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00570
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1-TV 1 T r•nnADT "IT•7 fl/d bcDnDm
DEPARI'MENT OF HEALTH
Division Of Environmer►tal Itealth Services PUT'NAM COUNTY DEPARTIIWNT Or IIEA1,Til /_tom
uwl
Office Use On y
/ — -? " ��
WELL LOCATION
SI9EE1.A0URESS: N TAX 6810 NUMOER:
Trc p�
WELL OWNER
NAME: I ADDRESS:
jQfPBIVATE
O PBLIC
USE OF WELL
I - primary
2 - secondary
Q) RESIDENTIAL O PUBLIC SUPPLY d AIRICOND, /HEAT PUMP O ABANDONED
O BUSINESS 0 FARM EJ TEST/ OBSERVATION O OTHER (specify)
Q INDUSTRIAL Q INSTITUTIONAL Cl STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT �.__ gpm.1NO. PEOPLE SERVED ....._ _.._. / EST. OF DAILY USAGE gat,
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY TEST /0$SERVATION QADDITIONAL SUPPLY
gt4rw SUPPLY (tew DWELLING) Q DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH � It.
STATIC WATER LEVEL _AQ 5ft.
DATE MEASURED d
DRILLING
EQUIPMENT
0 ROTARY COMPRESSED AIR PERCUSSION 0 DUG
O WELL POINT O CABLE PERCUSSION CJ OTHER (specify):
WELL TYPE
CI SCREENED D OPEN END CASING eOPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH fL
MATERIALS: LKSTEEL 0 PLASTIC C] OTHER
LENGTH BELOW GRADE � _ ft.
JOINTS: 0 WELDED WTHREADED O OTHER
-DIAMETER - 7 In,
SEAL; EffCEMENT GROUT O SENTONITE OOTHER
WEIGHT
PER FOOT .._17�1b. /It.
DRIVESHOE: YES ONO I LINER:GYES 0610
SCREEN
DETAI s
DIAMETER (in)
'SLOT SIZE.
LENGTH (It)
DEPTH SCREEN (tl)
DEVELOPED?
FIRST
YES ONO
WS
S NO
GRAVEL Fnd
O ES
O N
GRAVE
SIZE:
DIAM R
OF PACK In.
TOP
DEPTH n,
60 OM
OEM R.
WELL YIELD TEST tf detailed pumping
ME1H00: 13 PUMPED i tests were done )s in
IWCOMPRESSEO AIR a formation attached?
O 9AILt:O O OTHER ; O YES 0 NO
'WELL LOG it more detailed formation descriptions or sieve analyses
are available, pleastc Attach.
DEPTH ci+otii
. SURFACE.
tt : 11
w,ter
SOP
tnq
Well
Ott*
In
FORtAAnON DESCRIPTION
coot?
WELL DEPTH
tt.
DURATION
hr, min.
ORAWDOWN
it,
YIELD
qFm.
and
a�c�
cS N
__.. �4
�
7
WATEq 9f CLEAR TEMP.
t?UAUTY O CLOUDY iIARONESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES 0N0
STORAGE TANK! TYPE-01'.-t/
CAPACITY K /k)h G4
Xffif Atf'VIYATT R: INC. oA1E
Ao4RES5 Will S1CgaTURE! /��
Rte: �11' r' :: 171A
PAT1'1:t,..n,�, .._., wilK 12563 /y
PUMP INFO MATIUN,
TYPE CAPACITY 76f�ft
MAKER DEPTH
MODEL VOLTAGE2�QHP
J s'
-i.
n;wAwA nwAwA wA wA:wnnf n /rwnw AwA wA wn wn A A AwA nnwA wA w
rI
1
•r� ✓iY 'r :Yr::Yr Yr yr Yi ✓r;Y• yr Y ✓..Yr ✓i Yr v ✓ -vi✓r Yr r;✓r ✓
✓v Yr.Y✓:Yr Yi ✓v: ✓r'.Yr
-i.
FROM LRURENT ENG Assoc PC
4.18.1990 8:49
PUnIAM COMTrY I)M'JART1EW OF HFAL'I'H
DIVISION Or, aWTRoNRwfAL HFALTH SEayZCFB
1
1p (� E o� ►ry l� '_ rNS5C)
Owner or Purchaser of Building, ``
Building Const.ructea. by
P. 1
23: Z 3 }
Section 131ock Lot
LtT ZZ- HAM azz C i-,
Vocation - street. Subdivision Name
•�4 � t'.lLSory ZZ .
