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Home My WebLink About2600DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -2 -46 BOX 22 02600 'I ti Ir ?�' � .'. i-4 02600 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health SL02ETTA MOLINARI RN, MSN Associate Commissioner of Health June 1; 2005 Peter & Maureen Kennedy 4 Wiccopee Court Putnam Valley, NY 10579 Dear Mr. Harman: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Addition — Approval —Kennedy No Increases in Number of Bedrooms 4 Wiccopee Court (T) Putnam Valley, T.M. # 52. -2 -46 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 from this Department dated May 31, 2005. The addition is approved with the following conditions. 1. The total number of bedrooms must, remain at four without prior approval by this - _..Department. 2. The area of the existing sewage disposal system and 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 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. (3s erely, eph S. Paravati Jr. Assistant Public Health Engineer JP:cw cc: Building Inspector, Putnam Valley Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Y� i SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Qo — ADDITION APPLICATION RESIDENTIAL ONLY STREET �" ` aO�L Ca��T TOWN �,#/-/eiTAX MAP# "�"Z - -Z NAME !�E /fie '1 i*40F' ?^'16�Ae PHONF(YY ,SZ� �fl%� PCHD# &1 d MAILIN ADDRESS �G�� C' % �`/��9 �,�GLE/ /V >/ DESCRIPTION OF, ADDITION d-4 S'j,'g-r NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS ° C�� _4( (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 Hea th Dept., 1 Geneva Rd, Brewster-, NY .10509, Phone: (845) 278 -6130. 1. Certified check or money order for $1.00.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. 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 locations 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 Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA 1VIOLINARI, RN, MSN Associate Commissioner of Health May 19, 2005 Peter & Maureen Kennedy 4 Wiccopee Court Putnam Valley, NY 10579 Dear Mr. and Mrs. Kennedy: ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Addition — Incomplete - Kennedy 4 Wiccopee Court (T) Putnam Valley, T.M. #52. -2 -46 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. Based on the information submitted, the above mentioned addition cannot be approved for the following reasons: 1. Please provide dimensions for all existing rooms on the floor plans. 2. Please provide two copies of the proposed plans showing the entire existing layout and the addition. Make sure dimension of all rooms are provided. 3. Please draw existing floor plans so they exactly match the foot print of the house. 4. Please provide a dimension between the new deck posts and the existing septic tank. If you have any questions, please contact me at your convenience. Sincerely, oseph S. Paravati Jr. Assistant Public Health Engineer JP:cw Cc: Building Inspector, Putnam Valley Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 LORETTA MOLINARI Public Health Director ROBERT J. BONDI County Executive 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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Putnam County Dept. of Health 1 Geneva Road Brewster, NY 10509 To Whom It May Concern: January 4, 2005 Re: 4 Wiccopee Court Residence Tax Map 52 . -2 -46 Town . of P,±nam yzij 7 According to records maintained by the Town, the above noted dwelling, IS. xx _.. _ :_ :. ._.. _...... IS NOT In compliance with Town code and the total number of bedrooms on record is. This information has been obtained from: CERTIFICATE OF OCCUPANCY: xx ASSESSORS RECORD: OTHER: Building'411SpZor houseguidelines 4 Rev. 3 86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 Engineer Mast Provide _ P.C.H.D. Permit CERTIFICATE q CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEMS y r ► 1A.�r� �ly� .y Town o s .. . _.._ Located at W 1C_CU ,P 49- F-r Tax Map— Block 1 Lot Owner /applicant Name \,,i i C C C: S-' e E TAI ;;.t(. Formerly Sabdivis[on Name e- :.:7 r t Sabdv. Lot q Mailing Address ti {' >J 0 S-T It1 C- S--'`t T IZ A k— AV r- Zip 5 Z -� Date Permit Issued Cr_ `.t-A S Separate Sewerage System bullt by O W L T, i_- Iz p . Address-44 n.l e Z I l Consisting of 1 i ` �% Gallon Septic Tank and ` 1 L ; . �' _ : ' t 'T r`' T c. n C ' Water Supply: Public Supply From Address or: x Private Supply Drilled by - - ` ` " d Address -t'.