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BOX 22
02568
fill
16 L
I
02568
Rev.,.Z 3186
4at-
Owner/applicant Locat
Name -.dZ
Mailing Address 'Z7l
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel,'N.Y.10512
_ Engineer Mast. vide pt/
^ P.C.H.D. Permit 11
]INSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM er
9 G J F o07A "4' Tax Map Block Lot
roll 0
� ,r�''�, Formerly °° Subdivision Name 1� °� Sabdv. Lot N �
W Zip / i's"� Date Permit Issued
.L- rclloceh
Separate Sewerage System built by
Consisting of
I
d �p7� y f
-40 sd12 Address 1>'n a L rV cVV -..1 vim �Y
Jo Pwe,r, ✓�J� �-
�.i !
24-a' Gallon Septic Tank�a
Water Supply: PubBe Supply From Address
or: --D Private Supply Drilled by— +� h IJ e'211-17 Address /� o r3 �/ �jL • . ��9T' /!A %��it
Building Type ✓ a" Erosion Control Been Completed?
Number of Bedrooms Has Garb a Grinder Been Installed? /V 6
O_Nrer Requirements Cr / /i%
I certify that the system(s) as listed serving the above premises were constructed
of which are attach-ad), and in accordance with the standards, rules and regulations
Putnam County Department Of Health. j
Oats i
�
Address a �
Any person occupying premises served by the save systems) shall promptly take such;
conditions resulting from such usage. Approval of the separate sewerage system shit!
available and the approval of the private water supply shall become null and vokf when
subject to modifi tion or change when, in the judgment of the Commissi a N of Mt
Oats 12
eentitd s shown on the plans of the completed work ( copies
t �i l softh the filed plan, and the permit issued by the
0 ?� A-;2, y ,t 1 Licensa N0.''�
scary to secure the correction of any unsanitary
` �oii! as won as a Pubt': sanitary sewer becomes
4u Ply becomes available. - Such approvals are
turn, modification or change Is necessary.
z - A /
�/�
Title
M
PiT.I'NAM COUNTY DEPARTMENT OF HEALTH
- - - - - -- , - - - - -. DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purchaser of Building Section Block Lot
i/
Building Constructed by
4j CIO W14141 <1 "4,4
Location - Street l�
Municipality
Building Type
Y4, 1 0-1-01 /V
S visio Name
21
Subdivision Lot #
GUARAUI'EE OF SUBSURFACE S3&GE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for - the location,
wor)ananship, 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 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
- - "Cent- if- .ca- t-e --of- Con- str= uction =- Compliance" 'fot..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 occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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 building utilizing
the system.
Dated this ",2 T day of 3�9,v 191L Signature
Title
General-Contractor (Owner) - Signature
Corporation Name (if Corp.)
.
Address C,tAoV%I V) y, ios2o
rev. 9/85
mk
Corporation .Name.:, (if Corp.)
ess1oSb�.
<0SEd
WZLJI.. UUrirLzij_V v fcZrvni
y �e) DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COltNTY 'DEPARTMENT `O;' HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TOWN)V1ILLAArdUCII TAX GRIO NUMNEii:
)7
WELL OWNER
NAME a /
va
aPBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
,XR SI NTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY 0
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED ---- y-EST. OF DAILY USAGE `� gal.
REASON FOR
DRILLING
-_E-NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
! DEPTH '
WELL ft.
STATIC WATER 3 ® r
LEVEL ft.
DATE MEASURED �
DRILLING
EQUIPMENT
,ROTARY O COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT 0 CABLE PERCUSSION O OTHER (specify).
WELL TYPE
❑ SCREENED ❑ OPEN END CASING & OPEN HOLE IN .BEDROCK ❑ OTHER
TOTAL LENGTH fit
MATERIALS: sue. STEEL O PLASTIC ❑ OTHER
CASING
DETAILS
LENGTH.BELOW GRADE �� �''ft.
JOINTS: ❑ WELDED PTHREAOED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE '1q OTHER
WEIGHT
PER FOOT �Z 1b./ft.
DRIVE SHOE -AYES ❑ NO
I L1NER:O YES 0
SCREEN
DETAILS
DIAMETER (in)'
SLOT SIZE
LENGTH
(It)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
SECOND
-:
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH fL
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
t
METHOD: ❑ PUMPED t tests were done is in-
[COMPRESSED AIR , formation attached?
❑ BAILED ❑ OTHER :OYES -ONO
WELL LOG If more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
suRFAcE
wear- Water
ing
we1el
�!l
meter
In
FORMATION DESCRIPTION
pt1E.
ft.
iL
WELL DEPTH
It.
DURATION
hr. ;min.
DRAWOOWN
It,
YIELD
9pm.
