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Rev. 3186 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512 a \
,. Engineer Must Provide'
P:C.H.D, Permit IY
n , CERT�IC F CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL.SYSTEM _ ' ••_ - -
d'
j _ ��yy 'Town or Village'
Located at --t `-� Tax Map a" 1, ' Blo *. T' ot 7i
Owner /applicant Name 'J 424 � Formerly Subdivision Name _ tibdv. Lot N
Mailing Address A Zip Date Permit Issued ` M 12 "..7
1� OIL
Separate Sewerage System built by, t1k444VK Address - -ti u.
Consisting of Z� Gallon Septic Tank and '3 t30
r
.Water Supply: X Public Supply From 4y Ail &A4n -_= Address ,
or: Private Supply Drilled by Address
Building Type lr� y9 .tiw-�� _ Has Erosion Control Been Completed? hA2
Number of Bedrooms 3 Has Garbage Grinder Been Installed?
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown o the plans of the completed work ( copies
of which are attached), and in' accordance with the standards, rules and re , in accord ith f led plan, and the permit issued by the
Putnam County Department Of Health.
Date 31' `'/ Certified by P.E. R.A.
Address L/ �SYYMvna.^ •-: 1f11 J�Q 'b P''1 10License o, S`7 y•3
Any person occupying premises served by the above system(s) shall promptly take such action as
conditions resulting from such usage. Approval of the separate sewerage sy m sba ecome i
avaliable and the approval of the private water supply shall become null and old. a pub
subject to modification or change when, In the judgment of the Commi r ealth', h
Cate _ By
be necessary to secure the correction of any unsanitary
and void as soon asA pubVz- sanitary sewer becomes
��plly�cbm available. Such approvals are
rl/ Ifi Ion or change IlLnecessary.
t:d=
i
n
e
- Un.iCorn 'Industries. - 'LTD
Cw..�. Qw.
�.� Same f
Danand .Lane
wry FSmi
��•rrM�,.M ^ �
_ Ouail Ridge„
/2115
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5 - ��U.•V_� ri.
i ryh� �" • v,.�iw Z t C Cam'^ Z
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r v.�w _
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for S '� Oy .. — :2, ^.2 C.% 4-^8 5I�M �g w5�� S?5•.°':► CS
^Cr?_�3..
4.A C.� 4-,.o $� A�'..�' 2,w.. �rl, =�E tlA ..�r:.�''r�.^a -rr? C�JE_ei\.° �rC�i� yr� \..S
=� r' =are ^ �z Cr �c�,; c.-ant act- of �:e x of h; �_, w;;.-7 u- -
r s to rrrr as ..Oz. va p. G,. �aw-i ..
The L'::C° �a -C:1?C it1;,L:. _wc.Cj.. a �G a G �� 1,i..�
�.� ..w y: 1 C• t 4M �J�"'• AQ \.'•.� r a•w r�L� RW
-.; _.. �..... 'C..
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._ L •+ _ .r.�. C•r� was L_vt�_..i.
Gi the S!r.>b.'2.+:
- � ar.� cf &:-,Le b+3d
♦ Cz ns_ , Se =t CF w0_—
the syst
r
T `e Controller
�.U,nicornN.Indust[ries, LTD.
^ S�Cr...:�wr� `�r~r LAG. w.M.• 1•�+.i%e \i6•` C:• -
,.,
• 7 Cor orate�Drive
Corgi wi = : Nam t i�r
Peekskill, NY 10566
C' r
ass
~p C�o3
p16i0t? M per, opsratlfp apOridttiOn any' "goat of tep ssw±p 6NpoY1 syaAoln
im of tM`.`atlpvfaeol :ol tM CoRNirato of Conffeuetlon .iGOnlplNnsa o /:tom
srpl Oa loeataid M thouuw on flea t+POvewA' plow oleo that t•W wNl will 1t80
COlpl:y Qa�aftattallt W: It
Date sllwlao
APPROVED-FOR CONSTRUCT10 ft Viii:app►oval.aanphs,taq yeos froln the
' eoroCabeo fua eause or iieay to dl Mn®sa or• .eO;noeos ry
Ba®YNa6 i n pa/TB., Oo/a�
or atitpOtal Of;atOrnagk tanRa ►y faP0a�0.
