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HomeMy WebLinkAbout0865DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25. -1 -49 BOX 10 11:. ' I I 1 L Y ' .. 11:. "�% . PUTNAM COUNTY DEPARTMENT 'OF HEALTH . ENGINEER ;MUST :. \� '•'.. _ T. PROVIDE-` Division of - Enlriroifinenisl 'Helix /tl'►; Serwcea, Caime% N. Y. ,10512 RERMIT # 3Y6 CERTIFICATE -: NST.RUCTION COMPLIANCE FOR;SEWAGE- •DISPOSAL'- :SYSTEM ��z- /2�cc�,4J :' _ r i$..3 -9- Town o Village _.__. Na _ - Located .at IJWJ� -�+11� �7 Vt ✓19-i t— ? I)C.. £' x tiitSi4��!/ ' • Tax D �T70 aloox r Owner I JC_01LAJ -TVjDVC �� Formerly Tax Map Lot # © S.M. It k �O LTb Separate Sewerage System built by. 1JA91G-i,^L.iJ �.ti✓+�. 135T7Lf 920 Q p r ` i-5 r Address consisting of Gat. Septic Tank and Ad � one- if e �.. Other requirements 6. Water Supply: Public Supply From I VL �w -( EE' r-htr i4) Private Supply, Drilled By Address Building Type No, of. Bedrooms Oat Permit Isued Has Erosion Control Been Completed)" Has garbage grinder been installed? N� I certify that the system(s) as listed serving the above premises were - constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in.accordance -with the standards, rules arA regulations, in accordance with the filed plan, and the permit issued by the Putnam County Department Of Health. Date Certified Dy .� l2a��rtun�s i��v� . f /o :SIB' o a Address -- -� License No. `� f3/ Any person occupying premises served by the above- sys,an_ shall promptly-tako such action'ss may be necessary to secure the correction: of any unsanitary conditions resulting from such usage. Approval of the separate. sewerage system 'shall tlecOR10: null and void as soon as a public sanitary rower becomes available and the approval of the private: water supply shall`6acome' null and, hen a public water supply becomes available.. Such approvals are subject to modification or change who in the )udgment._of.tha Commt over Health, such revocation, modification or change Is necessary. Date H �6� BY . TRIO .' a.Rev. 6/85 .. -a e y -a. I a PUTNAM COUN`T'Y DEPART OF HEALTH _ .DIVISIO!q .OF ENVIRONMENTAL _HEALTH..SERVICFS- -___._ Uvilcu ldus-klej W Owner or Purchaser of Building U,ii curl Ind 1157fiLs ��A Building Constructed by bp►Wa Location - Street I I (�e /o Section Block Lot &PI, t At* d 6 Subdivision Name P'J_ A) /0 Municipality Subdivision Lot # Building Type GUARARrEE 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 immediately following the date of approval of the "Cer -t- fiea- to - -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 1()+ day of JAtJ 19 q Z Signature Title General dbntr�ctor (Owner) - Signature VniCo24 INd y A eS UcL Corporation Name (if Corp.) Z owe_ A& PetU :II uV 10SU Address rev. 9/85 mk :� Pro Tea MAV al�e1L Uri catJ .end uj_r6 y Corporation Name (if Corp.) S S4owe M &10 N,V I_oS 6 6 M, re - C_R L..JrT' _ i YES NIG C_i �'r? -S SS 2r c:=- Dam G_ t r — LTG u C c'" �tr"J. == I I 1'10 t C='L�- "sYC I , - ! z ? _J c_c t .000 % =0 -_mac =_ s_ == _ I ! so P=c` =�'= == mac.,; _ .: D_s -c= -___ - c _ ! E. Lo fa _ _ =_ cr =% '--_ = - 20 C C i - C Cam'-. ?, - 7 _'t r i =•_ ! i iJ_ C-f C =vim 1_l L_C3 2 cvarf Cy A?;=­,1r_ -='��= C. "•• __ -� -.- C.. -._T 1 r'.C..,,.G- ..+. 1. y _ tYr—• ._;_` i 1 1 C( —• G� L ►_ a=c-,;,ea 11 __ _ SEDS a c_ C ==mac 13 �' era c��__ I ( i ;a- cv_ a kLFcti1 =�=� j C_ ��� ri ces =�� ^wi`'1 i= �_ce cz C_r.