Lo Lace
�r �r
/y ✓
C� •t
a s�
J
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? O YES: ONO
ANALYSIS ATTACHED? ❑ YES O NO
STORAGE TANK: TYPE
CAPACITY �YO GAL.
PUMAFOMATION
TYPE /�'►� CAPACITY `
MA 4,. DEPTH
MODE'�YVOLTAGE2°0 Hv P
WELL DRILL�E i
AOl1RES 1 RE
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
914 3'203._ ..-_..
Director: Albert H. Padovani M. T. (ASCP).
L
^ , Ci23140 �.
LAB #
Date Taken:. f' Time: G'' ' 3-z�o
Date Rc.'.d: %rte Time.___) _
_.... _.... _..� a t"e'�- R e p o r t e d. -.• ---- ._
Collected By:
Referred By:
Sample Location:. /<lrn `4r
41 o(,
Phone. # a`�7i s s6
Phone # i Sample Type:
J Repeat Test? I (check one)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
Acidity
Alkalinity
Chloride
Detergents, MBAS
Hardness, Total
Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
GENERAL BACTERIA
Standard Plate Count
(CFU /1.OmL)
MEMBRA FILTRATION TECHNIQUE
�' Total Coliform
Fecal Coliform
— .Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Copper
Iron Total Coliform Index
Lead
_.._ ..Mangan.ese.- : -. - -._ .: __... : ,:._ .... _ ........:.:.... Fecal• Coli— orm
Mercury
Sodium KEY FOR TERMINOLOGY
Zinc CFU = Colony Forming Units
MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
N/A = Not Applicable
LT = Less Than (< )
GT = Greater Than (.>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
otable
_ Non - potable
STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
HNO3
HC1
— H2SO4
NaO-H-
ZnOAc
—. Na2S203
Other:
Other:
REMARKS /COMMENTS (For Lab Use) IELAP 1110323
THESE RESULTS INDICATE-THAT. THE WATER SAMPLE (W (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH W YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N/ MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT PNKING WATER
CODES, FOR THE ,PAIiAMETEAS TESTED, AT THE TIME OF COLLECTION.
x
Albert H: `dovani, M.T. (ASCP
, Director
2 /86(Rvsd7 /87)RWE
4 °C
,%LE 4
-4 °C
_ G
LE 2
pH G
GE 9
i pH G
GE 12
REMARKS /COMMENTS (For Lab Use) IELAP 1110323
THESE RESULTS INDICATE-THAT. THE WATER SAMPLE (W (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH W YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N/ MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT PNKING WATER
CODES, FOR THE ,PAIiAMETEAS TESTED, AT THE TIME OF COLLECTION.
x
Albert H: `dovani, M.T. (ASCP
, Director
2 /86(Rvsd7 /87)RWE
J,
'.PUTNAM COUNTY DEPARTMENT OF HEATH
Rev. 318�61 DIvIsion,of k6iltfi Services. dUiIieI.Niy;-10512 _jUlgIneer.90'Prviiei"i-# ����/
on CERTIFICATE'OF- COMPLIANCE: •:'
CONSTRUCTION. PE FORS GE", DISPOSAL' SYSTEM
:'__
Located a. z -nf To V
e, TjX Map Block
Subdivision am —Subd. Lot
t
R e newel
Owner/
Applicant Name 14
Date of Previous Approval
-
z
Mailing Address V.0 Town .22p
A
Building- Type e
IAt Area FIIJ Section volume L
Only Depth
PCEDNodficadotibRESH!T�Whenylfliscomple
Number of Bedrooms Design FloW G/O P
*401�Z
rag' Ist 3 7_
Sbparite Sewe e,:�ystpm,lb.cC0jnMWs Gallon Sep Tank and
to tie 6)nstz;aeftd.by
Address
Pdblk Sao-' I From Address '
P_ I 6ifli ed by
Or: Private.
S P
Other Requiretnentl
o
f
r—represent that.1 an who'lly and' ccompletely blet�iy responsible for the design an location cs a pro sewage disposal. ' syst rn 1) 'that the separate
above de.scr ibed will be constructed as shown on,the approved. a n1prid Tent tPer6L to and . r in ac, -c jt ir girsis, rules and regulations,ps! • the �Kiznam
County DaPartment of Health, and, I that on . cor�iiietio nt . hereof a "Certificate . - of 6 . onst ctoiy to the Ci5mmi'sil6nir of Healihwill
rs� Will
itti, t
b subriiitted to the Departrrisirit, 'and issir n guarantee will be furnished own 0 by the.builder, that 1 .1 . - , ._94arr. , ' , , , , I
place in good'. o0irating condition any part of . said •s""e disposal system du Inng. a. I in
w lately following 60dati.cif tho.issu-
ance of the: approval of the,'Cer6ticati of co'nstruction ,Compliance -of the .0H Ina ran -irs 0;. that.the drilled well cloicrilimcl4tic"'is
a a',n
will be located as'shown bri,mealiproved plan and.that said well, 1'siii1i tie.lnstailed im ic rdi wj "I a 01111 d' requTa ions -.of'.the, Putnam
County Department of Health.'
