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25. -1 -48
BOX 10
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'I certify that,the system(s)- as.listed serving "the above •pre Ia
of which are attached), and in accordance with the standards,
Putnam County Department of Health.,
sea were constructed essentially as shown on the plans of the completed work ( copies
rules and regulations, in accordanSp wittb th.Jfiled plan, and the perinit -issued by the
Date f9.- ` 1a Certified by
Address
P.E. WR:A.
License No.
Any person occupying premises served by the above ,system(s).shall promptly take such action at may bs e�ikJfiy to secure the correction of any unsanitary
conditions resulting from such usage, . Approval of the. separate sewerage sm shall become null and void as soon as a pubv-..sanitary awer becomes
available and the approval, of the private wafer,'supply shall. become null „d •v id when ',a public water supply ,becomes available. Such, approvals are
sub)ect to mo itiutfn, or change when, in the judgment 'of the Co` of "M Ith, revocation, modification or change Is mceasary:
Date �o T 4 BY TItle .
County DqwMpm
o.t. I tl
APPROVED F'01q'i
fsrote0le foi eamn
muk" a 1ow pq
Rev.
1Vt88 Oat®
ri
P.E.-MA.
,� uuwrisePN�
f -Lh bui10i1p.,ha8 b®IDn unONt =, and ib
Any ChsjP 6 or altw.atlon of c011ft►uctlon
m,
PUn- CMIUY DEPAr?` F.Rr OF h=U
D=ION OF ENVlnCRMML HEALTH b—z=C-�'S
_._. -Owner oz -Purchasez-of - Building Section Block Lot
UJ A (c4-.k.� 70,CCcA A- 0L,:-)Q (-4
Build=g Constructed by
Z,ocati.on -- Street
riunicipa3.ity
WO, ir�. -- - -
Building Type
Subdw vision Name
q
Subdivision Lot a.
GJARA2= OF SUBMILuACE SAGE DISMSAL SYSMI
I represent that I am wholly and completely responsible for the location,
workTenship, aaterial, construction and drainage of the sewage disposal system
serving the above described propest�l, and that it has been constructed as snc;,m on
A. approved plan or'approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Detz._ttne -rnt 4£ Health, and
,he.rebv gua. anted to the miner, his surassors, 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 iarmediately following the date of aparoval of the
"Certificate of Construction Compliancen for the sew -age &sposal, system, or any
repairs made by me to sach 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 dete=d-mtion of
the Director of the Division of Environmental Health Services of the Putnam County
Depa,r a en t 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 utilizing
the system.
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Dated this ,, tt day of OCA- 19 90 Si nature
Title c' Ce
A �.
General c6ntractor (Owner) - Signature
Corpozation Name (if Corp.
ot
C'o` me rporation Na (if Corp.) - �c�� 0���• Lakk-,�,�
AddreSS
x4dress
rev. 9/85
mk
PUTNAM COUN EY DEPARTMENT OF HEALTH
DIVISION— OF -ENVIRONMERIAL -HEALTH -SERVICES -
c Nvaq3 �k ,p.c�io JK
Owner or Purchaser of Building
Building Constructed by
Location - Street
Muni/cipality
/
/L wclG 77l "4g-
Building Type
i k -3 3A
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANPI'EE 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 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 irmediately 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 utilizing
the system.
Dated this day of 19 q o Signature ` / /�� ot/-2—
,��.� =dL� lii.•�..� / Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
I' V,4,4wJ 2)c /yi�
Address
rev. 9/85
mk
Corporation Name (if Corp.)
ess
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�Ob F'e �\ AREA = 0. 760 AC.
Putnam County Department of Health
22 h m \ \ Dt%sion of Environmental Health Services
6 52 = x 0 Approved as noted for conformance with
A
`7aR }400SE // v �lc
ap o ble Rules and Regulations of the
am oun �Halth Departmen
Signature & Title at
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tEtf NEW ),O.
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"This is to certify th at, ° �F
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the s= -•cage di< -oo-_l syste•n was constructed as indicated on this plan and Y
that the system was inspected by me before it was covered over. T'ne
system was constructed in accordance with all standard rules and
re ulations o•` the Putnam County Dena-rtmegt of health and the Ne.q Yor
State D=-� tment of Feslth• " - - -
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�Ob F'e �\ AREA = 0. 760 AC.
