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BOX 19
02146
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02146
PUTNAM COUNTY-DEPARTMENT° OF HEALTH ,
l+ :' _'' Division of; Enviro�menta/ Heald► Serv�c�ea,�Carm% N xY 10512 paihnit "
V
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CERTIFICATE OF.CONST.RUCTION . tCOMPLIANCE FOR - SEWAGE DISPOSAL'SYSTEM 1 let ,'',Cds.' t:
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s ,•, .z Located. at. 1 W�? r. � , ,, , ,. *•
• .� Tax Map ck
- ;Owner % -`�� ' rD'• o erly
> f L
:SeparateSewerage System built'by �� Address
i` s/C0 /79 C�'9y�
r
Consisting Gal. Oal.-Septic,Tank.and !r'. 9G'r ����� ��Y �� •
" Other requirements }'
a
Y ^r ti,' � ,� ' ..� ✓'�� e•, xt ` `' '- s� ��KT;� � $ a _,?i�Y1rt ta., (� ��,Ht� _ij . � •: �
x Water Supply t- Publlc •Supply Flom �.. ` , `" " �'" "
y y
;w
'Pr Supply - Dril
Address•' /�/'
BuNding:Type of Betlroomt Date Permit Issued * 1
;Has Erosion Control Been Completetl7
i
certify that;the systems) as;.listed. serving the above °premises'wera constructed essentially a( °shown on t'he plane of the completed work ( copies
;of which' are attached) ':and iri,pccordance with the stagdarda rules and ;equlations >in accordancg�wi�;h.: *t'}ha yfiled�p an, rand the permit issued tiy. the ;
C '•,Putnam Count De rtment`Of Health " ' `�t '`P��, =+ w'�fa
e� y pa
x �
° Date Ce t�fied by ~- " P.E R A
}y Address �s/ ti f2 4� it ? e Icense No
s b 'Any.;person occupying'premises'served by',fhe oJe systems) shall'promptlytake wehaetionasma� necessary,to seoyrsthe,eoriaetlon• of ;any unsanit6ry'
conditions resulting, fiom • such''usage approval •of the separate- sewerayo - _system hall becomeriulJ� and w_oldgas >o�► afsspublir sanitary- . ewer becomes . {
-avgilabicand the approval: of -the private`wetec supply "shah become' ,void' when a' public;rter pplyo b�eomesFy?ova ilabte: Such .approvals are 1
;''r .wb)ecL�to mod{flcatton or ehanye when, ari the )utlgmenY.- ,of,the•C mmis,- ner of Health, -iuch r n,;motlifteafton or- ehange;is, hecessery
, F .'j�'p 4....•- •y.•.�
/ . ��i�j•V��� .hr <
Date By
—e.
;Title
i fit. T,
-;Rev 9 -81 -• :.r. -. - r .. - � 1
m
AL SERVICES, INC p 'NQ.
ML
R (� �q$ ?5
fENED ❑ OTHER ❑
ENT ❑ OTN ER - : -
AM
TfM E-----' :
- WELL
3/71
au
4
)MPLETION REPORT PUTNAIM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
report is to be completed by well driller :a sutimitfed to County Health Department together with laboratory report of
ysis of water sample indicating water is of "satisfactory bacterial quality before certificate of construction compliance is issued.
",..REpC3'1iT 'MUST_'H(E SUBMITTED "WIT'FiM► 3,6" DAYS ' "GF- WEL'L "COMPLE'TIO
>
NAME
..
ADDRESS
Ow
.:
....
. , ..
'(No. 6 Sfreet)
(Town) '
(Lot
"� Number) "
^,
OF
❑
❑.FARM
❑ TEST WELL
PRO
DOMESTIC
ESTABLISHMENT
USE
W
PUBLIC
El
❑
_.
AIR
❑CONDITIONING
OTHER
(Specify)
SUPPLY
INDUSTRIAL
DRI
COMPRESSED
❑
CABLE
El
JDTHER
❑ f(Spscify)
Ed"
T.