Date I signed— P.E.
Z
Address license No Jr IPJr
APPROVED FOR CONSTRUCTION: This.approvalexpiirei r fro the 4/6 e*buildinj has been undertaken and is
revocable for cause or m b amended modified when conso or n6c ni changeK alteration of construction
9 may ejamers e or m a
requires a new I. A7
LrQ jor,disposal of domesticsa t "y w. as arid •Date— By' Me
FINAL JXl - N. CIUN Date
/ by c..✓
STRFIT IOCMTION O S L'9 w g j '''�✓ OWNER c/ P-<,q
PIMM.T_T a Jp 1 I �' �7' TM a OR SUBDIVISION LOT p -f�� Z I �„
I1
IV.
V.
a-
YES
NO CCY�±lI`S
.,SYo ?G DIS Pih.:A- REA... :_ _... ...__......
a. SDS area located as per amoroved plans
c
_ _ _ ...
b.
Fill section - Date of placarent
2:1 barrier. LGTH W= AVG.DPTH
c.
Natural soil not strirmed
d.
Stone, brush, etc., greater- than 15' fran SDS area.
e.
100 ft_ fran water course /wetlands-
I-
S�rZA� DISPOSAL SYSTHH -•;- >
a. Septic tank size - 1,250
b.
Senti.c tank instal-led level
c.
10' minzmun from foundation
IQ
I 1
d.
No 90° bends, cleanout within 10 ft. of 45° bend
15z
I
e.
DISTRIBUTION BOX
1. All outlets at same el =_vat , on - water- tes tea
(
I
2. Protected below frest
1
3. Minimon 2 ft_ original soil betwee*i box and trenches
f.
JUNCTION BOX - vroo--mly set
g.
T �
1. Len re=u:-, - - y Ie_� ��i insta7? e1i�
2. Distance to wate_r=urse ne sue--d : ft_
3. Inst lied ac-cording to Dlan
I 'All
I I
4. Dis tanc° . carit --- to c°nte --
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
ice.
I I
6. 10 feet from Drc�Ta. line - 20 feet - foundaticrs
15Z
7. Depth of trench < 30 inches from surface
8. Roan allaw -ed for ex arsion, 50%
I X
I
9. Size of aravel 3/4 - 1j" diameter
1
10. Depth of gravel in trench 12" miniAnrm
L. - Pine ends raced
1
1
h.
-vamp OR DOSE SYSTEms
1. -.Size of -y=-- chartoe*'
....._._._.�: Ove_rlow tank -
"I
3. Alarm, visual/audio
4. Pumas easilv accessible manhole to grade
5. First box baf =led
6. Cvcle wit -ness-a-d by He=--I th DenF-*t�nent
estimated flora per cycle
I
lI
HOUSE
a. House located per a:DDroved Dolan.
b.
Ntm2:>et of bedroars
Wr-'L.
a.
L
Well located as per a =roved plans
b.
Distance from SDS area me=asured ft_
I
I
I
c.
Casing 18" above arade.
I
d.
Surface drainage around well acceptable.`
I
-K-I
I
OVr RAM @yOPIMSTP
a. Boxes properly grouted
S
I
b.
A11 pipes tially backfilled
1
c.
A11 iDes flush with inside of box
d.
Bar-kfill material contains stones < 4" in diameter
e.
0=tain drain installed according to plan
1
f.
Ojzt,.ain drain cutfall protected & dir. to eYi stwatercoursd
� 1
I
g.
Footing drains discharae away from SDS area
I
h.
Surface water rotection adequate
i.
L=osion c--n=o Drovlded on slopes creates than 15 %.
1
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER.- CARMEL, N.Y. 10512 (914) 225 -3641
APPLI -ATION -TO -- CONSTRUC T` A-WATEFc WELL -
PCHD PERMIT #v /'D
WELL LOCATION
Street Address
/ Town Village Cit Tax Grid Number
WELL OWNER
Name' Mail' Address
�tJ /%C1� J21 � i `
rC,'P is 0,V A A
rivate
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY
O BUSINESS O FARM
0 INDUSTRIAL O INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
D ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT__,.�gpm /# PEOPLE
SERVED_ /EST. OF DAILY USAGEGaG gal
REASON FOR
DRILLING
EW SUPPLY
OREPLACE EXISTING
O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
SUPPLY 0DEEPEN. EXISTING WELL
DETAILED
REASON FOR.