Rev, ate +�By
10 %8g
-6
Wiry tM Orle0 of tenm'(Y) yNro knon4dNtoly folbwbe® t11o0ate W.tio®6 -
rl0lllal'tyttarn iif at* rap®irs lMratul 2) ( 'floc Avi11M ivaHt mexvtba® ;aiol+a
n aa%ova9anoo yr R�%tM' t�s►A ups end ve�u aii%na of" tWe Poetne�iw
P.E. / Pt A,
tote. , ktua9 ueobas edaR►ua tbn.:of -tho buildihS haSL.boon underUkeat and Is
�y the.Corrvinl'Won0/ og4tl Ril. Ann ch9� or,clfi�Petioe of c6iWrtidlon
Pad %OP priv ter ta'lovly only: - I
I rep aseAt that I am "allY .an
abOIN describW will W constru
Cou nty atbrtlilant ';f. ""N
M fubmitted is the 040artrn
oNa ill jtloo0: siYeritAlj COrld
one of teie att0►orii,.of iths ',
wIM M beJtW as MwwgOnAfte
AMY Of, H"Rk
rMOeabh' for •causs or ma
"Mukas a :new per
G2V{.
A/88 oats',
the proposed sysi•m(s) 1) that the-,.aeparata »wage d.ispossl,aystam
n accoreanci with tM;4nAardt; ruhs -a ►pu ns.o am,
�fnii fi'ifw rq jaA«.• VtigeCtMy t0:tIN Oo mm, tslOrm,of Nealthwill
laws. INlrsOr,a0sipni,by' the builder. that 'said bulkier will - -
f..two (21 y.art.knmediataly, folk/rvinq`,tMdate of ikN feu•
nY repairs it'wito 2� tlNt; the drilled well "fcribad a6me
he starWards, ruhs and_ rqu�ii oT�s of ;the ,Vlitnam
fcanfe NO LIX
COII'atrudiori of -the building .haf: been undertak� hand is
W of iMaNh.' Any "n" or alteration of c6rlahua3bn.
Off— 11 Only: t `.
Tex MAP #:
APPPEVDLY B
PTJ.Cj,q�'M CcuDTrY DERPR LV= OF HEALTH - DIVISICN OF
S 0 6- Nm e . OU,4iu ) lL 8HE2P - CGNSTRLTCTION P—E M T
JAY i .�
C. ac-,;e of Owner)
�y.
r:-
HEALTH SERVICES,
.DRNAo buc t_! . BY:
(Street Location)
�S
YES I NO
ri
x1
i
I
I.
L- = enc:1 provided O
re ti i _ ed
60 ft. rrax. I
Par- o co „-, I
I
x I
Ma. 'SLOPE sDS i
I
I
I
I
I
I
FLT, SYS�"S I
I
clavb=ier I
X I
10 f t. Imo'
f i 11 notes
I
cep to Qauaes I
I
'
t
100 vr. flood elm I
/1
200 fit,% res 1Z tc.
t
150 f t.
