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BOX 16
1111001110
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IN
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1111001110
OWNE9
SITE
MAIL:
PERS(
WNW
PROP(
n
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Vt-� P C�ce, fA-i 61 1, '9Lo rl Vry l%ff li); tiK -tea- ;?;d ad. L.
Proposal approved A Proposal Disapproved
Inspector's Signature &
Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,
or reported agent of
owner agree to the above conditions.
SIGNATURE
TITLE TiVO ff i eTO��- DATE
PHS: indite MV; Yellow Mvin SL); Pink (ARAicant)
A5 .8u r L-r ;
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71407
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lt�a 330 SRC.
s�fM ���� ►��,�� : �ocy`r�ytF,�� C�i�eys
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at
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Ti
ounty:�Pppa rt Mont of Health.
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4196, of any
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p v .tY"v sZ• :".Sr"h h ...,.ar,�^'�.`7` :rM?d_""17,.' ' 1'2 �% 5y7
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Mr. William Paa:ra g ine
F %st Branch Road
B%tterson, N. 12563
1 3 r
_ k"
Dear Mr.', Pa ragine S
1 have not been. able to issue the Certificate of
Construction Compliance for your sewage disp6sal system at
the above a9dr ss as, the required vater sairple result has
not yet been received.
i
6` I
is6imnee of', ate. Certifica .te :oi' .,occupancy unless the Certlf3.cate
:.. .:.......... _ of, Construction,Cc m�1Une Yea: - been—issued bar,
iie
Please submit a satisfactory result of 'a bact6ria2
test of your well so: that thin ertifiGate y be processed.
'- t4 *
� z
Very truly yours,
8.;
r ixq•'�,a
ry
Fred R. Ernst
{
\ Public Health Sanitarian.
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M pC
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T�SY ,,•.. F
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h rch 30,
197
Mr. William Paa:ra g ine
�
F %st Branch Road
B%tterson, N. 12563
1 3 r
_ k"
Dear Mr.', Pa ragine S
1 have not been. able to issue the Certificate of
Construction Compliance for your sewage disp6sal system at
the above a9dr ss as, the required vater sairple result has
not yet been received.
i
The lUtridm County Sanitary .Code prohibits the .
is6imnee of', ate. Certifica .te :oi' .,occupancy unless the Certlf3.cate
:.. .:.......... _ of, Construction,Cc m�1Une Yea: - been—issued bar,
iie
Please submit a satisfactory result of 'a bact6ria2
test of your well so: that thin ertifiGate y be processed.
'- t4 *
� z
Very truly yours,
8.;
r ixq•'�,a
ry
Fred R. Ernst
\ Public Health Sanitarian.
�s
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3
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T�SY ,,•.. F
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1 CONSTRUCTION PE_RMIT.'FOR SEW/
Subdivision l
owner
Buitdirig Type-
Number of Bedrooms
separate :;sewerage System to consist of
To ibe• constructed by , Tf�=
Y
f ',Water .supply :1public Supply. Froi
•¢ t
. Private 'Supply ao
s Address-
OtheY Requirements $
1;represent that I'am wholly and completgl
above described will be constructed as shown e
County 'Department of: Health; antl that•,on
be Submitted- ,to "the Department, and a wri
I place,-,in good'- operating',condf ion any .apart;
:anc6 %' of 'the approval of_ the Gertrficafe. of `f
will ;be' located as'shown,on the 5pproved: plan,,
•County Department of Health.
r
Date
a
Address r `;
i APPROVED,FOR CONSTRUCTION. This aF
revocable'for ;cause or may de amended `or me
requires a new 'permit Approved for dispo
.Date
at Septic Tank lineal feet X width trench
`�rR�rrCc� y >�xxts _
- t 4
[y led•�by } =
jn
Isiblefor?thedesignand lo cation of.: the proposed,system(s) `1) that'the•_separate sewage, isposal : m
_syste•'`':
i. n
eapproved amendment there to .and in accordance with the stantlaids rules an reguta, ions o-• - „� a ,u nam :.
pletion thereof a''Certrficate of .Construction Compliance .ysatisfactory So the Commissione'r.of Healthwill
:guarantee will "'be`furn�shed. the, owner; his successors heirs,or assigns by.the builder,'that said builder will
aid sewage disposal system during the period of two (2) years �rrimediately 'follow�ng:thedate.of th'e issu-
[ruction Compliance of 'the origi $1 system -or any -repairs thereto 2) 'that. the drilled "'described -above
Fiat said'well wh be installed ccordance with the stanclards rules, and "regulations .of. the Putnam
igned - � R.E •• R A.
