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HomeMy WebLinkAbout1715DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -36 BOX 15 '11' a IRV- r 'I f� ti � �, r , T *j +' G It f �r m 01715 Rev. /86 r. r, PUTNAM COUNTY DEPARTMENT OF HEALTH Dlvi i f E vlro ' sal Health Services Carmel N Y 10512 S on o n nmen , , Engineer Must Provide P— 72—e V P.C.H.D.Pensdtk— - - - - -- '1 COMPLIANCE FOR SEW Located at__Tilt\JAvttl Owner /applicant Name McWrig Address ► CMJ l ✓^' Separate Sewerage System built DISPOSAL ✓oti Consisting of 12,1-0 Gallon Septic Tank and town or Tax Map 5 S Block _ Date Peewit Issued Lot # _ ' -« -9/ Aiv Water Supply: Public Supply From ~ Address or: Private Supply Drilled by q - '�'ti Address p2 Yii�CO4 �� V Building Type 1 v 1 Has Erosion Control Been CompletedY Gf Number of Bedrooms Has Garbage Grinder Been Installed? Other Requirements I certify that the system(s) as listed serving the above premises were co stncted essentially as shown on the plans of the completed work ( copies of which ais attached), and in accordance with the standards, rules and re lotions, in accordance with the sad . la , and the permit issued by the Putnam County Department Of Health. Date 7 �� �1 Cer fietl,byj G' , P.E. �R,A. Address License No. 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 sewerage system shall become null and void as soon as a pub,I: unitary sewer becomes available and the approval of the private water supply shall become null and void when a public water, supply becomes available. Such approvals are subject to m dification of / change when, in the judgment of the Commissioner of Health, such-revocation. modification or change Is necessary. Date / / i _Title" Ji GUARA= OF SUBSURFACE SEWAGE DISPOSAL SYSIEI I represent that I am wholly and completely responsible for the location, worlananship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has-been constructed as sham on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Departcvent 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 iamediately 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 failure 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 detenaination of 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 S_ day of ::T;, 19 Z_ Signature Title General Contractor (Owner) - g t e Corporation Name (if Corp.) Address rev, 9/85 mk Corporation Name (if Corp.) Z L2iZA86774 Addres 1vs�� L k PUINAM COUM DEPARDUNT OF BEALZH DIVISION OF ENVIRMMERM REALTH SERVICES : Owner or Purchaser of Bui ding Section Block Lot ✓tom` t-b `'{,'ter Building Constructed by ` Location - Street.:`.` Subdivision Name Municipality Subdivision lot # Building. Type GUARA= OF SUBSURFACE SEWAGE DISPOSAL SYSIEI I represent that I am wholly and completely responsible for the location, worlananship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has-been constructed as sham on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Departcvent 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 iamediately 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 failure 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 detenaination of 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 S_ day of ::T;, 19 Z_ Signature Title General Contractor (Owner) - g t e Corporation Name (if Corp.) Address rev, 9/85 mk Corporation Name (if Corp.) Z L2iZA86774 Addres 1vs�� COG WELL COMPLETION REPORT Off ice se Only DEPARTMENT OF HEALTH Division Of Environmental Health Services VFW Y�4 PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS. wNwt / 1 Y Tax GatO NUMBER: