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41.05 -1 -17
BOX 19
jy
ILL.
02224
�.�
PUTNAM ,COUNT DEPARTMENT OF HEALTH
r • 0
�t rQivisfon, of Environments/ Healih Seivices, Crarrme% N. Y 10512
CERTIFICA7E,OF.;CONSTRUCTION .G,9MPLIANCE ,FOR'SEWAGE,:DISPOSA'L.SYSTEM Tj✓!�,FTNA!�fGLEY
j.. p Town or Village
LOCated at 40:���c ^AAQ Tax�Map B ock' r
Owner V /O �/ BEN,�O�T%"�O Tax Map ,Lot # §uzia. #
Separate." sewerage system built by THtJi2i20 /GI(C_ Address,�Ei�l/sTE�C,✓ y
�/� s
Consisting of JOaI.'septic tank and 6 "'%L!N- T Of=- ¢aN/% 7
Other requirdments
Water Supply Pu c: Supply, From f :`
V
Pri4ate, Supply Driltetl BY ,
._ •i u -
/
• Address
Building Types /l il/.�,9L `, NO. of Bedrooms' Date Permit ' Issued
Has Erosion control 'Been Completed?
x
...'.I. certify that the'systein(s) as listed.seryinq .° reconstructed essentially as,shown on the plans of the completed work ( copies
of which are attached)', and in accordwi6e wi, "d iregulati ,'in accordance with the filed, plan, and the permit issued by the
putiiam County pepartment�Of'Health
Date. P.E. R.A.
t
license No. 'Z'72 D
Any person occupying premi'e$ served, by th o0 4� ro ptl ake.such action.as may necessary to secure the correction of any unsanitary
conditions resulting irom_sucli usage App e' separat" ' rag stem, shall-become 'nuiPand void as soon.as .a public sanitary sewer becomes
available, and the approval'of., the privite"wate g/ void "when a ,pub w ter supply becomes available. Such approvals are
sub)ect to modification or chbng /e when,;`�n 'th is ne of IHealth, eh r 'tion, modification or change Is necessary.
Date. By Title
m
i F
•.,. ... • �� t/' /O ,.....�i'�/�%%�`.�_�..T'T'd' _.... : . - ,._; --,_ w ._.. -, -.- �d�'.rJ':Oj�'. UT`Ni9%'7 R- � -C:�C; :.. ..
Owner or urc aser of Build ng Run- icipality
Building-Constructed by TA1_ 1-14'.0
Location - Street Block
O.,j-17Y4L (O
Building ype 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 in accordance 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_ „- ......a
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 l day of v 19 15th` Signatures
IF
Title O N E-IL.
If corporation, 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
ETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE _BUILDING CARMEL. NEW YORK
;pis report is to be completed by "welft, filler and submitted to County He`•alth Department together with laboratory report of
.analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN) 30 DAYS OF- WELL COMPLETION
I
ADDRESS -
OWNER
LOCATION
8 Stre (Town) Number)
OF WELL
BUSINESS,'rt::"
P ❑ ❑ ❑TEST WELL
PROPOSED
DOMESTIC ESTABLISHMENT FARMi
USE OF
WELL
❑ ❑ ❑ CONDITIONING ❑ (Specify)
SUPPLY INDUSTRIAL
DRILLING
❑ OTHER
® ❑ ❑ )
EQUIPMENT
PMENT
ROTARY AIR PERCUSSION PERCUSSION.
CASING
LENGTH (laet)
t
DIAMETER( Inches)
t
WEIGHT PER FOOT
El
YES NO
DETAILS
7
THREADED
YES NO
:
HOURS G.P.M.
YIELD (G.P.M.) "
TEST
❑BAILED ❑ 'PUMPED IS-COMPRESSED AIR O
-7 f
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST (feet)
pepth of Completed Well
WATER
In feet below Land surface:
LEVEL
.200
MAKE
LENGTH OPEN TO ,AQUIFER (feel)
SCREEN
; • 1
DETAILS
SLOT SIZE DIAMETER (Inches)
IF GRAVEL
:
Diameter of well including.