1�� %,.�? -•(•ems '-., License.No.�cb
ral expires one year from`Yhe date ?issued unless construction of t'ha building has been undertaken and is
id when cons�tlereC necessary' by the Comm�sswner:of Health Ariy' change. or alteration of - construction
if- domesti�c /sanitary ew�ayge andjor private water supply only `
gy
{ „ _ _..:.
OF HEALTH '_-
►M COUNTY, DEPARTMENT
t
EnWro mn enta/ Heal_th Services, Caimel..N Y 1 :0512
DISPOSAL S_lr'STEMr9T
TES d!1
Town or'. villa
--Action,
' Block
A
Addiress °
Dt Are e.�
Total Habitable Spac��� Square Feet
at Septic Tank lineal feet X width trench
`�rR�rrCc� y >�xxts _
- t 4
[y led•�by } =
jn
Isiblefor?thedesignand lo cation of.: the proposed,system(s) `1) that'the•_separate sewage, isposal : m
_syste•'`':
i. n
eapproved amendment there to .and in accordance with the stantlaids rules an reguta, ions o-• - „� a ,u nam :.
pletion thereof a''Certrficate of .Construction Compliance .ysatisfactory So the Commissione'r.of Healthwill
:guarantee will "'be`furn�shed. the, owner; his successors heirs,or assigns by.the builder,'that said builder will
aid sewage disposal system during the period of two (2) years �rrimediately 'follow�ng:thedate.of th'e issu-
[ruction Compliance of 'the origi $1 system -or any -repairs thereto 2) 'that. the drilled "'described -above
Fiat said'well wh be installed ccordance with the stanclards rules, and "regulations .of. the Putnam
igned - � R.E •• R A.
1�� %,.�? -•(•ems '-., License.No.�cb
ral expires one year from`Yhe date ?issued unless construction of t'ha building has been undertaken and is
id when cons�tlereC necessary' by the Comm�sswner:of Health Ariy' change. or alteration of - construction
if- domesti�c /sanitary ew�ayge andjor private water supply only `
gy
{ „ _ _..:.
PUTNAM COUNTY DEPARTHRiT OFHEALTH
I-V- ISIO N-,-. O.F:. �: EN.yIRONMEN :TAIs._��A�'�H_ <3. RVIGES _
A— • Date � 'l � •
-
Re : Property of 42�2� G��r
Located at .. A? "Z , <.� rnc'7
Sectionv� Block y- Lot
Gentlemen:
Zhi.s letter ls. to authorize
a duly:licensed professional engineeri(Sr registered architect
.(Indicate)
to apply for a'Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated by the Commissioner of the Putnam County
Department of,Health,. and tolsign all necessary papers on my behalf.in
connection with this matter and.to supervise the construction of said'.
Sys terri or ; stems- in —co with_ the p.rovisions._.of:_Art cle 11 5 or
17, Education Law, the Public Health Law, and the Putnam County ,Sani
tary Code
Very truly yours.,
Signed 6111—G
Owner of Pro rt
p Y
• : �`� J jam: �1. -z •G�•' "`�
Countersigned: Address
]j
P.E., R A..9 # ;�jf!` . �._
elephone
Address
1 et
lylv m
$ ' 1 Adz �a
F
Telephone NEB zY f a
AY 5 yr
Air
OF
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USN_ .-4 CC,,-: .
