absorption Area Provided By AO& L.F. x 24" width trench Other Name F -AhKg,\/ W - - Signature P• N1 cH Address SEAL _ LU Cl) i ;► a No. 66124 THIS SPACE F1OR USE BY HEALTH DEPARTMENT ONLY: OFESSI4� Soil Rate Approved sq.ft /gal. Checked by Date i -PUTNAM~COUNTY DEPARTMENT OF HEALTH r \\ 2V. 3186 DlvlslonotEnvlronmeritdHoalth $ervices..Cprmel N.Y..10512 �. r ee to Provide _Permlt # - �., on CERT�ICATE OF CO NSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit # ?ATi"�� Located at C.p {214 Li i2 ©iAr� Town eN Subdivision Name r.o {ZAIWA -L i t b GIE Subd. Lot # 43 Tax Map , � � Block b Lot CaTamwkLL 14iLL C$ A3sfj 1 mt, Renewal_(]_ Revision p Owner /Applicant Name I .' —' Date'of Previous' Approval, Mailing Address ZZ 3 .. , K A'7O I iA H Avg . Town 1GA°a� '1V _Zip J6 � .4 1" Building Type G S rn1= t` G e Lot Aron :31.5 919 A C Fill Sectlon Only . Depth Vulttme Number of Bedrooms Design Flow G /P /D 88d PCHD.Notffication is Required When Fill le completed, 1Z5© r _ , Separate Sewerage system to' consist of Gallon Septic Tank and — Soo m L 1'• AS-6o Ri3Tl6 wa 72C'K1 C i-i. To be constructed by To Be T>ff TERMi s- c> Address' water SuPpb': Public Supply From Address or: is Private SUP PIy Drilled. by L----Address Other Requirements I represent that) am wholly and completely responsible for the design no location Of. the proposed systefn(s); i) :that the separate sewage tlispofel,System above described will be constructed as shown on.the approved amendment there to and in accordance with the standards, rules an .►egu a ions o e Putnam County •Department of Health; `and that on completion thereof a °Certificate'. of ,Construction ComDiiance" satisfactory to the Commissioner of Healthwill be submitted to `the Department; and a . written`, guarantee_ Willi ie'furriishe'd: the owner, his successors, heirs or assigns by, the buildar,.that sold builder.will place, in good operating condition any. part .of:. aid sewage 'tllsposaF system during the period of .two (2► years Immediately tollowi:tg the date of the issu- ance of the approval of the Certificate of Construction `Compliance o original system.or any repairs ther ) that the drilled well described above will be located as shawn'on the approved plbnantltnat Sal we i stalled - accordance with, theda S. es �Afllf . the Putnam County Department, of - Health. Oats' Lr. 7 g� Signed R.A. Address ,7. ,7ilt� \- L1..AI�IVIE .License No _ APPROVED F R- CONSTRUCTION. This approval expnes o yea 'from th ' -date issued .unless construction of the`building has been undertaken and is revocable for use may be amentled or motlifi'ed when cons ere neeessarC mi goner of Health. Any change or alteration of construction requires a n per i Approved for disposal of domestic i y -wag �' d e ater supply only: Date � �� By �- Title I �e 23 4 Sr4�'wt.�ryd'%j°' �{3;�trfisk�' from the desk of — JOHN KARELL JR., P.E. Director Of Environmental Health ervices 0 0 T-i=-' ' t L1 v CA-U -- � z SS DS PUTNAM COUNTY DEPARTMENT OF ILLALTH DIVISION OF.ENVIRONMLNTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512. DESIGN DATA SHr:I I'- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Uviier!Co %tNw0i,Lf VJNL : �rA s. lc - Addrese 'L2.3 KAT '1wHh AytF, K4110NBr 43 J o53h c.csU►t�..a+.�� ic.�, Ro. Located at (StreetMZica Z7. 1 (a•Q Sec. 1� Block ��Lot �..