Municipality / Subdivision Lot #
Wove
Building Type
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SXSM
I represent that X am wholly and completely responsible for the location,
woricnanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as sham 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 ownerr his successors, heirs or assigns, to place „ in good
operating condition any part of said system constructed by me which tails to
operate for a period of two years iamed.iately 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 Director of the Division of Environiental Health Services o
Department of* Health as to whether or not the failure of the
caused by the willful or negligent act: of the occupant of the
the system.
.. .1
Dated this 5 day of�``�
U-)��I-
General iContractor (Owner) - Signature
Corporation Name (if Corp.)
41 W. 00
Address � —�-- Y , c Z '_3 3
i—j, c QCvJ i
rev. 9/85
m!c
the determination of
f the Putnam County
system to operate was
building uti�U-ing
i
Signature��� %'�
Title 2L �K(-Wt,�/
iA I .G
Corporation Nam (if Corp.)
LA C\ ,c- COur X
Address
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
F AM
Brewster, New York 10509
RANDOLPH W. LAURENT, P.E. (9 14)278 6108 - (FAQ 278 -2658
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
January 31, 1996
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
ATT: Mr. William Hedges
RE: Individual SSDS - Lot 22
Hampshire Count
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing S -1 "As =Built Plan", dated 10- 22 -95.
2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 1- 30 -96.
3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System ", dated 1- 25 -96.
4. Well Completion and Well Log Report, dated 7 -7 -95.
5. Water Analysis Report, dated 1- 29. -96.
6. Money order in the amount of $200.00 payable to Putnam County Health Department.
If there are any questions concerning the enclosed, please call.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichol , Jr., P.E.
HWN:bd
92081
enc.
cc: Mr. J. Grasso w /enc.
mo®LI mog n1V0
CERTIFICATE OF LABORATORY ANALYSIS C:_
LAB ID NUMBER: 96 -0509
CLIENT: Neckles Builders Inc
47 West Old Farm
Carmel NY 10512
SAMPLING LOCATION: Kitchen sink: Grasso Residence, Hampshire Ct, Patterson NY
COLLECTED BY: W. Neckles
DATE COLLECTED: 01/25/96 TIME COLLECTED: 1:30 PM
DATE RECEIVED: 01/25/96
DATE OF REPORT: 01/29/96
ANALYTE _
RESULT* . -UNITS
MAX CNTMT LEVEL ** ...METHOD
_
ANALYZED
Total Coliform
E. Coli
Absent
Absent
Must be "Absent"
Must be "Absent"
SM18(9223)
SM18(9223)
01/25/96
01/25/96
This sample, as submitted to the laboratory, and as compared to the New York State limits for drinking
water quality for the tests performed, was:
ACCEPTABLE. _ NOT ACCEPTABLE.
:r
NYS ELAP #11218
CT Lab Approval #PH -0171
*Underlined results are unacceptable according to health department and /or US EPA codes.
** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US EPA codes).
618 Clock Tower Commons, Rte 22, Brewster, NY 10509 / 914. 278 -7600 1 Fax 914 - 297 -0536
tee""
Date Subdi
Odw
repreent that I am Wholly._"-C?m'plakaly. respbh$ibla for the design and location of the proposed system(s); 1) that the, Separate saws" di sal
above described will be constructed tsshoWn'on thSLOPP064id amendment there to and in accordance with ihostan4irds.. rules and reguWtsons-oT1VM
naM
County Depairtment of Health, and that on complitioil,thintof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Heelthwill
be submitted to the Depahnient. and 'a writhe guarantee will be furnis6W the owner, his sticcesims, heirs or assigns by the builder.4hat mid builder will
place in good operating condition any - part of laid Saws" 41sposal - sysiint during, the period of two (2) yews Immediately followitilp the date of the Issu-
apse of the approval of ibe Certificate, of Construction Compliance of the no$ system or any repairs thereto; 2) that the drilled well described above
well be located as shosvn a4v thj ipipreipW thMt plan and said well will be Installed I accordance with ,the standards, les a d oni of the Putnam
County Ospartme it' of Hftkh.L
Date -7 — 00 —q3 Sign ed
k' y Jc-.-- n 12:4
Addr
APPROVEO FOR CONSTRUCTION- This approval expires two years from the date Issued unless, construction of the building has been undertaken and Is
revocable for cause of may be smanded'ar modified wihsn considered necessary by the Commissioner of Health. Any Change or alteration of construction
,"w permit. -"W /or private water supply only.
requires a p Approved for disposal of domestic-sanifori, P ate
Rev.