GRAVEL SIZE (Inches)
FROM feet)
TO (feet)
.' v
PACKED:
gravel pack (Inches):
DEPTM'FROM LAND SURFACE
�FORMATI,ON DESCRIPTION
Sketch exact. locatlon.of wall with d istances, to at least
two permanent landmarks.
FEET to FEET
lI f-o
a
If yield was tested at differerii dipths during drilling, list below
FEET
GALLONS PER MINUTE
Al
DATE LL COMPLETEP COMPLETE
DATE OF REPORT
WEL ILLER ( naturg
az
I
,P� - .ASS u,�rce ✓1= � �Q���-
I PUTNAM COUNTY DEPARTMENT OF. HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512
?Xf4�`
CONSTRUCTION PERMIT FOR SEWAGE DISPOS�4L SYSTEM
Town or Village
-Located at
Owner 0902 ,-j &--A16 P,6I"T12
Building Type 7-1-41(-- Lot Area
Number of Bedrooms -3 Design Flow 60 O
Separate Sewerage System to consist of zoo b Gal. Septic Tank
To be constructed by
Water Supply: /Public Supply From
— f/Private Supply to be drilled bry�.
Address eA 45�5
Other Requirements
I represent that I am wholly and completely
above described will be constructed as sho t
County Department of Health, and th
be submitted to the Department, and i
place in good operating condition an f
ante of the approval of the Certifica °ai Con
will be located as shown on the approve p and
County Department of Health.
Date i
Address v '- "
APPROVED FOR CONSTRUCTION: This ap uC c a
revocabie for cause or may be amended or modifie sidered
requires a ne er it. A rov d for disposal of domestic a� tar
Date r By
Tax 'Map BIGLie Lam•
Lot Job
Addre��ss��U /���
Al''
Total ;Habitable Space �����Sj Square Feet
and .134 AA/ /,y- n 5z4: t✓ dl/ %/ate ER�e'f1�
Address /Yef/✓
L
and location of the proposed system(s); 1) that the separate sewage disposal system
t there to d in accordance with the standards, rules and regulations of the Putnam
ificate of Canonstruction Compliance" satisfactory to the Commissioner of Healthwill
y ished the owner, his successors, heirs or assigns by the builder, that said builder will
stem during the period of two (2) years immediately following the date of the issu-
the original system or any repairs thereto; 2) that the drilled well described above
1n lied Ni /accordance witty, the standards, rules and regulat —ions of the Putnam
i P.E. R.A.
C l A, 101 License No. 47—zz.ej
from the date issued unless construction of the building has been undertaken and is
igcessary by the Co issione. of Health. Anv change- eltgration of construction
Title
i L F 4" PUTNAM COUNTY
IC�r Vii,: i 'Division ;of: Environmental
4 t
CTION MCONSTRU T FOR SEWAGE DISPOSAL SYS
Located at
.., ..:.,:,., ,?r�..w�:. ;... ,,fj.a � :. ,h.W.- !••jh_rmiw.: ;.ox.}¢si;. - .w�•p'l. =er+.�I. tv� +_. �. r y
ounaut
Numbe
_ Separat
Water
Type
)f Bedrooms •De<
Sewerage System; to,.,-co*, niist
instructed ,by � �n�r�
pply Public SupF
r
Pe ivate 'S u pi
' ,Address `—
�. �. ,•.�
: -Lot Areal %
a t • -
iFlow
�f-Q6 rL9
t
From
Other Requirements
`.� , ¢ 47x.1. <, t'` • ON
Lrepresent -that 1.am wholly and completCe'ly_respo o` div
above`desi n. 6' ed .will be constructed as shown'on't amendr
County Department o, and that'on co
6e subrtiiftedato; -the Depp`rtment, and'a` .•write r n w
place m:igood operating condition any part di se•
Dance of ,the approvaI 0"the certl icate,of C str cti
willibe located as °shown'on the approved plan'a Sei
County Department of Health
r P p n i
,¢ 93
Address
APPROVED FO R'CONSTRUCTION This. ?approval ;expire_
revocable.for: cause r o may be amended or modified when considered
requires a, new permit Approved• for disposal of domestic sa
By`
3ARTMENT r, HEALTH 4
[h Services Game% N 'Y� 10512 `<
' a Town or illagif
a Lot, 6r Joob�
N Address; 0 '° I/►l�E!(/ t /C.a G�
Totals Habitable Space ®�E-� �J ,`•��Sq —uare Feet
ptic Tank and
Address
`�OCl LL E �:Y 1
on of.:the proposed�system(s) _ 1) that the' disposal .system .