`: =. = Building Type r.. . i C= t_ r.; " Has Erosion Control Been Completed?—+� Number of Bedrooms a Has Garbage Grinder Been Installed? 1 �' Other Requirements I certify that the 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 regulations, in accordance with the,filed plan, and the permit issued by the Putnam County Department Health.;' f, Date i� �`.' Certified by r _.e .L. `�/f;;..�... P.E. R.A. Address License No. Any person occupying premises served by the above systems) shall promptly take 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 publ;= sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply become#' available. Such approvals are subject to modification or change when, in the judgment of the C6mmissioner of Health, such revocation, modification, or change Is necessary. Date' "t evf),'ii� i .� i Title L,Or�tCON M4P j- - - - -- 7 I t 1 l 1 1� 1 1 1 ' I i �� - R'�1ovlOt.t Oei�•vvs'+rC 7iT� Vplat4* iF' . .. . ........ CERTIFICATE OF OCCUPANCY 6s " —1 1) 6 �) 2 b I Certificate. of Occupancy No ........ ...................Application No .............................. IJ13 ,�,ic,copee C'ourt - 'r,,y '35-1-3,6 - t,ct #6 Locatio'l of 'Premises ............................ �: ..................... ..................... ............................... ............................... ta t e s nc 7" Central Nve, ...... .................. of ................................................... ....... having heretofore - arf' application for a building permit pursuant to, the Zoning Ordinance, Sanitary Code .: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.,,compliahce 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 Valley this ................ day of .......................................... I Not valid unless signed in ink by a duly authorized agent TOWN 0 TNAM VALLLE E YORK' of and under the seal of the Town of Putnam Valley. By.... . .. ................ (orktown' Medical Laboratory, Inc. LAB MK, 003,3o.6 - 321 KearStreet Collection 'Station Used: - - - _ . :,.. Yorktown 1•ieig�is, I : °`ii: 1`05.x.8 . .....__ •arVnel . _:. ,pe.e:kski?:�. M . __ . �_ _ r .. _.....,.. . Mt. Kisco x N New City (914) 245 -3203 -- — ... Director: Albert H. Padovani M. T. (A $M. 1. Date Taken: _�• -'S -X3'1 T , Date Received: r- A Toflish & Sons Date.Reported: -II- PO Box 2T1 Collegted By: D. To.rlish Armonk; NY -10504 Referred By: Sample Source :�. L J Vj C LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA )/ !�, Standard Plate Count 1.0 per ml (Agar plate 35 0C) M:EMBRAidE FILTRATION TECHNIQUE (►•AFT) Coli. form per 100 ml i�Total Fecal Col iform ner 100 m1 Fecal S.tre•ptococcus Der 100 ml "OST PROBABLE NUP'.SFR TECIIINTOUF Total Coliforn:._ MP's Index r.er .100,'ml = — Fecal Coll forr.: NPN Index per 100 ml C -THER ANALYSES THESE FESULTS INDICATE THAT THE WATER SAMPLE (WAS)i(WAS NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING T NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT'. E TIME OF COLLECTION. Alb'ert H. Padovan , M.T. (ASCP), Director LEGEND RDS =Recommend Disinfect - ing Water Source TNTC Too •Numefous To Count 'CONF Confluent < = Less Than > _, Greater 'Than DF,PA�tI - ...s c' DIVISION OF ENVIROVImirAL ' APALTH SERVICES rIEGR'f'i G,G UEL DP MEAN CORP. 3s", Owner or. Purchaser of Building Section Block Lot Building Constructed by Lo IGGU.OaeE COU/LT WIC, C_C) _ Location Street Subdivision Name Pty Municipality Subdivision.Lot # Building Type GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 guatantee to the owner, his successors, heirs or••assigns, to place in good operating condition any part of said. system constructed by me which £ails.to operate: foz:_¢.:p riod of::two. dears immediately. fo1- Iawing...the_,dRe::of approval. of thee "Certificate of Construction Compliance" for 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 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, built .ng utilizing the system. �J Dated this day of 199 Signature �-� W6tT- A�1� �ugtK� Title General.Contractor (Owner) - 'Signature Corporation Name (if Corp..). q • cEvyA.* j.