WELL LOCATION WELL OWNER NA ADDRESS: � PRIVATE � In PUBLIC USE OF WELL RESIDENTIAL O BLIC SUPPLY ❑AIR /CONO. /HEAT PUMP ❑ ABANDONED 1 - primary ❑BUSINESS ❑FARM O TEST /OBSERVATION O OTHER (specify) 2 - secondary Q INDUSTRIAL O INSTITUTIONAL ❑STAND -BY ❑ MOUNT OF USE YIELD SOUGHT --,5- gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGEZ�6 gal. REASON FAR EPLACE EXISTING SUPPLY ❑ []ADDITIONAL TEST /OBSERVATION ADDITIONAL SUPPLY DRILLING �EW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA � WELL DEPTH a ft, STATIC WATER LEVEL �✓�`_. ft, [DATE MEASURED DRILLING ❑ROTARY COMPRESSED AIR PERCUSSION .0 DUG EQUIPMENT, ❑WELL POINT C3 CABLE PERCUSSION , O OTHER (specify): WELL TYPE ❑SCREENED ❑OPEN END CASING IM /OPEN HOLE IN BEDROCK ❑OTHER TOTAL LENGTH _ ft. MATERIALS: STEEL ❑PLASTIC O OTHER CASING LENGTH BELOW GRADE ft. JOINTS: ❑WELDED THREADED ❑OTHER DETAILS DIAMETER _ in SEAL: ❑CEMENT GROUT BENTONITE D07HE WEIGHT PER FOOT Ib.lft. ' DRIVE SHOE YES D NO LINER: (J YES NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (It) EPTH` SCREEN (it) DEVELOPED? DETAILS FIRs.T YES ❑ No SECOND URS GRAVEL PACK O NOS GRAVEL DIAMETER TOP 80 01;1 SIZE: OF PACK in. DEPTH -ft. DEPTH N. WELL YIELD TEST ; If detailed pumping 1�lELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. M 00: 0 PUMPED � tests were done is in- DEPTH FROM Water Welt COMPRESSED AIR ,formation attached? SURFACE Bear- Dia- ❑ BAILED ❑OTHER ; ❑YES ❑ NO ing meter FORMATION DESCRIPTION CODE In WELL DEPTH DURATION DRAM /DOWN YIELD land It. /hr, min. It. �9}pnm_ Surface � �i'Jt J WATER CLEAR TEMP, QUALITY ❑.CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? ❑YES ❑ NO STORAGE TANK: TYPE PUMP INFORMATION.. CAPACITY GAL. TYPE -3�. ;t %�t31° � ir C.L CAPACITY QV WELL DRILLER NAME DATE S MAKER 14 ') � �ls ALBERT M. HYATT &SONS, INC. `- � DEPTH � ADDRESS StGr1A1URE Well Drilling MODEL YOLTAGE6HP,3/-/ Rte. 311 R. R. 2 Box 171A PA7TCRS0N, NEW YOi2iC 12563 NORTH AMMCAN D /\ KD�-��� �l7��`��U���% UKJ�� u_��uov.�o��xux��mnou-.v o��x~ y ° REPORT'OF BACTERIOLOGICAL EXAMINATION OF WATER '^ ========================================================================= | Report to: | SAMPLE NO' l} _o���_ ^ ________________- | | 1 Address:_Rt,_311 _______________________| REPORT DATE_________________ | | ===============================| { Town: 'Pattersl}D_____State: Telephone no: ___ | � | | Sample source: A{lab-geJ�-laur-et ............................................ � 1 Locat ion: _��}}_ | ' � � | Street address:_ ----------------- --------------- | | Town:-Brewster ........ County: __jjaugML_______State: | | Sampled by:______________________ Date:_�=�=/�/_____ ' | ========================================================================= | RESULTS | METHOD | | ---------------------------------------------------------- + -------------- | | Total coliform MF: Present .......... Absent_`z'' |SM (16), 909A | | | 1 Total coliform MPN: Present Absent ............. � |SM (16), 908A | � | | E. Cali- Present .......... Absent ............. | � | | | � | Fecal coliform membrane filter:____________ no per 100 ml|SM (16) , 909C | i ( | | Fecal coliform MPN:________________________ no per 100 ml1SM (16), 908C | | � | Standard Plate Count: ...................... no per | 1.0 ml1SM . (16) , 907A | . '�' THIS SAMPLE AS RE VED,AT THIS LABORATORY MET_'/' DID NOT MEE' THE REQUIR EME-TIO- .| W YORK STATE DRlNKlN6 WATER STANDARDS, ` ___________________ ------- _�_�__------ ____ Deborah A. Wilson, Bacteriology Laboratory Director Date NEW YORK STATE DEPARTMENT OF HEALTH APPROVED LABORATORY: ELAP ID NO' 11218 � 08[LD[K TOWER COMMONS, RTE 22,0REN8TFR W W', , Awe 1: 4 2 ? Ai c a+� v4 o Z vas 133 . Numb.e d pa.a.. 4- Demlollo* c -P 1 ©� p ®N.1l ue.la 1...