= =; lc SAC ^Er < 1~ C_- - I I I E_ C .z i '2 c= =; _ �-+ i nC t7 F. C_ ._ l -_ C::� _ L'� L?�� Fs G__ _ I:'� Ev-� -cam -tic �..L• - I I ! 571L L C_ F',CL_nc Cr= C_.i =_c=C° cTcV f =vu _ �.c..ca c= —_ = � c. c ;: =cam; cr• s_cc= i_;_ e — - y S� t' PDTNAM C 'UNTY DEPARTMENT OF HEALTH Dlvlsloo Ibsv6pomentalHealt6 Servkeo. Qnnd. N Y 1051? ro0 on CERTH+ICATE OF CO CT10N ERIYIIT B 9M. w ;DLSPOSAL SYS?EM , n o Beuewal_ O ReAdon I Ownei /Appl{eant Nam r; Date /9 E ofPrevloao:Approva) © Bf Addree_i =�f�l:w2 7�eic -3� ; ' Town 9Zip GT ! � MfaWug nP4: yMon Lot Ares D.59) /� Fm seenoo Z t OPIY 'Depth Vdome�D— 3 l OD PCHD Notl9�tlon'lo R When Fil b com ted Number of Bedrooms :Design Flow G P D• Md Pm j Sepento Seweritge System to couaist of o o Wei Septic Tack ana a ier..ic is -- Td be consteacted by Addeesa 2 STdw Watei SapPb o"n. Q.PPIY u.4rt_` F�DC Addteas ? { orr = � Private Stplply DrWed by s- j Othei`Ee,�4ements � 2 n;�T ^•A�� f"" ?i,; Ireprosent that I am wholly and,:eompletely responsible for.the design, location Of `tha proposed systein(s) 1).;thst t e�sepa►ste sewage disposal, system i above•describetl will be`constructe0 as shown on thdappiove imendment:there'to and - --accordance wrth'the stindard"'i ws an regu ions o a u nom ..,_ ._. County .Dapa►tmant oi: HMKn - and.Mabon completion thereota "Certificate of Construction-COmplunee" satisfactory to the Commissioner of Healfltwill. be submitted to the` Department and a .written guarantee will be furnished the ownai his.sueassws; heirs.or assigns _by the buikNr, that said builder wilt ; 1 - , ,, i; place m -good, operating congition any, part'or said sewage disposal system durirq, tha periO4 "of two (2) years Immediately following the tlate,of the ifsu f. 1 rr once of •the ipprova `:of ,the Certificate of Construction Compliance'of the oryinal sy- _ .-,or, any repairs thenfo 2)'tMt, the tlrilled well discribe above ,, • 8 wily be loafed as shown "on -the epp►ovedrplan. and thatsaid well will be _ ' ae a with Ahe' stantlartli,�- rubs a n d regu axons of the Putnam County Department if: Health ,1 Diti; /�- ¢ --�1 %, ... S Wnad �n� 0 E. R.A. L- r 1 `� Adtlress �w i'_� ti'C �. % o ..r �, %7L7S 1. n r7 /0 8 License •fVO_ O. 3� . .APPROVED FOR CONSTRUCTIOW This approval expires two years -cfrom the- date ;issued unless construction' of Ahe building,has been,' nder" nand is revocable for causetor may be=amentle0:or modifiedwtten,consider`ed necessary "•by. the;'COmmiiysionsr of:- tisalth. An y change .or. altor -t qv of construction .� ;i , requires .a •-new Permit _ ADDrovsd fo /,disDOSaI of dornestic sanitary s"ge, and /or,- •.private' water.,.suDDly only. ,Rex. _., - a z.. . - 1/87 Date : BY Title.. Ou e►vwtovEO a =oea.CO" fMOWM,fck cause M n f00YN@B a: now, permit. y -s. Iw m {at ®,Iy:QOilo tRp „thedat® of 1114 {aeu- o. a) tnoe the drilled well �.. a” Above -PYMa BRdl 8 O�_Q .Of . -ill ®, 'PY�IIUT t.it0nse Fd0 ,construction 04 the building Ihas o6on under ken and i8 wr of Health.. Any change of alteration of construction __..... ........_....:__ _ .