Title
10/88 Tit
In
'p n .'� � ..- >. ... - >�eeslmt>a.1J1�i1, � 4 IeBY? : `�r Q; tw�Yi► hitiiM / - w ` .
Q,
J �` 25
0.. �—
ID
Bab FM
Ila
d_-
/TZ(Tr /i Mtsdais .,
e1uc�tlS
4616,
[iee�nt that 1 ein.'whO11Y &n0 tOg1olstely vedoonet®-10 -'for the ®esyn ett>t,0ocatton of`tho wopor� systems) ` 1) 4f►at tl� 'Y 'ate _ `Ai Y6 ` Mn
;irOee ei�s[Jiee® wiill �e eO�►ftPYCt69 aes8"fi, 00 t10o spWovdd m1VIg110Pr10ni i4iia t0 aite; Hi acao d® noo. prNh 4119 t38P1c"S- -IYlee e _ fMY__: ^ . -
Ottwlty t7!O�r ?w�eilt of, F1MRh. atei•,thot onsoew0lotbn.thwoo4 b °Catiti"to of Cor4ouetion C~i iamwP ,t®tisfectoryao thi ComPnlsNOnw of IIYRhwill
Oo:- srbwRtetl to tRe aw®'. a ravNten rawhf® will .®o furwiei{o8 the olsmav btls helva`w essyns by tho twgili edit rN O1UIOer wiB
pile M ti'►M, ®jiaRilo ColiANtM ewq !Ion M wld f ►af►e ®it�oYl t)le¢eafl OY►Me®; the �ilolfl of iwe (8) y!Mf bnwM0i0tehr fo110iNMM tlNgto of'tM NsY• . -
. 4tt0 ilk Of Me,'CertMkete 091,C enYvwe4Wn COw1®I,{alce Of ED MKlt eyit®In:'09 a014/ P�WpO.f i=)iilYi th0. _ tie 1, -wet as llartl jM ttge ree®6 qlm A arch theft pats step zAN ee In raitli tho'S ru rw a tM , 1*utnani
Cowky OepavtwNat M t4estt0.
APPIOOVZO Po" CAWSYAt/CTItiNsThM a9G(6aa1_ouptr®s ldvo.yemrs, im"Aho &No 'i unl&6 cOOftruttion Of the ipiijkli g leas beaq YMertaken anA is
fedetalDp`.IOr f�tffe W tray po aarsaAsf!'ev P11 N -tO® rsfaa� :oonti mro8, y ®y, the ',Cori+iniuigrt -of Mml4lL - An' cM_ was or a toietion of conftruetloli
sr®tdrm�s ` .i/assv itwiwtt. 1MN®Oaneaet Rat a waBEr 6uMM On1Y
9�8Y,
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL P-CPAZZ2
PCHD PERMIT #
WELL LOCATION
✓ Street Address Town Vil a City T x Grid Numb r
5 rJP_ a 7TH ® la ' - _/ -
WELL OWNER
Name
SSo
Mailing Address
0 4� /LO z_g
OPrivate
O Public
E OF WELL
1 - primary
- secondary
O RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
D INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT 97 gpm /4i PEOPLE SERVED 9 /EST. OF DAILY USAGE d� al
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13 ADDITIONAL SUPPLY
ELNEW SUPPLY NEW DWELLING1 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
C'
WELL TYPE
DRILLED
DRIVEN
ODUG 0GRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ep
Lot No. 22
WATER WELL CONTRACTOR: Name :017 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X_NO
NAME OF PUBLIC WATER SUPPLY: A)IA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: Nrj9-
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
MON SEPARATE SHEET 1V Z�
/D
(date) g si nature)
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 contat'nate surface or groundwater.
Date of Issue: 19
Date of Expiration I 9:�q Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
3'
:1
'.'re.'
