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Home My WebLink About2528DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51.19 -1 -5 BOX 22 02528 m or X r SL ;iT J.Lil.. i6 �.� . �- .i VON 02528 m or X r SL ;iT J.Lil.. ROVY UkMD12LIL41VID s M s' • e• * 13. v •1 D, zjU Led DESIG14 DATA SHEET- SUBSUFACE S5QAGE DISPOSAL SYSTEM FILE NO. Grier G r/r Located at (Street) kl}/ J TE // /L L �, Sec. L_ Block Lot / J (indicate nearest cross street) — A /.a y) municipality _ 1 � % N.°9 m Watershed SOIL PJMOOLATION TEST DATA REQUIRED TO BE SUBMr= WITH APPLICATICNS \ Date of Pre -So king / l g-,�: Date of Percolation Test j/ � XK HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop, Inches Inches Inches 4 - 1 /d - �9 -mod_• s� 9 � � � yr `3 ,.. � /� . r 3 41. 1.,2 11..2,-1 is �i a'/ 5 T _, 4 5 1 2 3 i 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. j rev. 9/815 TEST PIT DATA. REQUIRED TO.BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERFA IN TEST HOLES . DEPTH HOLE NO. J HOLE NO.. 02 HOLE NO. 'G L.-' 6r,OWi z ��Fri9Ni e 1' s o / L TO aSo �- 31 a �r 49 n Ir 51 �r 6 ° 'r n 71 I, 9' cT�y i�lnf� -, , E� lei Cis v d} 1 9.5 1197 715 10' "} 13° 14' _.: _., ., _...... . INIICA.TE . _ ..: :.. _.:_.�.. LEVEr, _AT WBICH (_�20L]NDWATER .,zS :ECJC'AUNTEREq INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED .t�OT �7v�t�J ✓'E� DEEP HOLE OBSERVATIONS MADE BY: 11� r C-f-AIZ- � i9�. DATE: DESIGN Soil Rate Used 7 Min /1" Drop: S.D. Usable Area Provided .,'?SGt) No. of Bedrooms 3 Septic Tank Capacity -00o gals. Type CylVe- 1,3410 Of Absorption Area Provided By Other x �!' �iT` . r�,l Ll ® SV Name N0✓+'{lk, of Signature �,, . Address g lAlf I A he SEAL (91g yws o), , Dy THIS SPACE FOR USE BY HEALTH DEPARMW ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PU NAM COUNTY DEPARnAIM OF HEALTH DIVISION OF .HEALTH SERVICES DESIGN DATA ")HEET-SUBSMCE SEWAGE DISPOSAL SYSTEM FILE NO. c7-� >: �✓ 5 �✓1 Address . s Located at (S'treet) c-�� ,G�._ e_ aiiec. Block Lot (uidicate nearest cross street) Municipality Watershed TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking ,i 1 Date of Percolation Test 1. S HOLE NUMBER. CLOG: TIME PERCOLATION OLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time I Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches 111 C> - �i �l l �� ,�%..� � I / � � jn : ✓1 �� Vr`' � ��,' 5 4 ode- 5 '.� L' � I 3 4 5 ++i .. i NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are'obtai.ned.at each percolation test hole. All data to'be submitted, for review. 2.. Depth measurements to be made from top of hole. rev. 9/85, 1° 21 3' 4' 5° - 6! 7' 8� 9' 10' ll' 12' 13° 14' _._...... _..� INDICATE-- LE°VEI,' -At 14HIC 1i.. GFcvJNDVa=- S` ENCOUNIM"M- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity gals. Type Absorption Area Provided By . L.F. x 24" width trench Other Name Signature Address SEAL THIS SPACE FOR USE BY HEALTH DEPARRENT ONLY: Soil Rate Approved sgaft /gale Checked by Date WZJJJLI UUrLrjLziLU" rIzzur" CAW DEPARTMENT OF HEALTH Division Of Environmental Health Services RRALTH. .. .... Off ice Use Only I/ — 4 -'r WELL LOCATION TOWN4VILLA"ICIrr" ESIM W'GRIO N ' A=P� a )Y au", YY WELL OWNER NAME: ADDRESS: FFe PRIVATE PUBLIC USE OF WELL I - primary 2 - secondary fig-RESIDENTIAL 0 PUBLIC SUPPLY ❑ AIR/CONO.IHEAT PUMP ❑ ABANDONED 0 BUSINESS 0 FARM ❑ TEST/.OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL 0 INSTITUTIONAL :,0 STAND.-BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED /EST. OF DAILY USAGE 'ro 0 gal. REASON FOR DRILLING XNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST/OBSERVATION 0 REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH -01140 r fl. I STATIC WATER LEVEL . ft. MEASURED DRILLING N . EQUIPME r 0 ROTARY O' COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED 0 OPEN END CASING. W OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH k MATERIALS: STEEL ❑ PLASTIC CI OTHER LEN"GTH.BELOW GRADE f ft. JOINTS: OWELDED THREADED -O OTHER DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE VIDTHER WEIGHT PER FOOT 4Z IbAt. DRIVE SHOE ONO LINER: O YES ZNO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑ YES ONO. HOURS SECOPO GRAVEL PACK ❑ YES NO GRAVEL SIZE... DIAMETER OF PACK n. IT❑ TOP DEPTH ft- BOTTOM DEPTH — It. WELL YIELD TEST 'P If detailed MPHOO: ❑ PUMPED t tests were done is in- )i(COMPRESSED AIR fo,tmation'attached? 