- ff Ua eA- nr,Gox: 0, .v- V. 16.r A3 ter. - rev. 9/85 mk HEC,nH 0,690. Corporation Name 4if Corp.) ess WLLL uu1.1rLL11Va rizrual y : DEPARTMENT OF HEALTH - _ -- _ -- Divi.s: ion - - -Df _Eny -iranmental Health Services..... W Y PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS. WNI 7 I TAX GRID NUMSFA, f "?eF '/zp Ft- T/Jolll V14��LCt� WELL OWNER NAME: ADDRESS: tUET P/a Ca NSA C�,07 -A ' AV, �� 5�2W AT p PRIVATE 7O PUBLIC USE OF WELL 1- primary 2 - secondary KRESIOENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED ❑ BUSINESS O FARM 0 TEST /OBSERVATION ❑. OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL 0 STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA yyELL.DEPTH ft. STATIC WATER LEVEL ft. DATE MEASURED —�� DRILLING EQUIPMENT ❑ ROTARY MCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O CABLE PERCUSSION O OTHER (specify: WELL TYPE ❑ SCREENED O OPEN END CASING. Pj OPEN HOLE IN, BEDROCK O OTHER CASING DETAILS TOTAL LENGTH_ fit_ MATERIALS: IP(STEEL ❑PLASTIC O OTHER LENGTH.BELOW GRADE 3a ft. JOINTS: O WELDED THREADED O OTHER DIAMETER — li�e in. SEAL: ❑ CEMENT GROUT O BENTONiTE OTHER WEIGHT PER FOOT lb./ft. I DRIVE SHOE: O YES �'NO LINER: O YES ONO SCREEN DETAILS _ DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST _ .:.. _._...::_ _... =: 0-YES-ONO = _ HOURS SECOND _ :.:. - .. �.._. .... _: GRAVEL PACK 0 YES O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH fL BOTTOM OEM ft. WELL YIELD TEST If detailed pumping METHOD:. O PUMPED tests were done is in- KCOMPRESSED AIR , formation attached? BAILED ❑ OTHER O YES ONO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE Water pear- ng Will Dia- meter ( FORMATION DESCRIPTION COOS. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gFm. Sura fce �� WATER 0CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ONO STORAGE TANK: TYPE �� X 744- CAPACITY PJ 'r aZS�C� GAL. PUMP I F RMAtION NQ TYPE t 1111 . f6 i CAPACITY L-- MAKER ��2 5 �yb DEPTH MODEL 9,!� VOLTAGE HP WELL DRILLER NAME 0 T / k- R- 445etf r- SOUS � ® . ADDRESS &X bz' ` SIGTfTU �4 Al 1crul o✓ �� DEPARTMENT' OFIMAdii" - . ; 2 -M p Rev. Health Services. Caiiiiel. N.Y. 1051 Er%in to Oro 4 COMPLIANCE Permit I on CERTIFICATE OF CO�l CONSTRU(CTIOWOERS& FOR _AGE DISPOSAL SYSTEM - Located at Town or 'Vlllage -3 Name Subd. Lot # Ta. U Subdivision _:ReRewa! Revision Owner/Applicant Nam. Date' of Previous Approval Nwiling Address Ce O�VA � p r— - Town—,F-,LMst ZIP Building, Type) Fill Section 'Only Depth 31t-l—V %J oluff Number of Bedrooms Design Flow G/P/D (4166 E;oh,. PCHD,Nodftcation Is Re4ulred When FM Is completed Separate Sewerage System to consist of Gallon'Septli Tank and he constructed by r:c_tAl 0M>Address Water SuPPb'. public Supply From A�d or: Private Supply Doped byT0 Other Requirements I represent that I am wholly and completely responsible for:the,design and location of the proposed system(s)'; 1) that the� separate sawage,disposal system above described will be constructed as sho wn on . the app , roved amendment there to . and in accordance with the standardi, rules'and regulot ions of the Putnam county Department 'of Health, arid.thit oil completion thereof a "Certificate of Construction CornpI ia rice" satisfaciory to.the Cdmrpissloner of Healthwill be submitted to I the Department, and 'a written guarantee will be fuinishad the owner, . his successoii, heirs or' assigns 1 1 -by the builder, that said builder will place in good operating condition any ipirt of. said .sewage 'disposal system during the period of two (2)*,years immediately following thedate of the issu- ance of.the approval of the Certificate of C , onstruction Compliance of. the original system or any repairs thereto- ) t hat the drilled well described above will be located as shown"on the approved plan and that said well will be Installed in a . ccordance, with -the. ndard s t1 and reg—MM—Ons' of the.. Putnam County D f Date I Signed P.E. — R.A. 9 1 L) F4 iK '6>T, 6,TOM Address License N APPROVED FOR CONSTRUCTION: This approval expires one year fro the' e issue -up ss construction of the building has been undertaken and is revocable for taus be amended or modified when considered net ssili the. rhissioner of 7or it rn� ed .for disposal of domestic w with Any change. oj_alteratlon of rnstruction requires r pr sanitary . itiry and/or v -lift 1 0 Y. Date By A Tit to F - L HUDSON VALLEY DIVISION Architects . Engineers . Surveyors Route 52, Cannel, Now York 10512 (914) 225-8088 CABLE: CASHASSOC MINEOLANEWYORKSTATE May 29, 1987 Mr. Robert Morris Putnam County Health Department 110, O l d Route 6 Center, Bldg. 