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Any pirfon occupyhq premifts ferved_by the: above fystpm(q shall_.promptly take such actbn.as matt' be neem t0 Nwn tM coiraetion of Any, dnsankary
conditions risuttlnq from such" ufape Approval of tM fepante 'swam system flMll beoona "ll and Vold of icon as a pout aanRny Miner become.
available and the apopoval of n e p►ivat water fuPDly (hall become null and void wMn a publk water supply bleoeia avallabli. SUCK; apOroyals, ae
,.. �,. �. F �' ct t xv� J
subject to nadif,la4bn or ,chanya when in tM )udym nt of,th Corgmiubna oR :14iaRh. cis, re4ogtion, modification or change is necwany.,
Date
3/89
ry;•r . rynmm CVtJI'lii DL.CL'ILC.Ll7Ci`fi OF HEALTH - -
U.tVJ.51ULV OF ENVI.KiAVrit' IAU til:1w1h Sk;KVlt. t: b
e-..._ . .
owner or Purchaser of Building Section Block Lot
Building Constructed by
Location - Street
i►zunzcipaJ,itY
w e Z C-
(_
Building Type
Subdivision ivame
.7t1L7.1.1V1u1L ' ll lrU l,. �f
GUARAN= OF SUBSLtWACE SB�GB DISPOSAL SYSTEM
T --- ----4- i- b.,,i- T yrn iot %^•1 1 cs nnA ^evnrtl o4-cl 17 rgm_- a i i-.l m 4:^ v- X1.0 1 rwa+ -�% ww
L' F•�. LJL �J••...JL WI.L .. .Y W.• �� ..=r ~��, � .Yr M...... Yr ♦ti V..•.. vr.V..,
workmanship, material, construction and drainage of the sewage disposal system.
Cr•. ng hV V 7cw j �t �t t In }room r lnatru-'rtee we c,hMM Cn
�� -�L, LL ���L� • n�� �- S LL LL the approved UJ.dt1 ui. aupi:Gvcu a Tea' uCnt 1.11CLCL•Vr d11u Lit dL>-:V �ud11L:C W.L L.11 6110
standards, rules and regulations of .the Putnam County Department of Health, and
hereby gutatulL•t t.0 ulL l uer, 11k� sac- cessorst 11C.L15 v�, aSSiyitSr CO pLacC Zil guGu
operating condition any pat L ni btL.IU 5y5 Lein UUIls Lt sic: Leu by' JUL- wilic:ii iaiis LU
L - L. r— ' i 1. .w j' 'w..•�.a ; J- ..'!.. . _1 1 • L.L... A-4— 4 1 F 4-1-
CjXe at=- for a iC" Of Lwv Year iu. aL.GLY L.u_L%JWAiy, La.G Vat-= QL appivva.4 v1 LLtC
"rArtA f carp of Construction Compliance" for the sewage disposal system, or any
. _. - .....�_:.... ......7.. L...' np a-.. ......L. •....rl Z•.w .w..�r.�.nJ. .:T6.,•�.r; . ki..' CU! l 666 -W WWrl- &4A'-C ......,kM..1 .• i
1 {taµtr._U2'_.11tG,. _.LV__.7 LL\.iA ..- _►���7.4Gt1r. Y•1144{/.4 _R6LV+.4 t.aiL.. A.Mii \ii G- t..v Vj./C:iu VG• ii/i- Vi./Gr.Ls. _.iV
1-%17 4-1ha Willfi,l nr noellimzM+' ar4: t_1f i-11a nc-r!1`rAn+_ elf 1+0* hlildinCT titiliOnlF
the system.
The undersigned further agrees to accept as conclusive the determination of
r _L rte_ -._ _L_1♦r__T LL n. _G a. t. � •. � �._
i.'11+.! l/
-! i (C:L:iAJL LJL L.11C ULV151•Uil UL "AV1.i WL9I=1' ^' 11CGLLi1 . LY1L.CJ UL 1.110 LUL.11GL{L L.VUlIL.y
Department of Health as to whether or not the failure of the system to operate was
1 1 • .: 1'1 �... -.- _ -� _� -.L' -�i .L LL ...._...L .1 LL L. -. 1 J_. ..L. I �S.
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the system.
Dated this day of•_- 1990 Signature
Ti4lc VAC \��ci��22v
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Corporation Name (if Corp.)
