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02639
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING ... CA ML N. Y... 1051.2
y
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner j�,;�' Address % �G���G sow_:,��,;� f9
Located at (Street J ��; ��,j'j jf/ sec. .s Block .._J Lot _;�% '4-
� :-,�.
ndica e neares cross streety
Municipality ex -k,,7 �111e- Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse
Depth to a e
Water revel
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop in
Min. /in drop
Inches Inches
Inches
4
3,40 V
Notes: 1) Te'�ts 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.
Vs�
4
3,40 V
Notes: 1) Te'�ts 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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH
HOLE -, NO 41
G. L.
611
ip
F
1211
1811
24"
J
30 n
�
3611
4211
4811
5411
60"
6611
72„
7811
HGLE NO. HOLE NO.,
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
zNDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED - ✓
TESTS. MADE - -BY— ' '" �� ,� `, �/ ; v Date a .
DESIGN
Soil Rate Used / Min/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms - 'G�✓
Septic Tank Capacity .%C Gals. Type
Absorption Area —Prov— By.5e L. F. x2411 width trench.'
Z �Qther
�
F P�FW �°oi►�
VI-I'1 .i
Address
gnature
O
THIS SPACE FOR USE 13Y HEALTH DEPARTPENT ONLY: X0'6 °• 948 '
%
. e
Soil Rate Approved_ Sq. Ft /Cal.
c�
-MAR 12 1984
PUTNAM CC U-Nl iV
OPT. of HEA�TIH
y .tp�'�'
Checked by �,.c�ti Date
1
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
. (914) 225 -0310
Mr. Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Dear Mr. Sullivan:
August 25, 1989
Re: Compliance - Forte
Peekskill Hollow Road
(T) Putnam Valley
Permit # PV -10 -84
Review of plans and other supporting documents submitted at this time
relative to the above-captioned project has been completed. Comments
are offered as follows:
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN KARELL Jr., P.E.
Director
"As Built" plans must include a legend., which reads as follows:
"This is to certify that the _sewage. disposa.l...system was-constructed _, ,._.. ..._....
...... "as:`.ind.mcai;ed• -on= tr�is plan-and that--the - syste'm was inspected by me
before it was covered over. The system was constructed in accordance
with all standard rules and. regulations of the Putnam County Department
of Health and the New York.State Department of Health."
Upon receipt of a submission, revised to reflect the above comments, this
application will be considered. further.
Very truly yours,
(( J�
Lawrence C. Werper
LCWLjr Assistant Public Health Engineer
Acidity
GENERAL BACTERIA
Alkalinity
Yorktown Medical Laboratory, Inc.
LAB N
Standard Plate Count
321 Kcar Street
Date Taken: 7/31/
9 Time:
Yorktown Heights, N. Y. 10598
Date Rc' d: �T7—
Time:
(914).245- 2800,- _ _
Date. ReporL.ed
-
ector: Albert H Padovani M. T. (ASCI�J
Collected By:
rapasso
Referred By
_ Fecal Coliform
' T- ,
Sample Location: Kitcnen
Tap
PHILIP TRAPASSO
Forte Residence:FeeKsKill,floilow
P, 0: BOX 57
15utnam Valley,NY.
SOML;RS,NY, lOr (9)
Phone N -
�,
L r � J
%�
Phone N
Repeat �
eat Test?
Sample Type:
(check each)
Potable
LABORATORY REPORT ON THE QUALITY OF WATER
i Non- potable
INORGANIC NON- METALS 'm L ) MICROBIOLOGICAL CPU /100mL
STP INF
Acidity
GENERAL BACTERIA
Alkalinity
1+ °C
Chloride
Standard Plate Count
` Detergents, MBAS
_
(CFU /1.OmL)
_ Hardness, Total
GE 12
_ Nitrogen, Ammonia
MEMBRANE FILTRATION TECHNIQUE
Nitrogen, Nitrate
f
r Phosphate, Total
Total Coliform
Sulfate
Sulfide
_ Fecal Coliform
Sulfite
_ Fecal Streptococcus
METALS (mg/L)
MOST PROBABLE NUMBER TECHNIQUE
Copper
Iron Total Coliform Index
Lead _..