�M w6a. E+m l� $wimrmis severeme . Sysism to ooalalet 1 1 13` n-, Saplc,Pedc •■A /�. :T. be agge o.ew b t��� 52 nn i C. P, ,res, wow !11: Pd& 9 Filamm Adder P"'1111111*111101M 1W, TO J�p eta Ott 4gitiMllid 1 ►apresent'IhatI' sm wholly ana'eompsetely responsiblefOr bi datign and location of the+ proposed: system(s)i l) that the separate saw disposal t slam above described •will -M constructed as shown on Me ap"90 aewndment tnwe to and .in accordance with•the standards, rules a_ regulations or ewnty 6iiiakwAnt'. of Heetk and that on corilpleftori;thereol .i!0ertifi6mi of,Conrtruetion Conipllane — satisfactory to the Commissioner of Health will aswago dispopl system durin/•th� patio0 of two (2) ya9r nsadistely following thedhto Of w111 M submitted to the Departnsw>t, 'and a written gWrantee will'Oe furnished the owner, his successor; heirs or assigns by the bulkkn• that aid builder fiajea` in OOpd .oPaatki/ eabitlon any_ Dart ;of >•b the tsau- a11q Mthe app►oaal of tM'CNtHteife of Coostrudion.Complin>ce o/ M IgMe1 system a any ;regks t. 0,2 t t'tba drilNd wall desuibsd above wIN 11 focatsi0 as sllOrrn,ai the apOtoved Phan aril thet saki will w4l tii M _ ' '"nilin' . with slit rii ad rayu a- WonS of the Putnem county' Department .ol HMith:.. - . Data 9 R.A. DL- fly Address l �t'kl fi 1=f? �� �%' or S �Innde No APPROVED FOR CONSTAUCTIONi Thb approval,eapi.es two y m the aafe i unless construction Of the Ouiaing Ms been undertaken and Is revocable IOr OYN M _ y's. anieri0sd or Modified whir, OOnA n Yry Oy'MORO mmissiOM► of Health. - Any change or alteration of construction repulses a n w w n Appiowei for d1l"I of domed' n aie &=*.water supply only. Rev. 10/88 Date 1 sr ' Title l011�IAt[ d9V* fr DWAi'lS0W OY BBAL� �� , ' ' : DNltii�atltaYatg�iM�lBarll `8aeirleea:Cat�al.FDY lilt 46>114e1ORli .:! in CZnnWAIM OF C0RIE18AM 1Psetlt / • :: s QOM! m f W" DIQOSAL >YYSl1D11 .. rJ-> R M Tam"1�\ S' C I ti R GG "tC 14) LL c.ea Las Munt12�9E i-F41�o1-t�S Bove ; &-c4 i! Ih G.v •T- C.. t) , L. T. D 0 Weis asl Ytmvlem iis A m 9 0 nn, y ZIP l 0 '2• W', , Awe 1: 4 2 ? Ai c a+� v4 o Z vas 133 . Numb.e d pa.a.. 4- Demlollo* c -P 1 ©� p ®N.1l ue.la 1...�M w6a. E+m l� $wimrmis severeme . Sysism to ooalalet 1 1 13` n-, Saplc,Pedc •■A /�. :T. be agge o.ew b t��� 52 nn i C. P, ,res, wow !11: Pd& 9 Filamm Adder P"'1111111*111101M 1W, TO J�p eta Ott 4gitiMllid 1 ►apresent'IhatI' sm wholly ana'eompsetely responsiblefOr bi datign and location of the+ proposed: system(s)i l) that the separate saw disposal t slam above described •will -M constructed as shown on Me ap"90 aewndment tnwe to and .in accordance with•the standards, rules a_ regulations or ewnty 6iiiakwAnt'. of Heetk and that on corilpleftori;thereol .i!0ertifi6mi of,Conrtruetion Conipllane — satisfactory to the Commissioner of Health will aswago dispopl system durin/•th� patio0 of two (2) ya9r nsadistely following thedhto Of w111 M submitted to the Departnsw>t, 'and a written gWrantee will'Oe furnished the owner, his successor; heirs or assigns by the bulkkn• that aid builder fiajea` in OOpd .oPaatki/ eabitlon any_ Dart ;of >•b the tsau- a11q Mthe app►oaal of tM'CNtHteife of Coostrudion.Complin>ce o/ M IgMe1 system a any ;regks t. 0,2 t t'tba drilNd wall desuibsd above wIN 11 focatsi0 as sllOrrn,ai the apOtoved Phan aril thet saki will w4l tii M _ ' '"nilin' . with slit rii ad rayu a- WonS of the Putnem county' Department .ol HMith:.. - . Data 9 R.A. DL- fly Address