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01722
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01722
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CONSTRUCTION CI
'OUNTYMEPARTMENTOFHEALTH ' x
amental Health Seevicee, Carmel, N Y 10512 � , ; .
Engineer Mast Provide
P C:H D Permit q�—
LANCE FOR SEWAGE DISPOSALS 0 3 0
p Taz;Map0_Block Lot -2.& j
Owner /appWaitt Name uwv Formerly Subdivision Name % Sdbdv. Lot N�
Lg
Mailing Address: =�'i� M. 22_ S"tt!`i►z_ . Ai _. ZtP '. 1 t3k Date Permit Issued
1�(t�
Separate Sewerage System built by r,1�Y.1,06pte- r,_CL LAWAadress ` �iD � sz. 5Q"�f k9_r&L W � (O
Conets+ting of � , Gallon Septic,.Taok and 15d� G�.A't :.t.e4 A!►113 Jf.�.
hag, nrr iaAl
Water Supply; Public Sapply,From Address
�L V6 Oyr-. AU!�Oyzy*" !v& -or: Private Sppply Drilled by d t.4
Building Type Fah � ', -r( X-C' Ilia Eloston Control Been CompletedY WSJ
Namber of Bedrooms. ' Has Garbage Grinder Been Installed?
Other Regnirements
I certify that the system(s) as listed serving the•above premises -were•coestructed essentially.as shown o the plans of the completed work ( copies
of which are , attached) ,; -and in 'accordance with, the;etandarda rules a-, 6 u tions in; accordance with e f ed plan, and the permit issued by the
putnam county'pepirimgt Of Health '
iri. b Le Q. �' Certified by ' P. R.A.
Date.E
Address License N
iJ 'u` 3 o
Any person ,occupy(n9 P!emises'seivsd by.the above.system(s) shall promptly take such actlon.as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage.. Approval of .the..separate aevvsnge sy tam ihall bacome null, and void'as won is a pub(;: sanitary sewer becomes
available' and, the appro4al of tmG OWite water supply shall become.nu `volt when a "puti4c water supply becomes, available. Such • approvals are
subject to modification or change whom,Im the Judgmant,'of the,, mm(i' ner:,of'Hea t eh _revocation, modification or change Is necessary.
Date / BY Title iv r w
_ P(Tf NAM COUNTY . DEPARINSET3T OF . HEALTH.
DIVISION OF ENVIRONMENAL HEALTH SERVI`C '
Owner or Purchaser of Building
Sll'119�
Building Constructed by
Location - Street
Municipality
Building Type
jo ,qo /0
Section Block Lot
5MA) 68 Ee . HI U- hl<,4 - .
),Wm 7"a Al AkeT .. 00 .5oAP1a1*V j
Subdivision Name
/®1- * /l
Subdivision Lot #
GUAkW= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and, completely responsible for the location,
workmanship, material, construction and drainage of the sewage disposal systeTn
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 fails to
_ aparate..for a - pe_ricr?. - of -twc .� rs imrn iately- Jfol.l.cvi.ng the. datP,of, abornval 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 determination of
the Director of the Division of Environirental 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 .pf ,the/lb gilding utilizinc
the system.
'/UA
General Cbn&actor (Owner) - Signature
A�Aoe #,Q$*I-s
Corporation Name (if Corp.)
AIEAI hjeP EQ IV
Address
rev. 9/85
mk
Signature /
VgTitle G2. 1,6/�- �sr�[Gc.� /�
S•)¢� E
Corporation Name (if Corp.)
IAtE
Address
, <A—: _0
WLLL UUrirLL11VLN LNXXVLC1
a DEPARTMENT OF HEALTH
Division--Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOORESS: nwNIVILLAGEICHY TAX GRID NUMBER:
Steinbeck Estates, -Farm -t.o- Market Rd„ Patterson, NY Lot 11
WELL OWNER
NAME: ADDRESS:
MONROE HEIGHTS DEVELOPMENT CORPORATION, PO Box 970, Carmel, NY
P8IVATE
PUBLIC
USE OF WELL
1 - primary
2 - secondary
&RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 _t05 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION OADDITIONAL SUPPLY
NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 305 ft. I
STATIC WATER LEVEL 10 ft.