3 Carmel, New York 10512 RE: Proposed SSDS Wiccopee Estates I, Lot 6 Wiccopee Court„ Putnam Valley Dear Mr. Morri s: Application for an SSDS for a three bedroom house on the above referenced lot was submitted to Mrs. Bittner on April 10 of this year. It now transpires that, a four bedroom house has been built. This submission contains the plans for a suitable SSDS. Since the proposed system is in a fill section, we felt a further detailed site inspection was required. The principle results of which are: 1. The fill section is located as shown on the revised plans. m: a X _1 -m.0 m.r s_q op e f..o f 115%, s._...f N o l earth r berm w a srequired �a t the . ...... _ ,... •.> top of the fill section. In light of this information, 400 LF of trench was located as shown. Should you have any questions or comments, please feel free to contact me at this office. Very truly yours, CASHIN ASSOCIATES, P.C. by: T. John Canni TJC /edb Enclosures �AC1�U E: _ .. ,/%, '1F,• V 11VHi 1 µJULY 1 liL:�UT� - bEkl k 1•iul`Il :DIVISION OF ENVI HEALTH SERVICES a John M. Simmons, M: D. " ttta Deputy Corssioner of Health = - M ITY ELD ACTIV ,REPORT = ; = Sheet l of J IN_SP _CTION NAM a. Orig Routine + Orig. Crn,plain ADtss Gir CG'aP €v2'f" z" - 3� /� �' 6 Qrig:: Request No. Street 1 No / Cctnplian, _ Signature and Ti a Complaint Carp" MAILING ADDRESS I acknowledge. this - Field Act vity_Report. SIGNATURES Final P O. `Box Post Office Zip Code Group Illness -TELEPHONE - :Construction Reins pection' :PERSlJN IN CHARGE. - Field, Sampling Ohly.^ . OR INTERVIEWEIf �/1�/i/ ��'�sla?�/v , . _ Field Conference i Other - DATE, - / Sr" ` TYPE FACILITY y TIlKE °ARRIVED TIME LEFT :Explain FINDINGS: `c a it i'"'4{ µ.de. ✓ t f o-' i` (.. xr.1 '`+ m'. t"' { X ; .. *I h a. + INSPECTOR ff/i'I " -'_'^ TFT.FCRONE; Signature and Ti a PERSON .IN CHARGE OR INTERVIEWED: > = I acknowledge. this - Field Act vity_Report. SIGNATURES 6/86 _ TITLE: ( PUTNAM COUNTY DEPARTMENT OF HEALTH Division of EnvironmentalHealtb Services. Carmel, N.Y.10512.w Engineer to Provide Permit # (� a on CERTIFICATE OF.COMP C STRUCTION ERMIT FOR SEWAGE DISPOSAL SYSTEM Permit N .� Pufrium a11QU Located at Town or Vlll e Sabdlvislon NemeIC�E? P_Qi�S 1 Saba. Let q Tax fi,4 Lot _n ��LL�� Owner/Applicant Name VIII GC�p�t? F—_&A C:� 1 n c- Renewal_ ❑ Revision —Fill-*, North .t, /� 1 f Date of Previous Approval Maftg Address 4' -4 Nor h CP,a9l ja 1 A414 Ve Town uwsf P °tea Zip Building Type l Fam f iV . VQlniCQ"C yet Area 666t-AC- Fill Section Only Depth Volmne Number of Bedrooms Design Flow G P D PCBD Notification Is Required When Fill is completed Separate Sewerage System to consist of 0 Gallon Septic Tank and A,00 n O o Zi W I Da. %tom ir aAICH To be constrnded by �t (�4't21V`�l1 iN! IP� Address Water Supply; Pdbllc Supply From Address ors Private Supply Drilled by �49f—Ad ss Other Requirements t ' tr i0d1 Box 1 represent that 1 am wholly and completely' responsible for; the design and location of the proposed system($); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations o e Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Health will 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 thedate of the issu- 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-ell will be installed in accordance with the stan ds, rules and regulate ons of the Putnam County Department of Health. Date /+ `j n _ Signed \fir /� P.E. R.A. — Address (�G6g Usso n t°- R License No .,t;_.6 o og APPROVED FOR CONSTRUCTION: This approval expires two rs from the date issued unless construction of the building has been undertaken and is revocable for cause or may be amended or modified when ca ere necessary by the Commissioner of Health. Any change or alteration of construction requires a new permit. Approved for disposal of domes c /s rwSg d /oorr �private water supply only. /187 Date ev �"—j/yl�l`�'v� Title 4 -�t� II. IV. V. VI. APPENDIX C �\ FINAL SITE INSPECTION Date G l U Inspected by ;% ;;CATION 22 V� �d OWNER r4 1. Size of pump che*nber I I 2. Overflow tank - 3. Alarm, visual /audio 4. Punp easily acces-sible manhole to grade 5. First box baffled -- 6. Cycle witnessed by Health Department --- estimated flew per cycle HOUSE a. House located r approved plans. b. Number of bedroars WELL I a. Well located as per anuroved plans b. Distance fran SDS area measured ft. c. 