Putnam County Department of Health
22 h m \ \ Dt%sion of Environmental Health Services
6 52 = x 0 Approved as noted for conformance with
A
`7aR }400SE // v �lc
ap o ble Rules and Regulations of the
am oun �Halth Departmen
Signature & Title at
�
qov ter- _
tEtf NEW ),O.
P C
"This is to certify th at, ° �F
r
the s= -•cage di< -oo-_l syste•n was constructed as indicated on this plan and Y
that the system was inspected by me before it was covered over. T'ne
system was constructed in accordance with all standard rules and
re ulations o•` the Putnam County Dena-rtmegt of health and the Ne.q Yor
State D=-� tment of Feslth• " - - -
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T,4x MAP #• 18.34 -,3 --�
APP--IIDLY B =
PUI:AM CCUNTY DEPPR2MIr OF HEALTH - DIVISICN OF ENVIRONDtI'AL HEALTH SERVICES
IOIVIDUAL WATER SUPPLY &
SJS UFAC✓ SaPGE DISPCSAL SISTIIuS
' r _S =__ CGNSTxLTION- _PS- - - -- --- •- :- S(JEtOT #O
DR Ntg o bue , . BY R�vr ,yam: l 0 l7 TS
Gdame of Owner) • (Street Location)
Curs I YES 1 190 1 DOCr3tTI'S
I Permit Application
Corpora t�- Resolution
Plans - Three sets
Ens* -,i- -s Authorization
Design Data Sheet (DCS)
Deep Hole Log
Consiste_ht Perc Results
--}-_
Parc Hole Depth
ns- rDwo='-
_
ReT.ies L
SLM...D- DIISICN
C,
ci
letter
Vii` PAL
Lec-a-1 Sui d vision
Swmi-r_sion P troval Checked
Ex-accrue 1 S---DS P di. Lots (Mecked
WeT? and (Tcw-,,/DEC Ps=. * t R & D)
Data On DDS Plans & Per-ait Se-na
REQLED D=A -Ill c ON PL NLIS
Sewage Sys-an Plan - (nor_h arrow)
caace System -Hydra Zavity Flow
Fill Profile & DL-ne2' c
ol -%
D orc;Trenom 'I /C_? 1_ry; Pump pit- 3IIs
Septic Tank - Size, Detail
Well Detail, Service Line if- over
Construction Notes (grinder rate)
Design eta: Perc and+deep resuls - -
Two -Foot Contours Ex isting & Pro_ocsed
Driveway & Sloces Cat
Foot? nJGatt`r,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of prinez -y and exrzr:sion
Expansion Psi.=; shcwr_; gravity flow, sz_ . size
If Pumtr Pit & D Bo rtt-of & Detailed
House - No. of Bedr
Wells & SSDS's w /in 000 ropcsed Svst---TLC
Prcoe_r`y motes &Bounds
House Setback Necessary (Tight lot)
House Saner - 1/4"/ft- 4 "0; Type pine
No Bends; Max. Bends 450 w /clea.nout
SEP_ARA"'ION DISTP.NCrS SPBCIFIED CN PIAN
Fi el";'-
P.L., Drive=way, Large Tre s,Top of fit
Foundation Walls
:o Well; 200' in D.L.O.D, 150' pits
.o Stream, Watercourse, Lake ( inc. eT..zr:
Drains - Curtain, Leader.. Foot -ng
catch basin, stonn rain, Pined watercourE
to Water Lin
i ntemdttent
p COUNTY DEPAR=4ENT OF BEALTH
• DIVISION OF RNIInHa7ML MUN SERVICES
�ETAGt4CS� RE31D6,Ja�ryAl,_C •si �JGIC FA�r,lw
DESIGN DATA SST- SUSSUFACE SEWAGE DISPOSM SYSTR4 ' .F= NO..
9(o MAI u STRCET (6k3 jT'C c�
Owner Lc sect m .3 1-FoRCH AC MEG WS'�� . ^3%/
�-IAYIL/�ND DTQIVC AIJD .