DATE MEASURED 10 %18/89
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING V OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH :125 fL
MATERIALS: )(M STEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE ft,
JOINTS: ❑ WELDED a THREADED ❑ OTHER
DETAILS
DIAMETER _13—in.
SEAL: WEMENT GROUT ❑ BENTONITE OOTHER
WEIGHT
PER FOOT 19 1b./ft.
1. DRIVE SHOE:AYES ❑ NO
I LINER: G YES O NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
HOURS -
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH N.
WELL YIELD TEST pumping
If detailed
METHOD: O PUMPED tests were done is in-
UXOMPRESSED AIR , f ormation attached?
O BAILED ❑ OTHER ❑ YES ❑ NO
G it more detailed formation descriptions or sieve analyses
are available, please attach.
hELL
Water
Bear-
in9
well
Dla-
meter
FORMATION DESCRIPTION
CODE
WELL DEPTH
1t.
DURATION
hr, min.
DRAWOOWN
It,
YIELD
gpm.
15
305
Meth to hard ink& white artz.
305
6
-
2.
WATER CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED?. OYES ONO
ANALYSIS ATTACHED? `,10(YES O No
STORAGE TANK: TYPE Tap. 'rCl�l11
CAPACITY GAk: 23
PUMP INFORMATION
TYPE SI I Sibs_ CAPACITY . 10
MAKER1�lds _ DEPTH 200'.
MODEL IOEJ07412 VOLTAGE 230 HP3L4
WELL DRILLER NAME
IILL_DRIL,LIN � 0
ADDRESS tnan Av e SIG ;� ' W
p� eW
Brewster, NY 11 Presi'
I/ t5v
BREWSTER LABORATORIES
224%� l0FIILL
(914) 279-4945
SAMPLE NO. 75 4 8
SOURCE: Steinbeck Estates
Indian Hill Ad.
Patterson, N.Y. 12563
COLLECTED: 10-18-89
BY: Mill Drilling, Inc.
NEW WELL LOV�-
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml.
Nk
4)
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
10-20-891
4
c. Natural soil not strip
d. Stone, br u-sh, etc-, great --- than 15' fran SLS are-a. � I
e. 100 ft. fran wat_*- course /wetlands. I I
II _ S :Uri DISPOSAL SY$TRM_
a.
yeotic tank size - 1,000
:1,250
b.
Semtic tank insta 1 ed leve+1
c.
S"L'Q.Fr?'
LOC�3TION
Ct+vT2. =�
No 90° bends, cle =*lout within
P=RM.ST
a
Z OR urISIN LT a �%
1. AU outlets at sane ele4Gt-liOn - water tested
I Y't9 Na Ca-'�ft5
2. Protecam belcw f_cst
I. SDa.x. DISPOSAL PRF2
3. Minimum 2 f"-- cric? nil sc 7
"a.
5uS ' area "`locate as
m v per a�r6ve3 plans
b.
Fill szc7 cn - Data
cf plac---r---nt
re=u, red -
2:1 barrier _
I= W7Z')TH AVG.DPM
c. Natural soil not strip
d. Stone, br u-sh, etc-, great --- than 15' fran SLS are-a. � I
e. 100 ft. fran wat_*- course /wetlands. I I
II _ S :Uri DISPOSAL SY$TRM_
a.
yeotic tank size - 1,000
:1,250
b.
Semtic tank insta 1 ed leve+1
c.
10' miniman fran fcundaticn
d.
No 90° bends, cle =*lout within
10 f_. of 45° bend
e.
DIS=Tj -- T-CiN BQX
1. AU outlets at sane ele4Gt-liOn - water tested
2. Protecam belcw f_cst
3. Minimum 2 f"-- cric? nil sc 7
be _ri n bcx and t_ =ncns
f.