'Casing 18" above grade. d. Surface drainage around well acceptable. OVERALL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All ]Ripes flush with inside of box d. Backfill material contains stones < 4" in diameter e. Curtain drain installed according to plan f. Curtain drain outfall protected & dir.to exist.watercours g. Footing drains dischar e away from SDS area h. Surface water protection adequate i. rosion control provided on slopes reater than 15 %. YES N NO I I C CM-MEMi'S Sr`yvAGE DISPOSAL ARFA a. SDS area located as per approved plans I I��,•, b. Fill section - Date of placement \ \ c. Natural soil not stripped d. Stone, brush, etc., greater than 15' fran SDS are=. e. 100 ft. fran water course /wetlands. SFVaGE DISPOSAL SYSTEM a. Septic tank size - 1,000 1,250 b. 'Septic tank installed level c. 10 ` minimum fran foundation . . d. No 90° be -*ids, cler.r_cut. within 10 ft. of 45° be--id e. DISTRIBUTION BOX 1. All outlets at same elevation - water test G G S` 2. Protected below frost - --- 3. Minimum 2 ft. original soil betwe_. d trenches f. JUNCTION BOX -' rooerl set g .S f . - - 2. Distance to wat=Tcourse mea=sured. ft. " " 3. Installed acccrd-ing to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 "/foot. 6. 10 feet fran prcce_ -tv line - 20 feet - foundations I I ✓ J n r) , 7. Depth of trench < 30 inches from surface 8. Rocm allowed for e.xnsicn, 50% 9. Size of gravell 3/4 - 1j" diameter 10. Depth of gravel in trench 12" minimum 11. Pi e.*�ds . c :per C. L h.L�IP OR DOSES2' EIS"__.. _.___..__....__..�_.,_.._.__... Putnam County Department of Health / map Division of Environmental Sanitation AFFIDAVIT CORPORATE (X%TNER APPLICATION ' .. .rr•p -� _. r__.. c'..�tt_ :rr..... ... =.c ..0 . ..: _.. . -. ._...., -:.. r..... = -u �.�:. -x: :..Y' - =v.•:. ��_,��.- �_- � ".- � -aT... ^� � � J+. c- s..s. •.r -. FOR PERMIT APPLICATION,•- �ESONTI TEDD TO PUTNAM COUNTY, H&N.LTH DEP ME TO:, Commissioner of Health In the matter of application for -- — — —. — — — - - — — — _ "_ _ .— I, ----- - - - - --- — — — — represent that I am.an officer or employee of the corporation and am authorized to act for _ _ lti c. �_� L CS�•� S r _ — — (name of corporation)— — having offices at fJU Cctj .; 14� �p5;Z.:-5.. Whose .officers are - - - -- --- y - - - - - - - - - President p g- .9 Vl._ (Nam.e and Ad ess) — Vice- President __Ci�,�2_ L�=�1. 't� �_r�(i 2 —(�_ r��a�,C �t jNare and Address) Secretary — — — — --- _ (Name and Address) _ -- ...Treasurer-._.,. _ _to, `(Flame !a w A7d-ress ): and that I am and will be individually -- b for any or. all ac is of the corporation with respect to tfie -- approval requested and all sub- sequent acts relating thereto. Sworn day Signed of of f97 19 Title C'ommisioo� u -- — — — — — — — — -- Corporate Seal PUTNAM COUNTY DEPART OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES +k FIELD INSPECTION REPORT (Name 6f Owner) (Streef Location) INITIAL SITE INSPECTION = YES I NO COMMENTS Wetlands on /or proximate to property.............. Property lines or corners found ................... Can estimate house location ....................... Willdriveway need cut ............................ Must trees be* removed - note these ................ Deep holes representative of entire SDS area...... Additional deep holes needed .......... ........... Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells /septics............................ D.H. 1 Lot, D.H. 2 Depth to G:W. Depth G. Depth to rock De o VC Soil De cri tion 0 ft. ft. G 3 ft. - � 3 ft. 6 ft. 9,ft. 9 ft. 12 ft. 12 ft. � DATE: FINAL SITE INSPECTION INSP.BY: k G.W.- Groundwater _ D. H. 3 Lot - De th to G.W. th to rock Oft. Descrip-tio� j1k House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Roan allowed for expansion trenches .............. Over 100 ft. from watercourse ................... Natural soil not stripped or SDS area unnecessarly graded .......... ........ ........ 10 ft. maintained from property line and 20 ft. fran house .. .... ...................... Distance well to SSDS (ft.) ...................... Number of bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft..fran nearest trench ................ 15 ft. of peripheral soil horizontally fran trench ..... ............................... Boxes properly set ............................... Could surface runoff fran driveway, roads, ground surface,.etc., channel near SDS area.... Does lot drainage appear OK,Jh area of SDS::...... TPT-KiaT. r--PanTY-. nF STTE AC=ABLE ................. 