ROTARY
AIR PERCUSSION
.PERCUSSION
CAS
CE GTH (feet)/
OIAMETE (1ncAes) WEIGHT PER FOOT(
9:THREADED 1:1
0 ? € —V
[]NO
DET
h
WELDED
YES ES NO'
_
YI
❑
HOURS
❑
G.P:M.
YIELD'(a.P.M.)
T
BAILED
PUMPED COMPRESSED
AIR
°W�
MEASURE FROM LAND SURFACE - STATIC (Speclty teat)
DURING YIELD TEST (leaf) .
Depth of Completed. Well
in feet below Land surface:
—
MAKE
H OPEN TO AQUIFER (feet)
LENGTH
SIC
DET;
SLOT SIZE
-(Inches
IF GRAYEI
Diameter of well including
GRAVEL SIZE (Inches)
FROM (feet)
TO (feet)
{°
PACKED:
gravel pack (Inches):
DEPTH ;F
LAND -SUR /ACE
Sketch exact
location of well with dlstancea, to at /asst
FORMATION DESCRIPTION
two permanent landmarks.
F.E.•
o FEET
yield was #a fed at different depths during drilling, list below
FEET
GALLONS PER MINUTE
'1
DATE W
COMPLE ED
DATE OF REPORT
WELL DRII R (Si9riat1,,,6
/
ONE
LEE
Owner or urchaser of Building
"u •, "BuY.� ding "'' C "oris t�rur:
/} j
Location Street
Municipality
Building Type
Section
Bl 6'&k
Lot
Subdivision Name
Subdv. Lot ##
GUARANTEE 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 in accordance with the standards, rules and regulations of the Putnam
County Department of Health, and hereby guarantee to the owner, his success-
ors, 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 determin-
ation of the-Di-rector-of the-.Division of Environmental Heal.th.._Servi.ce.s
.,
of the "Putnam- C`ou.rity "Department " of `Heal "t'1i " -to wYiether "' or '- not '--t1he
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
4/ • `
Dated this day of ,� 19 Signature
Title— 0.X4 ^'.p L
Corporation Name if corp.)
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
\1��� m s PUTNAM COUNTY; DEPARTMEN
j- (L Division of <Enwronmenia/ Hea /tti Services
,CONSTRUCTfON PERMIT FOR SEWAGEy'DISPOSAL SYSTEM
I L
at `. /J
.Located � '��• -�
SLCd vision - �^ �� Subd Lot q�
1 D -owner /Address Y i a� ✓1'Gt:,..r1C'iII Ytc t t�, j7 / �I
71 y' i.
r �8u11d�ng:TyPe �.� 3'i:wt c'' Lpt 'Area': , L
ty
Number of Bedrooms � �Design'">aow G /P /D Oe1
k Separate .Sewerage System to cor"sist of 7�G } Gal Septic Tank,
' ,To ,De` constructed by s ��� ''
n Water Supply JPUb1ic Supply F►om
�' Pnvate Supply to be dnlletl by `� -`
��ti5 -•cF 4'', 5 n 7 kn. }° . n
a„n
t Address'•.
z� Other Rbqu vements
(,represent that F am wholly
and completelyiresponsible for he tlesign' and location of the•
L &bove described °w,ill be n", tructed as shown on the approved amendment there to and.fima
County ,`Department of `ealth;, _and that on complehort thereot a Cert�fii atp of Goristri
wbniitted to `the DepartmenC, and a -- written guarantee. will be ,furnished' the owner;
place in "good. operating -iii nilitipri any part of said sewage disposal system during the
ante of -she approval of, the Ceitificate''of Consti:uction,.Compliaficenof the ongmal; iys
will be. located =arshawn on the a'pp'roved plan and th5t said ,well wilt be, installed m acco`rtla
�i s County Department ofxHealth
z
i s
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8y
HEALTH Permit f�
N Y 10512
mown or ' IagV� a -�
Z .�.
lock:
Rcvarign
,` Approval
ion Only ❑ -
Notification Required
w
1 Y •
v�4"��.,' „�, #. �r � s, xr ^- of �• .i
a
x
f systems) 1) that_ the separate- sewage disposal system
with -444 ds, rules an , regu ations,of the u nam
mpliance satisfactory, to' tlieCommiisfoner,ofHealthwfll•'
sa`lie"tii3t'O_Aassigrir:by the builder; that, said builder will
immediately follow irg,fhe'data of the isw-
[f 9i3� to °; 2) atiat• the drilled well. described, above.