DRILLING
WELL TYPE
®DRILLED
❑
DRIVEN
ODUG
13
GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: C� ors
Lot No. AT
WATER WELL CONTRACTOR: Name 1 ar VAr7 ����a*rl Address : do-v f fe
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d/' NO
NAME OF PUBLIC WATER SUPPLY: °'° TOWN /VIL /CITY
___.:_D'ISTANCE-- TO -PROPERTY --FROM NEr;REST VATER-MAIN-: - -- . -... _::....__.__.._...._.._.... _ > __ -. ___......._,__.. _.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED �
ON REAR OF THIS APPLICATION SEPARATE SHEET
( ate)
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. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well C mpletion Report on a form prov ed y th y
Health Departm t.
Date of Issue: 19
Date of Expiration: 19 rmit ssu ng fficia
Permit is Non - Transferrable
2/87
White copy: H. D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
APPENDIX
pTlIMM COUNTY DEPARTMENr OF HEALTH - DIVISION OF ENVIRONM ENTAL HEALTH SERVICES
REVIEW SHEET - CONSTRUCTION PERMIT
- --
_ .: .a -
(J-
BY:
(Name of Owner) (Street Location) 7 2,
DOC[MMNLrS
Permit Application
Corporate Resolution
Plans - Three sets ---
s/s ---''
Engineers Authorization
Design Data Sheet (DDS)
SUBDIVISION
Deep Hole Log
Perc is
Consistent Perc Results
(3)
Fill
Perc Hole Depth
cd S r X 9V
House Plans - Two sets
Well---- permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/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 (grinder notes)
Design Data: perc and deep results
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 Pumped Pith! D Box Shawn & Detailed
House - No. of /Bedrooms
Wells & SSDS's Win 200 ft. of Proposed Systems
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' tran Foundation; 50' to well
15' Well to PL
E
PUINN4 0DUU1'Y DFU'PRiMU-Ir OF HEALTH
DIVISION OF ENVIROWW-AL HEALTH SERVICES
DESIGN DATA SHEET-SUBSUFACE S&qAGE DISPOSAL SYSTEM FIDE NID.
i-7
Owner e
Located. at (Street) 6. • A 6 Sec. -34'- Block
Lot
(indicate nearest cross street)
municipa.Lity/ Qj /,;7,
Watershed
SOIL PERCOLATION TEST DATA RBQMM TO BE SUBMITTED WITH APPLICATIONS
Date of Pre-Soaking Date of Percolation Test
HOLE
NUCM CL= TIME PE ROOLATION
PERCOLATION
Run Elapse Depth to Water Fran
Water Level
No. Time Ground Surface
In Inches
Soil Rate
St,3-rt-Stop Min. Start stop
Drop In
Min/In Drop
Inches Inches
Inches
GLLz spy/
XV
3F 2, r3 -36, 7-W 2,3
Aa
4
5
.10
4
5
2
3
4
5
NOM: 1. Tests t6 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 fran top of hole.
rev. 9/85
DEPTH
G.L.
1°
2' ,
TEST PIT DATA RDK
DESCRIPTION OF
3'
4'
5'
6'
7'
i
g.
9°
10'
11'
12'
13'
14'
INDICATE LEVEL` AT -WHICH- GROUNDRATER - IS ENOQUNTERED -
INDICATE LEVEL TO WHICH DATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: /vr�/ / DATE:
DESIGN
Soil Rate-Used Min/1" Drop: S.D. Usable Area Provided d dc,
No. of Bedrooms -� Septic Tank Capacity lee v gals. Type
Absorption Area Provided By 3 %'' L.F. x 24" width trench /
Other
Name O% T� %/ i I� Si
Address
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: ::,�+ro •,'°'o, Mpg a
Soil Rate Approved sq.ft /gal. C'h�e•C�� Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIUIShON -_OF;- :ENVIRONMENTAL ;HEAL TH,. SEF2VICES. -_
Re: Property of
Located at
Date
j'
(T)%� Sections Block
Subdi visi o n of �/ 0_/,5 rl -r2l
Subdv. Lot #
Gentlemen:
2 Lot ;*--. ,/ ,--
Filed Map # Date
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
connection wi. h_.ahia",nj _t:ter_._and_ to __superv.i.-g,e thy. c.ons.tr_ucti.on _of..-s.ai.d. __...._:= �.._..._
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersign
4 t .�
P.E.
Address
y'�'
Telephone
"ON
Very truly yours,
Signed
Owner of Property
) ., scex�" L N,
Address
C-A� OyN
Town
Ot
Telephone
4-4 Sn 1. I
lo ,6"¢ k
a+ G
z..
D
/57
4+
70
k
5,7
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