�.. _ . _.. _ T,*x MAP #:.. j�• 3�, - 3 -� APPMIX B _PUTNAM COUNTY DEPARTMFIU OF HEALTH - DIVISICN OF ENVIRONMMAL HEALTH SERVICES INDDTIDUAL WATER SUPPLY & SUBSURFACE S I&.GE DISPCSAL SYSTEMS f' a _ _.,_- _.... -11 V]_'W SiiEET —CONSTRUCTION P�MIT S'(fB L''T# 10- o f�11�1(_' %Ipltl IND. DATE REU EKED: / 0 17 I TA DANAo La, BY: ,�PT1i _M, (Nmme of OwnA= (Street Locaticn) cav-%XNTS NO DOCiIR N 10' to Water Line (pits -20') 50' intermittent drainage course Seotic Tanks 10' fran Foundation; 50' to well ' Well to PL 9 Pernit Application ' I Corxrato Resoluticn Plans - Three sets s/s Engineers Authorizaticn I Design Data Sheet (DOS) SUEDIVISICN Deep. Hole Log Consstent Perc Results (3 - -, 3 70 e Perc Hole Depth _ _... - House Plans - Two r- I --- f -- Well pe<r-ai -- -I-- -- Variance Recrsest II I gas �� � o 1 Leal Subdivision I I Subdi lr -sion A- .coroval I Ex-ao prcval SSDS Adi. Lots Cie:k wet'-and (Tcwn/DEC Pewit R & D) Data On DDS Pans & Pe -snit Lam, t=ench provided REQUMM DETA_II c ON PLANS r�_uired I Swage Sys wan Plan - ( north arrow) 60 �t. mom. ( ( Sewage System :Hydraulic Profile - Gravity Fl cw ellel to nto4rs I 1 Profile & Dimensi.cns - Volure I V I D ot J Box;Tre*zch /GaUerv; Pam pit de moils FILL SYSTEMS clavbrrier 10 ft. f ill notes / "-eptic Tank - Size, Mail #ell Detail, Service Line if over Construction Notes (grinder- rate) - Design--Data: - perc and deep results - - Twoa -Foot Contours Existing & Procosed _Driveaav & Slooes Cyst Footing/Gutte_r,Curtain Drains (discharge OR) Perc & Deep Holes Lac -ated Representative of primary and expansicn Expansion Area; shcw-n; gravity flow,suf=. size If Purnne3 Pit & D Box Shc wn & Detailed House - No. of Bedroans Wells & SSDS's Win 200 f-:%-.. of r8� s 'OSystemsc th Qau es Prcpe -rty MLetes & Bounds iT.back Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pice No Bends; b+ax. Bends 450 w /clesnout SEPARATION DISTANCES SPECIFIED CN PLAUN ields 10' to P.L. , Driveway, Large Tra°.,s, Top of f iI 20' _to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. ear. 15' to Drains- Cur..ain, Leader, Footing 351to catch basin, stormdrain, piDed wate-rcours l' '`100 vr. f elev. I _ I E- W PJ 200 ft. reservo' , etc. 150 ft. trigall/ I 10' to Water Line (pits -20') 50' intermittent drainage course Seotic Tanks 10' fran Foundation; 50' to well ' Well to PL 9 p a U XY DEPART[`�Nr OF HEALTH DIVISION OFRWI1UNWMFfMLTHSaMCES AETAC?iCp RE3�DSr�T'JnL C •Si uc.t.c FAM1�.y � - DESIGN DATA SFiEi'T- SUBSUFACE SII G 'DISPOSAL SYSTEM• -. - 9(o MAJ E p) ! Omer l -6l>EQ mA ttj 14oRC H Address _ti33REWS-��. Aw/ 10,_19C42 HAVIL.AWD biZJVC ANfl' Located at (Street) SZI H-_STo1-3G 14%LL: 1204i> Sec. - 1$ Block 3; Lot Z (indicate nearest cross street) Mun.icipali.ty Watershed C: 2 0 T<3 N SOIL PEf20pI.AT••LON TEST DATA RDQU= TO BE SUBMI= WITH APPLICATIONS i Date of: Pre- Soaking J Z S/ 8 (o Date of Percolation Test ! P Zs g.(, to Nth C?�OCg TIME PERaQLATION pERC0LATI0N • Run Elapse. Depth to-Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min/7n Drop . Inches inches- Inches $1 2 3 4 , Z_ C. Z7 Z Z--- - - -z L, 1 4 r­� 5 % 1 JJ :s1 _ J2 :os -'rte Z �° z•7 3 :c},7. �. 2 z 4. Z7 3 R, TEST PIT DATA RMUIRED TO BE SUaM1%tM WrM APPLICATION DESCP=10N OF SOILS ENCOUNTERED IN TEST EOLES 7.1 8' 9r 10' 11' - 12' 13' 14' - INDICATE LEVEL AT WHICH GROG IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL: RISES AFTER BEING ENCOUNTERED N DEEP HOLE OaSERVATIONS MADE BY: 'M. Bufl21 /�Sr.f r2, -S. C LAR.iK DATE: :DESIGN Soil Rate Used 6 - 7 Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms • 3 Septic Tank Capacity 1 o 00 gals. Type Absorption .Area Provided By 3 o o L.F. x. 24" width trench Other Z -'EST L r. F W Name I�A►,lyo �j�l -� l� . LAy f zmm 'Re. Signature Address '7 '> i21 yE - SEAL Ei z ti rn 4 Z THIS SPACE FOR USE BY BEAUS DEPT ONLY:' V `0� S40 Soil. Rate Approved sq.ft/gal. Checked by Date i PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services AFFIDAVfiT - CORPORATE -OWNER —, PPLICATION' FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: IrVt�obJ� -r represent that I am an officer or employee of the corporation and am authorized to act for `%milC�cNi.rU -� -� �°�S i-`A A (Name of Corporation) having offices at Cca2(�R.p11CL P,9 -P—L& V-t LL Whose officers are: President: P0.�� �ut Lc �4�0 k qQ- Mtkk (Name and Address.). Vice - President: L �p e ENV (Name and Address) Secretary: Treasurer: _ ,Tame and`Address) -`- Name and Address) t (V-0 �w�c�•.® 1�l( (l'�J I 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 164 day Signed: of �C�� 19 ! Title : �C-e Nota , T u lic Corvorste Seal PAIR m & WALZ NOTARY PUBLIC, State of NM Reg, No. 4948824 Qualified in Outct�ess Cow Commission Expires Z"t T7,1CJ 8/84 PUTNAM COUNTY DEPARTMENT OF HEALTH- SUB - Lc J DIVISION OF HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE owner UNIC04*T 0 vii ,� 5 Z),ddress Located at (Street) �%� L,�4 -!� Sec. Block Lot (indicate nearest c oss street) Municipality U s',Q �V (7-) Watershed • ■ • �1• •• •' I US 0 I-17yes 509,11A ■• Y■ • 213 win wVVER 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 K, 3 4 5 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 submitted for review. 2. Depth measurements to be made from top of hole. n In r TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DF�TH - HOLE N0. -- .. HOLE NO... G.L. 1' 2' 3' 6' 7' 8' 9' 10' 11' 12' 13' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH DATER LEVEL RISES AFTER BEING ENCOUNTERED /0 DEEP HOLE OBSERVATIONS MADE BY: DATE: - DESIGN - - Soil Rate Used Min/1" Drop: S.D. Usable Area Provided 00 O No. of Bedrooms Septic Tank Capacity Z50 gals. Type CGX). G Absorption Area Provided By V L.F. x 24" width tr ' E 1,p�, Other L L_ Name C4ielllrZ - OOX, Signatu Address 2-6- 61 S;f'�eIA1 L-lV gf % IWO SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: P. 0 Soil Rate Approved sq.ft /gal. Checked by Date N -75 ,;k I 4b/ 'A Sf—I 0 7 is &;l U ROCA I=",— V7 -PLAN Putnam County Department of Health Division of Environmental Health SOrV i0OS Approved,as note . d for conformance with apR,I, Able Rules and Regulations of the — 7 y 1jealth Department 0i 1 7 1)? 1,1 AAK R ca. 0 A­^ (DC, lay Z .z 170, yo I -r/f/5 It, -T. 7?ft-r CN -"41S 7r 7�7t� . 4,AjT� -77J,4_ Ai11 kl=A I-T'71" Z> :Z4, _0 9 73'-1* 72 '-311 A 7 72 A S 7t -'1,4 A 9 A it 79 f3s�y• A BIZ 7e. N -75 ,;k I 4b/ 'A Sf—I 0 7 is &;l U ROCA I=",— V7 -PLAN Putnam County Department of Health Division of Environmental Health SOrV i0OS Approved,as note . d for conformance with apR,I, Able Rules and Regulations of the — 7 y 1jealth Department 0i 1 7 1)? 1,1 AAK R ca. 0 A­^ (DC, lay Z .z 170, yo I -r/f/5 It, -T. 7?ft-r CN -"41S 7r 7�7t� . 4,AjT� -77J,4_ Ai11 kl=A I-T'71" :Z4, _0 72 '-311 A 7 wto# A S 7t -'1,4 A 9 A it 79 f3s�y• A N -75 ,;k I 4b/ 'A Sf—I 0 7 is &;l U ROCA I=",— V7 -PLAN Putnam County Department of Health Division of Environmental Health SOrV i0OS Approved,as note . d for conformance with apR,I, Able Rules and Regulations of the — 7 y 1jealth Department 0i 1 7 1)? 1,1 AAK R ca. 0 A­^ (DC, lay Z .z 170, yo I -r/f/5 It, -T. 7?ft-r CN -"41S 7r 7�7t� . 4,AjT� -77J,4_ Ai11 kl=A I-T'71"