t�
I
Y
.Sd Cos
ATE REVI��v % : 7
M. 4k_
=JME TS
Per-nit Application
Corperatr Resolution
Plans - Three sets s/s
Engineers Autnorizaticn
Design Data Sheet (DL'S) SUEDDTISICN
Deep Hole Log p_c —�-- --
Consistent Perc Results (3) will
Perc Hole Deoth
House Plans - Ttivo s T -
Well pe_�-.� , �Nb
Var_ance Request
Ia---al Subdi vie icn
Subdi r_sion P :oroval Checked
Esc- approval SS-DS Adi . Lots Ciecsed
Wet and (Tcw-n /DEC Per—mitt— R & D)
Data On DDS Plans & Permit Sarre
REQUZ'RED DEM I r c CN PL.a`S
Sewa-a' System P? an = (nor =h arrow)
ScgCe System Hydraulic Pr o1 ile - G=avi =v F, cw
Fill Profile & Di rrenssicns - . Vol=ne
D or J Box;Trancz /G:? lery; P'.� pit ce -? ils
Septic Tank - Size, DeT =11
Well Detail. Service Line
Construction Notes (grinder rte)
Design Data: Perc and deep results
Two -Foot Contours Existing & Proocs-
Drivetaav & Slopes Cut
Footing/Gstte_-,Cur-L:=--,n Drains (discharge OK)
Perc & Deeo Holes L.^cated
Reoreseitative of primary and e .zr:sicn
Expansion Area; showan; gravity flow, s-a= =. size
_ PMMDeed Pi t & D Box Shown & I}e- i led
House - No. of Bearoars
Wells
/&II �/in 200 f-:--. of Proposed Syste-ns
Prcpe --ty IlLetes & Bounds
Setback Necessary (Tight lot)
House Seger - 1 /4 " /ft. 4 "0; Type pi^A
No Bends; Max. Bends 45° w /cleanout
SEPAP.AMON DI- c:MNC= S SPECIFIED CN PIAN
Fields
10' to P.L., Driveway, large Trees,Too of fii
20' to Foundation walls
200' in D.L.O.D, 150' pits
10 4tr-- , Watercourse, Lake ( inc. e =. -r.
19�� r�'Curtain, Leader, Footing
cr- O catch basin,stOMM=in,rdned watercou--E
to Water Line (pits-201)
int.=nittent drainage course
Septic Tanks
x,10' fran Foundation; 50' to well
� ►'VP_! � fn DT O
i
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
-- AFFIDAVIT -- CORPORATE. ' OWNER-- APPL- ICA-TION- - - - - --
FOR PERMIT APPI:ICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
represent that I am an officer or employee of the corporation and'am authorized
to act for up, c_. Q (A)
(Name of Corporation)
having offices at rtlole _
Whose officers are:
President: Pave &LA lC.A ' (94- MAU* V&,%�_ t4yp q
(dame and Address)
Vice - President: CAAW � �j
(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 164 day Signed:
o f �C�} Q�, 1( Title:
Nota u lic
CorDOr &tQ Seal
PATRICIA I =2
WOW PUBLIC, %te d 111110111111
Reg. No. 4948824
Qualified. in Dutclmss
Commission Expires Mara A 27, 17..L
8/84
pUT1IAM COUNTY DEPARn4EVr of HEALTH
• DIVISION OF HEALTH SE IMCES
DETAC "C-,T> RE31 a �ry,41� _ C -s► uc.Lc Ee M, %4: .
-- - DESIGN. .DATA - STMT- SUBSUFACE S3QGE DISPOSAL SYSTEM - -• -- -
aj. mAk11.1 •STREET (Sv 1TE D)
C wner LEr>E7_1AA1.1, 4- 14orCH Address
- "Ay U o!N fj1>- D 1z1 YE A W rL>
Located at (Street) f3R► HsToNG 4%LL 12oAD Sec. • 18 Block . 3 Lot Z.
(indicate nearest cross street)
Miunicipality Watershed C )z o To 1J
SOIL PER0OI;A' CN TEST DATA RBDUIRFD TO BE SUBMI= WITH APPLICAT ONS
Date of Pre- SoAking 1 z s / 8 (o Date of Percolation Test f Z s- / SG
NWBER Cr= TI�M - PERCOLATION PEROO=ON .
Run Elapse Depth to Water Fran Water bevel
No. Time Ground Surface ?.n'In(. es Soil Rate
Start-Stop . Min. Start Stop: Drop In'. Min/In Drop
Inches Inches Inches
1 3'01 - 3°.Zo )9 Z4- Z7 3 CI
- 2a21 -3'
q..
5
1 303 - 3
Z. 2
z4 Z
Z4 . Z1
3
3
4 Z7 3
E
. 7,
7
3
4
5
NOTES: 1. Tests to be repeated: at same depth until apprmimately equal soil rates
are obtained at each percolation test. • hole. All data to' be submi ttmd
for review.
2. Depth rrasure ants to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS MDOUN ERED IN TEST HOLES,
DEPTH . -HOLE NO. I HOLE- NO..
