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BOX 11
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01075
L
7 �- RUTNAM COUNT
Dtviston of Env�ronmem
of k
' .CONSTRU I:ON PERMIT ;FOR $WAGE'; DISPOSALrxS
•Lo cot ed, •at,
o:od
Subtlrvisfon Ste'
.�' Owner /Address
BdiIdln9 TYPe �� i't �Z7 L� Cot Area J -+
'Number'of Bedrooms:' Design Flow G /P /D: �o °o• ,
t l .Separate seweri g"'S itb` to consist TofR //�]�O
V • To be constructed by ° �4
Water Supply , Public Supply 'From {
Prwate ^Supply: to be drilled by;.. 2
f Addres;,
r °Other Requirements
P
1-,represent that I•`am wholly and completely responsible,tor the desii
above described will be constructed as'shown on e'approved amend
Eounty :Depart men t of Health; .sand that on +compietion'thereof;a:'
be submitted to ",the Department;- and a writton IgUirintee will i6i
place in good operating= conddio'n any part of s--id sewage °aisO
-ante oi.the' approval oi_;4he Ceitificite ,of Construction ,Complii
..'will.be located.as'shown on the approved plan and that said, well will'I
County! Department of Health
Date Y C3 tit f
igne
APPROVED FOk CONSTRUCTION This approva"I ezpiie{ one ye
revocable for cause or may be'amended?
PUTNAM COUNTY - DEPARTMENT OF HEALTH,
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
Date C�
Re: Property o
Located at
(T) ection Block Lot
Subdivision of 9�fT? UAL /'%
Subdv. Lot Filed Map # Date.
� ?ylvj
Gentlemen: n
This letter is to authorize c+ r ���i�44t' i
a duly licensed professional engineer or registered architect
(Indicate
to apply for a Construction Permit for a separate 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 pap.ers.on my behalf in
connection with this matter and.to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education.Law, the Public Health Law, and the Putnam County Sani-
tary Code.
.Very truly
0
Countersign d: � G"/ er 9190 le i
r.E., R.A., # Address..
X X.
Address
4D Ci L�Q' 'G D(J
Telephone
Town.
Telephone
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 - - Address+���
1
Located at ( Street 4ndicate 6�jl C 1496 Block Lot ?j L ")--3 � �
n aces cross � street)
°
Municipality, d N Watershed 4j�
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole .
Number. CLOCK TIME-t4- PERCOLATION PERCOLATION
Run Elapse Depth to Water Va er Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
2z= .12 i2
,a
,.
Z_ 4
Z 5 3L-
ai
2
Notes: 1) Tests to be repeated at same
rates are obtained at each percolation
for review.
2) Depth measurements to be made
depth until approximately equal soil
test hole. All data to be submitted
from top of hole.
TEST PIT DATA REQUIRED
TO BE SUBMITTED WITH APPLICATION
... _...... .. _ :._...
-..... .DESCRIPT•ION OF SOTLS ::ENCOUN` FRED IN -.T-EST —HOLES,
DEPTH
HOLE NO.
HOLE NO. 2 HOLE NO.
G.L.
�^ c
r�
c9� � c� J
611
Lk
12"
_
18"
24
30"
r
9►
42"
4811
I
11
.54"
6011
Iff
66"
72
8411-
.r .
INDICATE
-LEVEL AT- WHICH GROUND WATER -IS ENCOUNTERED '� � F-
INDICATE'LE"VEL
T
TO WHICH W TER LEVEL'RISES'AFTER BEING 'EN UN C `('
TESTS MADE BY-
Date 1
Soil Rate
Used( Min/l "Drop:
DESIGN
` S.-D. Usable Area Provided 1 (l`34: a
No. of Bedrooms
Septic Tank Capacity Gals. e nf!' -C
Absorption Area Proved By
L.F. x24 "j '- e�-
i
P �
ame
lgna ure
Address
Se.
SEAL � i;�� r
p '0 84roo
AA`��ESS
THIS SPACE
ONAN'�r4y�
FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate
Approved Sq.
Ft /Cal. Checked by Date
I '
r o ;• n
1 �
'. 1 \ \\ ` � 1 � - ,►•;pal � �` ;`4�� :.s�� � p�.
l000
\ 5J� o►:L f, .� i� ,�i�l
h \ r N.A
N.
rPr«:r�K. ✓o.,•1:J�a: toil T=4! j
A
!D SECTION
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