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R V,. 3/ 86 PUTNAM COUNTY DEPARTMENT OF HEALTH
�� Division of Ebvironmentid Hoalth Services, Carmel, N.Y 10512
f,. Enpineer MuA Provlde
�� P C:H D Permitq
-• - - CA OF CONSTRUCTION. COMPLIANCE .FOR SEWAGE DISPOSAL SYSTEM
Town of V e ,
Located rl - T�PBlock .' Lot
Owner /applicant Name v�� `' "O""' ' "�-L Fo�rm�erly Subdivision Name. v abdv. Lot
Mailing Address /�"/�� �'�`� Zip IO S6 6 Date Permit issued
. - rI -
Separate Sewerage System bapt by ( /h.uo%7v� ' Addr�e/ssa
Consisting of I Z SD Gallon Septic Tank and %J� 7- 'A40- �
Water Supply: Public Supply From. ('�2U Address
.or: Q Private Supply Drilled by Address
Building ape 1-1,r� Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed? k
Other Regairementer��
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 and ens, in accordance with the filed plan, and the.permit issued by the
Putnam County Department.Of Health.
Date 30 90 Certified by Aj E. ✓ R.A.
Address ZG I Sys "� ' J �' Icense r4 3
Any person occupying premises served by the above System(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate b:
.Sewerage system shall become null and void as soon as a pu': Sanitary sewer becomes
available and. the approval of the private water supply shall become null and void when a public water supply becomes avallabhL Such approvals are
sub)eet to difiutio or change when,, in .the Judgment of the'Commissioner of HeSth, s eh revocation, modification or change Is necessary.
Date By �� Tftle
PUTNAM CO'+�T1'k DEPAR M-7: OF F7ALTE AO
Diffs-10NOT ENMORe= FJMLTR SE_R lac s
Owner or Purchaser of Building -+� Section Block Lot i
Building Constructed by
Location - Street
�
ft=icina lity
Bail-ding Type
S13 division Nan;
Subdi.vi.sion Lot #
GUARS OF SUBSUPEAa SDMGE DISPOSAL SYSTV!
I represent that I am wholly and completely responsible for the location,
wor3dr,a^sbip, material., Construction and drainage of the sewage disposal system
serving the above described property, and that it has ,been constructedi 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
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by me to such system, except where the fax? ure 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 Lnvira:ftental: 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 Ja 19
u&eral tractor. (Owner) Signature
Corporation Name (if Corp.)
LL
Address t �(cG
rev. s /85
Mk
signature �^^"` -� ` •�,
Title
Corporation Name (if Corp-)
R=ess
FINAL SITE In =-✓_ _ �v%i
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I reprowrthaf f am wholly and completely responsible for the design and,location of the proposed system(s); 1) that the te rate sew di sal System
above described wilt be constructed as sriown on the approved arms xlrnenfthere to and in accordance with the standard; rules a regu of o hem
County OpNtment of Halth, and that an completion thireof a "Certificate; of Con ruction Compliance'' satisfactory to the Commissioner of Health will
basubmtted to, the ;Ofprtnis«it. and a. writteni;gua► ante will ' be;furn -W. d the owner. his successors, hetrsor assigns by the builder. that sold builder will
place lei' .11ooe opNatini coedttfon . any pa•c of laid iewaae tlispOfaI syft Im dwing the period of two (2) yews ImmeOlately following the date of the )enf-
anon of tow` appreval.''if t", Certificate -of Construn3lon,Complionce of tM orlginaf.sykem- or, any repairs thereto; 2) that the drilled vase} described above
sww be located es shown on the aPproirod plin :artA'lhat YIO wN1;wi11.lie;M accordance with tM s. rules and red—UM onof, the Putnam
County Deprty ent oyt.fNalth.'
Oats .? °'9 \Sill, �-��✓ `+� p . R.A.
Address— cents Li NO
APPROVED FOR CONSTRUCTION: This approval oapirM two yeas from the date issued unless construction of the building has been undertaken and is
revocable for cause or may W anlen0ed or modified where' considered necanaiy by the Commissioner of H"Ith. Any charge or alteration of construction
raCuites a new permit.. Approved for disposal of domestic sanitary sewage. and /or private water supply only.