0 BAILED ❑ OTHER ❑ YES. ❑ NO it more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE I water Sear- ing Well Oia- meter In FORMATION DESCRIPTION C00E. It . it. WELL OEM fL DURATION fir. min. DRAWDOWN it. YIELD gpm- Land sur�ace W # / I WATER 0 CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES 0 No PUMP INFORMAT N TYPE CAPACITY y MAKER DEPTH MODEL VOLTAGE — HP -------- L_ STORAGE TANk: TYPE' CAPACITY GAL. WELL DRILLER NAME i 5--�' ADDRES6gtr-SiGfdMRE S-7 f t7 j 32. 0).2125 3 i LAB # Yorktown Medical Laboratory, Inc. 321 Kear Street Date Taken:"-' aken ' Time N'orktown ,. _•„ H4er�ig �5i= s N. Y. 10598 Date R c' d . ...- :. .._ _ ,. - •'�r�tt?-'��'iL'�"�`Ci ... ..... ._,- �.,..- ----- .�•.___. ... • _. -'gam -• - Director: Albert 1i. Padovani M. T. (ASCP) Collected By : T_ �,Zl %S0A/ s r�)6 W/91_t/ Referred By: Sample Location: _*O/ -;r- 7� Phone # ,AA SU Phone #. — I Sample Type: ,J Repeat Test? (check one) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL) _ Acidity — Alkalinity _ Chloride Deterl3ents, MBAS Hardness, Total Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite GENERAL BACTERIA _ Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform Fecal Streptococcus ' METALS Ong/L) Copper Iron Lead MBmgan-e.se...: _.. Mercury _ Sodium. Zinc MISCELLANEOUS PH- (units) Color (units) Odor (TON) Turbidity (N:PU) MOST PROBABLE NUMBER TECHNIQUE Total Coliform Index Index -.... KEY FOR TERMINOLOGY CFU = Colony.Forming Units N/A = Not Applicable LT = Less Than (C ) GT = Greater Than (>) TNT C= Too Numerous To Count CON = Confluent ( =TNTC) NR Non- reactive Potable _ Non - potable _ STP INF STP EFF Other: Sample Status: (check each) Outgoing HNO3 _ HC1 H2SO4 NaOH ZnOAc Na2S203 Other: `In-c omirig LE 4 °C _ :::�GT 4 °C _ pH LE.2 _ pH GE 9 _ pH GE 12 Other: REMARKS /COMMENTS (For Lab Use) IELAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TAZ N YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECDINKING THESE RESULTS INDICATE THAT THE; WATER SAMPLE (DID) (DIDN'T) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. 2 /86(Rvsd7 /87)RWE Albert H. Padovani, M.T. ASCPJ, Director n;. NI APPENDIX I PUTNAM, COUNTY DEPARTMENT OF HEALTH Building -. 5creez .. . DT.VISION OF- -0 WIRO_q�MTAT . HE -ALTEH SEA ?ICES: Section Block. Lot Tax Map Number Subdivision Name Subdivision Lot-#. GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent. -that I am wholly and completely responsible for the location, wor)manship, material, construction and drainage of the sewage disposal system serving the; above described property, and that it has been constructed as shown on s 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 operate for a. period of two years immediately following the date of approval of the 10'L'.^-.rtif -iea-tem of ' i'GiaStrTaC tioii Cvifipi i &iiCC'° . 'f "OiC i:iie S-Eaage Sp35cil" SyStHYI," 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 Environmental 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 of the buildin utilizing the system. Dated this L,24�_ day of (.5-- 195 Signature Title l� �- General Contra or-...(Owner) - .Signature _..._ _..._._. _.. Corporation -'Name (if. Corp.) Corporation Name (if Corp.) ,I / ..... ... ... dress P -Sldl✓ /�i� �/ _ rev. 9/85 l y _ 16 mk FINAL SITE INSPECTION Date - In spec4 tea 1� STREET I.C-ITION T�� (1`l- OWNER j LIJ PERMIT # TM 11r' OR SUBDIVISION LOT # II IV. M VI. 1 YF-q NO 'SP7-QGE-,DISP(DSALr-- REA A a. SDS area located as per armroved plans b. Fill section - Date of placement 2:1 barrier. IGTH W-J= AVG.DPTH- c. Natural soil not stri=:)ed d. Stone, brush, etc., greater than 15' fran SDS area. e. 100 ft. fran water course wetlands. SEWAGE DISPOSAL SYSTEM . a. Septic tank size - 1,00 1,250 b. Septic tank inqtal-laie:1-level c. 1 -0' minimun fran foundation d. No 90' bends, cleanout within 10 ft- of-Aa! bend e. DISTRIBUTION BOX. I-- - - All outlets at same elevation - ��-ter test C* 0 U. 2. Protected below frost 3. Minim= 2 ft. original soil between box and trenches f. JUNCTION BOX :- propex-ly set g. TRMKHES 1. Len -1 reguilred - /�:' 1,--,Icjth instailedZ'7� 2. Distance to watercourse measured ft. 3. Installed according to Dlan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 "/foot. 6. 