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02637
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date -701
Re: Property of 'W6-5 lek� &
Located at
(T
Subdivision of
n,,- /�ie!e d'
Section5 Lot �2
Block
Subdv. Lot # Filed Map
Pate I I
Gentlemen:
b
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 with this matter and to supervise the construction of said
r-mi" or
or systems in conformity with the provisions.o 4-5
0
147, Education Law, the Public Health Law, and the Putnam County Sani- 0
tary Code.
Countersigned:
:,2 7 2- -4
Address
Telephone
Very truly yours,
Signed
Rd
0 er (of Property
Address
A1,1V /0 1'17
Town
Telephone
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~ ::, i° iS. t x s.. ' y-'t ^ 1... °_• i . t''°f��.,e ?,4 r,
7z5
Owner o urc aser of Building Section
Building Constructed by Block
.� �/�.� ./1'%11 � /�����• �d � 4' I
Location /- Streets/ Lot
�i A7 7G rrl d` �/�i 4_
Municipality / Subdivision Name
Building Type Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE SYSTEM
I represent that I am wholly and completely responsible for the
location, workmanship, material, construction and drainage of the sewage
disposal system serving the. above described property, and that it has been
constructed as shown on the approved plan or approved amendment thereto;
and in accordance with the standards, rules and regulations of the Putnam
County Department of Health, and hereby guarantee to the owner, his success-
ors, heirs or assigns, to place in good operating condition any part of
said system constructed by me which fails to operate for a period of two
years immediately following the date of initial use of the sewage disposal
system, or any repairs made by me to such system, except where the failure
to operate properly is caused by the willful or negligent act of the occu-
pant of the building utilizing the system.
The undersigned further agrees to accept as conclusive the determin-
_ .- -. a-tioxr -of the D2recta � o €- the <Div on of En ronment�a -1-- - He_a -lth-
.of the Putnam County Department of Health as to whether or not the fail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of of the building utilizing the system
Dated this day of Signature
Title h
I`C)
Corporation Name if co,p'.
41 c am
Address-
- - - - - - - - - - -,��� r - - - - - - - - - - - - - - - - - -
THREE ( 3 ) COPIES ARE REQUTA1ED=,WI-TH;r-THREE ( 3 ) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION• WILL B9 "I'S SUED.
PU i IN. AM (7
GUARANTOR IS REQUIRED T�L �T �OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
�� . � �:_ °�iy�.: .t. Vii' w.-^�'�2O - a ,.w �;+a x � fi _ -
PUINAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMERML HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SDU GE DISPOSAL SYSTEMS
_ FIIkL,D INSPECTION REPORT
DATE:
INSP. BY:
(Name'of Owner) (Street Location)
INITIAL SITE INSPECTION I YES I NO
Wetlands on /or proximate to property ..............
Property lines or corners found ...................
Can estimate house location .......................
Will driveway need cut ............................
Must trees be remved - 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 _
Depth to G. W. _
Depth to rock
Soil Descri
0 ft.
3 ft.
6 ft.
9 ft.
D.H. 2 Lot
Depth to G.W.
Depth to rock
Soil Descri tia
0 ft.
3 ft.
6 ft.
9 ft.
D.H. - Deep Hole
G.W.- Groundwater
D.H. 3 Lot
Depth to G. W.
Depth to rock
�0
0 ft.
3 ft.
6 ft.
9 ft.
12. -ft..J
DATE: 3 - 27-
FINAL SITE INSPEC'T'ION INSP.BY:
YES
NO
CHI'S
House SSDS located per approved plan .............
�!
Length of trench measured 81-11-LED
Width of trench average
Slope of tile line and trench acceptable.........
✓
r
Roan allowed for expansion trenches ..............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded .......... • .... ........
10 ft. maintained fran property line and
20 ft. from house... ........................
Distance well to SSDS (ft.) ......................
Number of bedroans checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. fran nearest trench ................
15 ft. of peripheral soil horizontally
fran trench ..... ...............................
"
Boxes properly set......... ...............