�f #sndard .Igles° and, regu a— a 5;ns of • the Putnam.
A u.:
.� P1. RA
"`* ° ^ License No o^�
constructionyof� thepbuilding has 16` eeh 'undertaken and is
ierkof Health, Anchsnge or. alteration of - construction
it Au P I W, zor(lyy°`a'W
V M.,3
t �o
� Sills
-
•M� � E
v,
h '. 4 i y 1l
s
r
8y
HEALTH Permit f�
N Y 10512
mown or ' IagV� a -�
Z .�.
lock:
Rcvarign
,` Approval
ion Only ❑ -
Notification Required
w
1 Y •
v�4"��.,' „�, #. �r � s, xr ^- of �• .i
a
x
f systems) 1) that_ the separate- sewage disposal system
with -444 ds, rules an , regu ations,of the u nam
mpliance satisfactory, to' tlieCommiisfoner,ofHealthwfll•'
sa`lie"tii3t'O_Aassigrir:by the builder; that, said builder will
immediately follow irg,fhe'data of the isw-
[f 9i3� to °; 2) atiat• the drilled well. described, above.
�f #sndard .Igles° and, regu a— a 5;ns of • the Putnam.
A u.:
.� P1. RA
"`* ° ^ License No o^�
constructionyof� thepbuilding has 16` eeh 'undertaken and is
ierkof Health, Anchsnge or. alteration of - construction
it Au P I W, zor(lyy°`a'W
V M.,3
t �o
� Sills
CON�UUCT,16N OE FOR
L_ SYSTEW7
Bidck
ob
iG
Owner res C7
Building tq__
u bit
JotAl 11,
-Square Feet
ara e rage
o
6er
Requirements'
| j
||
0
NST
0
64,
,rIV@pfV%2pulations,'of the,.,
pi
N, cl�b6ilcleir will
at,.t &i ll.clescribed- above
i :0100 undertaken and is
/17
t7 / v>/i ��•rT /goo'
z
A
F
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cp
L DIC
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30 e ""a
AL TO SEPTIC TANK.AND FIELDS ...AREA ','�RESERVED 'I'O.
SYSTEM TO FiEfAMN
UNDISTURBED ALL CONSTRUCTION TO CONFORM Td'/&A
AND LOCAL STANDARDS' AND REGULATIONS'..
10
60,
A
Ict-
3
c'.
SOIL PERCOLATIO RATE ....... ;IN/IN 900 GALLON SEPTIC TANK
DEEP TEST .. 210 6. k/
I . 1 • 300 L P Y _2_1 ABS. TRENCH
P2 /9 A/
7r
00 & 1�1
004 �r27 0
&
tit 0&
A14.
pie'? 2 2r4-
7_,¢X ^/ Q Ap 810 CK ,e 4o, 7 'Z
PROPOSED
SEPARATE SEWAGE DISPOSAL SYSTEM
V, � 4-o o- � p a, c c
c, l<
TOWN OF i5xi V-% a
-COUNTY, NEW. YORK
DATE , 2 SCALE . A- -
SULLIVAN
CONSULTING ENGINEtRS
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ESTABLISH ELEVATION OF HOUSE TO PROVIDE DRAINAGE OF LOWEST FIXTURE
TO SEPTIC TANK AND FIELDS ... ✓, . AREA RESERVED FOR SEWAGE DISPOSAL
SYSTEM TO REMAIN UNDISTURSED.ALL CONSTRUCTION TO CONFORM TO STATE
AND LOCAL STANDARDS AND REGULATIONS ✓.