10 feet fran vrcpe--ty line - 20 feat - foundations-- 7. Depth of trench < 30 inches fran s=ace 8. Roan zLllcwed for e-kc-pansion, 50% 9. Size of cravel 3/4 - 1j" diameter 10.. Depth of gravel in trench 12" minim= ll. - Pir>-- emds; canued h. PTDIP OR DOSE SYSTEMS l.. Size of ourm chamber- T7Alarm, visual/audio 4. ]P�=— easily accessible manhole to ara-de 5. First box baffled 6. Cycle witnessed by Health De�*tnent estimated flow per cycle. HOUSE a. House located per approved plans. ,v6 b. Number of bedroans W7;LL t� a. Well located as per approved Tans \I b. Distance fran SDS area measured C. Casing 81" above qrade. d. Surface drainace around well acceptable. .OVERALL WORIM:LTHIP a. Baxes prop_ erly qrouted b-* All pipes _par-aallv Lack. -filled c. —L piloes flush with inside of box d. Backfill material contains stones < 411 in diameter e. CLu--tain drain installed according to plan f. Cw:-tain drain outfall protected & dir.to exist-watercours I g c g. TC-()tinh.ains discharge away fran SDS area h. Surface Wc-Lter prot-ect-ion adequate i. EE-osion cont-r-6I provided on slopes greater than 15%. 1 •: APPENDIX B PUTNAM COUN'T'Y DEPARTMEar OF HEALTH - DIVISION OF ENVIRMEMAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS Ev -`TION PE'FMIT DATE REVIIWED BY: (Name of Owner ( L ca ion DOCUMENT'S Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth s/s SUBDIVISION Perc (3) Fill cd House Plans - Two sets Well permit; PWS letter Variance Request GENERAL Legal Subdivision subdivision Approval Checked IV3�''aii'y. Ers=approval SSDS Adj. Lots Checked Wetland (Tcwn/DEC Permit R & D) Data On DDS Plans.& Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design -Data = pasc•und� -deep r.. -su? ts: =._. __.._...:...._._a. _ _.: Two-Foot Contours Existing.& Proposed Driveway & Slopes Cut Footing /Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Pimped Pit & D Box Shown & Detailed House - No. of Bedrecns Wells & SSDS's w /in 200 ft. of Proposed System Property M-etes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe . No Bends; Max. Bends 45" w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, large Trees,Top of fi 20' to Foundation Walls 100' to Well; 2001.in D.L.O.D, 150' pits 100' to Stream, Watercourse, Take Unc. expa 15' to Drains - Curtain, Leader, Footing .35'to catch basin,stormdrain,piped watercour. 10'. to Water Line (pits -201) 50' intermittent drainage course Septic Tanks . 10' from Foundation; 50' to w-11 15' Well to PL DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ;;..,_ ....�• _ .._, APPLICATION TO. CONSTRUCT A WATER WELL PCHD PERMIT # '�J WELL LOCATION Street Address Fown /Vi,age/city Tax Grid Number WELL OWNER Nam Address �/ S. L.i�0 N W 7.�0N <,.; !/ /O rivate 0Public USE OF WELL 1 - primary 2 - secondary EhZSIDENTIAL ❑PUBLIC SUPPLY QAIR /COND /HEA PUMP ❑ BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL b INSTITUTIONAL O STAND -BY 0ABANDONED 0 OTHER (specify ❑ AMOUNT OF USE YIELD SOUGHT_,--� gpm / # PEOPLE SERVED__,/, /EST. OF DAILY USAGE gal REASON FOR DRILLING NEW SUPPLY � ;[]PROVIDE ADDITIONAL SUPPLY OR PLACE EXISTING SUPPLY `: ODEEPEN EXISTING WELL ❑TEST /OBSERVATION DETAILED REASON FOR DRILLING L -7•✓ GGLV 'Al 0 SE' WELL TYPE RILLED DRIVEN DUG GRAVEL -Q OTHER IS WELL SITE SUBJECT TO FLOODING? YES _e:�<-NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELI, CONTRACTOR: Name 1t1D% cC.0S�.,V Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SI-TEE: YES NO NAME OF PUBLIC WATER SUPPLY: N TOWN /VIL /CITY ._., -._. D.ISTANQFE,.7'Q..PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED r DON REAR OF THIS APPLICATION N SE ;'ET (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. 2. 3. Date of Date of Permit R /A6 Pump the well until the water is clear. Disinfect th'e..Wel l in accordance with the County Health. Department attached to this Submit a Well Completion Report on a form Health Dep rtment. Issue: 7'—.- 19 V 7- Expiration: f 19 is Non - Transfers le requirements of the Putnam permit. provided by the Putnam County e it Issuing Official PUTNAM COUNTY DEPARTMENT OF HEA - HO'?S PT ANS APPROVED FOR EJ :vOhi COUNT ONLY; E DRO0MS ! - a re ° Title y- _"� Date jeo u Vantage Bi -Level 26'x 48'3 Br. -1 %z Bath O O p O ePTN fo'.r e'e :eo e wP3KP /OPYp tl4 I qq(e 14LL NULL OPMML OPTION WINOO'N BNTN OPTION I n ftT OPTION 1'PUr e.rr .x e.erew t ele.erlN !!