Mangs.nese .. _ F.eo.al. Co.li-f.ar.m. Index
Sodium KEY FOR TERMINOLOGY
-- Z i 1!C CFU = Colony Formi no' Units
,MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
CON = Confluent (q.v. TNTC)
LT = < = Less Than -
GT = > = Greater Than
N/A = Not Applicable
S/A = See Attached
TNTC= Too Numerous To Count
REMARKS /COMMENTS (For Lab Use)
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
HNO3
_ HC1
_ H2SOh
NaOH
ZnOAc
Na2S203
Other:
LE
i+ °C
GT
1+ °C
_
pH
LE 2
pH
GE 9
pH
GE 12
Other:
ELAP No. 10323
TH ESE RESULTS INDICATE THAT THE WATER SAMPLE ((Was ) (Wasn't) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW ORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TME OF SAMPLE COL TION.
-1HESE RESULTS 1NDICATE.THAT THE WATER SAMPLE (Did) (Didn't) (N /A). MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK PUBLIC RIN NG WATER
CODES, FOR T/HE-,PAR A�(E ERS TESTED, AT THE. TIME OF SAMPLE COLLECTI0 .
Albert H. Padovani, M.T. (ASCP
, Director
2 /86(Rvsd7 /87)RWE
�9
WILL. (VM1'LJ1'E1uly 1c -hruAl Office Use Only
a .t
DEPARTMENT OF HEALTH
_
Division Of Environmental Health Services
}DEPARTMENT�OF
PUTNAM COUNTY HEALTH
STREET AU RESS: YIN7YIL / ITY TAX GRIO NUMBER:
WELL LOCATION
PEEKSKILL HOLLOW ROAD
WELL OWNER
AOORESS: P6iVATE N "bRTE
PUBLIC.
USE OF WELL
)Q RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS 0-'FARM ❑ TEST /OBSERVATION O OTHER (specify)
2 - secondary
Q INDUSTRIAL 0-. INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT _.- 5 gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
AM NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION
DRILLING
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH _32Q ft.
STATIC WATER LEVEL QV
DATE.MEASURED '
DRILLING
XQ ROTARY O COMPRESSED AIR PERCUSSION ❑ DUG
I' EQUIPMENT
❑ WELL POINT . 0 CABLE PERCUSSION ❑OTHER (specify):
WELL TYPE
0 SCREENED- - f OPEN „END CASK,- O OPEN HOLE IN BEDROCK ❑ OTHER
TAL LENGTH=, - 2
MATERIALS. STEEL ❑. PLaSTIC� D OTHER
•
CASING -
"LENGTR-48LOW GRADE � a.. � •,fit _
4
JOINTS; ❑ WELDED MTHREADED 0' OTHER
I, ,
rA, DETAILS:., :'
___...._ - ..,..... _ ------ _._ ;.,
CEMENT ❑ BENTO NIT E
g3OTHEDIAMETER
_
:,....
WEIGHT PER FOOT Ibaft J!
°- DRIVE..SHOE._Q.YES ,01. NO_
LINER OYES) N0.
DIAMETER (►n)
'"SLOT SIZE
LENGTH
(fQ,-
DEPTH TO SCREEN. (ft) ,...-
,...DEVELO.PED7
SCREEN ...
FIRST
O YES ONO
;DETAILS
:.Novas
GRAVEL PACK
C1. YES ....
staAVEt ,..
'DIAMETER -..
TOP - .......,.. -.... ...Qorroht._..,.
a.
` ....:._...- . - ._. • .:_ -
O NO
SIZE:
OF PACK in.
DEPTH n
oEPTH.
WELL; YIELD TEST I( detail 6d pumping
)f more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
METHOO:h O PUMPED +. tests Were done is in-
,
DEPTH FROM
Water
Well
C] COMPRESSED AIR
,
,formation ,attached?
SURFACE
Bear-
,
FORMATION FORMATION, DESCRIPTION
Cook
ft.
it.
' YES 0 N0
O BAILED :. 0 OTHER ,.
in
meter
In
WELL DEPTH
DURATION
DRAWOOWN,:
+ YIELD
Lana
Surla e
t ...
fk ,:
hr.. min...
ft.
9Cm. .
