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631- 589 -8100
35.-3-11
BOX 15
P.
01677
ILL
Mrleif or - or. Building.
1 • • Cons truc!ottle • by
_ Y
Building Type
- .�
Municipality .
J
Block
Lot
GUARANTY OF SEPARATE SEWAGE-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 ina.ccordance with the standards, rules and regulations of the Putnam
County Department of Health, and hereby guaranty to the owner, his succes-
sors, 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 initial use.of the sewage disposal
system, or any repairs made by me to such system, except where. the failure
to operate properly is caused by the willful or negligent act of the occu-
pant of the building utilizing the system.
.The" undersigned further.agrees to accept as conclusive the de-
termination of the Director of the Division of Environmental Health Ser-
vices 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 ne li
act of the occupant of th uilding utilizing the s
Dated this day of l9 Z'A Signature
Title
If p anon, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO .FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
> sa Y � . � .� yo �y'$4 � rl•ydr�_..,.
r-A I QV
r ZZ
P,U i AM�GOUNTYD�EP�ARTMNT: OF HEALTH
` ` sy ;� ;r fj0/V /S/On Of EnlrlOnmental 3Healrh Se�viceS Camel ; N Y 10512'
(CONSTRUCdTIbN P!RMtTFORtSEWAGE DISPOSAYLSYSTEMr�
1 �c NAP
TO Town or Vitlege
�urc u.`i d vz' F -.> L } f 7yy,. s "�{, .-',. ♦ °�Y`?k'- "4''�R�atv+'� ,� c N �i
,S bdiviiionns rz} _°�c1 tix s� $ awY �aFr L= w v s N'LOt i (• i/.m w a iObi
�31r Na";'.t{,o-r" C,i 2 h .ri`Y.,'FST v'.. 5.'A'k9`+�q . cm• �i' dz�" r'S'.'``•0��r5'3�}.tyr.teri3,ay .d +IGH e. `'u r 4 _ !J° 4
�ow�er����Eifl�E'��f ��z���� �L.G�wC4'��3�' seta' f��' Ej� 'ft�•.if{ +�c't- �.��A�d'd:ess� ��frrt.tdW o9��.9- T7'L�-l1So:✓.J1PY
1 w Z.i[• -'� y.: bid � -�=f" '3n '-i -'s� rr1 y, �. k�' fir .�"` s an ��. -,=.4 hx5 , k to �� � r r - y,
Building'Type� Lot A ea
xw3 F,`e'r >-
' �0 j
Number{ of Bedrooms k 6 J °� ` Total Habitible Space V Square Feet
rg x 'w7 �. r,,, a"T.•, i" a STX �J 'b+r` v v t Fq?..
Seperote Sewera em-- to consist b f2��°
g GPISepttctTankr t lineal f//e��et X �� y width trench
d ; saC/� 6G N *' ✓_
To Abe cgnstructed b _ Address
.Water�SUPPIy bliG SUPPIy From'` r �§ s °
e ''". -� u a `+(� +s.. , G � �y w .0 ,a. � � , i �:.r _ -nom t n tr E„.„ L 4�y `.( a & .� -�^.1- ,y. t•S`i Y,� �fMt r 1 -...,� 'c
'•'r kt' -ri: -�' r � Private,aSuPPI'yp +toV be -� Tilled �bY, ��� � � 1�.r' .t.. F a a:� .�, � � _ �� �� +�?. t r_ r rf�✓
EI x,� hr1
�� s '" yF) "=�'y"�`1���•k ii key ". ,.+; x ��
3:
,� Jr
�r
g Other Regwrements
4 PF 't"rJ'pb �. �: �. -w tj ?4t,,.,.,k It5'�i ,�•r , �.t>vk'�"�.- ,-Ft A:i4 r t," F
ep went }that I am wholly andi;completely ; respo ,location 'of ithe proposed system(sj, 1) ;that. the se.pagafe- sewage, disposal system
Ir r
:above described Twill be constructed as shown on` p er-fVq ar 8 m�accordari a -with th~e standard's; rules an ,regu a wns'o e Putnam
u County- Department of Healthandt�that on'` `e o to of .Construction Compliance ysatisfacFOry tosthe Commissioner of'Healthwill
;be submitted Loathe ,Department, and a wr theownerishsuecessotls heirs,or4assigns'by the bwlder;;that said builder Will
place in;, good ioperating condiLon� any par sp 'sa during the period ofJtwo (2) y.earsnimmediately; following the date of the issu-
ance ofifthe approval of'theCetif�cate •.,o ru e• o[ al systemdor'any?Srepa7irs thereto 2) that -the tlrill_etl, well described' above
:w�11,be Gocated'as shown on the approved pl an -' that �n' , c�cordance� with the st ards rules and reguI ions of, the P.,utnam`
' �7 ;County, :Depart ent Of��Health '`
R.A.