� VANTAGE SERIES SPECIFICATIONS FLOOR Exterior porch light at front & rear door 2 x 8 Floor Joists White 8" Foam backed aluminum siding (Bedroom /Bath sections of split -level have - 2 x 10 floor joists.: -. ,._ - :•:- - -•.•• - -- -- — - --- ' ` " "'7: "'T - &'u Plywood•ilooring glued and nailed -° Permanent 103/. "'eaves with ventilated soffit i tojoists front & rear of home with 6" fascia Floor Bridging —Solid Block W' Drywall ceilings taped, bedded and WALLS painted 2 x 4 Exterior Walls Spacious 90" ceilings 2 x 4 Interior Walls 3/12 Roof Pitch %zr' Drywall on all walls, taped, bedded & Double 15 lb. Asphalt Saturated Felt paper painted under 235 lb. 3 -tab self - sealing shingles %" Exterior wall sheathing 6" (R -19) Fiber batt insulation 3%" (R -13) Fiberglass Insulation secured to /z" Plywood roof sheathing exterior wall studs Ridge Vent HEATING EXTERIOR Baseboard Electric heat With individual Wood double hung windows with screens wall mounted thermostats Insulated steel front & rear doors with glass 42 gallon Energy Saver Water Heater i t r R VVV � . . .. ........ -qJ - - - - -- -- l; - -- -- - r 4 M.. } t, . PUTNAM COURrY DEPARTMENT OF HEALTH - DIVISION. OF ENVMONMENTAL HEALTH SERVICES K DATE: INSP. BY: (Name of Owner) (Street Location) INITIAL SITE INSPECTION YES NO MMM Wetlands on /or proximate to property..........,,.. Property lines or corners found ................... , Can estimate house location...:.. ............... Willdriveway need cut .......................... . Must trees be*renoved - note these ................ Deep holes representative of entire SDS area...... Additional deep holes needed..... .. ............ I IPA Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells/ septics ............................ D. H. 1 Lot, Depth to G.W. Depth to rock D.H. 2 Lot Depth to G.W. -Depth to rock Soil Descri tion 0 ft. 0 ft, 3 ft. 3 ft. 6 ft. 6 ft. 9,ft. 9 ft. 12 ft. _:..... 127ft. soil E r— D.H. - Deep Hole G.W.- Groundwater D.H. 3 Lot Depth to G.W. Depth to rock Soil Description 0 ft. . . 3 ft. 6 ft. 9 ft. DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS located per approved plan...... Length of trench measured Width of trench average. Slope of tile line and trench acceptable......... Room allowed for expansion trenches .............. Over 100 ft. fran watercourse .................... Natural soil not stripped or SDS area unnecessarly graded........... .............. 10 ft. maintained fran property line and 20 ft. fran house .... ...................... Distance well to SSDS (ft.) ...................... Number of bedrocros checks........ .............. Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench.. .......... . 15 ft. of peripheral soil horizontally from trench....... Boxes properly set . ............................... Could surface runoff from driveway, roads,' ground surface,.etc., channel near SDS area.... Does lot drainage appear OK-,in area of SDSeo,..... FTNAT, C,RADNC OF SITE ACCEPTABLE .. . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..... _ . ..n . _ Date -... _ .. /a / /��c�G _ ......., ... _...- ......_ ,. Re: Property of %-�sE' e+/ `' S n Located at �Ii/�� TL-� ifiLL "o /q- (T)-.-ZI6G% {�� /-1- zSection 2�Block Lot'yr, Subdivision of �j,�`�;r` /�`"�` QCL✓�garJ.9stf� ��✓/�'�� Subdv. Lot # Filed Map # &Cv17/� Date Gentlemen: This .letter is to authorize &jtj 7-/}f-,r-A1 a duly licensed professional engineer or reg (Indicate to apply for a Construction Permit for a.separate serve the above noted property in accordance with ..<i. �o r/•�� L. o istered architect sewage system, to 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 system or systems in conformity with the provisions o"f Article -A5 or 147, Education Law, the Public Health Law, and the Putnam County Sarii- tary Code. Very truly yours, Signed CourLtersie;ned: � 0 r of,/Property . P.E,• , R%1*., # 061Is-� dress /0.19 Address /o Telephone ap Telephone t PETER C. AIEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services Mr. Stanley Petersen P.O. Box 449 RD #3 Putnam Valley, New York 10579 Dear Mr. Petersen: January 13, 1987 JOHN SIMMONS. M.D. Deputy Commissioner RE: Proposed Construction Permit - Petersen Whitehill Road Putnam Valley, N.Y. Tax Map #29 -4 -5 P. V. Review of plans and other materials relative to a construction