Loading...
HomeMy WebLinkAbout1607DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -5 -80 BOX 15 01607 No. No IR -to No r :1; IN _ . , - r;� .. ti sell ; *e to , IN IN I ' ' r - . -� No ,, IL L.LLk 01607 sm', 'I-, . ' fib - PUTNAM COUNTY DEPAETMENT;OF HEALTH DMsion of Enyhonm_ mtal Bed& Servloer, Carmel, N.Y 10512 Engineer Most Provide @ . PXXX. Peimlt f 7 ' Owner/applicant Name /`l I - [ir u MaWoQ Address � � Fee Enclosed Amount. FOR SEWAGE DISPOSAL SYSTEM ay ri1.S_D lo-V .. _...- - Towner YlllsRe' ; �A Tom map .Formerly 511 bdvision Name ZIP' . l DSG Subdv. Lot # Date Permit Issued —90 Separate SoweMbh A D' � . 4 /" W, 2 �e Conale �g of 12- -0 Galiou Se do Tank,and F `, Water Supply: Public Supply From Address on --Private:Supply DO' 'by&. ck Yahs: Address R.--4-54 w- TYP.0 e- Lot .Size j I (a% . Has Erosion Cnntrnl Rppn rnrn I Pt- pd9 Number of Bedrooms '¢ Hie Garbage Grinder Been Installed? /Y G Other Requirements i certify that the system(s) as listed serving the above premises were constructed essentially as shown on he plane of the completed work ( copies of which are attached), and in accordance with the etandarda, rules and rerfations, in accordance with th fil pl ; and the permit issued by the Putnam County Department Of Health. 4 ' Date � Ca itisdb'jy RE21-00 A.A. Address 1 ° Limnos No. Any parson occupying p►amisss saved by the above systein(s) shall ►gmptly tske.sueA ac n ,�siruly.be necessary to secure the correction of any unsanitary conditions resulting from such usage: Apaova) of the •Noanteawv�aq��sy ; fINII {blooms null and void as soon as a pubt%. sanitary sower becomes avallible and the approval of tM private water supply .461-1 becwm ; nu gar ?ofd whan a ,public watw . supply becomes ovallebl& Such appovals we wbliet to modif lion change when, in •film luAgment of. the Coin Neilth, ocation, niodlflcation or change Is necessary. 3/89 Date %f / By Title c, PUTNAM COUNTY DEPARTMENT OF HEALIH DIVISION OF ENVIRUIZ L_ HEALTH SERVICES otu C" 1:4 5 3 Owner or Purchaser of Building Section Block Lot 51 Building Constructed by 3 5T r A1'6 Location - Street ¢-✓' 0 A-'_-1-4r r3 if A/ Municipality Building Type -80 (wNFw) J �fiLyl lj�G � �l`1 Subdivision Dame 3� Subdivision Lot # GUARANI'E.E OF SUBSURFACE SEPOGE 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.falsIto operate for a period of two years immediately following the date of approval of the "Certificate- of- _Construction. Compliance" for -the sewage dsspasal..system, - -br repairs made by me to such system, except where the failure to operate properly-'tis r 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 detenminationof_ the Director of the Division of Environinental 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 cx,r 19, `� Signature (Owner) - Signature Corporation Nau a 4i:rCorpo ) 96-9d C Address rev. 9/85 mk Title &WA Li s C %r de Corporation ]dame (if Corp.) 7 MEe—ss s Wr.,LL UVr1rj1zi.LV" rtclrVLAi DEPARTMENT OF HEALTH • Division– Of.- Of -nonmental •.Heal.th :_:Services- W Y PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only - ­57 L07— 343 WELL LOCATION STREET AOURESS: WNIVI I Y TAX G IO NUMBER: Steinbeck Hill Brewster NY 'S WELL OWNER NAME: ADDRESS: Al Galizia 45 Juniper Circle, Brewster,, NY ❑ PBIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary 0 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O 'ABANOONED ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL 0 STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE . gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADD ITIONAL SUPPLY ®NEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL DEPTH DATA ` WELL DEPTH 305 ft. I STATIC WATER LEVEL 41 ft. DATE MEASURED 1XI 9 T DRILLING EQUIPMENT ICI ROTARY .O COMPRESSED AIR PERCUSSION O DUG O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED O OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 31 fL MATERIALS: I@ STEEL O PLASTIC ❑ OTHER LENGTH BELOW GRADE 30 ft. JOINTS: O WELDED QTHREADED ❑ OTHER DIAMETER S in. SEAL: f] CEMENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT 19 Ib.lft. I DRIVE SHOE ® YES ❑ NO LINER: G YES X NO SCREEN DETAILS . . DIAMETER (in) SL07 SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO HOURS SECOND. GRAVEL PACK ❑ YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST If detailed pumping METHOD: QPUMPED tests were done is in- • COMPRESSED AIR , formation attached? • BAILED ❑ OTHER ; ❑ YES O NO IELL LOG )f more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE water Bear- ing Well Oia- In FORMATION DESCRIPTION cooE tt. ft. WELL DEPTH It. DURATION hr, min. ORAWOOWN ft, YIELD gym- Lan 10 Drilllinq in overburden clay & bl rS it rock at 10' 305 6 2135 812- 10 31 Dr'lling in rock,set casing, gro to 31 305 Drikling in rock granite. Y ❑ CLOUDY HARDNESS O COLORED ANALYZED? ❑ YES ONO ANALYSIS ATTACHED? O YES O NO [MAKO CLEAR TEMP. STORAGE TANK: TYPE CAPACITY GAI.. WELL DRILLER NAME P.F. BEAL & SONS, INC. DAYO /3/91 ADDRESS P.O. Box B SIOMTt1RE Brewster, NY 10509 INFORMATION CAPACITY DEPTH VOLTAGE HP J/ 07 "BRIMTER LABORATCiMt6 Box 224 - BREWSTER, N.Y. (914) 855-1930 M-- % t, MIN E: &IMI LE UN I SAMPLE NO. 8190 TEST WELL SOURCE: Al Galizia Farm to Market Road Brewster, N.Y. COLLECTED: 11-2-91 BY: P.F. Beal & Sons BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 0 per 100 mi. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 11-2-91 CR DISPCEAL Pc_a SE r-= j r-r :s as par aLlor en D7 ^rG b_ F =11 se, - Dam Cr- Plec = ;nL LCD' w 1 _Y C_ T=ea _ e 1 ri0 f �_ f =c. Nc= cCt'rcn E_ ':�_ DIS= CS?L crc t � ,000 c0 1 1 -' b_ C_ iC COo =r�=r C_— �L•�. W_ =�� 10 C. Lc �cL G'=t b C= t =__ V - j1 =, ec t= a7—=-r ve D! tar: �i I �I 4 c_ ^ -YES CrCt�.:'i C_^.L'• �.� pi CES f.''Q , ^G.? �-1 1: �ZC °_ of b _t - I _tr`; 1 1 IC.- __'_^ 1 CCI: _ i :1c s -gnec < 4" f.=-an 52S area re Cn s'_cce< c =� --t Set G� �• - -- -_ =__-_ - ^_r Li _ c - L0 T =- %. Da Cis =': _ :: = E . 'FC CCil c! i'_":� =C� Er.__r 50% 1 S_c_ of t=. C7 c to C =AG .. by Gc�1 b C= t =__ V - j1 =, ec t= a7—=-r ve D! tar: �i I �I 4 c_ ^ -YES CrCt�.:'i C_^.L'• �.� pi CES f.''Q , ^G.? �-1 1: �ZC °_ of b _t - I _tr`; 1 1 IC.- __'_^ 1 CCI: _ i :1c s -gnec < 4" f.=-an 52S area re Cn s'_cce< c =� --t �twsEi3s:�t T r ym r I -r 4 rw y,ace .Gs `�r;x yi;a.yo ;, cc +r.!:r, be r..n�exdaA +r( 5fo �j 6y pig ' � %I�i42- n�l�6f/i t91'l crl ✓ rte, +� • 6y� � .�� = rewaso of that l ofn aiA011y owo;comgtra4© a®sa e. epecr W,11.1'be cofistPUe4� WlOgf 8 as (J'+1 E'.F�irardd'•BfD the 't➢®t9Q1PlFAQ and '0;� mmsa xo yam. ocl�o �i(on any; - a5t$ci ®f QBeO anal ,®f th®,COrtifieato calb Iile,DID¢Al6+a 1sa tA¢�uia M QOlfi . appraty AOi6m, do "MRO. Ito : sly Ira ly vofpofii to for the design an . n "!the tlpprogKV ar0QrWManl on eoen�Cattofti tliwOOf a. "Cad¢ tavltta3n. �traPafB200: 10111 N; Puv of+ r Cone9duc41on` Com®O�rece; -� ®tan and 2M silo ey0B1 aa16 6ein At .. - appmoVED tzot°1 Gofd$YWI/GYtt9W: YhiB atAproaDl ottpiioo 4n�o yc va VoJecabb for Ctauca or.'