7
a:rrwy- , Address. 'v' ,LlCense NO'
'fix
APPRQ;VEDFOR CONSTRUCTION Thisappro c s�r3 r m the date issued ;unlessco,nstruction of tAe 6u9ldirig has :been undertaken ;and is,
k.
revoca5te for cause orYmay be amended
fled M? " ecessary4by theComm�ss�one�"r. o Health Any change: or alteration ,of construction
A:requves- anew; ermit A roved for disposal of domes is san�tar sewage nd /or pr�yate ter supply only -, sr ,'tg
Lk
s } 7r F i".�as �r �Y� F. rt ;�. nr �. `.,•* �` �' .rt.K, "' '-Y '� ,'C•t"d
, ?w - e�:.,F'ri>` .?'�i�`v` :.,. ?nom -� C,; s. _,: , .?�...�r�, c •:::'�" a �-n: _... ..�: �.- ��''�. `�.. �8'f�••,�= •,�`.?+�� �a'a�.z��. L•x .�i:.� � R N "s
r[
Datr
:. CI:OI Yes oo 111ITT AL SITE J Ccm ?rani; `� T
property ' lines or- corn_e rs d . • . .. a
Can estiina.te' house loci.. oil a
}
Will driveway need cu-C.
Must :trees be rernoved -notle these . • . . •. . :1
Is. deep hole r.cpresenta.tivz of entire SDS area r
Additional deeX) holes nee&,d.
Sufficient SE area avai.] -able corsid rir
driveway cut, house location,.separa -ion
."di•.Vtances, etc. . . . . O ` \O\ . . O. . . . 0 ., .
DEEP HOE, P.ATA . r
Depth:
eater elevation: tt
Rock elevation: d
Soils description:
Date:
FINAL .'.SITE Il`.SFECTTO�I Insn. b� *: n
House located where shown on approved flan.
Width of trench average
Slope. of the line and trench acceptable
:..hOOa� ..SJ.1:.O5Fc��1 i�or eXI-lansion -
�'rver ®
Natural soil not stliAped or SDS area
unnecessai ily. graded • . 0 . . Q
.10 Ft. irraintc.yred from prop. lin° an
20 ft. from house . . . . . . . . o ® G c
S °paration of 'tr`n- -h f--on, house, well
1
etc. follows. plan
Nu.tr.ber of bedrooms checks . . . . . . o . o o �
Stones. brus', stt:n ps, r'ub:ol e, etc . orez ter - -
tIn, 15 f't . frOr'] P_Pa?'� St tr encr
15 It - of peripheral soil horizontally from
trench . . . . . . . . . .. . . . . . O O ® 0 • - -�
Junction boxes prop,-L_1_
Ly yet
Could Surface run of-L". from driv6way ; roads, tiR'
groand surf2 ce, eic.. cr:�nnel near SDS . • . _jy,
area e o a s m � a e o o • o • o o a m o
Does 3.6t drainage appear O.K. in area of SDS
FML GRADING OF SITE ACCEPTABLE
--
CIE IT
L t REVTD�T CIE CK SF
Meets
Std. Remarks
Yes
No
DOCTJlENTS mad :
House plans O. k.