permit for the above captioned property has been completed by the Department. Based upon such review and pursuant to the provisions of Article III of the Putnam County Sanitary Code and Part 75 of the State of New York Official Compilation of Codes, Rules and Regulations, you are hereby advised ghat the proposed method providing water supply and sewage disposal are .. considered_ inadequate...as set .forth .below, therefore,._.approval. n ._oY....theseplans--cannot --be 'graateo:.:...s , .. .._._ The proposed well location is not shown at least 100 feet from the existing sewage disposal system'_on the adjacent lot to the west. Field inspection by Mrs. Sittner of this Department indicates a separation of 75 - 80 feet is provided. Returned herewith, please find one copy of the sewage system plan. If you have any questions, please call me at 225 -0310, Ext. 304. I 7 Ve ruly ours , ' f IJ f t ohn Kare11, Jr., P. E. Director, Environmental Health Services JK: AB: pt cc:V. Ettari Noviello Assoc. IJK . 110 ' OLD ROUTE SIX CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 July 11, 2002 Onnot Leyds 19 Whitehill Rd. Putnam Valley, 10579 Re: Addition- Leyds, 19 Whitehill Rd. No Increases in Number of Bedrooms (T)Putnam Valley, TM #51.19 -1 -5 Dear Ms. Leyds: I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp form this Department dated July 102002. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this department. 2. , Tae area of the existing sewage disposal 'system; add its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you have any questions, please contact me at your convenience. Very truly yours, - William Hedges WH:lm Senior Public Health Sanitarian cc: BI BRUCE R. FO-LEY. Public'. Health ~bisector :LORE t A A i�JLiNAI�i R N.,' M.S.N_ . Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 1� ADDITION �/�,<APPLICATION (RESIDENTIAL ONLY STREET I � Cc� kh J Td l TOWN7tAG4d X MAP# < ��- 19 - / NAB L & 30 W ► PHONE � � PCHD #.3�3 MAILING ADDRESS ��( -(�C k ll I� �'Q��`��?� DESCRIPTION OF ADDITION ��JL4 l7 20 NL-NIBER OF EXISTING BEDROOMS - PROPOSED # OF BEDROOMS 0 (/L Q GHQ Q et tS{ (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) *Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 4 Geneva Road, Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00. . 2. Sketches ofezisting -floor plan (drawn to scale, all living area including basement) *Non- professional sketches are acceptable. I. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) *Non-professional sketches are acceptable. . 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Cert. Of Occupancy from Town or Certification from Building Dept: with legal bedroom count of dwelling. OFFICE USE Comments Feb98 BFhousewidelines BRUCE R- FOLEY L0RF..TTA ..M0Lp2J/':P.i- R.i :., v:.S.i�1 ' I }..liilr �jeCtOr VT-, 4 ...:Associate Public Health' ass P lr lth Director Director of Patient Services DEPARTM_ ENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845)278-6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 6/25/02 Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Eq_�ffij-t-PYi; 11 Road Residence Tax Map 51.19 -1-5 Town nf Putnam Valley Gentlemen: According to records maintained by the Town, the above noted dwelling IS XXX _ . IS NOT incompliance with Town code and the total number of bedrooms on record is _ This information has been obtained from: CERTIFICATE OF OCCUPANCY: xx . (1 / 4 / 8 9 ) ASSESSORS RECORD: xxxx OTHER BFliouseguidelines Deputy Zoning Inspector CERTIFICATE OF OCCUPANCY — One FamilyAo Deck Certificate of Occupancy No.......... $.9.' 2......... Application No..... 87-1748 . . ...... Location of Premises ......th,it ehill Road - Ttr2.9 -4 -5 ...................................................................................... ............................... .t'nle�:.. Peters .on .......................... of 21 „Wa�s,c, };...k�.�Y...7 ... Pula� gm..ti.'! �.�ey..l��' having her ofore filed an application for a building permit pursuant to the Zoning Ordinance, Sanitary Cool. and the Laws 'in effect in the Town of Putnam Valley, Putnam County, New York, having paid the required fee:: therefor and the undersigned having by personal inspection ascertained that the applicant has subsequently proceeded with the erection or improvement of the proposed struc- ture in compliance with the requirements of the laws as aforementioned and that the said work and materials met every requirement of the laws as aforementioned and that the premises have now been fully- completed and are ready for occupancy pursuant to the provisions of law, Now, therefore, this certificate of occupancy is hereby issued under the seal of the Town of Putnam..