To PC' �.4 L-
Could surface runoff fran driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRAM OF SITE ACCEPTABLE..
I
.. �17 .PIE CIIECKC 1AST.
Date:
Insp.by:
INITIAL SITE I1I3PECTION y
Yes
No
Comments
,Property lines or corners found . . . . . . . .
.
Can estimate house ]_ovation . . .
Will drivcway need Cut <. ,
Must trees be remov"d -note these .
_
Is deep hole represt;nt-ative of entire SDS area
Additional deep holes needed. . . , , .
_ --
Sufficient SDS area available considering
-
driveway cut, house: location, separation .
distances, etc.
DEEP HOLE DATA .
Depth:
ldater elevation:
-
- Rock elevation:
Soils d.escr_i.ntion:
Date : i 3 -1.3
PIS` AL SI - ] DIS P 1OC`i'I()�: Insp. by: G
House located uher.•e - sholrn on approved plan = .
SDS located whiere approved 7
:length of trench mca s ured
-
Width of trench avera 'se _
Slops of the line and .:.trench,. acceptable
.....�_
L
_
Over ,50 ft. from swamp, lratercourse
Idatural soil r_ot . stripped or SDS area
'— -
_ -
iuunecessarily graded ,
10 ri t m-a intained from prop . line and
-
20. ft . from house . : . . . . , o
Separation of trench from house, well
:--etc.—follows plan
-
'hhuiiber of bedroo-ms checks . .
Stone::,' brush, * stumps, rubble, etc-*. greater
than 15 ft. from nearest trench . . . . . .
25 Pt. of peripheral soil horizontally from
trench. .. . . . . . . . . . . .
Junction boxes prop ,rly set
Could surface run 61 "f from driveway, roads.,
• ground surface, etc. chaiulel near SDS
area. . . . . . . . . . . °
Does :l.ot drain:.ige app-ear 0. K. J.n area of SnS
_
FINAL GRADING OF SITE ACCEPTABLE
o
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- ,-:......_:-COUNTY OFFICE -BUILDING;,= :,CARME, L;—N- Y~._..
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner
Address -5410 ae 23-0-� / .0 �✓ - -
Located at ( Street fee -,) o.v.�� Sec . ,&' Block Lot
n ica e'neares _cross street),
Muni cipalit Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
3
1I-
� � l// %/ �& / s`' -1-70 >i3
3
4
5
Hole
1 .
Number CLOCK TIME
PERCOLATION
PERCOLATION
TEE apse
Dep
o a er.
Water ve
.
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
3
1I-
� � l// %/ �& / s`' -1-70 >i3
3
4
5
1 .
2
4
5
Notes: 1)
rates are
for review
2)
Tuts to be repeated at same depth until approximatelyy equal soil
obtained at each percolation test hole. All data to be submitted
Depth measurements to be made from top of hole.
DEPTH" * -
G. L.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUYIMED -7 TEST HOLES
HOLE_ NO. ma XG. HOLE NO.
611
12"
18"
24"
3011
36"
42"
48"
54".
6oll
66"
6
7211
7811
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
..INDICATE:. UW.j, TO TE RISES AFTER _,BEING ENCOUNTERED
�y o��J�g LEVEL R
--M3TS-,1V1ADE, *BY* Z
DESIGN
Soil Rate Used_.,,7 Min/l"Drop: S.D. Usable Area Provided
No. of Bedrooms---.3 septic Tank Capacity /e9o-e Gals. Type,�
Absorption Area Provided By L.F.x2411 width trench.
Other
iName \, j v_5 .:,> w ) I I vow
Signature_
Address
THIS SPACE FOR USE BY HEALTH, DEPARTMENT ONLY:
Soil Rate Approved_ Sq. Ft/Cal. Checked by
4
W4,;jl e7a
. gu
'CA 0 �.A a t e
30 \�� PUTNAM COUNTY DEPARTMENT OF HEALTH �� , —,3 j
r � o /
1 Division of Environmental Health Services, Carmel, N. Y. 10512 Permit #
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM � r+'► �" /��-N
/ r✓ / /�� /�l�. - Tax Map a J _ Town or Village
J
LocAterl_ cat _n. Block
6ol
Separate Sewerage System built by
®ot� .In e
Consisting of %C?af�Gal. Septic Tank and
Other requirements
Water Supply: /Public Supply From _._.