.MAV w w, ft"O 1 eon 00*6170a O r�ca mo, ' At r 9ov. ©it�oesal-oP dowMaafl/t - -..1 Rev. D OV iii Moil a.,of tho propoO d ayat®m(a):,l) that the mporoto tror�ag0 COMM SY90m bn in accordanco•tvith tho atandarda, ruloa a vC-3 eons - ham f: t onstruction i c6mplianw - muctoctory to the commis"nCr of mmltheflll 0.oi ncr, Oki a,wlccOMW6. h0178 or awfahe by the bUICOa: tMt DDtJ OukdCr ryill IrIGq'lh0 1 M1 Of two (8) HW' a ImrnOS60110ly fOlIC=lVQ �tWafltO of the) Imu- lgfeeal:$yatom o� any r�tTa ¢ oa a) that tho drilled tj0i1' dd=McM 06CUO occOrab ao7' With thq 'Olti a, °r a wd Pcgal o Of 11110 FORM 3 Lko �0 54 I z 4- s o _i 34 untam can ruf:4ioo 09 the buitding .has bcm undertakon and Is y. th0 •Cowarn WOnof of K=Rh. Any chonoo or oltpotton of Construction is /0/7 01140to e1jotm Ou "tV only. Yltb A. s' FT:�r.4mr. urBA� DEPARTMENT OF HEALTH R Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #_F- - 7 WELL LOCATION Street Address Town Tax Grid Number ypra� TO M �L�� �� , -�-t -s�,� - -z -- i WELL OWNER Name S Mailing Address v rivate D Public USE OF WELL primary secondary JgRESIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION b INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT j gpm/ # PEOPLE SERVED g j:_ /EST. OF DAILY USAGE ,± 'b gal O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13 ADDITIONAL SUPPLY W SUPPLY NEW DWELLING)- 13 DEEPEN E I TING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED 13DRIVE.N []DUG GRAVEL. OTHER IS WELL SITE SUBJECT TO FLOODING? YES iC NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: '5-r�Z Lot No. WATER WELL CONTRACTOR: Name 1-b Tea- M_,(Z W W Address : IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: J�,�, TOWN /VIL /CITY --DISTANCE-TO PROPERTY FROM NEAREST WATER MAIN: - - - - LOCATION SKETCgN SOURCES OF CONTAMINATION PROVIDE / SEPARATE SHEET / / ,51-7 I go I (date) s gn ture PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt! (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. -3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner. as not to degrade or otherwise ontaminate surface or groundwater. Date of Issue:' J 2-S q j 12- Date of Expiration S L 19 Z rmit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller '?.T . � . �... ,. ..r ...... «_.- 'HCSC._ .,..-- rn- rv�..--,.�.�.. « .:.. ..:.. .r •...v .n: - .S,w -. 'C fr _ _ _ .'M� _� _� rr •. -ar- ....ter { PUTNAM COUNTY DEPARTMENT OF BEALTH ' Rev. n 3/8. ( Division of Environmental Health. Seiv : Carmel. N.Y 1051? Engin Provide Permit # on C_ ERTIFICATE OF COMPLIANCE. , P®t®it b ' CONSTRUCTION P . FOR SEWAGE DI,SPPO.S�AL,SYYSTEEM Located at( - Town, Subdivielon Name I IL C-.. Subd. Let .# Tau Map Block t`:,_�_,..__ e�cxF L � ' � • � �: J- Renewal-0 Revision p Owner /Applicant -Nam . ' Date of �Pcvlous Appeovel �% Matting Address , d • Tovm_ % Zip.- Building Type Iesm )&L_ Lot.' An' a I • (Ur� F111 Section Only Depth Volume Number of Bedrooms Design Flow G /P /D . PCM Noditcatlon is Required When Fill Is completed Separate Sewerage System to consist of '+-! Gallon Septie Tank -ndL A-46 To be constructed by °VQ Address Water Supply: Public Supply Fro m Address ors Private Supply Drilled by p. 6"ii Address Other Regnleenients represent that l am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to. and in accordance with the standards, rules an regulations O e Putnam County Department of Health, andthaton completionahereof a "��Certyficate- of Construction Compliance" satisfactory to the Commissioner of. Health will be submitted, to the. Department, and a written guarantee, will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating,Condition any part of said sewage disposal system during the, pe►iod of two (2) years immediately following thedate of the Issu- ance of the approval of the Certificate of Construction Compliance o the original system or any repairs here 2) that the drilled well described above will be located as shown 'on the approved plan and that. Said well wilPbe fns led in accord nce with the sta and rules nd regu aa�kTons of the Putnam County Department of Health. Oats Signed' P. E. �uC�. 