PUTNAM COUNTY DEPARTHiENT OF HEA'
- r ' - T -• ; j "•• H )IT SE VT. ME' APP-17. 77D l'uR
r4
800111
"ASTER +BEDROOM
— B'D?OGriS
BEDROOM a 17•-0
2 o
� 1s.•B..
13. O•' x 15'•8'• —
1 as- L•.�.�i�
S Qnature f I l c i
STUDY
SECOND FLOOR 4828 = .-1344SF
48'
•• KITCHEN ' i . -
yMo
k s,Ko,
DINING ROOM p MORNING ROOM
13'0 "a
s
IN
OPEN '
ABOVE
LIVING ROOM w
ROYER �•
- - --- -w- ---T.... - -- — . _
FIRRT Fi nnR
FAMILY ROOM
13' O•• a 1 7' 0"
4828
Tai
U =
BATH
=
L6i�ll•.
•.�
BEDROOM 4
;�
•�.,
g DRESSING-
W-8 x 12.0••
BEDROOM 3•
WALK*
—
IN
13' -0" x 10' -0"
��•!
CLOSET
1
PUTNAM COUNTY DEPARTHiENT OF HEA'
- r ' - T -• ; j "•• H )IT SE VT. ME' APP-17. 77D l'uR
r4
800111
"ASTER +BEDROOM
— B'D?OGriS
BEDROOM a 17•-0
2 o
� 1s.•B..
13. O•' x 15'•8'• —
1 as- L•.�.�i�
S Qnature f I l c i
STUDY
SECOND FLOOR 4828 = .-1344SF
48'
•• KITCHEN ' i . -
yMo
k s,Ko,
DINING ROOM p MORNING ROOM
13'0 "a
s
IN
OPEN '
ABOVE
LIVING ROOM w
ROYER �•
- - --- -w- ---T.... - -- — . _
FIRRT Fi nnR
FAMILY ROOM
13' O•• a 1 7' 0"
4828
Tai
'
LAURENT ENGINEERING
ASSOCIATES, RC.
%
73 FAIRFIELD DRIVE
PATTERSON. NEW YORK 12563
X.
914-278-6108
%%
\
CONSULTING SITE ENGINEERS
Date: 10 -30 -92
To: Job No.:
Putnam County Health Department 92081
Project:
Route 312, Geneva Road Fill Permit - Lot #22
Brewster, NY 10509
Attention:
Mr. William Hedges
Cornwall Ridge Subdivision
Patterson, N.Y.
Gentlemen: We enclose (4 ) copies of:
B/W Prints ❑ Reproducibles ❑ Reports ❑ Tracings
❑ Specifications ❑ Memorandum ❑ Copy of Letter ❑
Description:
SS -1F "Fill Plan"
Revised per your comments.
Sent Via:
EN Our Messenger ❑ Blueprinter
❑ Your Messenger ❑ Hand Delivery
Copy to:
Revision /Date No.
10 -27 -92
❑ First Class Mail ❑ Special Delivery
101
Very truly yours.
LAURENT ENGINEERING ASSOCIATES, P.C.
_.4 .Ii )- i.fa
PUIMM COUNTY DEPAMIEM OF BEALTH
DIVISION OF EWIRCMaML HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SE3QAGE DISPOSAL SYSTEM FILE NO.
' S
Address � P2 W 7 B REN STE2 ti y Owner Td 0
Located at (Street) q7,n P5:141RE G0lJ2T Sec. 23 Block 1 Lot
(indicate nearest cross street)
Municipality VA-F 2SONJ Watershed G1<9 TOI`1
Date of pre - Soaking 6,1 9'_4
Date of Percolation Test
Co %�
HOLE
Nth CLOCK ME
P�_..F" tCQLATION
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
51 PO -3'05 ;05 I 22 25 3 2
?1 -I 2
3
?T-2
12 25
�2 2 25
4
5 •
9
3
2
2 .3'. io -3' 22 : IZ 22 . 25
3 3'25 - x'38`:
4
5
1 .
7
3
5 T.
3
4
5
NOTES: 1. Tests to be repeate6 at same depth until approxiasately equal soil rates
are'obtained at each percolation test hole.:. All data to* be submittbd
for review........ .
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE'SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO.
G.L.
1'
2'
HOLE NO. 2. HOLE NO.
3'
4,
5'
6' izoGlG 4',�„
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNUq2= IS ENCOUN'T'ERED
INDICATE LEVEL TO WHICH wATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: 12L(/L M, P9 cff,2'LI WS Kr DATE:.