and in accordancelwith theataridards,.rules an regu a tons.o e u nam
Construction Compliance - ':satisfactory to jFe'LCommissioner of'Healthwill,.
owner, nq, successori heirs dr assign ;,by the- buiider,.tliat said. t ulider will ,
ing ahe ,period of twb (2) years' immediately ,:following_�the'date of the issu
o in'I;;system or any repairs thereto; -2j that the;drilled.welI described above
"I ordance with tne'. tandards les` and.-r egulaa s'. f..'tfie Putnam
tA, , � 4' n ` i . 1
3�Z o
License No
ie date : 3-sued unl t nstruction' of the bu ing`pas been undertaken;' and is
tne'Commi ston of SHebitll T Any;change,or alterat)on of "construction
nd� irate w f s
Title
I
~ 4' PUTNAM COUNTY DEPARTMENT OF HEALTH
- DIVISION. OF ENVIRONMENTAL HEALTH SERVICES
Re: Property of
Located at
Section I Block ! Lot
Gentlemen:
This letter is to authorize ` STANLEY J. LANDER
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
i:v,l,i�C Liuii w.l Ln ULL6 wa is i_ei• WIL.i to. supervise the cunstruc ciurl of said
system or systems in conformity.with the provisions of Article 145 or
.147, Education .Law, .-the Public Health. -Law,
and the Putn Tom)
Y
Very truly yours, DE'
Pr.. rF
Signed
Owner of Property
3 0 Z_ i-&-11 61
Address A/j --,,/ �
P.Ea9 9 # 3 2�72_a S- 26 5
Telephone
Y �
, t C
• rTP +
A f;
.., i; • : raj
• , , Ccgn L' ,;;tip �, , �4,,;�.
. ;' - • �+/ ® q► pro
r
' � ��ewey ' Ce•�p!e�ey! • LD -B -�5
AD
r VA
Slate
l.�
t
A
PUT
DIVIS1121), cit znWidi
_CONSTRUCTION _RE
AM T : OR' SEWAG.E'01$P _
OS1
7
J pol i
Owner 2,
%7777
:z Bedrooms �,
Number. -qf,-_
Separate` Sewerage System to Ift
i
P TO bo", constructed
.From �:
?Private ^Supply Ab.'-bedrilled ,. by
V
be submitted:
-. -
bm
.,,pla ce in'_ gqqd _
a nce, of "thi"a
whi'beiocat6d
-County Depar
spartr
1 cons
Vethe
revocable for use orma!
requires
bate
Ition any part aoi said se
'ertificate'of J:66stij "1 .
ruct o 0 a
approved that sal eAL 110
Health Ser.
ITEM
�W
Rp
[VOlp- -HEALTH"
M.-Y..40512-
Town - or Village .7
ens W. 4 7
t6til''Habitable -Space .-_�V�4, ",.Square Feet
7 width trench
M,
pr [j'. separate: - sewage ,.disposal' system
19pos" SY,
;5Riaanc& with AoA" I"
C5
ps�apd,.r,"ulatjqps of Ahe',,Putnam.
if theCdminisiloner, -H
sati actory to I of,.,' ealthwill
0 ,
. S, suttesi6is,'hiiri=6i-ia�lihs,�y' the ..buiider.'-ihai,iaid builder will...
I MI. I , following Yt , , J- -1
riod 61 two -(2)'years'Im mod lately'- hedate-of the ISM
or. - any. . irepal I rs . `roio;'4` that the'dr-Hi6d well described above
-
wit g �r� :6g_u1k_Tro_nsof he, 'Puthan!
t
moe
I SS co n ru.cilop, he building �hds��bbin - Lindirtaken 'and IS
.