-. _. 4......:.:.' day Qf ��a' uary :::...:.......::.:...I9. ': Valle this v Y Not valid unless signed in ink by a duly authorized agent TOWN OF PUTNAM V LLE NE YORK of and under the seal of the Town of Putnam Valley. By....... ........ :............. $ 0 r t� L i I of IPARTMW OF Maw, PVMM COMM -D HOUSE PLWAPPROVED FOR BFJ)ROOM C MOOT ONLY; aft Iwo 6b 74 wcm� l (NI"5 P, 4— 1 ZZ: V T Z. I, " Ta 1:PM I o.�q- T : TT �UTITO/TP JUL -10 -02 10:32 AM ONNO LEYDS 9145269163 P.ei l O!. s. p,�po ao U QH N �� to p 6v f x 1111 TOM- a -acaA THE 13:24 TEL:845- 278 -7921 �j ►� Ijj 0 �. n C4 i s i A I NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 V � VIN 1111 TOM- a -acaA THE 13:24 TEL:845- 278 -7921 �j ►� Ijj 0 �. n C4 i s i A I NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 hz� o kpv i ct -c� _-6 .,..t c 'y1 o — MA4q.IAIJ fit- r N AA G) t IL 0910s7 N. Or -vt;tA< L0 • Fri n 71 11 rr I JUL -10 -02 10:33 AM ONNO LEYDS 9145269166 q • v, � A`'0' f i • t I" Poi • ° . e V. r 3"j Amu$ Y x bVV M� . 4S� • Y DEPARTMENT OF P. 2 TOKI- a -PSAVI TUE 13:25 TEL:845- 278 -7921 NAME:PUTNAM COUNT •rww�.I -uw wuRM�, L A K osCA �--- - . ..�._ ANA �•A�,� N14 a� N won F Ile loped -, `w "�'�.. ~'�.•, I� ? , alq,q --.• wdl! 1. 1 q�q' erar ` ok i �• � ! ' / , � � • • �. 011 IMIO {l ,' V ,. _. �� d• ¢'� ... � � ' ✓..�•�"L. Zano on lino y nYY @'ciA�,w !ill Ni 11 G 1 In N f� m v rtako tolled • - I on line Iron tad }yYfld .. d't 44461' �� • rani W + a :t ' rod �e1 Iron pips tewnd m ACV ' ,- , WHITE HILL ROAD I SURVEY 6F mph 'r PREPARED FOR :`�. Tai NL F Y 8 CA R1.. f`F TE FE'S ON I SITUATE IN THE TOWN OF PUTNAM VALLEY PUTNAM COUNTY NEW YORK , SCALE i In. - 3 Q t1..__...., , t, RICHARD H. GORR the surwyor who msda,th/a map, certify NOW: 1MtlbpayraOyeApwnAeraon woffampialasbymaon t. All certifications are valid for this map and coplas thereof die-/ �„� 1486 , Maf (hfemap We$ complaredoyme only If the said map or copi#A boar the lrnpiassod Seal of the on 0'.. ?r -e 7 .tag,, surveyor wtipse sionaturo appears hereon, and Mat this survey y h been praParsd in aomdence with the 2. alteration of this ductimani, oxciipt by B 11conved Lbrld aidalirly Coda of Ptaotleae for tend Surveys edttpled by rho New Suryoyor, Is illegal. Yort Stria Asaoctatfon of prpfesstona► Land Surveyors. 3. This map and copies thereof ;rrs cof liod to the above - named owner end the tilte company and lending Insti. Pfi0Posqf I, Nou li(! A NO 06C-11 tort n l: h r and t lPl ;t rtfua only. Cd�t� a Q 4. LOT eFIG'�� n filAP R'I]itii 0 EC'` LAK OICAWANA ACRFa- A b r.a f: t,'C h,t bC e J S i I L7 �s FILe.D IN TfW PUTNAM COU14TY CLERK% OFPICF JAN. ®,1981 A3 MAP MAP gdvt�e.r, OtAy z0� 067 NO, 40 A. hryr robool ANN rp)"?. S. DIJe TO LACK OF mot4u *NTATtON. euRV[YOA9 MAY OVER BY ra. IN A NORTHERLY AND SOWTHEAL't OMEC OW, !'cwpor ro D.aF? r.° r,Vie f!, S0& .4A>" t'tIK�l1��D At 11L tr.�,t.�e�a; CERTIFIED TO: STANLEY A CARL PETFRSON MiDLANTiC HOME MORTGAGE CORPORATION R)ONAHbN. BONA, P.L.N. N.Y,8. tic. No. 00613 COMMONWEALTH LANG TITLE INSURANCE COMPANY ROUTIN it P.O, box Vo MAHOPAC, N.V. 10641 RICHAR4 I$. 4,ORR LAND SURVEYOM a GEOLOGISTS a ENVIRONMENTAL STUDIES JOB No.$ 4v oT 79 5 CAKE OS CA WAIVA - , Nlla EAST Ir�wpipe... ,9' O., /UO 3 �e tr'cl'er KO /f NPej : +,s/l ao' ' !;�i:� ••% i / wooc d oat N 24.49' ! /� %.�• /.!� '. / /2 S7*001Y FAv1AA4VF e fad• -._ DVYLLLdVI; �'• to v i ' I stake found an Ilne i G ' a Iron rod , found ' rod 32 °17'i0 -E r - --- 90,00'' -X I9g'9, WHITE HILL ROAD -Iran pipe . •� • 0.30' over 7777 shad o� • f .. chain Mk teace on Ana 3.. . I I Y� 4't clear rod UJ O M N t� CO L .Iron pipe found ' !.o.40- 0' —mss SURVEY OF PROPERTY PREPARED FOR S TANLE_ Y 8 CARL 1---1E. TE. RSON SITUATE IN THE TOWN OF PUTNAM VALLEY PUTNAM COUNTY NEW YORK SCALE 1 in. — 3o ft.._._._. —..__ 196io I, RICHARD R: GORR the surveyor who made this ,nap, certify NOTES: thal4hesufYey shown hereon was completed by me on t. All certifications are valid for this map and copies thereof Oe/ /3 19g& that this map was compleredbymo 1, on �.,r ,27 . 