4 1 �►Z� h Address +-}�'r�� license No APPROVED FOR C NSTR CTION: This'approyal ezpiresi+7�ear from th date issue unless construction of the building has been undertaken and is revocable for cau r a amendetl or modified when considers ece by the, mmissioner H Ith. ny change or alteration"af con ction requires a n for disposal of. domestic rani r ge, and /or w - r p on Date By Title c� ..Eu• PUINAM COMM DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS (Name of Owner) REVIEW SHEET - CONSTRUCTION PERMIT (Street Location) DOCOMEDTTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth BY: s/s SUBDIVISION Perc (3) Fill cd House P Two sets Well 4 permit; PWS letter Variance Request GENERAL - Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Tcwn/DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity. Flew Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc and deep results Two--'Foot Cont "ours" Existing & Driveway & Slopes Cut Footing/Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SE ARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. ern) 15' to Drains - Curtain, Leader, Footing 351 to catch basin, stormdrain,piped watercourse• 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well to PL 1t ;r 9 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914),225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address own illage City Tax Grid Number WELL OWNER Name Ma' ling Address - CO.. L-40. �1 rivate O Public USE OF WELL 10- primary 2 - secondary rVOIRESIDENTIAL ® BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED7�2 /EST. OF DAILY USAGEtCO(:�, gal REASON FOR DRILLING MEW SUPPLY OREPLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY ®DEEPEN EXISTING WELL ® TEST OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE 21 5R"I-LLED ®DRIVEN ®DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �L L Lot No. WATER WELL CONTRACTOR: Name ,m(Niiso Address: IS PUBLIC. WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION ON SEP T HEE i i i3 7 (date) signa ure PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant s.hall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the County Health Department attached to this 3. Submit a Well Completion Report on a form Health Depar Date of Issue: 19 Date of Expiration: 19 Permit is Non - Transferrable requirements of the Putnam permit. pro ide by t Putn C unty Pe it ssuing Official White copy: H. D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller PuiMM, COUMY DEPARTVMT OF BEALTH DIVISION OF RVIRMOML HEALTH SERVICES' DFSIGN DATA SHEET-$UB$UM GE DISPOSAL -SYSTDi FILE- NO. Owner Z\JELA Q. Address .0. �)( 2-70 aa_/E(__O Located at -(Street) Sec.- C'X-D Block Lot7EG.] (indicate nearest cross street) Municipality -T6oj" cl;F Watershed CZcq -itJ SOIL PERCOLATION TEST DATA =X= TO BE SUBMITTED WITH APPLICATIONS . Date of Pre- Soaking Le /6-7 Date of Peroplation.Zest. HOLE NMBM C= T•HE PERCOLATION PEROOLATION Run Elapse Ti U No. ri,- -Start-Stop Min. LTC 33 Depth to Water E'raa Ground Surface start stop Inches Inches Water Level. Ili inches Soil Rate Min /In Dr Drop In OP Inches 2. 