1 ,
,
_.. Q
Q
ell
J
A P PR (��
l
1
APR7 97�
DIVISION OF
'i y
,.nnwuxMni HFNTH &FRVIC� j
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P
y. ,
YY ^
^ L
SOIL PERCOLATION RATE ...'V .... .... MIN /IN I ltjO
GALLON SEPTIC TANK
DEEP TEST,V . /ey�(J �, 3•i,�.
;i Alo Zt't.t .a f„ rJ fJ LF X 24 ABS. TRENCH
..1
81 o cit r .0 ca 7 Z, I
PROPOSED
SEPARATE SEWAGE DISPOSAL SYSTEM
�/tc-Ear S Pa4c. a rt° �1;
TOWN OF Pr3 4 c
COUNTY. NEW. YORK
DATE 31 y 73- SCALE A..S •SAwrs I JOB NO. ]Q ► /_S
-- SULLIVAN -
CONSULTING ENGINEERS
ll�'
t`
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of: Environmental Health Services, Came% N Y 10512
CONSTRUCTION ,PERMIT _FOR. SEWAGE :DISPOSAL SYSTEM. .0 rr?;
• �JA�
or ViIIa ge
�� l„a :
Town
- `� '` Section < ,Block
y, , Subdivision ;. :•. =" °': -' _
.: � . • .. `� Lot - . .�
x•
Owner 4A G A rr AddressD D�J /"r•Gb
A
vi
Building Type Lot Area s
Nu ber ;of Bedrooms ;;fi Total Habitable ,Space :3'00 `a•! — Square Feet
Sep arafe';Sewerage- :System to consist of �! DQ' Gal Septic Tank %SO,.. lineii feetrx d4 width ,french
:To be " con
structed by ~ ss
� v
' Addre
upP1Y :Public Supply From } {
Water S "
Private to
.Supply be drilletl by ^
Adtlreis
q� t
t
. •;Other„Re uvements -
'I represent that I: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 a "s.shown.on.:the approved amendment there to and` n accordance wjth the sfandardS,.rules an regulations o . e.., Putnam
County,,., of `.Health, and that'ori completion thereof a :Certify cafe of Construction Compliance � ty r'y to the'.Commissioner of Health wilF
be submitted to:'fhe Department Wand ;a written guarantee wdl be furn,islieil the owner his successors, t seF:a4WAP the builder; that said builder will
:.place in `good operating condition any .part•, of said sewage disposal system during _the period °of t,�ye$rsdp�ned° ''following 4hedate of the 'issu
'L_�;
ance of .the approval of .the Certificate = of= Construction 'Compl,ance�of tfie original systerri_'or an" ?eV i ,� �p3 drilletl well described above
will be located as shown on the ap`pr'oved plan'and''that sa�tl well will be installed in accordance itfi� he :, ifatds,,; ui� r d `r ulaions ;:of the 'Putnani
I Countyl epart eht of Health
Date �• - {' Signed £ e L e�;3t a P E R.A.
.APPROVED FOR CONSTRUCTION .This:app`roval exp!res.one year from the date rlssued unless t.➢1#if cti y ti� &-has -been ..undertaken and is
revocable "for cause or may be amended or'modifieq when con u r b sio, 69 nr al lion of ,con6 n
requires a, new, ermit /II (/� %� /proWS posal "of dome Hilary sews a and pr e.�
Date -� �, BY �4T ills
,... ..
PUTNAM COUNTY DEPARTMENT OF HEALTH
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner
Located at (Street, d�(ii4WAI Sec. .S Block % Lot' �. >
indicate neares cross street)
Municipality f a ry, a; p-�7 yo/ e
SOIL PERCOLATION TEST DATA RE�
Watershed
TO BE SUBMITTED WITH APPLICATIONS
3
5
3
4
5
1
3
4
5
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 submitted
for review.
2) Depth measurements to be made from top of hole.
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water
Water Levei
No.
Time
From Ground
Surface in Inches
Soil Rate
Start -Stop
Min.
