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02518
4.
PUTNAM COUNTY DEPARTMENT OF _
HEALTH
Division of Environmental Health Services, Carmel, N. Y, 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM p/
Located at SvN�! r,�4c F f" 1JT 0/
�g �r v /J d i
Town • ,yam
Block
Owner AA 9i�AJ a' °® Lot -7-5
Job
Building Type _ . Address 0 lo+ 6 714 f
L 00 d % Gt'l�'S° .,:T1
Lot Area
Number of Bedrooms 'Lr .. p,� � � `:�
Separate Sewerage System to consist of _ �ej� Total Habitable Space- %0® S
Gal. Septic Tank 1 / Square Fef ,:; =
To De constructed by N'" f�a.. �-�� .s ,�, lineal feet X 3 t. °t width trenc
Water Supply: P 6lic Supply From Address __t °�E{�� jt, jr A
r d
_.,
Private Supply to be drille by L9 ( E ( '
Address
Other Requirements r '�
�r
I represent that 1 am wholly and completely re sp , � IeY���i� =
above described will be constructed as shown on 'YrP@
n cation of the proposed system(s); 1) that they "'
County Department of Health, and that on ame to and in accordance with the standards, rules a pare a wage disposal. system
be submitted to the Department, and a wr' f � of Construction Compliance "satisfactory es fh
place in rte gula ions o the
u name
good operating condition any par a �yY'f�1�1be^fu he
ance of the approval of the Certificate of
will be located as shown on the approved plan
County Department of Health.
Date t yf -7 �,-
owner, his successors, heirs or assfgns.by th'e b- Ommissioner, of Health will.
Sy uring the period of two 2
of a rigin lfsystem or any repairs thereto 2)thaY!the drilled flowing weft deter f the isiiu-
St I d n a cortlanee with the stand 's, rules and regulations of the Putnam,
tJ
0. Q� �r y a+
Address P•E• R.A.
APPROVED FOR CONSTRUCTION: This .a r
revocable for cause or may PProval ex rom the License No. .32,72,*
requires a new y be amended or modified when considered necessary ate issued unless construction of the building has been undertaken and is
permit. Approved for disposal of domestic anitar y by the Commissioner of Health. Any change oh alteration de construction .
Date 9� Y sewage, d /or pr• ate water supply only.
By
Title A41&4 i w
Lf
' PUTNAM COUNTY. DEPARTMENT OF. HEALTH
` Division of Environmental Health Services, Carmel, N. r. 1ir.�12 +"
n �/
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM fa�a�•f �CYyr'dA" VAccF.y
Town or Village
3i Block Z
Located at 5 yn/ M�N� '� c%A l� Tax Map
Owner Separate Sewerage System built by
Consisting of 750—Gal. Septic Tank and
Other requirements
Water Supply: Public Supply From
Private supply Drilled By
Address
Building Type +"C 5l Z7cN Ir/ fi aa
Has Erosion Control Been Completed? Q6
I certify that the system(s) as listed serving the above
attached), and in accordance with the standards,. ru
Date _/mss
Address
Any person occupying premises served by the above systenl%Sely
conditions resulting from such usage. Approval of the se
a
par
vailable and the approval of the private water supply shall beco
subject to modification or change when, in the judgment of the
Date By-
Lot '71,5- Job-
Address
U r'1/
Bedrooms Date Permit Issued
as shown on the plan of the completed work (copies of which are
ie pe mit iss the utnam County Department of Health.
C� I9/V de P.E. R.A. E
C /V • I._ 106-01 License No. 327ZO
r
h action as may be necessary to secure the correction of any unsanitary,/
shall become null and void as soon as a public sanitary sewer become
vhpgn a public water supp"ecomes available. Such approvals;
f �l&aeh- such revocation( ofodifieation or change is necessary. j f
Title--L .
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Pl,"
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-a WAVDA, 1AKE,
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MAX- M
DAZE RECEIVED;, q a'Y4 RECEIVED BY .c<, t }�- 7 `d'y°`G},xy S, sL +ry w,f'^
PU "I"
No
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BLOOD Zi7a
CULTURE
'SENSITIVITY 77"
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COPY
ID %s -�, t ,y �F. L Tt R El
p Sample '2 • Total colony5 count 440 co oniesper Ow
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FUNGUS E A
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OTHER S—R t C- I M -E N
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE.ONLY
9--41,-or-
SITE LOCATION
OWNER'S NAME
366 /110
S'f1 a
. 2404611 k�,,
TM# 1 _q
PHONE j 26 - 3 3 S-0
t IN
76 611 sTo
4
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint # ^Joui-C
aMe a ations ip i. owner, enant, etc.
DATE �� z o� TYPE FACILITY O S
PROPOSED INSTALLER cg_p a p c. T, c�IREGISTRATION#
PHONE ZZ-7 - S o 57
ADDRESS ;3 S A(• 56e_<_ e_<_ P-J . P fwt� l/S� _
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.