Design data sheet
Peres. presoaked?
O.
Mi 3 ff
n. perc test depth
Const. results for 3 runs-
D. Hole log O.K..
'C orporate •Affidavit for other than individual,
Authorization for engineer
letter from Water Supply if -applicable
If :-variance requested.-such noted .on plans & apps.
DETAILS
4if change; is proposed.,)
Existing contours. shown.kshow new contours)
Slopes for driveway cuts, etc. shown,
✓
Water•service line location
Footing .drain, etc. location
Top slope, bottom slope of
Percolation tests...and deep test pit locati*on
.Septi'c tank •size and conformance to std.
3 E. R house. minim-am
House setback s hown -
Dis. t ow "ras-L
... . ........
H11 W 13.
a.U(jI UILUIL I U W FL
Plan and profile SD5
-
All- other wells'and,SDS closer 2001
shown -o rP
reerence made.
Property ,boundaries metes and bound s-clearly shown)
SEPARATION DISTANCES SPECIFIED ON PLAN
L
101 to P.L.
201 to Foundation walls
1001 to Nearest well
50' to stream, march, la
15' to Curtain drain.
.101 to water.line.(pits-
15' to storm drain
.101 to large trees
101 from foundatior.
5'.tO Pipe - frOM 1E
etc. kincl.expansion)-i
201)
4
PTJTNAM CO1RrI f : DEPARTMENT' i T' OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
owner /C_g lyer,4 r 1-octw1G Address 7 .4ri�Aw ,eoAP �Tr0WVt, , Al-Y ZS'63
rARM ro T ,Poao A MAP
Located at ( Street Caui✓rY Ali6NwAY 6z Block 'Z. Lot
�'n ica e neares cross s ee
Municipality. _772�_yr�y arc AT-�ef 44 Watershed 4-4rmn1 )ei ✓F-IL.
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
oe
Number CLOCK TIME
PERCOLATION
PERCOLATION
apse
Depth to
a er
WaEer ve
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
�j 1 //° 3S� /%*4-J
to
/7�
go
3•3
2
17
3
37
3 - JI 12-
1-7
�Z o
3.
2 ,/ /_- S4- / 2,- lo le / ,7 2 ® S -2
3 12-11 11: 2JP i7 %Zi a-26 4- } s
4
1A.1 Ae
2
3 .
4
5
Notes: 1) Te,�ts to be repeated at same deptn until approximately equal soil
rates are obtained at each percolation test hole. All data to e submitted
for review.
2) Depth measurements to be made from top of hole.
b O;
TEST.: PIT_ DATA. REQUIRED: O -BE.SUBMIT TED.. WITH
' y` "•DESCRIPTION OF SOIhS ENCOUNTERED IN TEST HOLES
DEPTH
HOLE NO.
HOLE NO. /�
HOLE NO . De -60 74.
G.L.
%�PSDiL
4>00r.,
611
h
A
12"
2!1
1811
18"
24"
y
Of ti .. q
3611
1'
`t2"
481
54
6011 .�
66"
7211 R
78'1 .
84" q
-` --- iNDICAT'r. -LEVEE 7iT- °Wt`IIC%1'GROTTND —W_ -- IS "�1VUOUNTET�- ____�. - - - -- s�,Z.._.....�-- ..__..
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
;'TESTS MADE BY .S-= �A�Yo �/1 Date
DESIGIV �
Soil Rate Used_L Min/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms 4-septic Tank Capacity 12-oo Gals. Type 4or cia�/_
Absorption By,�?_-?6. L.,F..x24" 5b a/ width trench..
2 Other n
Address
THIS SPACE°' FOR USE - BY_ HEALTH DE
Soil Rate i Approved 'p F
�!! -r 1974
COUNTY
DEr P T 0 +=. HEAL..TRI!
d by Date