Su=ION BOX - n. oesly se=
re=u, red -
Le-n_a -ch inst —1 1 ed l /�
�
2. Dist? ^Ls to watercourse ft.
3. to r)—'=n
C Di sta c°_ cemtte " to C --mtar
5. Slere- of t_ errich acc_otale 1/16 - 1/32 " /fc
6. 10 fst f=an orcce"r 1'_ne - 20 feEt - four.
%. De nth of tench < 30 inches f-cn SiLri_c=
B. Rccm al c, .Y-=-d fcr em--P- si on, 50%
— Size' craJel 3/4--- 1i" d.i.a-ne =t.
10. Deotn of a_avel in trench 12" Miiirlm
11. Pire ends cmed
h. _ OR DCSB SY.S
1. Size of y ch- - --,ber
3. AlaLZI, V1S� � /atIrSZO
4 Puy easily ac_ssible sanPOle to c*-.de
5. First box=fl�
6. Ovcle w_ Sze =sue by H —1 tl Dry--u t
estimated" flaw r. =r cvccl e f I rrPi
-�— v Y lJ
IV. RXISE
a. Ebu-ce lec--'Lea, ue_r a:=reved plans.
b. Nuub 'r- of bedrooms y
V. y r-
a. Well loc--t---; as r,--r a-- mroved plans
b. Distance fran S✓S aze me- ured jQp-r` ft.
c. Casing 18" above trade_
d. Surface hound w,--U accen t-able.
VI.
a. Fixes properly crcute3
b. all pines ro-r`La I 1y b--6c 'Lea
c. All pipes f" Leh with inside of box
d. ;Z-ckfill iraterial Contains stones < 4" in diameter
e. 0-- ta.i.n drain installed according to plan
f. C'.r`,a-'rn dr i n cutfzll trot -tom & di r. to Rest- waterc
g. Footing dm2rs di scl=cre away frog SLS area
h- SLrface water urct_ectticn adea?ate
i. =-_-cszon c--nE--o-i urovide cn slooes cre ter than 15 %.
UY oy, &Aal� 11'", , ;I!,11! ljj���ll
� ��,$ � S� to °X ✓n�' des �e ���x�,
&VIJ.' t
UWW��.OFIMAL
�j ;z,
VOIDU
COMWATROF AM
f
0
ty
F I
D.4t
zz,57 Fees Eh
rety . !I
LI
!% #Cft FM la of pieced,
jw
Taink -aid LQ
Tp OlaJAW by.
it i 6ilI64tlOn ;Of-`thO'% P!OP4?,* -;J)'.l t -'t
Ivi segrite -saws" 4i= Yl;t Item
J" fas� j�jjl.bW.' Stfuaid 0%�Md fn"t tfifoiaL td'j"d_'Jjj:jjCj&d&nca'Wjth the sunoara%. ruies eqm ►�sguvax ions o
.:
the Tuinam
C Ity �Dipertfnent:., clory to COM
oul isim inissioner 6UNsalihWill
!�c�s.Jk4i • or; -=' *n f by tlie:buI6iiWj tliitAWid:buililW will
1**4 Soo
:,c6m4li ion an ijiteli fo6iWing thodat• 6 ,,the tau-
:,of Iftb-'apprftal 'of the Cart kato Of of, 66 iiiinollsystorn or any 2) hat the Gritted wieisescreed 060"
iiiijila' i
id , lie nee and as 6 of the Putnern
-AX
oil
cv.
7
Aj"6Vi C TOI_ O!'This "!Fq"! _unievs- construction,' OfL tfii_ buildtnj lys ONn undertakai and is
`�:
i"ry lby A# Conn lsilonw, of milk
-Any chan, m: e L or
afte() rat
ionof constructon
"u d6w" C N8", water ttippb on iy.
Title
LAURENT.- ENGINEERING JOB No. 776 --1 t
ASSOCIATES, P.C..... -
73 FAIRFIELD DRIVE SHEET No
_ _
8. COMPUTED 8
DATE.
-Co- E ENGINEERS CHECKED BY -
CONSULTING DATE
SCALE
YA
4
-7-7
A
T P4
J
-/v
!00--Y
-4
/./v Y.