Private Supply Drilled By
Tax Map Lot # 4_YLL Subd. Lot #
Address .7 3 Y X 4
2-4't ' r`e',7-7E %A=S
Address
Building Type z 4- r' ; No: ofl Bedrooms:
Has Erosion Control Been Completed?
Date Permit Issued
- W. G"Zo6z C1vomVek
I certify that the system(s) as listed serving the above premises`were,construated essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules'an4,,jegtii;9E� ups in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health. e�;;' °� (i+'•'.{'f,['�r�m�'�,a�
>` V
a
Date C rtified,byP P.E. RA.
Address Lice
) nse No.
Any person occupying premises served by th above system(s) shall promptly fake sub aetioo's tlnay b necessary to secure the correction of any unsanitary
conditions resulting from such usage. A roval of the separate,,sewerage system shall be4ro,J°ne mull and void as soon as a public sanitary ewer becomes
available and the approval of the private water supply shall becomi,ri lif and +,yokf when 4 ". c water supply becomes available. Such approvals are
subject 'to modification or change when, in the judgment of the Co "Aissione "of i jeelV ych revocation, modification or change Is necessary.
Ci/ (V(O0 ' ` d
Date e� Title
Rev. 9 -81
1
,� 1. 1
CONSTRUCTION . PERMIT
Located at / 4✓�/
subdivision
Building Type
G -
PUTNAM COUNTY DEPARTMENT OF
Division of Environmental Hea /th Services, Carmel HEALTH
Permit
N. Y. 10512: -.:
I.OR Sg,W.A 3E DISPOSAL SYS`T EM' _
S f
i Town or Village�
b Tax Map J S Block f
Subd. Lot '# s Lot
(� e Renewal Revision
Number of Bedrooms _-.�� Lot Area G� %�•,
Design Flow a /P /D � �--
Separate Sewerage System to consist of
✓� f t ls''
To be constructed by Gal. Septic Tank
Water Supply:
.P,ublic Supply From
-_ Prlvate Supply to be drilled by
Address
Other Requirements
Date Of Previous Approval
Fill Section only
P'C• N• D. Notification Required
and 3 e,-- sr
Address _ / �� �✓G�C�
1 represent that I am wholly and completely responsible for the design and location of the L `
above described will be constructed as shown on the a
County Department of PProved Of
there to and in accordance with the standards rules an r
be wbm(tted to the Health, and that on completion thereof a (). 1) that the separate Sewage
Department, and a written Certificate 9 disposal system
Place in good Operating guarantee will be furnished the owne►, Construction Compliance °� b egyla ,ons o
ante of the 9 condition any part of said e u nam
approval of the sewage di oral wceessprs, �}(�}#i�y' in; of Healthwill
Will be located as Certificate la Construction p system tluring the �Vr ° i9M "SY,�}h builder, that said builder will
shown on the approved plan and that said well sW,yl Hance o the original system anyw par t 9 Bdi tel following thedate of the issu-
County Department f H ."�� S
cal h. accordance with 8 t'a ` , p' %th8t the ~drilled well described above
Date / /� ifi - C". fea aril °oegu iaTf*on- s of the Putnam
APPROVED FOR CONSTRUCTION:
revocable for cause or may be amended
requires a new na—f
Date
Rev. 9 -81
P.E. R.A.
has been undertaken and is
IV alteration of construction
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Putnam County Department of Health
Division of Environmental Health Service
Approved as noted for conformance with
applicable Rules and Regulations of the
Putnam County Health Department.
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4794F
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Putnam County Department of Health
Division of Environmental Health Service
Approved as noted for conformance with
applicable Rules and Regulations of the
Putnam County Health Department.
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4794F
ghature &Titl Date
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