,
:;rfKjill�n of"Heditti,4 - a;iionof :construct Ion
,o wa PLY-0.
i
p W-An-0 pET T 1 i%1 A ?"o
PUTM I Cf '; :'I'1' n1:1':\RTNh._'T n1- 1117M.T11
DTVTSTn\ nr
- ..�.•.. • Date •
Re: Property of �E C-76 e..A 'e P
Located. at 0,4kRjjo(;;F o"q 0 40 o.;r y W4111 A-
Block Lot
Gentlemen:
11, Ulm
This letter is to authorize
i"duly licensed professional engineer a,// 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 pr,omula;ated 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
. i
system or systems in•confgrmity with the provisions of Artie'le 145 or
147, Education Law, the Public Healtfi_. Law., onl. -the Putnam - Counfy San'i-
Lary -Code'.
Very truly.yours,
Signed
Coun ersigned: 0
P.E., R.A., Y ZT2�
UNDER
Address A 267
AMAW ALKY _ Y: X0501
Telephone '
Wner IQ
Address
operty
V
�NiLf/L� All
i
:I.Thes or corracr.''s ..F and a o_..a0 v.0 . ,o 0
:Location 0 . . . s
drj.VC -.).y n':ed cut: < a <
be, remc)vccl- -note th c- <
U.Gep }IO�•O : cq),'esenta.i:?.vc, Of' ci.1'La.r'C IS}. £3 J' J.
ioi°!.:). UCUI) }I U.I.C:� 7.` .;C vC }.
i`' ic., �,
_.,lZ: '•. .Cl_C ll � 1.I)$ c, wl c..a.�.<,.i)�.0 ;U: •_1.U..
0- o-1_veway cut, house :1_ma t. I_on, S cp�.r��.tion .
d't- 1.stari ,G c.,;
1'Iaf-1e:P G1 o3vati0ii:
flock elewation.:
Soil r . de c,r- r ; on:
Ins-,). by
Yours- loci "' -d i:rhere shown. on. approved plan
3.":; .1(?C:'.atc:d `wh.er` c`j:pprm7ed . . . .. . . •< • • c . . -
1.1 ti N Y- I1 /•, 1 Y •..� v n 1� .-. _ _ n v.._ rw . .. 1
SloUj - Of' ime. and' trer -c}
.
'Rcloi-) a r
llowed '. or d xl :.ns.ion treiic }•yes
Over-- 50 ft . from st ;at;TU, ti a.tercourse
Na•i, ra.l soil not str .peed. or. STO area _—
14 , TP�
. z -aint- ed � rom prop. line -and.
P-0 ft. 11ilo'm i7ouse . . . . . . . . . .
3ci:)aration of t-j nch from house, well
c .;c . f o l o i "4 s plR n . . . . . • . . . . G . a
RuT: ;ber of bedroc� �s checks . . . . .
wL n ^s, brush, stuTnps, rubble, etc . groater
Vnan : }. `j t . from nearest trench . . . .
? c f,, • �" ','�'ral 5011 ii0?'i —on a—I may- J. 0111
l l a_. ..,
ty-- canch . . . . . •• . . . . . . .. . . . . . ...
C:ti_on boxes properly set
1_d surface run off frc-T driveway, roads,
rC�und :::ur. face, etc . chmrinel ne=ar SL3 .
i
are a. . a. . . . . ... . 6.1-1*. . 7. . e . z . . —
br' .L..I. . .L11 of SDS
CR:ir:1:T,), OF SITE ACCEPU PL E
1
I
1
I
REVIEU CHE,,CK S 1 I T
T 1 Meets Std. Remarks
Yes i No
DOCUMTMS
House plans 0. K.