67a
\1029,
ze, -;57,6
. . . .. . . . . . . .
'cz 6-1l, c/5 ?G.2 S
Pp"
PuMM 00(WY DEPARTKEV OF HEALTH r �v 1 �9 18`j
DIVISION .OF HEALTH •SEWICES � l • ' 2 g `7 .
DESIGN DATA SFEEZ`SUBSUFACE SEWAGE- DISPOSAL SYSTEM FILE M. '
- er . �m v. ".. v , , /LSi� Ckw .
Located at ' (Street)_ _: F24e,C, TAN /1O :_. � _._ ......... Sec, 00 .. z yet z.6./ '
(indicate nearest cross street)' (SuBoN. [orr Ir)
Msuni cipal ity : %yWit/ v c- A477 �lI S s ti Watershed CCAJTO�kl
SOM PERCMA77CM-TEST DATA RDQUMM m BE .SOamiTI'ED WITS :APPLICATIONS
Date of Pre-Soaking 4"97 Date of percolation Test t7
HOLE
e
p Water ]�!rcm
Water Level
No.
.:._ . Time
Ground : Surf�cc�
In Inches . ,
Soil Rate
Start Shop Min.
Start Stop
Drop in
Min/In Dr '
op
Inches inches
Inches
F21-
37'- ll:o 7 ...:3�
:Z�...:..... Z�.
Z�,
3
11 =a8— 0119 :30
ZY :. z
z
2
2
//; yy : /L '/y e 3� .._, .
Z c/,.. ' �y
j yy ::
;. z y t
.3 /2 ' /S- /z, Z/S-
2
_
3
«.
1...•Tests to be repeated at same depth 'until
apprcoamately equal soil rates
'ere' `obtained at each percolation test .hole.'.. 'All =data to' be
...
svbcnitt�d
review. ' ..
:.- ;
2. "' Depth measurements to be made'•fran top of hole.
_ _.._
.... .
rev. 9/85
• / . • �• 1 /' �/ • / Y�/ N. • • r. •.
DEPTH HOLE NOo
1° .
0&
39 Z% Ii PY
.40
5°
7°
8°
9�
10°
11° .
HOLE NO. EOLE NO.
13
13°
14°
•�,
.L' a ��M VR�N' �� �er" �T/E .�..
T;a • • _ .-_.. -... _ _ _ . _ _
INDICATE LEVEL TO MCH WATER LEVEL RISES AFTER BEMG F.tJ000 A11,14
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used Z(-'30 Min,/1" Drops 0. & o S.D. Usable Area Provided
No. of Bedrocros 4- Septic Tank • Capacity 125-0 gals, Type Cwj c
Absorption Area Provided By (o71- L.P. x 24" width trend
Other v M. F' CA-{ A M13 t;_�R- Of NEly y
111 ckiN
Ea>re �Aei/11xiT it/l /�/, ,e Gv� 4.Sf O G. PC_ Signature p
Address 7..�`/� /��I,EL/� ��, SEAL n 1 �"
�. i /1n LU
No. 56124
ESSMIA
THIS SPACE FOR USE BY HEALTH DEF. V"
Soil Rate Approved sq.f %galo Caecked by Date
CqpMDRARTMENTOPMEAL
IM
or
Opt
Oth
6 so 096 system
Pe submitted to the Ions
of the 4006�81'61
pproi, oil" Cw 'the Putnam
SO
it-
Ope
C6unt 77,
:Add No
for cause pf may"" to 6, OW: 0 h It 'ition of c4nsiruction
0, mmiss on A,' change Or a or
Rev.