3, .43 - S'S 5 tZ Z4 -2�7 4,o 3 z'd 4 5 34, A, Z6 3 Z4 Z-7 4 5 2 3 4 5 Tests to be at same depth until approximately. equal Soil rates are obtained .at each percolation test. hole. All data to'be. suhdtteti for review*.....-' 2." Depth' measureTjdnts' to be made fran top of bole. • . • a• •• Oi• • D WITH APPLICATION IN TEST HOLES DEPTH HOLE NO. I HOLE NO. HOLE NO. G.L. 2' 3' 4' 5' .. 6' iV 8' 9' . 10, 11' 12' 13' 14' _INMCA.TE LEVEL AT WHICH GROUNDWATER IS F, =NTERED_ INDICATE LEVEL To WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED ►�1� DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used ]--10 Min /1" Dro�: S.D. Usable Area Provided E;000 No. of Bedrooms 4 Septic Tank Capacity IZ60 gals. Type Absorption Area Provided By. L.F. x 24" width trench Other NamealJ�2111(�fzil�G C . Signatur Q Address `7� �1TCS(E1C) DZAve . SEAL ;� 1 a� 140.56934 to THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:. Soil Rate Approved sgaft /gal, Checked by Date _ A) 14' _INMCA.TE LEVEL AT WHICH GROUNDWATER IS F, =NTERED_ INDICATE LEVEL To WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED ►�1� DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used ]--10 Min /1" Dro�: S.D. Usable Area Provided E;000 No. of Bedrooms 4 Septic Tank Capacity IZ60 gals. Type Absorption Area Provided By. L.F. x 24" width trench Other NamealJ�2111(�fzil�G C . Signatur Q Address `7� �1TCS(E1C) DZAve . SEAL ;� 1 a� 140.56934 to THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:. Soil Rate Approved sgaft /gal, Checked by Date _ 0 Putnam County Department of Health Division of Environmental Sanitation : -_ _: .:.::...:...:.�.... ,.;AFFIDAVIT CORPORATE.. .OWNER A•PPLICATION•: _ j • FOR PERMIT. APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT Tb: Commissioner of Health - In the matter of application for ._.: D✓,1Q0 E . If E (6- o�114�u - I� ..� �.� �.:.� lc? (�DU�,NT,�(_ _ _ _ ^...= —•� - ' represent that I am an officer or employee of the corporation and arm authorised, to act for - ,�.eoc_�1 �t�rS_•�(Jv�GU,f�i✓ %�__� L7� _ _ (name of corporation) having offices at YQG(�LG �1 �HA:5j 2--4 . D _ Aj) q _ _,•_ Whose- officers -are . _._. PresidentQS�% (Name and Address) Vice- President IDf} Cl j C (o_ GC-O t G n/IOL /icr �/ - - - - -- I� (Name and Address) '- Secretary _� l� GLo GCA L- _41A71 _ G _�'h E- _ xJ (Name and Address) _ ^ _ (Name. and Address) _ _ _ — _ and that I am and will be individually responsible for any or all : acts ; of the corporation with -respect to the approval requested and all -sub- sequeht act9 relating- tliereto.' Sworn to before me this `/ day Signed _ of A 1987 Title otary Public I 0 ANNE B. COhRIDAN wrcti l u Rey r�ie74 Corporate Seal F+s.. �y^d�w ,�ft��,�t'3'�'a��"'.a"�Yr�i"'. •t >„u,.^- R}a;:�F.�`�.. tF�s �z- ✓ yTTr s•� ,r het s� .F M-N'�7 x.�'K.r z' '�v'�'`7q�'',.Y.''^"^ a AS - 5UIL-T DIMENSION CHAR-T N° A E I I b.2 30. 5 2 27.7 362 . 7 3 32 -G 40.5 4 37 .D 44 •4 5 -13 .q .4r Z) .5 6, X8.5 53.0 7 53.5 58.0 8 5�D.0 CIO 3. 5 ID 75.5 IO7.3 10 7 (:2, . 5 10-7 . 7 11 80.5 10°x.7 12 g'}.5 112.5 13 62,0 107 . D 14 89' •0 108 .7 15 84.0 loco .5 THIS Is TO GE iPUIFY THAT THE G- 5TEM WAS CONSTIZUGTED AS INOICATEO ON THIS PLAN AND THAT THE S-,(5TEM WAS INSPEGTEr:' 3i ME t3ErOKE LT WAS GOVEt2E0 OVEK. . TH!✓ S -fsTEM WAS CONSTRUCTED IN ACL02t7ANCE WITH ALL- STANPAK.0 KULES AND KC5; vULATION' OF THE PUrNAM COUNTY I?EPAKTMEKIT OF: HEAL.TH AND THE W5K/ YOIe -K, STATE L?EPAI2,TMENT OI= HEALTH u JUNCTION CoX (NP) F-;)(I fZESIDENCE GAL. tF-PTIC TAN K- ` 101� 5OL110 1-.V,C, 2-3) ARM -ro AS - BUILT - County Department of Health