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DIVISIO,
DESIGN D-%T -�4--T SE-",P�,TE DI SY S TE FILE NO S
r- a A. � m add = e_-s
As i -B R A. VIC
Lo` ated at C S t 1- e t 9.404APP Sec B10 Lot
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Hunici Dal? t," 7.-,,,v /i d Z
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PEPC CT N TE IS T DAT RE C) 1 PEn 1-0 Bi T1 ON
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Notes
1) Tests to be repe-=t-ed -::�t SaT-ne de-ot-7f) -,til -21-- e SO-
17oie to he sun.-;t-M'
p t or tes� CIZI
-Laine� on. c o n L
2) Dpn t,`i JE1,0• tG:) 0; 17;0i
. -
TEST PTT DATA RE,O1 -TP,ED �J �u3�iT1TE0 .._,H APPLTCATIO
DESC°TPTIO� 0!= ^.LS = ,��;TE?ED r, - =ST HOLES .
DEPTH HOLE ti Q.: ; .HOLE \0. •HOLE N
G.L.
121. ,<
18 r1
241
30"
36
42'•
43
6o"_
66'1
S 4t1
,Tl..,.: Ti, Li `•L. �• �'. j•�Cij l.it l�l.:.,`D .'i �. T'�. _� �.�. �,�!�•��T\mr+ -i -•;1
U'_ 1. A _ .
:CNDTCa D I t TO tF'tTCci aTE LEA �L RT_ =S AFTER BEING .E`;COu` TER D
Tr,STS KADE 3) Y
�����a�L Yrcrt,� o Date /v
Soil. Re L-` :'s _lL-� �_Mliri /1'• DrO�. S.D. L's��?c `_,`_ P.,
0-.
N0. 0� .50�_-eo -.s Sera is Te i:: Ca2�_��}r^ 900 G 1s. Typ
_ 1�e�,✓
A s0r t' O L Area Er01'ided By L. F. x 2 3,.5 width h irenc 7. 0tllcr
Name o�•9� i� �L1y JR /S�sfoc Sic _ t , re
Address ,;�' ,y ,�%, -- SEAL
PUT--- COCA i �' DLPr.RT�G .T 0� HEALTH
t
I Sq Ft./Cal. Chec =;ee? - Date
*'•�� °39 coo ��i. Y43 O� {y'� N N11\
37- T51
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p1 S � h \Y c� •
i
a L (`J
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PLAN
NCO
I_
® _ GAD LEVEL a '
JIJN�_I!CN BOX
MINI i3 MAR'
a "Min.
Y
SECTION i GA IYFTA Y TEE
TYPICAL- C ON. PF
SEPTIC TAN 1t I� l E thrF -Pe' G. B -/w
GR0. LEVELS
s2 � •
aLOGParr
� ��
OR HAY
-� �-
.w4 .6, .,' F R ORA-IED Zg ,
! VRA N E6URv „ . °. iEt,ml, :',•n
i PPE
:d 3§ CLEAN IRAEL CAP -
,�. .,CRUSHED STON(t,
AOSORFTION TRIZAICH
1 - -- - - -- r --
... VERT j`
N4TES.
SYSTEM TO e CONSTRUCTED IN ACCORDANCE WITH 1HPRblES AND
,� �, j REGULATIONS OF THE_�J1 -KlL A___.._._ COUINTY DePAOtTMENT
L PPP Y ® OF HEALTH.
�'SYSTEPA SHALk NOT BE 6ACKE1Lf ED 'UNTIL i 1SF?ET1 i5`Dr DESIGN
x� oG ENGINEER AND THE LOCAL HEALTH OEF'AR T MENT' !F REC3UIRE'D.
JUN221971 'Y`ST[M ro CONSIST O TANK
F A _R 2CL __ Yom! L ON- SE'1'iG
LG'---FT. Of _ — FT. TRENCH WITH ai MAXIMUM
gip y T Or' 1/16' PER FOOT.
PI.:T A f. T. Ow.�..._. �t �'�t..
UiZ `T
BY .. _ •,
bNMENTA DIVISION OF B S `; 5 T E A N' 'i r
trv� ^n `•7nENTAL HEALTH SERVtC$9 30 .�``• EM N'
`�bbtunnrrri R A. K . !„L J
itle,OFNf''o — ASS0CIAT;kES
CARM -t N. Y. !�12
0, 0 o �r sy-„: .. i5 a..F2 RrJ �I,tafe� -
A� '
PE 041 �C� �� �` pate i 11TDre wrn0 Na _ ~� 3
''rrtrrrlti Appel
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