Located at (Street) sy-,I MSTopa6 I-+IL4 RoAT> Sec. _-:18 Block 3 Lot !# z
(indicate nearest cross street) —'"
Municipality iTA 1• TE M-Sa J ' Watershed C R e. -ro
SOIL PEftCOLATION* TEST DATA RDQUIRED TO BE SUBMITTED WIM APPLICATIONS
ki
Date of Pre- Soaking 1 z s/ ac. Date of Percolation Test 11. z s- / 8 6 :
t -o-TN --
UMBEF� -9 ..
TIME....:.. - PEItaQLATION • ' �ERCIOLATION .
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
1 I1 ;45- )1;53 , 3 �4•.. Z%.
W. j 1 21i:s� -
3
I
3 �7 3 S.O
4
5
l 11"V7 - ►Zr.oa :1.3.._ Z 4 . :. .i7 - -
z iz ;o i- l z'.Is f4 Z 4 'Z7 3
�7
• Y• 00M 1• 21 DEM k93 I WIN IW WONT19"'NK I
IIAWMI
[ i�D►
_ 9
I .,. -
3'
4'
5'- RO C. K 1'2o C. 1C
71 _ ..
81
9'
10'
11'
12'
13'
14' _
INDICATE LEVEL AT WfirtCH GROONDRATER, IS ENCOUNTERED Nom c
INDICATE LEVEL TO -WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED nM /Q IEZ
DEEP HOLE OBSERVATIONS MADE BY: M. Byo't1 j,3 rZ 'S . CLARK BATE:
DESIGN
• Soil Rate Used to • 7 14in/1" Drop: S.D. Uiable Area Provided 5 oo o S .
No. of Bedrooms - 3 Septic Tank Capacity i o 0 0 gals. Type
Absorption Area Provided By 300 - -L.P. x.24" width trench
Other Z
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
SEAL
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Soil Rate Approved .ft✓3a1. Checked _ - --
� bI' -- Date
i
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
_ AFFIDAVI-T_ CORPORATE -OWN E-R--A-RP-L-1-CA-T-ION- - - - - - - -
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
f�vr L ✓off V.1 .
represent that I am.aln� officer or employee of.the corporation and am authorized
to act for
(Name of Corporation)
having offices at
PA .P—" V-t (,L
Whose officers are: -
President: — t 94-
V1
(Name and Address)
Vice - President: t LO.e \ 1i�1I (l�J
(;tame 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 /64` day
of C�� 193
Not a , _YU'S I i c
PATRiC1A S.
NOTARY PUBLIC, Stale Of NO %6 .
Reg. Na 4948824
Qualified. in Outchest Ce f /
Commission Expires ir+arch T7,11G�
8/84
Signed:
Title:
PUTNAM COUNTY DEPARDENr OF HEALTH- So 6 LOT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM _._FILE NO._...._._ _
owner UN %A41IA U- % �'f � 104dress CD
Located at (Street). =V_ __AjA j0 � � .. Sec. 'rM Block Lot
(indicate nearest c oss s t)
Municipality �,� �''Ty�",GS'� � �T Watershed
SOIL PERCOLATION TEST. DATA, REQUIRED TO BE SUBMITTID WITH APPLICATIONS
Date of Pre- Soaking Date of.Percolation Test
HOLE
NUMBER CLOCK 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 ..-
2.
3
5
2
4
5
1
2
r - -- -
4
y.
5 t
NOTES: 1. "�T.Osts''to��be repeated at same depth until approximately equal soil rates
are obtained at each percolation test-hole., All data to'be submitted
for review.
2. Depth measurements to be made fran top of hole.
TEST PIT _DATA R
nVgf10TmTTn1
UIRID TO BE SUBMITTED WITH APPLICATION
OF SOILS ENCOUNTERED. IN TEST HOLES
DEPTH HOLE -NO. _.._ ....._.. HOLE . NO. - HOLE-NO:
G. L.
1'
2' }Y
3'
41 5-V ..
6'
9'
10'
11'
12`
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED /V U /V
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: Sj 6P. DATE:
DESIGN
Soil Rate Used Min/1" Drop: S.D: Usable Area Provided 5L ..0.
No. of Bedrooms Septic Tank capacity U60 gals . Type C'AJ G
Absorption Area Provided By L.F.' x 24" width trenc
A aVF
Other —T
s' NEw�roR�
Name �/l��'1 --� �iel� =- Signature " f
Address. 6/ SP2�a���'��' % SEAL,
ZJY 0
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date