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00971
PUl'NAM COIA?I'Y HEALTH DEPARB4W
DIVISION OF HEALTH SERVICES
1�
._ PROPOSAL FOR SEWAGE DISPOSAL SYSTEM -REPAIR- - - -- - -
OWNER'S NAME 6�� " S r,2% mm
SITE :IDCATION ;7 MOni Rd, Allen o Ale ✓ loth 'III I: �.y/ "'/ -,VJE
MAILING ADDRESS 4?- H t" Jn04 d. Rd- 9ML-g *i- k� V r l S: 10J -P y
PEA INTERVIEWED PC HD Camplaint #
Name'& Relationship (i.e, owner,tenant, etc.)
DATE K-30 19 TYPE FACILITY
Pl�MED INSTALLER T me S 6;zk1m1& PHC NE
REGISTRATION # . r? C. (?-;/
Proposal (include sketch locating all adjacent wells):
Nam: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect. //�� `` _
vsa/ %c .;.►Sfs IJ d/ W /Ovo 6.,11 n / A'1 %S 4nd xA#v/ /i�/ur -i �✓
UYr,Wf, i yh j /N yer? 01— 0JCL -3 yr/eet. i /W- C.—St �1 f�rx wt i/ Ins r/
9e 60,,, , TeC 729 (tee- de,&V� 7-gAk.
w
s Signature & Title
_Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed eanponents tied to two fixed points (e.g. "house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE Lyv" TITLE �ss.�l DATE
TW: Hhite MM Yellow (Mm HI); Pink (AFpUant.)
PC -RP 97
0--Q
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDA.L ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project - `v (T)M
Year of Construction
Size of Parcel
y
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. milly ❑Rolling ❑Steep Slope ❑Gentle Slope ❑Flat
2. ❑Evidence of wetland []Low area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident? ❑ _
4. Water courses exist on, or.adjacent to parcel: ❑ ❑
5. Existing individual wells within 200ft of the existing SSTS? ❑ O
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
l Physical character of existing SSTS area.
A. ❑Level ❑Gentle Slope ❑Steep slope
B. ❑Well drained ❑Moderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited ❑Somewhat limited ❑Adequate ft x ft
U
4 "' n
D. INSPECTION Date Inspector
U \o evidence of failure L �'ce of failure ®Evidence of seasonal failure
-=-------------------=--
-----------------------------------------------------=--------------
(Indicate North)
i
� -fix
rn Y
N
n '
HOUSE
`\ -------------------------------------------------------- ------- ---------- ----- -- - - - -- -- -- - --- --
(1) Indicate location of SSTS --
A. Size and type of septic tank gallons
LJ`4eta1 Concrete Mplastic
B. Type of absorption a ea
)P P �
1. Fields ft. 2. Pits C-3-Gallies.
ft.
(2) Indicate setbacks, front street, backyard, and side yard dimensions
(3) Show :location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams /wetlands)
SECTION E. EXISTL iG WATER SUPPLY
MPWS M Shared well 1 well
DDrilled ®Dug ❑Casing above ground
COi I ',NTS :
REPAIRS ONLY:
As Built Inspection Required:
Status:
As Built Subinitted:
As Built. Inspection Done: Inspector:
1 ;PUTNAM CO. TI
vision. Enaro im "fa
- k a .rte,, tt
:;CONSTRUCTION PERMIT FOR-,;SE
WAGE'.;DfSPOSAL -1l
L_OCatea °et'
:;!.Subdivision.,y
1 Building _TYDe ���'�'I•''� � Lot Area'
Number of Bedrooms = gi^- •.
� �• i' Separate ::Sewerage System' to consist of � �� cz s
To be constructed by'
e.
Water Supply PUblir Supply From
:Private 5uppiy to be tlrilletl by'N
Address p f�
'Other R'equlrements
1 represent it at j.am wholly and completely resp6ni6le,for the desigr
;:above "described .will be constructed as shown on the`approve . amendn
;,County lgepartment of :;Health, `and that;on eompletion thereof a "(
6e ,submitted to'the Department,: and a ,written guarantee will be;
place in ::good' <operating;conditio:n any ;part of'said sewage dispos
:-ance of /the, approval of" the 'Certificate, of ,construction.'Compliih�
'will be rotated as shown on the approved plan and'ttiat said'well will 1 �
,County'U rtment of Flealth.
Date ' tK Sign%e /d
- j
Address-' { v �W
"APPROVED_FOR CONSTRUCTION This approval expires one yea
wrevocabie7for,.cause- or•may be amended or, modified when' considered
requires .a new permit 7Approved for disposal of domestic sin
bite h
J.
9
)EPARTMENT: =OF HEAL H
le+ekh Serv!ces, Carme% N Y 10512
Block l _.