Rev.
APP -IDLY B
n.. "PL:�M COUNTY DEPARTMENT OF HEAL'IIi - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SM GE DISPOSAL. SYSTEMS
REMEV SHEET - CCNSTRLz'ION PERMIT
, .... -PAT
J OPAI u Lam.../ ^�'- -� BY:
(i3ai�ie of Cwne-r) .. Lv __7 (Street Locaticn)
DOC'aw -ENTS
Permit Anol.ication
CorooratW Resolution
Plans - Three sets
Engineers authorization
Design Data Sheet (DDS)
Deep Hole Log
Consiste.nt Perc Results
Perc Hole Deoth
REV=~ vr�" :
Al.&,
e-
/G
s/s
SUEDIVISION
Dcr`
House Plans - Two sets
Well pe--.,i t; P-XS letter
Variance Rec_uest
Cr7vr RAL
Legal Subdivision
Sardivision Aooroval Checked
Mc- approval S DS Adj . Lots Check
Wet and (Tcw-n/DEC Permit R & D)
Data On DDS Plans & Permit- Serra
REQUIRED D .�. Tr c ON PLANS
Sewage Sys-Lem Plan -- ( nor _h array)
Sewage System Hydraulic Profile cavity Flcw
D Box Tr.ncz /C�? lery; P'.rrm pit. details
Septic - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder rate)
Design Data: perc and deep results
Two -Foot Contours Ex =sung & Proposed
Driveway & Slopes Cut
Footin /Gatte-r,Curtain Drains (discharge OR)
Perc & Deep Holes Located
Representative of primary and e- c.
Expansion Aces; shoran; gravity flow, s rz. size
Ii Pumped Pit & D Box Shoran & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 f t. of Proposed System
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sever - 1 /4 " /ft. 4 "0; Type pipe
No Berms; Maas. Bends 45° w /cleanout
SEMARA"ZON DISTANCES SPEC—TFIED ON PLAN
Fields
10' to P.L., Driveway, Large Traes,Top of Z
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 - Curtain, Leader, Footing
35'to catch basin, stormdrain,pined watercours
10' to Water Line (pits -20')
50' intermittent drainage course
Sentic Tanks
10' from Foundation; 50' to well
15' We? 1 to PL 9
P=" COUNTY DEPARTMENT OF
DIVISION OF ENVIRUMIML BEALTH SERVICES
DESIGN DATA .SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM- -FILE- NO. - - -
Owner dd.� Address
Located at (Street) �.v�,o�')° Sec. Block Lot
(indicate nearest cross street)
Municipality- ,- 7-- L- ,r�s-.�,J Watershed �• y' C.
Date of Pre- Soaking
Date of Percolation Test
HOLE"
NUMBER CLOCK TIME ICOLATION
PERCOLATION
Run Elapse Depth to Water Frcm
Water Level
No. Time Ground Surface
In Inches Soil Rate
Start -Stop Min. Start Stop
Drop In Min/In Drop
Inches Inches
Inches
1
F4
3
4
1
2
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.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED'IN TEST HOLES
DEPTH HOLE NO.
HOLE NO. HOLE NO.
G.L.
1'
2'
4'
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�t1�
No. of Bedrooms Septic Tank Capacity /2,0-°d gals. Type
Absorption Area Provided By p L.F. x 24" width trench
Other L 06 �L
Name �i� �rv� ✓ ��� Signature
Address 1 7— � —�•—S �' Gc.A�';� SEAL
UZ/
THIS SPACE FOR USE BY HEALTH DEPART ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
. 0. 0531
Soil Rate Approved sq.ft /gal. Checked by Date
Ti 'AM COUNTY DEPARTMENT OF EEALM
DlvfS-I,.e OF ENV1PnWWM HEALTH SEMCtS
DESIGN -DATA-*Sl=-c-;L7WMC-E-.43E -DTSI�=---..SYSTIM
9(o M A 11,1 ST ?,C- e -r C. r>)
Owner Lc-r>r--zmAtj 4- Hoim-H Address
"AVIL-AWD r->R-)VG- AW11>
Located at (Street) SIZ I H--STOPZG 14 %LL IZO.Ar> Sec. - 18 Block 3 Lot Z.