Cnrmra t i on Name (if Corn, ) _7 G_'IZ !r-D 4 LC� -i L L
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3 Owbitt+';O�pirtnwnt:'of Niat tl, a' tAat on,eotnpation ttiNaOf a- ;Certif{rjta of Lcoeitiuttion=COmplianta' satitfido y to t1ie3Commissbna► of Naakhwill
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APPMLK B
PUMUU4 COUNTY DERAM U OF HFALM - DIVISICN OF RMTRORMEAL HEALTH SEEM. CES
IDIDIVZD[gAL WATER S'JPDLY & SUBSURFACE Sc.n&C,E DISPOSAL SYSTEMS
ME : % REVIE V SHEET - CONSTRUCTION P7RMIT
DATE REVI -E-W sD• 1171
aMAI 7AIA I rJ.) - -NAIRAID tqAic , ?,#;rr
(142"ume of Owner) • • ( Street Location)
CCMM NTS
YES I NO
I
I x I
i
I
i
I
.D • ERI'!i
I j
IF trench. provided 00
recui=ed _0 0
60 ft. max.
�e,00"Parellel to contours
100% e-xp.
I Y,
I
1
I X I
I
SLOPE SDS 1
I i.
I I
FILL SYSTEMS
-°-
—
cl avbarrier I
T
10 ft.
fill notes
new so,-c. = % 'll
depth gauges
100 vr. flood elev. I•
200 ft. reservoir, etc.
P,
150 ft. trigall /gall.
r
*
DOMMI S .
Perait ADolicstion
.Coroora-t 7 Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Pe_rc Hole Deoth
s/s
SMIVISICN
per` ---7-
(3) Fill /sl JCS
c3
House Plans -Iwo sets
Well pe= t; R; s letter .
Variance Reo'sest
Gr � "---mss
Leal Subdivision
Sumi-rision P -ooroval C' e`:
S
"{.
PU1 A COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIPtONMENTIAL HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. _ --
'
Owner f�.�ico•c J 1,Jnv✓-Tzi�Er L%ro Address 7
Located at (Street) �- V.),o,J �. v/` y'', /^�a sec. dock Lot 2
. ( indicate nearest cross street)
`rr Watershed .tJ• �C,
Municipality 7--1 j hR -T ,' _tea J ;x�.y
• • • �1• �• � •' Y�. 1 � Y• ' �• 1' �• • 1 III • • •
Date of Pre- Soaking
Date of Percolation Test
2
3
4
5
1
2
3
4
zn� ; . Er.
6
5
i
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained.at each percolation test hole. All data.to'be sukmitta3
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
HOLE
NUMBER C.L,OCR TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water From
Water Level
No. Time Ground Surface
In Inches Soil Rate
Start -Stop Min. Start Stop
Drop In Min /In Drop
Inches Inches
Inches
2
3
4
5
1
2
3
4
zn� ; . Er.
6
5
i
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained.at each percolation test hole. All data.to'be sukmitta3
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNT M IN TEST HOLES
DEPTH - ._ -HOLE NO. HOLE NO. -- - -- -- - HOLE -NO.
G.L.
1'
✓Lp 12' j A 6�
3'
4'
5'
6'
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: DATE:
DESIGN
Soil Rate Used % Min /1" Drop: S.D. Usable Area Provided 5-av-i;
No. of Bedroars ' of / Septic Tank Capacity /ZS-0 gals. Type ao -rz:.
Absorption Area Provided By ren L.F. x 24" width trench
Other / "7— 0.
Name Signature
Address ap SEAL
THIS SPACE FOR "USE
Soil Rate Approved
HEALTH DEPARDTM ONLY:
sq.ft /gal. Checked by
0.
0531A"
�AROFESSIONp
: pUINAM COUN'T'Y .DEPAFnNT OF BEALTH
- DIVISION OF M rnaM 'ML ML01 _ SMWICE.S
DETncHGt� RE3W m", MA ..- aLc Ej!t y�
__. DESIGN DATA.. SHEET- SUBSUFACE SAGE DISPOSAL - SYSTTM- - -- __ . _ :.FILE N0. - -
• � "' 9(0 1�14iW.1 STRC.ET �Sv ETC D�
Gamer LEnE2twWAW.1 -_ t#oRGH.....' Addres�.s3REWS- ��/ IOSoy
HAY•1LAW•D tAZIYG AWJD.
Ipmt6d_ at _ (Street) - Bli W..M-osToNE- -1f WL;L.. ROAD Sec. 18 Block 3 Lot Z ;
(indicate nearest.cross street)
Municipality �A �' �'E 2� Watershed C 2 07-0= .