Start
Stop Drop in
Min. /in drop
Inches
Inches Inches
1 � 6 L Sr
/;S�
41011
3
5
3
4
5
1
3
4
5
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 submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
. _...... ,. ._... DES- Cl�IPT�?ON..OTa:S. OILS,:: ENC_ OUI�ITERED;., �. Y�i .E�T:..HQ��- --- _•.:.�::.,R.:- �'��,,�.�_��' -� ...
DEPTH HOLE NO. > HOLE NO. 2 HOLE NO
l
G.L.
611
12" _
1811 �� �a ✓c° o� ✓�� �l'i
2411
3011 .
3611
4211
48'1
5411
6011
66'1
7211
7811
84'1
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHIC .WATER LEV� ISES AFTER BEING ENCOUNTERED
TESTS MADE BY j /'/ y Date
DESIGN
Soil Rate Used 4( Min/1 �� Drop: S. D. Usable Area Provided ;!1-V00 ,-
No. of Bedrooms 3 Septic Tank Capacity &e—) Gals. Type Absorption Area Provided By�L. F. x24" � �w� 7-'H' -$,renc .
,o9�'h�r�•'�r$
s Pout
CEP ' .�
n.
Address 0- La w—k ftc �- q,
THIS SPACE FOR USE BY HEALTH DEPARTP/IENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by
�a
� GL
Date
T--
\1
to
-5,n r�
i
// (o
/- qts- f fit- C.A.
dam•_ --
h� f - o/ k�
ej
.' p4- elI
N 8 `;
4
1
Q ,
ESTABLISH ELEVATION OF HOUSE TO PROVIDE DRAINAGE 9F LOWEST FIXTURE
TO SEPTIC TANK AND FIELDS ...... AREA RESERVED FOR SEWAGE DISPOSAL
SYSTEM TO REMAIN UNDISTURBED.ALL CONSTRUCTION TO SONFORM TO STATE
AND LOCAL STANDARDS AND REGULATIONS.......... a
I J
-� Qce",4, . ,-, % "--4 ez
�x,3 /jn5 P
APPROVED
PLAN Qd
SOIL PERCOLATION RATE ........4........ MIN /IN
DEEP TEST .. /✓O � r-o ij n d We;
/✓o L C. Ll c
1) 11,174
}UT
gR1 Of H EALTh SION OF
WRONMENTAL HSALTN SEKYL®
J
X100
GALLON 1 SEPTIC TANK
O LF X +FLABS. TRENCH
n�
' �0 SSps
100
P�apo1 S�.d
y
a�t '
Ti
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N 1�
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TAX MJ� P S QLVC!( /s L o Tl. /
PROPOSED
SEPARATE SEWAGE DISPOSAL f SYSTEM
v C + y- SPgGG At c'l i
a-
pic ktown
TOWN OF p q m 4 c. `.
COU TY. NEW YORK
DATE 11 C7 7 Lf SCALERS 11 W n J08. NO. ) 14 - 7 LA
SULLIVAN - THIEDE! ;;
CONSULTING ENGINEERS
CLARK PLACE MAiMPAC. NEW YORK
• 1
x'
• it
41
PUTNAM COUNTY DEPARTMENT OF HEALTH
- DIVISION-, OF , ENVIRONMENTAL ''' -HLAL-TH'-S£RVICES - <.._ �_.....
Date
Re: Property of
Located at ,Zi° Gl"'"6 WW / 41
Section Block / Lot a. /
'Gentlemen:
This letter is to authorize
a duly licensed professional engineer `� or registered architect
(Indicate)
to apply for a 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
L: V111jtVV LiV11 w.L i.Il U"b u1d C Lev anti to. supeI' vise ini e construc ciun of said
system or systems in conformity with the provisions of Article 145 or
- .. - 1.4a;--- Education- -raw; -.the Public_- Health -Law,. and the..- Putnam _County San-i-
'tary Code
Very truly, yours
rie ... Signed 7&IA
Owner of Property
�• d
P r�
C Uun e Ai5'iT� �i e n . 6 ifi � � Q ��
Address
P.E.,A., 6 •_3
SZ -8.72 '71
Telephone
Address
Zjege,7
Telephone
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90 Oct
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