3 ft. 6 ft. / 9 ft. 12 ft. 106101 PMAM COUNTY 'DEPIO, �I'.. OF:- MALTi DIVISION OF UMROrmWAL WALZH VftVICES .:_,::c - .�:r.. - cos. . .•,r ... �.. >:.r•- .a <..- •.rr.._ ,: r• -.e ._r -,ca_; . .:r.. -.. .. t � �: �,:i. 1 _ .. .. -.. _ .-.�.. �� m ,.- �4a _ .. Q. _m .... .. -. ,.e. -.�-y ..�' . r Re: Proper ty of 1,ocated at K r .tx .. �A Section Subdivision of Subdv. Lot # �o Field • Map ¢ Gentlapen' f >ta This letter is to- authorize '1. m a duly. licensed Professional. sneer �8 r ATE ar: Re' Axchi_to TMI C, � 4.f apply for a Cohstruction :permit far a` separate sewage ' .noted property in accordance-with the standards, rules-or r °by the Ccmaissi.oner of the Putnam County .Department of Hlelathh + `t " - ' 8axy:.papers on my behalf In cormection with this matter and to � :of said system 'or' systems in conforms with the tY provisions ofe'45 La PU ry S8Ili Countersigned: • CP. Address r ZZ ej2> Yh, Tel e • `t it L r V •• o �• '�o is 81 11507010 •' •t WIN ■• a F., is V 'ry Y: 3 ;gg •la. DESIGN DATA SHEET- SUB.SUF'ACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner I( ICORee. Esfates �n Address `i-A Nor-fh Gerifra ue -r Located at (Street) W i c o _ G( r 4 Sec. 3S Block • ( Lot 3 Undicalte nearest cross street) t ot'6 Municipality P 1 Il a M ocT Watershed - HU d 5 o4 • ■ • �'.�• •' Yap. • • V• 7• ■' 7�• • I: 1 Y�■ •I• •; I. Date of Pre - Soaking M tj t <► 1 r? 7 _ Date of Percolation Test MC / /,S- f 7 HOLE 3 3 39'4 g -S S II NU-MM CU= TIME zG PERCOLATION PERCLATION Run Elapse Depth to Water From Water Level S No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop 3 Inches Inches Inches 2-2- 3 1 g;2� -�29 Q 2 Z�s 25 3 3. 2a3o -8:3-� z2 2S 3 3 3 g: 3 9- z 176 24 3 -� 4 �'5-I -9:03 fz 2--,2-- ZS 3 59.04- q %(6 2-SA 3 `� 20 34- 'S --f3 9 23 s 2� g 3 3 39'4 g -S S II 2 3 8 zG 3 4 S S6 -9" ( 0 ►4 2 3 �Z Z41 3 S 12- 2 3 2 S; -f.o g: S3 13, 2-2- 4% 09 '. z 6 )7 2.2 2 S 3 6 5 2g=�' =�� NMES: 1. Tests to be repeated' at same depth until approximately equal soil rates • are obtained at each percolation test bole. All data to' be submitted ' for review. 2. Depth measurements to be made fran top of hole. rev. 9/85' TEST PIT DATA REQUIRED TO BE !Tip ?e)iiL'f 4�M43;;*aI. A)/I: DEPTH. HOLE NO. HOLE NO. HOLE NO. 4' O �L,, S C. u k Signature g Address irn 5' ��, "- _ 6 c._ 7 8' r: 9 10' 11' 12' 13' :._. 14'.... _ INDICATE LE,'VE[. AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BF.TNG ENOOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used 6 - -7 Min/1" Drop: S.D. Usable Area Provided 3 700 No. of Bedrooms y- Septic Tank Capacity (.2S-0 gals. Type Oosoj Absorption Area Provided By -4 0C-) L.F. x 24" width trench Other 3 (� ®3 • 111 I J 01-S l bc(t l 0 0 box: Name C O �L,, S C. u k Signature g Address Q f ��e� SEALS ��, N. 260(3'- THIS SPACE FOR USE BY HEALTH DEPARDlENT ONLY: Soil Rate Approved sq.ft/gal. Checked by Date PUT NAM COUN'T'Y DEPART OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH.SEtVICES DESIGN DATA .SHEET- SUBSUFAGE ;SEWAGE DISPOSAL, SYSTEM Owner li tcopga &b� tnc- Address 44 (doe fk 6414-CIA (Lr-- Located at (Street) rnL, Sec. _3� Block _I Lot 3.6 Undichte, nearest cross street) Lot # Municipality ec'Garn L)C j (eu Watershed Cro f or1 SOIL PERCOLATION TEST DATA MW RED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking QAr 9 'g, -7 Date of Percolation Test Q,or, / 10 s>7 HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/in Drop Inches Inches Inches 1 g: oh -q03 g 2,0 13 3 I 2' o4 -9:13 9 110 23 3 3 4! :Z7 -9,V l2- 2 0 �? 3 4 5 2 9: on 24A- 3 Z 3 J :o1 - ?:t3 11 4 -P: f 3- 9izS7 1l- 2� 24 3 5 1 D S an"n� teL 2 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 sukmitted for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA RDQUIRED TO BE SUBMITTED, WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES :... DEPTH -E LE -N0: � HOLE NO. -- 2._ _ .HOLE NO: _ G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED A%OA DEEP-HOLE OBSERVATIONS MADE BY: E H DATE: g -20 /94 DESIGN Soil Rate Used 6-7 Min /1" Drop: S.D. Usable Area Provided SGCb No. of Bedrooms 3 Septic Tank Capacity (oo a gals. Type !?-- Absorption Area Provided By 10 0 L.F. x 24" width trench Other 3� �ZO3 �ic� Core 015T LLr(&c6o++ Name C ftu0r_Lat1& Signature pt- Address Q. S�2 ar tfu 1 SEAL, �. 