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMIT.i'ED WITH APPLICATIONS
Date of- Pre- Soaking W ]. Z_ s/ 8 (o Date of Percolation; Test - i Z s 'Ps 6
t-o'T • 3 roc? :L .
,.
CT�OCIZ TIME PEROQ=ON. PEROOLATION .
Run Elapse Depth to Water Fran Water Level
No: Time Ground Surface In Indies Soil Rate
Start-Stop, Min. Start Stop Drop In'. Min/In Drop
Inches Inches ..Inches-
1 ►o : I Z - lo,iz 17 Z4- Z7
V. 2,1 :.- io : 48 Pa Z.q.... Z7
3 ioAq , .07 lE3 Z4 Z7 3 o
4
NOTES: 1. . Tests to be repeated • at same depth until approximately equal. soil rates
are.obtained.at each percolation test hole. All data'to'be sukmittod
for review.
2. Depth measurements to be made fran top of hole.
l so, ► ►o :3
Z6
Z
Z7
#Z 2
Z °o
Z
2.7
3
3 JP, 1-7
Z t
Zg-'
5
2
NOTES: 1. . Tests to be repeated • at same depth until approximately equal. soil rates
are.obtained.at each percolation test hole. All data'to'be sukmittod
for review.
2. Depth measurements to be made fran top of hole.
AP-1 / • V. • �� 1 /• �/ 0
DEPTH HOLE N0. i HOLE N0. Z
G.L.
C� Torso 1-L To �`xi1L
2' r« !, mp V LL V LL
'1 ``' M P1ovt,.P "QS LociM w Ps�uc,P'¢S
3' a _J z. r'
4' u .
5
a >..
61 ujuj .,
7' ROCK
$r
TH APPLICATION
TEST HOLES
HOLE N0.
9'
10'
12'
13!
14'
INDICATE LEVEL`AT WHICH GROUNDWATER.IS ENCOUNTERED
INDICATE .LEVEL 7b WHICH VATER LEVEL RISES AFTER BEING_ ENOOUNTERW
DEEP .HOLE OBSERVATIONS. MADE BY:': M. Byp2I tjS�,-1 CLARK + DATE: 11 4 as-
DESIGN
• Soil Rate Used (6-7 Min/1" Drop: S.D. Usable Area Provided 500 o .-S t=,
No. of Bedrocmn . 3 Sept ic "Tank Capacity 1 000 gals. Type
Absorption Area Provided By 3 0 0 L.P. x. 24" width trench
Other 1 FOOT 1 I-L
F N E W
Name ►ZA W-C> o g_ j�? i-i _ lJ� . L A R� NTH �. E . Signature
Address 7 3 _FA I Tz 71211ye SEAL. El 0 z "►
• �A-�-u Rs� Ny � y 125 6 3 l`�`d ti� � .
THIS SPACE FOR USE BY HEALTH DEPA ONLY:
Soil Rate Approved s4-ft/gal. Checked by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
- AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
QUAi L /�-- I r,6 C eoz,) l
X :13 we,
11vrlvl x7v-,_ 47 � 1
I, O2Alopi
represent that I am an officer or employee of the corporation and am authorized
to act for iv t Co <- J ,_/4)71'04-?"2 / a-Nr, ZTO.
having offices at
(Name of Corpdration)
Whose officers are:
President: rAc�Zy,��LA2�
(Name and Ac
Vice- President: 2i.prJ
ress
/z C$ O-P�Je-zl l.Jry � a%•
Name and Address
Secretary:
(Name and Address)
Treasurer:
(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.
Sworn to before me this 7 day Signed:
of rQP�� L 8 9 Title: OeA
ota Public
JOSEPH A. GHIRARDI
Motery P ih� +r "ork
QuGi;:::.:: '.;aunt --\\
Commjssion Expires Swember-3Q 191.0
8/84
Corporate Seal
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93
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' 44.75
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9
50.75
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51.5
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L�i✓q�f T,eG,�/cy 2EQU /,e�1� Sroo��'
PP_o v. /1" 0 �foo c
i
1:
"This is to certify that
the s_oa7e dis-x3sal system was constructed as indicated on this plan and
that the system was inspected by me before it was covered over. The
_system was constructed in accordance with all standard rules anti
regulations of the Putnam County Department of health and the N'ai York
State Department of Health."
'"'LLdLI I.ULLRLy Ley:yl'�mtlu� �.
nvlsion off vino ental•Realtb Servio-
iPProved as. note = conformance with
IPPlicable Rules and Regulations of the
Putnam County R th Department.
- Qi®atnre.b s Ao
S�P�EOf NEW yc