| um Date—
~
.,,.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION - tb-dONSTRUCT A WATER WELL
PCHD PERMIT 3- [J
WELL LOCATION
Street Address Town V!+ .4y-- Tax Grid Number
1-zp AA-rtecK-t t4, E�, - (aftsdrj P i J% - -2- -7.4, 1
WELL OWNER
Name Mailing Address p o, 8o>0 q-7 o Private
#"Abdo@, till Kff � M , (0, L G o5i 0Public
USE OF WELL
(g)- primary
2 - secondary
'RRESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® ABANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
O INDUSTRIAL O INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED 4--(o /EST. OF DAILY USAGE _L8O0 gal
REASON FOR
DRILLING
NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
AMW F-510 G&
WELL TYPE
DRILLED ODRIVEN ODUG ®GRAVEL ® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL .IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. [ I
WATER WELL CONTRACTOR: Name -,TO 13f- pi, 6 zmtPJW Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ NO
NAME OF PUBLIC WATER SUPPLY: fV 1p, TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION ON SEP
1.3o 105
(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 thirty (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 pro ided y t e Putnam Co ty
Health Department.
Date of Issue: � / 2-- -� 19
Date of Expiration: — 19
Permit Issuing f icial
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
14 Mx d
ILI El
CZU-IrTf CF E_.' --r M -
sup=,
�16 & 57,
I-z -AJ 7
AM
c _-G'.S 0 ccc-2-HEME-S
C--27-cza�
- ------------
Aiz- criz=--
(ADS)
C
7-0-
Fsrc F F-la
61-, b Amig
cz.
� "UO t'l-e-a (Of t -I- I\ I I
7
60
c
vie! t;
va:::
G =.- ia A _--
L
Z-
vc-
D cr P
Ttr-k cc__
7-
Per► arc- C=-.:2:) r
Dri-veiay & SlIcCes CIt.
C
C---ta- Ora—;"-s
perc & ce=--= Holes
tati-i-e cz
a,—ar
cn
E-cuse - ITC. cf
s 2.0 ft- cf Prc:Dcc1
&
Ecuse NTecassazv Micnt ict)
Ec,—,-=- _z-vier 4"0; piga
Nc Ber-�c; EenEs A-3, W/,C!=--=-ic,-,t
S
F-;=
10, -6L:!
20' to r; c,-, Wa
loo, t:z ro�all; 200' in D.•.C.D., pi 7=
St---Sam,
ric. E=
Water--
!a I to t =r Lie (--i tZ-20'
Fcumdat--cn.; 50' t-.2 wal-'
waL-1 tc =--r
3-1
I A
vr. alev.
vie! t;
va:::
G =.- ia A _--
L
Z-
vc-
D cr P
Ttr-k cc__
7-
Per► arc- C=-.:2:) r
Dri-veiay & SlIcCes CIt.
C
C---ta- Ora—;"-s
perc & ce=--= Holes
tati-i-e cz
a,—ar
cn
E-cuse - ITC. cf
s 2.0 ft- cf Prc:Dcc1
&
Ecuse NTecassazv Micnt ict)
Ec,—,-=- _z-vier 4"0; piga
Nc Ber-�c; EenEs A-3, W/,C!=--=-ic,-,t
S
F-;=
10, -6L:!
20' to r; c,-, Wa
loo, t:z ro�all; 200' in D.•.C.D., pi 7=
St---Sam,
ric. E=
Water--
!a I to t =r Lie (--i tZ-20'
Fcumdat--cn.; 50' t-.2 wal-'
waL-1 tc =--r
3-1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date AUCAl.( S'( 7 I ► Iq�7
Re: Property of MptJCZ�' 1G�-CS _cam- fF �-j' Cc) L:ro
Located at �,�(ZJ•�( --CD �`- (,�t'�l lam, Q ,
(T) Section Block Z Lot 7Z76.1
Subdivision of
Subdv. Lot # Filed Map # ZZ,5`7 Date 8 IS/ AS7
Gentlemen:
This leter is to authorize- �A�Z� //
a duly licensed professional engineer ✓ or registered architect
(Indicate
to apply fora 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 papers on my behalf in
connection with this matter and to'supervise the construction of said
__. _ -_ _
ccnfo�mity -= :�ith� °t;:e pro�rlsioris o:t- Articl'e 145-or
1479 Educatibn Law, the Public Health Law, and the Putnam County Sani-
tary
YKA
No. 56124
Countersigned A \,
q�FES5lONP
P. E. , Imo. , # - -
Very truly yours,
�on 6 -#75 PCV6EdP01:5WT
(� Signed � • Vo
` Owner of Property
Address
-73 ��l1zC =lE�=Q \ s25:::,
Address
Telephone
cl",�,e In
Town
9iV -01-)f-
Telephone
di
I.