-Job
"F Address>��
Total Habitable 5p8ce Y ` Square .Feet
Septic Tan, lineal feet X �- width ,trench
fi�l�GfS` S'�l�s��f E P z
b
= r4. -
x
d.location of: the proposed- `,system(s);. 1) "that the,siparate sewage disposal system
there to and; in' accordance with the•standards,'rules.:an regu a_ ons.o a :, Putnam
ificate of Construction Compliance'!, sat , sfacto -ry to the Comniissioner;of H"lthwill .•
_t
Wished the owner, his wccessors, heir.'s or assigns by tFe`.builde „that said; builder will `.
ystem dur;ngx the period ofawo (2) years immediately following the date of the -asst=
�f ;the origihal-systern or any.; repairs' thereto;:. t) thattherdrilled, well described: above
italled iq accordance with the standards ,:rules and regula— fTons- of the .'- Putnam' --
x
s ,
-
;m the date _,issued:.unless construction of the;- building has been undertaken;: and is
essary by fhe`COmmissioner -:.of `Health Any; change `or alteration •of� construction
aw ge and /or rivate water supply only /
PUTNAM. COUNTY DEPARTN^ENT OF HEALTH
DIVISION OF EI4yTRr)NrEN'T*A:L HEALTH SERV_('Cf.S
DatesiE�
Re : Property of %f1EO�o.eE yv6 f�ELEi,/ Z��XTE�
' Located at o05w"e.rii✓
Section Block Lot 3zoa 7-11xe
'00"-
Gentlemen • -y9D
�jLE,O 3 /.ZO /•�/
This letter is to authorize
a duly licensed professional engineer_ x or registered architect.
(Indicate)
to apply for a Construction Permit for a sep.ar.ate sewage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of .Health, and to sign all necessary papers on my behalf in
connectlon with this matter and to. supervise the construction of said
system or, systems in conformity with the provisions of Article 145 or
1.47, Education Law, the Fablie Health Law, and the Putnam County Sani-
tary Code.
Very truly yo rs,
Signed
Owner of Property
Countersigned
Address
P.E., # �-
Sc�v.�`ti /E,o,/Sy� Telephone
Address
Ids -o 7iy
Telephone
,4 . -..
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
owner �he 0i,o_ e, re,.XFcY Address exe,a,gGPiy
Located at (Street $ Yo,h, me wJ Aal Sec. Block Lot x200 —3.zo3 iVcc,
Indicate nearest cross street)
Municipality.
Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number 0 CLOCK TIME
PERCOLATION
PERCOLATION
htun apse
Depth to Water
Water ve
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop in
Min. /in drop
Inches Inches
Inches
11
4
1
2
13 �►,,`w. .
1
2
3
4
5
Notes: 1) Tests to be repeated at same depth until aroximatelyy equal soil
rates are obtained at each percolation test hole. All pp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
DEPTH
- G.L.
6"
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPT /ION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. / HOLE NO. HOLE N0.
l�',�AVEG
12" �w�ris �,eac
24"
3011
36►'
42"
48"
}
54•• _
60"
66"
72
7811
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE ILL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERE
TESTS MADE BY '7-�� � TE,e Date BIZ 7
�p/� /%�>!i /7 u;tiNC 6cGZvv DESIGN
Soil Rate Used /5- Min/11vv"Drop: Aoo>r >o:y D. Usable Area Provided
No. of Bedrooms //% � Septic.. Tank Capacity <Ga %,�6ueeoeo, Type
Absorption. Area Provided By 5g�L.F.x24" e�.�° SEW fth trench :
WETAddress ,�� S'a vT`/ !/ /E� �G % S
,�'L Fi=i� .4ANTd� /G L /�/ • �QS'7d �J,' h0. 048
2'6
OHO `� � _. _- •_•nra• -_�i
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by
f
Date
:roo of Luilding •
.1dill" Constructed by
4,
ztion Street
Iding IYPC
Block
o-v
Lot
-GUARANTY Or- SEPARATE Sl,,.-?i GE SYSTE'Ll
represent that I am wholly and completely responsible for the 1.ccation,
Rnianshio, material, construction and drainage of the se;-,,a,7--L,, disposal SVSi:1_1.-.1
vin-. the above described property, and that it has been 'constructed as Sho.,.,-,n, oil
C�
.approved plan or approved amend-Ment t1hereto, and in accorc_,-nce with
es. and regulations of the Putnam County Department of Heal -h, and hiereby guzzi-ran�I.-,-
" C3
the o,.,,,ner, his successors, heirs or assigns, to place in good-operrting conr]iL__"C-7.--`-
C�
-e C'Wo
part of sai=d system construe-Led by m which fails to oparaAL for a. period ol.
rs. immiediat-ely follr,-..;in- the date of initial use of -he set,:cge disoosal sv s m, or
A L
-repairs made by me to such system, except where the failure to operate p r or ),n iv.
cau"(20 •LjV 'cile will U1 U1% L" Of Lile C)L:L:LiPcxija u.L I Li_'
ag.-Oees- to accept as deteimin. tion
the Director of the Division of Envhoni,,,,en'L:a1 Health Services of the Pati'lam
artr- L s t
nent of Health -o •hethcr or not the failure of the system, to operate. .1.1 a s
sera by IL-he- willful or negligent act of the occupant of the building util i z i i Cg t]
negligent
tem..
ed, this 5 day of '19 Signature
Title
'T
(if corporation, I C3 Ive naMe and and ac!
-------------- -------------------------------- ---------------------------------
.EE 3.) COPIES ARE ZE QU i RE D 11ITH. THREE (3) COPIES OF FIN,1L PLANS B El -01'E C E 11 T I r I. C- TE
CO`IPLETION WILL LE ISSUED.
P, N T 0 T'S RFOUTP,7D TO. FILE NOTICE OF DINTr OF 'r I K'S_T USF OF SYSTEM.
--------------- -------------------- --------------------------------------------------
'iSion of Envirojiment Co Departir-ent Of Health
til 11ca1th Services, Putnam unty
7A
74
i i U N i f DEPT.' OF HEALTH
'UTNAM 9U�=!' QF
40.1PPONMENTAL HEALTH SERVI(W
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APPROVED
JUL 9 1974
Cott 2JPT. OF HEALIh
p
ar Me.
WW W, DIVISION 0
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