l �t'kl fi 1=f? �� �%' or S �Innde No APPROVED FOR CONSTAUCTIONi Thb approval,eapi.es two y m the aafe i unless construction Of the Ouiaing Ms been undertaken and Is revocable IOr OYN M _ y's. anieri0sd or Modified whir, OOnA n Yry Oy'MORO mmissiOM► of Health. - Any change or alteration of construction repulses a n w w n Appiowei for d1l"I of domed' n aie &=*.water supply only. Rev. 10/88 Date 1 sr ' Title WELL LOCATION WELL OWNER SE OF WELL 1�- primary secondary AMOUNT OF USE DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL P ,�� � PCHD PERMIT (# reet Address Town/Village/City Tax Grid Number o i. 7- SSa ZI-6 3 66 Z -2-4, Name Mailing . Address c ? 6 rivate % pi�E %47 Yee k, r— % T h� L=,42 F-L /G�17 Public "RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® ABANDONED ® BUSINESS O FARM . O TEST /OBSERVATION 0 OTHER (specify 0 INDUSTRIAL O INSTITUTIONAL [ISTAND -BY O YIELD SOUGHT 57 gpm /41 PEOPLE SERVE /EST. OF DAILY USAGE ail REASON FOR O REPLACE EXISTING SUPPLY DRILLING O NEW SUPPLY NEW DWELLING DETAILED IU u kT S DEN G!? REASON FOR 'DRILLING WELL TYPE DRILLED ®DRIVEN 13 TEST /OBSERVATION LJ ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL IS WELL SITE SUBJECT TO FLOODING? YES ODUG O GRAVEL O OTHER 1 gF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name %` U D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: )V 1A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH.& SOURCES OF CONTAMINATION PROVIDED `,ON SEPARATE SHEET L, -� signature -- ) (date) 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 ;: ;thirt3� (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. l During all well drilling operations, the applicant shall take appropriate action to assure that 4�perty and all water or waste products from such well dri ing operations be contained on this and in such a manner as not to degrade or er 'se containinate surface or groundwater. ;Date of Issue: 19 r .-`Date of Expiration 19 mit Issuing Official ermit is Non- Transferrable White copy: HD File Pink copy: Owner -:,3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller v 7n....`-s33 I G}V7 D PDTNAM COUNTY DEPAR° MENT OF HEALTH I o 3 DM" if Envhaamental Health Servlces.'Carmel, N.Y..10512 . r,0o Provide Peemk M on CERTIFICATE OF cow LIANCR CON ON PEIl1VHT FOR SEWAGE'A1ROSAL,SYSTEM Pea tit'. "N $. Loateaalt Town Malls Subdivision Name S )A) .. /L L cubd. Lot M v/ T� Map Block lot ' ildiU�OE /lCl� T$ Renewal_❑ Revbilou ❑ Owne,•i t Name D�'VC ztr pm r�IJ. 11i : L77� . Date of Previous Approval MaWng Addiress U• .GX G170 _ Town G'f�2/I7 e'L A,i Zip > WMbg Type !�� Lot Aran r G Fill Secfbo Ouly Dept6O-A 'Volu CAW . Number of Bedm Design Flow G P: D d G /► PCHDNotl&atlon Is RequirRequired Witen'Flll Is completed Separ%te S-011111110 Sye= to W=kt df J S D Gallon SePtic Tank n ! �1' F rJ D /0 rR To be coeatabcted by:Q. 3!!' DeTE m I�(%�D pddreee Water Supply: Pdbpc.Suppiy;From Address on ✓ Private Supply Drilled by?D YJ r% . l7ET _Addeeae' Other Re4uiremeuts, 1 represent that I am wholly and compl0tely. ►efponfible for the des�yn and location o_- the proposed'syitem(s); 1) 'that the separate sews a dis oral s stem above described will be constructed ss shown on the approved amendment there to and'in accordance with the standards, rules an requ a ions .7 • u ham County Department , of Health, and the! on completion thereof a- "Certificate. of Construction Compliance" satisfecfory to the Commissioner of Health will be submitted to that `Ospertment, 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: sa wage disposal system during 1hB period