(indicate nearest cross street)
Municipality -PA1- TEt->--S,0-,x4 - Watershed
SOIL PERCD=CN TEST DATA RBQU= TO BE S=TIM WITH APPLICATIONS
Date of Pre-Soaking i I zs18 G Date of Percolation Test tz t;-
L-OT
�C1= TIME PEROO=ON PERCOLATION
Run Elapse Depth -to Water Fran Water Level
NO. Time Ground Surface In Inches 'Soil Rate
Start-Stop Min. Start stop Dropjn!! Min/In Drop
-Inches Inches Indies
1 2"0.q - 2,.2 z-
49 , l 2 z%za -2;42
-7
-7
a
(.•-3
3 2'.x -3 -a Z7 3 C•7
14
5
*Z- � 2 3 ;a 1 - S.
Z- 4. Z-7
(..I
L- 3 :3,. zz -Z- i . Z-4, -- Z7 3 -/.(Zl
4
5
2
3
4
5
W=S: 1. Tests to be repeated* at swn-- depth until approximately equal soil rates
are * obtained at each percolation test hole. All data to* be submitt?2d
for review.
2. Depth rezzureimnts to be made frcm top of hole.
2
3
4
5
W=S: 1. Tests to be repeated* at swn-- depth until approximately equal soil rates
are * obtained at each percolation test hole. All data to* be submitt?2d
for review.
2. Depth rezzureimnts to be made frcm top of hole.
TEST PIT DA', BMUIRED TO BE SUBMItED W1:M , ?LICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO.. 2. HOLE No...
G.L.
(� o'�-'�o ►� T0'a�o tL
21
3'
4'
5t
61
7'
81
9r
i.1.'
121
13!
SA-as+y C Rflvi�t.<r �
Lo p>m
i-o Gy
SAtaQ�r CnRAyF,Z,Ly
L.aA�
141
I:,'DICATE LE'; : Y, .2 jti'c lal GROUNI7r'MM?, !S EL40OUNTERM
INDICATE LEVEL TO WHICH WATER LEM, Y SES AFTER REM: !-- r,'.
DEEP EME C3SERV .. "IONS MADE BY: M. ,fl-44 ajSr- t ti" K DATE: t, +I 85
DESI&
Soil Fate U<-,-:d -7 Min/1" Drof;.. S.D. i.,. --a :' Area Provide. 5 a ( o
No. of Bedroc. -s ^ 3 Sept.._ Tank Capacit y 1 <___) o gals. Type
Absorption Area .ovided By 300 _ _ L.F. x. 24" t•. dtl [ =ench
Other Z F cE ; r- ►L-L
:. ' \L
Name -,
♦
Address •
illy-
Soil Rate Approved sq.ft /qal. 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:
Quail Ridge Subdivision Lot##%/:Permit For Sewage Disposal System
I, Brian R. Dyer
represent that I am an officer or employee of the corporation and am authorized
to act for Unicorn Industries, LTD.
(Name of Corporation)
having offices at 7 Corporate Drive
Peekskill, NY
Whose officers are:
President: Paul F. Guillaro Millwood Rd., Chappaqua, NY
(Name and Address)
Vice — President: Brian R. Dyer 12 Gedney Way, .White Plains, NY
(Name and Address)
(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 f day Signed: �.
of .o. 1989 Title: Vi cm!e_prp— i d nt
Notary ublic
- MARJORIE DiCAPRIO
Notary Public, State of New York
No. 4851814
Qualified in Putnam County ��
Commission Expires February 18, 19E
8/84
Corporate Sea
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the se.izrje di =_.nsal system was cor.en. -uct�? as indicated on this _olan and
ti\at the system was insoected by me ce_`or.a it was covered 'rta
Aver.
syst =_m was constructed in accordant_ with all standard rulas a. nR
raguiations of the -Putnam County Department oF. Health and Liz D1_.i Yni:k
State D?G_'_ ti =nt of HE.:lth. "
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"ULlcela County Lepartment uI nelLltc.
:11,1 iL4n of Environmental Health Service.
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approved as noted for conformance with
applicable Rules and Regulations of the
wtnam County Health Department.
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