_7 /V Tim Jl ! / J / / -/O S�i�v /1%21 -�'0 S W; �L
_1__c� ✓ro.r w i %¢t.� Ae rr
;-as owner; or reyorted agent of-owner agree to tare obnditions -stated on this form: - - -
SIGNATURE%-+ /� TITLE pl�GSf�� -� DATE��'f�i�f
_Pro osr� al 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' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Propo ap roved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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I/ C11
DATE
Exs,sT�u g 6 � O �-
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WG- ANIX-REFORT-"'
el:
qq
Brame of IJlace Cityj village OWTOWn
Owners P.O. Address
pepth7of -w--11_, -Yizld 1411' s well disinfected70'
Z!Y�Diameter I
ft. in. gpM yes or no
Amt. of casing above ground /f Below -,.,round Woll seal
in ft packer, cement, grout
Draw a diagram in the space provided below and show `Jhe depth of
c: sing; the w^ll s,I-al, kind and thickness of forma'"ions -enetrated, water
JA
(bearing orma-Lions, diameter of drill holes with dott�qd lines and
casing s) with solid-lined.
T7
.;r N RML,.M
'WELL DIA! RAPT FORHeMUNS PE D,.I:
Diameter, in. Depth 1=d—, thickness and
Type of well
in ft. if wat.--7,r bearing drilling mitho
Grade as well dynamited?,2&
25
1 200
250
a sketch of the property
Dn the back of this sheet locatiog
lw'-`-J.-�L IL D S WAGE DISPOSAL SYS--:.i.-TZ
M
PUMPING
Details.
Static aater
levell in ft.
below
Jpumping rate
in gpm
Irumping ievei in
ft. below .::rade
Duration of,
tcst in hr . s
TS
WAT-6.1c AT LiND Uff '-L,
Clear Cloud-yTurbid
Recommended depth of pump in
wc,11, feet below ,rade
W,--LL;' IN & GRi-;.VEL: I
Sand Eff. size Mm I
Hald.eftefsize i
Length of screen ft.
Diam. of screen i
T.vpe of screen* . TI..
Drilling start,-.,d,
Well Driller r.
I
C; ;mplet:--dam
I/tt ",ILL
ure
0
0
Drilling start,-.,d,
Well Driller r.
I
C; ;mplet:--dam
I/tt ",ILL
ure
0
owner or Purchaser or ui ing Municipality '
--Tu-Ilding onstruct6 .7AX 04 1 P
Location Street B oc
Buuilding Type Lot
GUARANTY OF : S:EYARATE SEWAGE SYSTE14
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, 4nd . horeby- 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 puch 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-
vitas 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 � 9 31
gnature
Title
corporatio , give name
and address')
- - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - -
THREE. (3) COPIES ARE RE4UIRED WITH THREE. (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED...
GUARANTOR IS REQUJUP REQUIRE TO FILE OTC _PF R&E OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
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j I7UTNA.M COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES._
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
_DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL
Owner Fo y ASO Jogfj5l�jla U Addre s s (no
SYSTEM FILE NO.
_- Located at (Street �va� M A Block
i�� cep
Indicate nearest cross s ree
...Municipality yWn9 V,�LLE, ,. Watershed QffCAWAM4 L E__
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
_Number CLOCK TINLW PERCOLATION PERCOLATION
Run lapse Depth to Water water Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
•Inches Inches Inches
2 /Z - 3 I 'L .4¢ tr} 17 `2- 0 3 7
4
2 27
/D 3 '3 -3,
5 ,
1
�s.
2
5
Dotes: 1) Tests to be repeated at same depth until a roximately 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
EESQRIPTION- OF SOILS. ENC.OIT-NTERED.--TN--TEST--,HOLgS-...--.-.-.
EP - TH HOLE NO., P1 HOLE NO. 'P'Z HOLE NO.. PEE-P
211
411
:)
7
311
c 11
'TICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED KI WA. rf /�
,rDICATE LEVEL 'TO.WHICHWATER LEVEL RISES AFTER BEING ENCOUNTERED
]ASTS MADE BY 15" L Date ..5- 2 7
DESIGN
Ail Rate Used Mlin/l"Drop: S. D. Usable Area Provided-
of Bedrooms— 12- Septic Tank Capacity :750- Gals Type PjLCA'-%r-. aAj.c,
)sorption Area Provided By LLO L.F.x2411 width trench.
Other
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[IS SPACE FOR USE BY HEALTH DEPARTM"T ,
)il Rate Approved Sq. Ft . . . . . .
ked by Date
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Ldress
245-264b r 'l
[IS SPACE FOR USE BY HEALTH DEPARTM"T ,
)il Rate Approved Sq. Ft . . . . . .
ked by Date