ot,tvvo (Y) years Immediately following the data of the Issu- once of the approval of the Certificate of Construction Compliance of the original system or any repairs.thersto; 2) that the drilled.wdl described above Will be located a; shown on tha app►oii•d plan snd that aid weltwitl be List I in accordance with the stand ds, rubs and requ a ons of the. Putnam County Depsrtinsnt. of Health.' // Date �d g , $ U. Sionatl P.E. Y R.A. _ �l n Address ✓ �A /K'ILD /" / License No APPROVED FOR CONSTRUCTION: This approval expires twX ' from t ate is a .unless construction bf he building has been undertaken and is revocable for cause or sy,be & ended.or odifisd when cons ces by.th ommissio r, M Ith. ny change or alteration of construction requires a new ermit pr Y for of domestic se" qe, and i` w r p o r/ /W Date By Title 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 # ~ / o IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: S IfILL Lot No. / WATER WELL CONTRACTOR: Name 7V Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: /y% TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION ON SEPA TE SH T d -,aF (date) signature) 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: Date Date 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 pletion Report on a form Zermi vided y t Putna Co y Health Departm t. of Issue: �" 19 of Expiration) 19�L'cl t Is suing fficial Permit is Non-Transferrable White -- H.D. File Yell Buildin In for 2/87 ow copy. g spec Pink Copy: Owner ()rant -M r1nrn7° Tn7c1 1 Tl'V-i 11 cr Street Address Town/Village/City Tax Grid Number WELL LOCATION rQR_M 7P b y go WELL OWNER Name Mailing ddress g �� Dx X70 rivate � ECG � � *21 A D Public USE OF WELL RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED 1 - primary 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify, 2 - secondary ® INDUSTRIAL C3INSTITUTIONAL O STAND -BY 0 AMOUNT OF USE YIELD SOUGHT Gj .o gpm /# PEOPLE SERVED -t /EST. OF DAILY USAGE /©00 gal REASON FOR IONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ® TEST /OBSERVATION DRILLING OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE 15DRILLED 13DRIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: S IfILL Lot No. / WATER WELL CONTRACTOR: Name 7V Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: /y% TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION ON SEPA TE SH T d -,aF (date) signature) 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: Date Date 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 pletion Report on a form Zermi vided y t Putna Co y Health Departm t. of Issue: �" 19 of Expiration) 19�L'cl t Is suing fficial Permit is Non-Transferrable White -- H.D. File Yell Buildin In for 2/87 ow copy. g spec Pink Copy: Owner ()rant -M r1nrn7° Tn7c1 1 Tl'V-i 11 cr • i A • - Ym ••i12 • . - 4 I UPS M 00" • we amm ■• •' '412 31ARN 03- 1 a MJti DESIGN DATA SHEET- SUSSUFACE S9gAGE DISPOSAL SYSTEM FILE NO. Owner ce , L,:(19: Address ?.o- go')c 9'7y los'12. Located at (Street) E= FL G7C ?Ini "TC7V�liJ IZD, Sec. &-V Block -L Lot (indicate nearest cross street) Lo Municipality y',h7`7 ai45c ;,J Watershed GP—o °lo N' • ■ • DI• m •' IM M • Y• • �• ■• �� • ■ Y:N� • • • • Date of Pre- Soaking (G 3 Date of Percolation Test (G 13 1 JQ HOLE NU 4EM CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 1 T. 54 ' I.24- "34., Z4- 2� �, j ��: 2-7 2 t Zs ° -5 : 3 mod- 25 j 3n 3 1 �5� 2:2� :3� mod- Z��j� yo �5 4 5 1 z'.5'3 - i :27 '.'3 "2-4 ZS° i -30 3 -3 4 5 1. NOTES: 1. nests 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 fran 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. 