G.L.
2' �nNay CSZtivWLL�(_
1-O RM -
3'
�j
V
8t
9'
10'
11'
12'
13'
14! --
INDICATE LEVEL, AT WHICH GROUNDWA= IS ENOWNTERED /moo N �
INDICATE LEVEL TO WHICH WATER `LEVEL RISES AFTEh BEING =UNTERED' lyc� N
DEEP HOLE OBSERVATIONS MADE BY:—M- 8UD21►OSkl It c.LAZV, DATE: 4) 85
DESIGN
• Soil Rate Used C -7 Min/1" Drop: S.D. Usable Area Provided 5 a 0 o
No. of Bedrooms. 3 Septic Tank Capacity 1.0 6 0 ' gals. Type
Absorption Area Provided By 300 L.F. x.24" width trench
s
Other 1 z. rF—F—T FIt-L
N ..
ame RAi ar->0 14 lJ� . LAl�Qm_WTI 1'�.C, Signature
Address -7 -3 . FA I 1'z' G ��n ° "� i21 vE SEAL
�igZS-�tZ4+N _ �.v 125 6 3
THIS SPA= -FOR USE BY HEALTH DEPARDEWT ONLY:
Soil Rate Approved sq.ft,/gal- Checked by
2�..:_ _.1..�
i
PUIMM CXXTRN DEPARTMERr OF HEALTH
SU L `' I
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- - - DESIGiV IIATA SHE�T= SUBSUFACE SBAIME DISPOSAL SYSTIIrI
Owner 111V 1C'0r --W 1 .D ^4%d Tess '76MAEMe
Located at (Street)�/V Sec. Block —� Lot
Un)=2 ) street)
/i 5T i
Municipality �24 T7 re-5..0 Al Watershed /&J V
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBNIITM WITH APPLICATIONS
Date of Pre- Soaking Date of Percolation Test
HOLE
NUMBER CL= 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
1
2
3
5
1 �A �
_ V� ' / 1--t-Al
2
3
4
5
1
2
3
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 submitted .
for review.
2. Depth measurements to be made from top of hole.
rev_ VAS
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
G.L.
HOLE NO.
.. .. _. ......HOLE- NO.; -..
1'
2'
3'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED �0 Iv
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
15
DEEP HOLE OBSERVATIONS MADE BY: 5j B:D ► DATE:
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided -t)000'
No. of Bedrooms Septic Tank Capacity JZ60 gals. Type C.01J' G
Absorption Area Provided By q 6 L.F. x 24" width tr q�NE� �0
Other l �7.-�' l�r �8 �/L L- r C4
Name ,L�P/�i%L -� C,4±Wl, , PX, Sighatu
Address 2-6e- 61 SPA' A16Z&IXY / PAV SEAL
r cold /fi7:5 ZJ
THIS SPACE FOR USE BY HEALTH DEPARMCNT ONLY:
4
Neill
s ®® c
*!
Soil Rate Approved sq.ft /gal. Checked by _ Date
"This is to certify t-h--t
the S-; 'lage dis=aSaI Sys,,----I Was Corstru:=,-ed as indicated on t.i,*s plan and
that the system was inspect-ad by me before it was covered over. 7:1.3
sys t tructed in accordance with all standard rules and
en was conz
regulations of the Putnam County Department of Realth and the Ne:,, York
S
-�-=tta. C--Pa7'-,n2nt of Fealth."
4
N,
C
C h;rn -
At
t - 340
'0
--3-0
77-
PLAN
LOT /5
AREA = 0.489 AC.
6 P, go V
IN5rALJ-" '36o LF
-500
(A
I zo I
50 '6" I - I I
ZG 39 1 - I I TIE!
�
1-1- DAm e-"-,q otos # m r-e&r
Putnam County Department ONTealth
Division of Enva-Ilonmen,",al Health Servicog
Approved as r ' o, ' -ci f: P
IL '0110 of the
DCOartm
/WignatureE Title ----'7- Date
NbAN
19ATUR50�
2(v61 SPFIrJ!��KS
I Pi
RO OAi-D CA e)
wy,-, OvO V '