Design data sheet + �✓
Peres presoaked? ! +
Kin. 30 perc test 'depth j
Const. results for ,3 runs I i
D. Hole log O.K.
Corporate Affidavit for.other than individual N A i
Authorization for engineer I i
Letter from Water Supply if applicable + f
If variance requested -such noted on plans'& apps.:
DETAILS
if charge is proposed, )
Existing contours show n show new contours)
Slopes for driveway cuts, etc. shown '
Water.service line: location
Footing.drain, etc. location I
Top slope;, bottom slope of fill ! iv 7A I +
Percolation tests and deep test pit location ; f
Septic tank size and conformance to std. !
3 B.R. house minimum i I
House setback. shown i
111fi1.1 IJ.. ..J.V11.
� oax.
.n.l -�.• .I1C %.1_Vw 11•V�J V _.. ._. ....:! ... ...
AllWa ue..L' aL,vw -ii M ,,. _ ..; _, .. , —...M .1_ .. �I . � ..... -_ - •-
.Plan and profile_ SDS ..._.......... _.......: _. :....... ' .�.:._.. (....:_. .I.:..:: :::..:.::.
t
All .other' wells. and SDS closer 200' /
shown or, reference made
.Property boundaries (;.netes and bounds - clearly .show i
SEPARATION' DISTANCES ' SPECIFIED ON PLAiv'
10' to P.L.
20' to Foundation walls I ✓ + I
100' to Nearest well I 1
50' to stream,.march, lake, etc. incl.expansion ;
.15' to Curtain drain I
10' to water line. (pits -20' ) i f I
15' to storm drain +
.10' to larJe trees ! +
0' from foundation to septic tank ! i
5' to pipe from leader drain & footing drain
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner,/ 1A5,411% Address :2b Ste- 49914 o Vj4 � %T 9F j9a ie.�r /% lo 7D1
74A HA
Located at (Street i -Ap SM. Block _Lot
�Indicate neare cross s ree
Municipality „) = ;N,9M �LLE�' Watershed Pe6�5/ei o,ef_
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water a er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
2002 /0; 23 /4 1' 4(-3
3 /p;2 � 10: 3f 1.3 / JF . o 9 0 .3
5
GY l p"
2 /0;./J lo- 2q M ��Z 2Z 4 ¢__
3 10 -'30 /v /Q .9/ � 3 W-o
5
1
2 SQLL Ts` w Ae6tau hzyedy-
3
4
5
Notes: 1) Teqts 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
_..::1.:.:... DESCRIPTION-Or, SOILS .Fj.COUNTERED..IN TEST_. HOLES _..
DEPTH HOLE NO.� .
G.L.
6"
1211
18"
2411 H
3611
42"
48"
54
60"
72"
7819- -
HOLE NO. P;� HOLE NO. L.'
f � "Ps it !
y h
Of
r� 1$ N�•
.11
9
.h
8411 .�
I1�MICATE LEVEL AT WHICH GROUND. WATER IS ENCO
- � UNTERED
INbICAT9 LEVEL TO W'fIICR W TER Mrm`
TESTS MADE BY ..�s'�'ltj,lU�iz- Date �?- /S' ZY
DESIGN
Soil Rate Used /a : Min/l. Drop: S.D. Usable Area Provided .5; dam.®
No. of Bedrooms Septic Tank Capacity Dee, Gals . Type F
Absorption Area
Provided By L.F. �f ;width trenc .
STANLEY I LA
T Other
Address o
245-2645 _
THIS SPACE FOR USE BY BaITH DEPA
Soil Rate Approved Sq. Ft /Ga cked by Date
i u Q
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GYEGC
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S /9- ¢9 -�3ovv $s.00'
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20'
POIrI T
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20'
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4
44'
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45-ta
61'
d
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fhi9 a t8 atUiti Wt At s��aoQ
gipw sym was smmeted as 10•
diced 09 ttk3 pm 26 t"M a SySt??
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SYsre �
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eU'Cnam Bouncy llepa,Li,
ilvieion of Environmental
appeove as noted for con•
appi ble s d eg
PU
County H epa:
- �•�.uav m�-R1Z1B, .
/;ye LoT sr.'owN .`�eR� =oi
6 , oeK li AX 1+1.4,0 9
,MR PS.
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