21 . 3' 4' D 4 5' 6' 71 a 8' 9' 10' 11' 12° 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED t�/A DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used 4S' Min /1" Drop:., S.D. Usable Area Provided No. of Bedrooms 4- Septic Tank Capacity I -Z o gals. Type 6e .0 c Absorption Area Provided By L.F. x 24'° width` trencYi;};�jr� +, ;� Al- Other Name L A-0a4 N-( .Asgoc., PC Signature Z~` f: ;•� {``� ,+;� ut Address f i �' l V� t -t<,aJ l'� f2t V.. ¢ SEAL I �1 `ry1 t ; ; J`l - Cr V7 i"" �ry jj G J �i THIS SPACE FOR USE BY HEALTH DEPARTMENP ONLY: Soil Rate Approved sq.ft /gal. Checked by Date a- r CE?_r.cr -. a CF ?r��, - DICc L. 5?T77-G Sur °r'1 & �uc-��nr�= �?C DLt�'� L S-tcnc R�- (t DNSL =ICN PETMT -T EY .� C_2n -�T",c i0r: ( NO j DCCJ UP I I C✓LrCLat= ;s��:1:1L?C1 Lam= --Ca MCE ) -n= er-- P�-c aCi� De- t.-H u fiC -N: l�c_r•+ c= Va. r:anc a 5t I:c — C7, CCU 'v. = ^_5 & L�N-1 .C. _ C:1 D✓ �Cerc arm G_P rte__= & Dr- -raYay & ElccG Cat. C1} �df, Si � I F F i t& D Ecx ECLZ - Nv. Cr Wells 200 f-'--- c= r COCSE!:� Ec, -,-e Set =:ack NcC =5 s.= v ( TIC:, C ! c t c_�artar'V DLSZ'= E = =C C`i 10' to _ .L. r'T'CC C. _ 20' t7 Fct= =pica iva? 1s 100' tc, Well; 200' _ia D.L.C.D, 100' to S`_=�'Ci, We _,- ..•urc �; - (� C. E Laac- * C_; 10' tz) ,Qatar Line (=its-201) 50, C MIS fiC -N: l�c_r•+ c= Va. r:anc a 5t I:c — C7, CCU 'v. = ^_5 & L�N-1 .C. _ C:1 D✓ �Cerc arm G_P rte__= & Dr- -raYay & ElccG Cat. C1} �df, Si � I F F i t& D Ecx ECLZ - Nv. Cr Wells 200 f-'--- c= r COCSE!:� Ec, -,-e Set =:ack NcC =5 s.= v ( TIC:, C ! c t c_�artar'V DLSZ'= E = =C C`i 10' to _ .L. r'T'CC C. _ 20' t7 Fct= =pica iva? 1s 100' tc, Well; 200' _ia D.L.C.D, 100' to S`_=�'Ci, We _,- ..•urc �; - (� C. E Laac- * C_; 10' tz) ,Qatar Line (=its-201) 50, C a a i A_ttnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT. A PPLICATION SUBMITTED TO PUTNAM COURTY }(EALTH DEPARTMENT Tb: Commissioner of Health ­In the matter of application for ` mjo — — — — — o represent that I am an officer or employee of the corporation and arh authorized: to act forD� (name of corp Ora tign) • having offices at ,�Ql_ffi� ;�_� •..�a1 �'t!1 �� �_ �?� _ � ,� Whose- officers *are PresidentpSJ C,�,OGC�?L _ �i�E�v_ST_E,_2 �•� _ _ _ _ (Name ani3•Address) r Vice - President '�}} (� I C�( o G<�1- 1J 47 G _ (�iame and Address) Secretary _�Z 1 L _ G,( eo 0_ �- �9,47/ G4y? °11 E-e_ J� (Name and Address) Treasurer _ — ,(Name- and Address) and that I am and will be individually responsible for any or all :acts o the corporation with -respect to the approval requested and all: sub- - sequent act8 rele tin g- ttieretoo' Sworn to before me ills / /;� day Signed of : 190 Tiale ,� .L � jj_ l - � iii • � ' - ' ottLry Public ANNE B: CGFiRIDfcN Qj try Co ®ice � rcw � J, . 'k Corporate Seal Q ��15TING W ��L FAR a ML12M K TAX PROJECT ST FA R TOWN Off F CLIEN�T /��/ IV 11 . AS -8UUT p1MLNS10N CHANT NS E3 L Co 2 . o 1 60 2 -t .0. 2�.0 3 49.5_ 32.5 4 50.0 37.0 5 54.3 X2.0 Co 57.5. 47.0 7 co 1.0 52.0 8 Co5.0 SB.O .°� Coo . 5 G3 . 5 10 74 . 0 (0 ID 0 1 1 44 .O 37 .0 I 4Co1 0 9 I o 13 -t .).0 45 .(2) 14 52 .5 50.5 15 5Co . 5 5.5.0 ICo Col O Col ,0 11 Co 5 5 &&. 0 18 70.0 7 I . O 19 1 � .2 57.0 20 24.5 89.0 21 30.0 -5 0 22 3-7 . o 'D4 , 0 23 10.5 95.5 24 -t 9 .0 99 .0 25 5C2) '0 102.0 2 r co 1 .0 105,0 27 102 .0 35 .O 28 f 00 . O 40 '0 2°, 103.0 4 5. 0 30 105.0 50 , 0 31 107.0 55.0 32 109.0 GO.0 33 113 .O X05.0 34 115.0 70.0 THIS 15 TO M- K-TIFY THAT .THE 5V5WA&e 171SP0aAl, 5YSTEM WAS CONSTKUcTE�D" A5 INDICATED oN THI5 PLAN AND THAT THF- SYST5M VVAS INSF>%GTED 15Y M5 IT WAS GoVe KEV 67V6K- .