1a.&, , o� 'rte c •� O `/ existing Code olPrecttce for Land Surveys adopted by Tna New 3. This map and copies thereof are certified to the abovo- C I� CI- 0 tLugpn 5 n red here n, �((jf�(21h•pSe O�II1e5 Only. a 4( 9HGWN ON MQP Er+n1tEv 5EC 5 CAKE OS CA WAIVA - , Nlla EAST Ir�wpipe... ,9' O., /UO 3 �e tr'cl'er KO /f NPej : +,s/l ao' ' !;�i:� ••% i / wooc d oat N 24.49' ! /� %.�• /.!� '. / /2 S7*001Y FAv1AA4VF e fad• -._ DVYLLLdVI; �'• to v i ' I stake found an Ilne i G ' a Iron rod , found ' rod 32 °17'i0 -E r - --- 90,00'' -X I9g'9, WHITE HILL ROAD -Iran pipe . •� • 0.30' over 7777 shad o� • f .. chain Mk teace on Ana 3.. . I I Y� 4't clear rod UJ O M N t� CO L .Iron pipe found ' !.o.40- 0' —mss SURVEY OF PROPERTY PREPARED FOR S TANLE_ Y 8 CARL 1---1E. TE. RSON SITUATE IN THE TOWN OF PUTNAM VALLEY PUTNAM COUNTY NEW YORK SCALE 1 in. — 3o ft.._._._. —..__ 196io I, RICHARD R: GORR the surveyor who made this ,nap, certify NOTES: thal4hesufYey shown hereon was completed by me on t. All certifications are valid for this map and copies thereof Oe/ /3 19g& that this map was compleredbymo only if the said map or copies bear the Impressed seal of the on �.,r ,27 . 1a.&, , surveyor whose signaluru appears hereon. . 04d .that this survey has been prepared in accordance with the 2. Alteration of this document, except by a licensed Land Surveyor, is illegal. existing Code olPrecttce for Land Surveys adopted by Tna New 3. This map and copies thereof are certified to the abovo- Yoik State Association of Professional Land Surveyors. named owner and the title company and lending Insli• pea SE)- f� NOtr Sr_ A NO S !e l I tLugpn 5 n red here n, �((jf�(21h•pSe O�II1e5 Only. a 4( 9HGWN ON MQP Er+n1tEv 5EC ��]] � p f> C. C Wt !�C <<•• ! U �� -LO7 LAKE 03CAWA14A ACRE FILED M 'THE PUTNAM COUNTY CLERK'S OFFICE JAN. B, 1961 AS MA MArl Pavl5eo MAY ,ZOO 1487 No. 367 A. male rev"i Jana 12,/987, 5. DUE TO LACK OF MONUMENTATION, SURVEYORS MAY RIFER BY ri, IN A NORTHERLY AND SOUTHERLY DIRECTION. BROUGHT TO D.4 77.' rYOV. f/, ,1988 H jr.•uLsed.'t_)ec.9 t',es.. t o tn. rehvtsF >> a . e� _ ... CERTIFIED TO f�...�.1.`e.y�% a�jX • _ STA14LE.Y 8 CARL PETERSON MIDLANTIC HOME MORTGAGE CORPORATION RICHARD H. GORA, P.L.S. N.Y.S. Lic. No. 40513 COMMONWEALTH LAND TITLE INSURANCE COMPANY ROUTE 6 P.O. BOX Gie MAHOPAC, N.Y. 10541 RICHAM) H. GORR & l4SSOCS. LAND SURVEYORS a GEOLOGISTS a ENVIRONMENTAL STUDIES JOB No.8 % d79 ' 51,19 -1- TITLE No. cgKF OSCA WgNq N Egsr ._ . Iq °3 � N iron pipe.:. 6'00,' Q 2 - found i _� . - «... _.. .. _ groyad water\ r •Irol pipe found wg// AIPes ;r 0.30• over shad V; wood dart/ �I y N 24:44'__ line (� - -chain link fence on line 5 2 STORY FRNA/E- e rod.--. QWEGLbV& rod : 3 25.20' t I w N ri � } / 4'! clear CD r roe) 1 r � C • � a stake found ' j1 on line ` I W hip e Ip ,o ;r ' j m iron rod - -_— - lound '- . `- 1r, °D_PiPO i 32e17'30'•E —e -- 90,00'' ) 0.40 VVHITE HILL P 0 A D SURVEY OF PROPERTY PREPARED FOR S �lallN2 &7 -Y 8 d(A (IV eE T do<EJ -Ed?5 Dell SITUATE IN THE TOWN OF PUTNAM VALLEY PUTNAM COUNTY NEW YORK SCALE 1 in. = 3o ft. 196(. I. RICHARD H. GORR the surveyor who made this map. certify that the survey shown hereon was completed byme on 0,115 19&r . that this map was completed byme nn Ci`-/ --07 •1920 . and that this Survey has been prepared in accordance with the existing Code of Practice for Land Surveys adopted by The New York State Association of Professional Land Surveyors. MAP 9evlse0 MAy 20.) 1997 .map revhed rune 1219971 BROL/G.NT 70 AAT:- Ntiv ib ;.sae NOTES: 1. All certifications are valid for this map and copies thereof only if the said map or copies bear the impressed seal of the surveyor whose signature appears hereon. 2 Alteration of this document, except by a licensed Land Surveyor, is illegal. 3. This map and copies thereof are certified to the above - named / lowner and the title company and lending insti- a �LOTn4(siS SHGWN ONrMAP ENi1TLEDh�SgC. 4 LAKE OSCAWANA ACRE FILED IN THE PUTNAM COUNTY CLERK'S OFFICE JAN. a, 1951 A5 MA NO. 367 A. 5. DUE TO LACK OF MONUMENTATION, SURVEYORS MAY DIFER BY 1'!. IN A NORTHERLY AND SOUTHERLY DIRECTION. .. RICHARD H. GORR, P.L.S. N.Y.S. Lic. No. 40513 ROUTE 6 P.O. BOX 916 MAHOPAC, N.Y. 10541 RICHARD H. GORR & ASSOCS. LAND SURVEYORS ^ GEOLOGISTS • ENVIRONMENTAL STUDIES JOB N0.8 6 - ,,� 79 Rev. 3186 CONSTRUCTION E nO� PUTNAM COUNTY DEPARTMENT OF HEALTH �iY I Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit # . SEWAGE DISPOSAL SYSTEM Located at _W ZY /T -A-[ l Af /LL l d . Subdivision Naane�%� ' �� •m_ __ _ �� ^. Lot H .:...