-- DESIGN
Soil Rate Used -� Min/1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity 2 5 p gals. Type C-GNG
Absorption Area Provided By +&v L.F. x 24" width trench
Other 3 ' I L� _'c� °F oo
Name LadrZOVT tW& , A-5506 -j e C , Signature.. oc
w
0
Address %�� rR �� IA fJRl V E SEAL
J'F O No. 56124 ��•
g'�J 7TE2s�nl . 'Al l� I ZSICo j A9OFESSI�NP�.
THIS SPACE FOR USE BY,HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
R
PUTNAM COUNTY D E PARTMENT O F H EAL TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applic ant:
S�Oi -�- �2f�550.
)24Ap f2g 7
2. Name of Project: 15�'120f7. 55r75 3.._• Location T/V /C: �g77 2S6r�1
4. Project Engineer: 4Ag1ZY W. AJ ;640L5 ,JI2 P. 5. Address:-?
)-i..
A .... t t�fI77�2sonl. J�' lZS�3
License Number: Phone:
6. Tip of Pro.iect: " ,• ;> is : _..
1- 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 (SEQR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted �C _
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. xi0
9. Has DEIS been completed and found acceptable by Lead Agency? ........... A/ /A
10: Name of Lead Agency
11. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ........................................ lll�0
12. If so, have plans been-submitted to such:. authorities ......................
13. Has preliminary approval been granted by such authorities? N Date Granted:_
14. Type of Sewage Disposal:System Discharge...... ! Surface Water _?Ground Waters
15. If surface water discharge, what is the stream class designation ?........
+6. Waters index number ( surface) ........... ............................... 1ll�i'4
17. Is project located near a"public water supply system? .................. N a
:8. If yes, name of water supply M Iii- Distance to water supply 1`1
;9.
Is project site near a public sewage collection
or disposal system ?.....
X10
'O.-Name
of sewage system IJ�/�
Distance to
sewage system
A.
Date observed: %1r5 23. Name of
Health Inspector:
M,
4. Project design flow (gallons per day) ...... ............................... 9470
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. X1/0
26. Has SPDES Application been submitted to local DEC Office? ...............
27. Is any portion of this project located within a designated Town or State
wetland? .................................. ...............................
28. Wetland ID Number ........................ ............................... Jul
29. -Is Wetland Permit, required?•.. ........................................... n10
t
Has application been made to Town or Local DEC Office? ................... N A
30. Does project' require a DEC Stream Disturbance Permit? . °.... °............ X10
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 0
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ........... nl�
34. Are community water, sewer facilities planned to be developed within 15 years ?.
35. Are any sewage disposal areas -in excess of 15% slope? ........................ N
36. Tax Map ID Number ........................................................
37. Approved Plans are tobe: returned to: ................ . Applicant �X Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application must be-accompanied by y-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 Hisdemeanor pursuant to Section 210.45 of
the Pena] Law. i A
SIGNATURES & OFFICIAL TITLES:
TAILING ADDRESS: '3 PA lrr -f5Ln TT2, , s�'r"iT���0n1, MY 1Z5_10_
0
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9
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I� I WELL
Iel _
I -
I
I FX /ST. 4 BORM. R,5SIOENCE
I
12
13
14,
15
16
17
18•
19•
20
V.
/250 CAL.
SEPTjC 1
TANK
R�N�N
y
I,
DECK I
Ii
SITE
PTOF'�i��
TAX MA P
i vision o:
•pproved a;
ipplioable
Putnam Cour
C
3i
PROJECT
C
SECTION TP
PA•TTERSON , W
CLIENT
7Acl ,a,L
AS -BU /L %
D /MENS /ON CH,9RT t,"2N FT.
No.
A
5
/
35.00
46.00
2
50.00
58.00
3
55.50
63.00
4
60.50
69.00
5
6600
72.00
6
7150
78.00
7
7700
63.00
a
63.00
69.00
9
88.00
93.50
/0
9400
9900
!l
99 50
10450
12
54.00
9700
0
59,50
100-00
14
6500
/02. 00
15
72.00
/05-00
16
76.00
/ 09.00
.17
83.50
/ 13 DO
I8
89.50
//700
19
9550
/26.00
ZO
/0/.50
13J. 00
Zl
/0700
/35 50