Putnam County Department of Health
Division of Environmental. Sanitation
AFFIDAVIT. - CORPORATE - 04t1NER _ A PPLIC _TI ON,
FOR PERMIT. APPLICATION SUBMITTED TO -
PUTNAM COUNTY }[EALTH DEPARTMENT.
Tb: Commissioner of Health - In the matter of application for `
6-�ZSE
I, J .� �....� �O . {�Ot_�NT� — — — — -- — — -- • represent
that I am an officer or employee of the..corporation and am authorized, .
to act for Otc� �4.C_ .L1 ' i ff'IS_ �!�vEG�,�1fi�i✓Y G� —� L 7.� — — —
(name of corporatign)
having offices at
Whose. officers -are
President _�E�
Name and��ddress)
Vice- President 2w 1— �' ( o Gcoc.j"71 Gr�l
(Name and AddressT
- - --- .
Secretary ._� �� _ GL °.G GO L, iATI
_ (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-
seque'* t acts relating _ thereto. ' - '
Sworn to before me this Signed
Of 1987 Title L tq('C
otary Public
ANNE B. COkR10AN
WAY _ *W yet
' myco••t" q
mmf n.
RED •Aia7l
:. 't488743�
�t .........._.........--
Corporate Seal
r '�
DIVISION • r • E v FM r: E• tea.
DESSIGN DM SHEET- SUBSOFACE S& AGE DISPOSAL SYSTEM
Owner 1_710 Address Po Q ,)X y7o /L %y /L.S /L
UM 7_6
Located at (Street) RA9.. Sec. ga Block Z Lot zG/
(indicate nearest cross street)' (SUBDid. Lor T
Municipality
Watershed C1Z L) Tc) �/
Date of Pre- Soaking g 1 / o Date of Percolation Test
8 1l (g
'HOLE
NI3NlflER aAC R TIME PEROQLA7 CN
PERCOiAMON
Run Elapse Depth to Water ]From
Water bevel
No. Time Ground Surf ce
In Inches
.Soil Rate ..
Start-Stop Min. Start stop
Drop In
Min/In Drop
Inches Inches
Inches
2 (0'37
3 zit ZG
4 ..
2 2 il'yy- /1-/9'
.3 .12 .' /s - /L ; YS- :34) 5-
4
5
1
2
3
4
5
.; 3 6
NOTES: 1. Tests to be repeated'at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to* be suhnittod
for review. r
2. Depth measurements to be made 'fran top of hole.
rnv_ 9 /RS
TEST PIT DATA REQ IM TO BE SUBMI= WITH APPLICATION
DESCRIPTION OF SOILS EZXX UNTERED IN TEST HOLES '
DEPTH HOLE No. I HOLE NO. HOLE NO.
G.L.
1.°
2°
39 �A __ S%
6° A,
7°
8°
9.
10°
11°
12P.
13°
14°
INDICATE LEVEL TO IMCH WATER LEVEL RISES AFTER BEING ED MUNTEBED
DEEP HOLE OBSERVATIONS MADE.BY: DATE:
DESIGN .
Soil Rate Used V - 3 ° Min/1" Drop: 0. &o S.D. Usable Area. Provided
No. of Bedrooms Septic Tank Capacity 125-0 gals. Type foN c, .
• Absorption Area Provided By (oi1- L.F. x 24" Vidth trench
Other C44 A m 0 r r_ r-
pF NEIV
t
Name G,46, i, 4I/uwt -- ", /dSSo c Signature -
�
Address 7. Y C_411C'Azgz o SFAL
v�FO No. 56124
AESSIONP�'
THIS SPACE FOR USE BY HEALTH DEPARDlEW ONLY:
Soil Rate approved sg. f t/% al . Checked by Date
1
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