- _ OSe'A1✓AA0 9 n Renewal_C Owner /Appllcaltt Name�� Date of Previous Melling Address %119TSo/I✓ iafAY Town Building. Type. Woo,> Ale#4rs- Lot Area F Section ., 0 t Number of Bedrooms .Design Flown /G P/D I/P i0 b ! PCHD Separate Sewerage System to consist of _, �Galloon epde Tank an a To be constructed by A107— 6 -000 3e N Aaa on CERTIFICATE OF COMPLIANCE Permit # Town or Villa¢e Z. . zip / C, 5- _ J Depth Volume Is Required When FIB is completed Water Supply:_ Public Supply From % A or._�Private Supply Drilled by f � Other Requirements ok /% /e 1 represent that I am wholly and completely responsible for the design a d location of the proposed system(s); 1) that the separate an sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules regu a ions o e u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will Place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately following thetlats of the iss' ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be install in accordance wii�t /ihthe � standards, rules and regu a Ions of the Putnam County Depart ent f Health. �p r^"• 1/t, / w r sf/ Date IZ? $` Signetl_ P. E. R.A. — e r Address �/�%3 L/�N� 0/✓ /0'VILicense No /"G IN PPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless constructi'n of the building has been undertaken and is I for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction 'wires a new permit. Approved for disposal of domestic sanitary sewage, and/or private water supply only. By Title / 86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 Q Engineer Mast Provide v 3-2-7 O ( =J� P.C.H.D. Permit+: Located Owner /applicant Mailing Address OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM W, , //i'L, ,zP- vT��1� Town or v Tax Map x�2 .Block Lot Subdivision N 4 ! ' a �,LM� v.'ISt jN y / Date Permit Issued �v Separate Sewerage System built by 6-61— 4- l -' /t. J0-4/ A ZZ O a WAS/", /yllY/V%in1 r Consisting of — = 00 b Gallon Septic Tank and 3 O� T/�J` IF Water Supply:— PU apply From Address �, �� , ` / I , or: '� Private Supply Drilled by--.. Address / MAW �L r ,y • y Building Type /�dd�E -Has Erosion Control Been Completed? ES Number of Bedrooms - Has Garbage Grinder Been Installed? 0 Other Requirements e ,�l 7 I certify that Use system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulationaf in acc rdance with the filed plan, and the permit issued by the Putnam County Deei'.xrtme t Of H lth. , //� Date J, r Certified b _ N P.E. )I R.A. EZ Address 0`� W4 " L� use No. t/� if Any person occupying premises served by the above system(s) shall promptly t e such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a pubt% sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification ors change when, in the judgment of the CoTmi"ner of Health, such /revocation, modification or change Is necessary._ T J RIAM COUNTY litOARTNIENT'OF HEALTH r',, RMT 'EIvIslopo f kn nm-6n`W,Aiw'th,SerWc o n:CER - 61ftlit CONSTRUCTION PE STEM 4 o:� SdbdIvIA6n.N... 4 Renewal Owner /AppUcanfName ` Z 1. Date of Pievikii A00i -ova Town 0 -Bufid.lug;-- Type y y Number. 10f.19146 WS ICHRNotifleaum "T t6d'by- 6 lorli6x6astrue Water 5 ;qp or,. -51 0"r, R I e�e&e's46r f ' that -I,,aM wholly pand gn.snd location,p;,t�e,pr.pp?s., W ste (S) 1): atqve,ces rrb ph the ` �fppamendment -6ire to and 'ind,in accordance r:with ,t he,s tand, County Department f , ec f on t-� atisl � anCer OT inw, approval will be located ps's"p, o..,,the�appio County 6,;Djrt t f 'Health Date APPROVED FOR CONSTRUCTION : -T-h revocable for cause or may be T 0 :en', reQuims a ew i !' t 'A jprove4zf6r-.c P I rn DaN Si4ni approval. Oires one .ye inodiflid'When c6risidere ibOSil-04 dom-eitic sanit, or 5.village evlslon ❑ R P A.: -,-License No-"01611Y • he date gissuee unless c66str'Ciction of .the building .has bean undertaken . a . nd is my-by ,the Commissioner of Hiialth Any charigo,or, -'alters Ion of construction r p!ivqte -wkitei SuPR!Y- on,y., Title LgKF OSC,4 WAIAIA EAST Alo. 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