2600 a �hE STAB`; THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date 4 Putnam County Department of Health W lcvais p .64 .Division of Environmental Sanitation <319-r4 -iLL45 AFFIDAVIT CORPOIZA.TE 01,RNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEILTH DEPARI", IlE N T `TO: Commissioner of Health In the matter of application for - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - — 9 represent that I am an officer or employee of the corporation and am authorized to act for C_* — 0, E-5 F - -- — —------------ — ----------- (name of corporation) having offices at — CAO — — — — — — — — - — — — — — — — — — — — — S 7- Whose officers are President -0 -q- F_ 0 - - - - - - - - - (Name and kXe_s_S)11 - - - - - - - - 'A Vice-President IL, 01 (NG r - - - - - -- :! (Nainte and Address) Secretary_________ . . . . . - - - - - - - - - - - - - - - (Name and Address) Treasurer es and that I am and will be individually responsible for any or all ects of the corporation With respect to the approval requested and all sub- sequent acts relating thereto. S% v o r6n day Signedir olf Qu" 197*jy_iq�j Title - - - - - - - - - - - - - Notary' Public, Corporate Seal APPENDIX B PUTNAM COUNTY DEPARTMEW OF HEALTH - DIVISION OF HEALTH SERVICES _ - INDIVI-DOAL MUM SUPPLY & SUBSURFACE SEW;GE DISPOSAL SYSTEMS - - - �a RVFEW,: SHEET CONSTRUCTION. PERMIT..._ J .\ -� DATE Pi BY: � r U' (Name of er) (Street cation) C ,NTS YES NO DOMAENTS Permit Application Corporate Resolution Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) SUBDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill Perc Hole Depth cd House Plans - Two sets Well Pe--Ttit; PW-S letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked _ Ex- approval SSDS ALj. 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 �esign_Dat : _ .perc :.and deed _results Two-Foot Contours Existing.& Proposed - Driveway & Slopes Cut Footing /Gutter,Cartain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shawn;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed System Property Rtes & 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 fi' 20' to Foundation Walls 100' to Well; 2001 in D.L.O.D, 150' pits 100' to Stream, Watercourse, Take (inc. expa 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped waterccur. 101. to Water Line (pits -201) 50' intennittent drainage course Septic Tanks . 10' fran Foundation; 50' to well 15' Well to PL A PUTNAM L _jUNTY DEPARTMENT OF HEALT DIVISION OF ENVIRONMENTAL HEALTR ZE COUNi'Y OFFICE BUILDING, CARMEL, W'.O; C DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL 5Y'SM- Ownerl JA -rte SmFFT &f�ii4TG� Address Located at ( Street cHwFtNA N f3. �Z� -Sec . 5` °' , kinndica e nearest cross a ree Municipality iii E[N A (�'1 U�ll C_E y Waters ed SOIL PERCOLATION TEST DATA REQUIRED TO BE Bu o e 2 1 2 Number CLOCK TIME PERCOIATJ Run Elapse p o a, ar!- No. Time From Ground Surf Start -Stop Min. Start 3tp Inches. Ino I 1 X06 - yob 3 1 g ' 2`�,t 2,909'— 5 . 2 1 2 .-�- 3W7- y 2 q 1 12 I Imo/ 2Z.1 �d�� w A'�- E•� •° v yy44 2 , �A 3 5 9':`_ Notes: 1) Te4ts to be repeated at same depth' rates are obtained at each percolation test. hta3� fdr review. 2) Depth measurements to be made from t•QF f= n ,,., rIONS A ATION Rate jai drop t:- ;PEA. S'Yp 4! Iltiw 1 soil Omitted �r n ,,., rIONS A ATION Rate jai drop t:- ;PEA. S'Yp 4! Iltiw 1 soil Omitted �r Iry RY TEST PIT DATA REQUIRED TO BE SUBMITTED DESCRIPTION OF SOILS BNCQUNTEM. DEPTH HOLE NO. 1 TIOLE NO. G.L. rt 6 1pff 181f 2411 0 3611 4211 u (\j yi 48" 8 54 t. tis 6011 66 7211 78 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOT INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER TESTS MADE-:& TESTS J.- DESI Soil Rate Usedb-.S-- Mir�/1"Drop: No. of Bedrooms 3 Septic Tank Capacit r** Absorption Area rov e3 By_ L. F. x24-11... 00.