� a nearest -cross a ree lIujilclpality � +"T'C��,�'c7*;s Watershed C- Zo -rok -A t :.oil, PERCOLATION TEST DATA RIQUIRED TO BE SUBMITTED WITH APPLICATIONS J .3 t na 2 • �g 2: a3 a a� 3 Z Nutis:+: 1) '!'gists to be repeated at :3ume deptlj until a );roximatelyy equal soil u. r•t.O." w4% obtained. at each parnolnt ton test ho.1e. All daVL to b� submitted for Nivi,•w. . , 16•Iith measurements tn h? nvtclC from top of hole. - Nu,ill -4: V CLOCK TIMr PERCOLATION PERCOLATION Hun haapse DepUh to a er Water Level Nu. Time From Ground Surface in Inches Soil Rate Start' -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches to �6� (� 9-0- 4 J .3 t na 2 • �g 2: a3 a a� 3 Z Nutis:+: 1) '!'gists to be repeated at :3ume deptlj until a );roximatelyy equal soil u. r•t.O." w4% obtained. at each parnolnt ton test ho.1e. All daVL to b� submitted for Nivi,•w. . , 16•Iith measurements tn h? nvtclC from top of hole. TEST PIT BATA ld -MIHM •TO BE SU13Ma1 '.I'FD WITH APPLICATION DESCRIP`1'ION OT' SOIL; i'IJCUUIV`'LR1 D IN `1']<:S`1' HO! M1PTH HOLE NO. HOLE NO. HOLE NO. (;.L. v" 121, 18" .,4" ts•�^II 4 211 481' 1.j4 11 W1 X11 • 7 it I N1.) 1 CA'!'F, I EVEJ, AT WHICH GROUND WATHR 3'S ENCOUNTEIMM I NI )1 CA'I'N. LEVI:L TO WHICH WATER 1EVLL RM S AFTER BEING ENCOUNT Z tJ?.'D Date $S ION :Soil Rate Used :_MirVl "Drop: S.D. Usable Area Provided :S'00(3 40.F 12-so _ Nt>. of l3CdreJO,r,�; Septic Tar,k Capacity CJa N: AbsorpLlon Area rov t�aa By L.I+'.x24" .`:cK.:� r }-• enc .. .. .` Numu ;a— -per tJ. L �/1-- f is -u` c r' Address-73 V///y� � ' i' � '1.2(�_ ST.A,'U �S•��Y.:•'ba'i ' / / 111:1 S!'ACL•' H'UJI USE BY ! L'1'll DJsPAJt`l'P4lWit ONLY: �`��'tv�% :3oi1 Rate Approved Sq. Tt /Cal. Checked by Date RECi: �l VE SEP 2 0 1985 DEPT P"VA , �OUI Ji y � HE,gCTI -i PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW �q\4"� W, SHEET - CONSTRUCTION PERMIT ./f w� t BY: Location) DOCUMENTS Permit Application Corporate Resolution Plans - Three sets O'S Engineers Authorization" Design Data Sheet (DDS) d _? Deep Hole Log Consistent Perc Results (3) q6V 30" Perc Hole Other House Plans - Two sets If PWS Letter -7 Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- C=tain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same (Name of Owner) COMMENTS (Street YESJ NO ✓ ✓ / �- le ' /N o I PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: Cornwall Hill Estates, Inc. I, Kenneth Emerson represent that I am an officer or employee of the corporation and am authorized to act for Cornwall Hill Estates, Inc. (Name of Corporation) having offices at 223 Katonah Avenue Katonah, N.Y. 10536 Whose officers are: President: Edward H. Emerson, 223 Katonah Ave., Katonah, N.Y. 10536, (Name and Address) Vice - President: Kenneth Emerson & Martin Diano, 223 Katonah Ave., Katonah, N . Y . (Name and Address) Secretary: Janet G. Mastropietro, 223 Katonah Ave., Katonah, N.Y. 10536 (Name and Address) Treasurer: Lynne Diano, 223 Katonah Ave., Katonah, N.Y. 10536 (Name and Address) and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. 1"A Sworn to before me this day Signed:' o f Ott . 19 Notary Public LIONEL WEINSTEIN Notary Public-, State of New YDtirt No. 60.4199150 Qualified in Weatriiw,tcr Cet.rit'$; Uonunlsaoh Expires Morch 30. 19 8/84 Title: Vice President Corporate Seal d r5 29 °!f 351Ei , oe ele 1p OD lo, le 1/ I , ► ' / 1 /LD / j ' �' /, f /// / , j7� � /i. •��. /, i{ / it / / / •/ 'o, Ile Yoo III � �1 1 I / / •!� J , �/ /o" �01 // // 1/. 1► 1 \ \ \ 1 I I 1 / / / / Ile 111 l I 11't`j \\ 1 \ \ \ \1 \\ ✓ ! j" / j ,/ / / /,' ` / / //. / /! �� 111` I 1 II \\ 1\ ► t i / // �. 1. '. ►111 \\ 1111:. \1 1 C 1 I ,`:I I I1 :r / /, f / // / / / �, y � / • , � / .. � ► 1 1 1► 1 \\ ! 1 1.' 1 1 ,1 : I, ► I (1! I I I I I j /: L '•~ , . 1 I .;;. 1. 1 I I ; 1 •1 11 1 11 1 , ►:( I I 1, I. 1'. .► � /. 1? 11�\ ' n11'I1 \\ iI I 1 , II1 �I II I \ ► I `�1 1 \ I / - 1. ► � 1.' 11'.11► I 1 \ 1 I 1 1.� . , 1 I �.► ► �\ 1 i'► "�\ \ \ t ► / li 1 1 11 1 � . 11 \ � i - 1 .11; ►1 .11 i i 1 i \1 11 1\ . o \..,} 1 \\ \\ \`. �\ 1` \\ i � 1 ►I 1. II1f 1\ I 1 1 ►... 11 1 1 1•\ \` \ \ \\ \ \ \\ \ \ 1 11 ►1 1 II 1tl 1.\ 1i 1 \\ � 1 I1 1 \ \ 1' \\ - \. `.\ \ \\ \. \ \ \. 1 1 I •I :1.. \ 1 1 1 1 1 C\ 1 1 1\ 1 1 \\ �\ \� "` \ � � ► 1 ( I 1 1 \ �1 .1 1 , I 1 1 1 \ 1. 1 \ 1 1.. t; \ \..: ,� � \ \\ \ \\ \\ \ \\ \ \ \.�\ I �1 1 I ►1. 11 \I \\ ►'1 \ 1:1 I , ► \ 1 \ \ 1 ► \ \ \ \ \ \ \ \ \ \ \ VA