�, Name /Y AS L421e-/ i+1FY Bignat Address Sri Y11 Y, THIS SPACE FOR USE BY- Hr,,ALfrH DEPARTMENT ONLY: Soil Rate Appr'oved Sq. Ft/Cal. ChoC Iry RY PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL [ALTER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS RSVIEW - - .. SHE'FT ....:,,:_._.:._..._.:... -- .,CONSTRUCTION_:_PERMIT .. _ .,... _._ / / - 7 / DATE REVI C� ! �p BY: (Name of Owner).. (Street Location) COMMENTS YES VNO DOCUM US Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan 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 Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains AZ Perc & Deep Holes Located Representative of Sewage & Expansion Area Esic- Arm;= shown; gravity, flow, If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located 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 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,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same DEPARTMENT OF HEALTH Division Of Environmental Hi .aA Services TWO COUNTY CENTER - CARMEL, N.Y..10512 (914) 225-3641 APPLICATION TO CONSTRUCT A WATER WELL IS WELL SITE SUBJECT TO FLOODING? _ YES _'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: LOT NO.. WATER WELL CONTRACTOR: Name L Ay 't:>Ii��Pt-�\ dress: IS PUBLIC WATER:SUPPLY AVAILABLE TO SITE: NAME OF PUBLIC -WATER SUPPLY: DISTANCE:- TO,:_PROPERT.Y.FROM:.N•EAREST WATER -MAIN LOCATION SKETCH & SOURCES OF CONTAMINATION. 06 (d te) YES X NO - TOWNZ /V /C �c �\5 1. cask .a siE, tore); '4\i' "�� nee ��c; • `t , 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 W 11 Completion Beport on.a orm rovid d1by the Putnam County.Healt epartmen Date of Issue:, —T Perm t Issuing Offic ia l _ Permit . is Non Transferrable STREEI AUORESS. IUWNIVILLAGElCIIY IAX GRW NUMBER. WELL LOCATION WELL OWNER NAME. • ADDRESS: ).)0!PnA- ce�j7o -.,,. Jkj PSIVATE PUBLIC USE OF WELL •K RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ AMOUNT OF USE YIELD SOUGHT Si�� E✓A,eult, PEOPLE SERVED L-- 'kxf ES . OF DAILY USAGE � g21. REASON FOR ,9 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING ❑ aEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL WELL TYPE DRILLED F_� DRIVEN r__j DUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? _ YES _'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: LOT NO.. WATER WELL CONTRACTOR: Name L Ay 't:>Ii��Pt-�\ dress: IS PUBLIC WATER:SUPPLY AVAILABLE TO SITE: NAME OF PUBLIC -WATER SUPPLY: DISTANCE:- TO,:_PROPERT.Y.FROM:.N•EAREST WATER -MAIN LOCATION SKETCH & SOURCES OF CONTAMINATION. 06 (d te) YES X NO - TOWNZ /V /C �c �\5 1. cask .a siE, tore); '4\i' "�� nee ��c; • `t , 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 W 11 Completion Beport on.a orm rovid d1by the Putnam County.Healt epartmen Date of Issue:, —T Perm t Issuing Offic ia l _ Permit . is Non Transferrable PLMJAM OOUNIY DEPAR T OF HEALTH DIVISION OF ENVIPMMU TAL HEALTH SERVICES Date Re: Property ofI(1� I✓"�"1"�t� i i Located at 0 (T) .7u,��-h�A Ll, _ Section li;� Block Lot Subdivision of l'lCC4CC— Subdv, Loth Field Map # I Date Gentlem . This letter is to. authorize I K) ��x, i t:r5 C M a duly licensed Professional. Engineer, jL or -Re istered Architect to ICATE5. apply for a Construction .'Permit for a separate sewage system, to serve the above noted property in accordance w- ththe standards, rules or regulations as prod gated by the Commissioner of the;:Putnmm County .Department of Helath, and to sign all - necessary papers an my; behalf . in ` "onnection with this matter and to supervise the. construction of said system.or systems in:;conformity with the provisions of Article 145 or 147, Education Law, __t-he = P-ubl c ,,He:alth --L&w, . and.'the Putnam Cddfit`y "Sanitary Code. Very. truly. yours, Ctessigcled. GO �t, C �TQ 5 /P Owner of Property Telephone 'relephom Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT -- CORPORATE OWNER APPLICATTON FOR PERMIT APPLICATTON SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for I' _ir�--- - - - - -- — — — — - -- represent that I am an officer or employee of the corporation and am authorized to act for -- — — — — — — — — — — (name of corporation) having offices at___j & &�-- _____ -- - — — — Whose officers are President _ lz�xJ -)kl�— _ �t Ff _ 14 (Name and Address). Vice - President _____ ____ _______ (Name and Address) Secretary _ P1G_•b- /.�_t:57L.,— — �/ -�1Z�E U _D= �'�t1l�AA (Name and Address) Treasurer - _ _ _ _ _ t a_•....- __ - . . . _ - __.._._r_ _. ..Q,. -. •--- (Name and Address) — — — — — — — — — — — — — and that I am and will be individually responsible for any or all acts of the corporation with respect to the approval requested nd all sub- sequent acts rela i g thereto. Swor efore e -his. day Signed` - _ — — _ BRIAN TING of c, aofNew 190 Title Cualified in t ester i ion E ires Mat Nota y Public Corporate Seal t -Ar, __