`320:,
,7+
10 +Ga
1, ;,
ER
c TEM
r-W'A
tOUDY
tOLORED ANALYZED? .,0 YES 7 'O NO .
YSIS ATTACFIEDONO -
T:
S- T.C±RAGf TANK TYPE
CAP..AGITY .
.. ...... -...
RMATION._:.. ._.
TYPE'
CAPACITY
WELL DRILLER NAME NORMAN "A.NDERSON INC' DATE 7/ ”- /89
MAKER
DEPTH
ADDRESS SIGNATURE - ;
152 Barger ST _
5
MODEL
VOLTAGE HP
Putnam valley , ny. • 1'05
I W11-
PUTNAM 0CXW'Y DEPARTMENT OF HEALTH
DIVISION OF ENVIROWINrAL HEALTH SERVICES
✓ � ;Jr 3 �v
Owner or Purchaser of Building Section Block Lot
Building Constructed by
P� /� /.Y //V //G * / - /-f d,
Location - Street
Municipality
Building Type
Subdivision -Name
Subdivision Lot #
GUARANTM 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 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
"Certificate of Constructs on.. Compl fiance" for the sewage disposal systan;
_ _. .
repairs made -by me --io-suchf systOff; exceptwfiere 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 E:nvironinental 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 day (�f �� y 19 Signature
Title 151 pgi
- Signature
Address
Address
rev. 9/85
mk
y�
STREET ICCATION 1/C c �. Il� < � MJ / L4 -R „L 7
PERMIT 4 ^� �/ . •- t� f Lm a OR Su7EiDIWSICN LC7I'
I
I]
IV.
V.
vi.
'l-
YES NO
SAGE DISPOSAL AREA -
a. SDS a=ea located as r aporove3 let' -s
b_ Fill section - Date of plac-aient
2:1 barrier - I=- WID'IR AVG.DPTH
c_ Natural soil not stripped
I
d. Stone, brush, etc-, crate_- than 15' fran SDS area.
e. 100 ft. fran water course /wetlands.
I I
Ste.f E DISPOSALL SYSTEM
a. Septic tank size - 1,00 1,250
b. Seotis tank inst- 1 level
c. 10' minim= fran fcur_ca t:--,Lcn
1� I
d_ No 90° bends, cleanout within 10 ft_ of 450 bend
e_ DISTRIBUTION BOX
1. All outlets at saz el eva-tion - water testea
I
I
2. Protects belcw f_cst
I I
I
3. Ntinim= 2 ft _ oriciral soil bebwee i box and tr= mc-:es
( I
I
f. JUNCTION BOX - properly set
I I
1
TRENCBES
1. 1,ength remir-ed -- 3 a Ie ^. `h instal-led 3 ey d
I
2. Distance to watercourse ft.
I I
I
3. Installed ac rrdinq to plan
I
4. Distance center to c--n c 61
1 1
1
5. Slorz of trench acc=t =-ble 1/16 - 1/32 "/foot.
41:7-- 1
1
6. 10 fit from prccr `)r line - 20 feet - foun t? cns
4 aZ
7. D -..pth of t_ e hcn < 30 inches f-an surface
8. Roan a-l-a4 d for eY•can-sion, 50%
1
9. Size of travel 3/4 - li" dia*net_-
10. Depth of crravel in trench 12" m nimmm
1
C'
L. • Pipe ends C"-'pped
h. PUMP OR DOSE SYSTEY-S
1. Size of v= chamber
. -2.-- Vver-.EIcw '-jj. ... .. . -
1.
3. Alain, vi-mm-1 /audio
( ( I
4 PL= easTiv ac^essible nanhole to e--aae
I 1
5. First bcx baf=Zed
I ( I
6. Cwcle witnesse-d by Heal th Dew Lment
1 ( I
estimated flow Per Cycle
a. Eduse looted ver a:=raved plans.
b. Number of bedrocws I
I I
a. Well lcc--at-----d as r,--*- a =roved plans
( `
b. Distanca frcm SDS ar`= zr= ur - -ft.-
c. Casing 18" above trade_ I I
d. Surface d_- airace a-ound well accentable. (� I
OVERALW .�� • *
a. Boxes prowl crrcut=
b. All pipes rar -aaLy baccill e3 I I
-
c. All.pipes f?u--h with inside of box
d. Backfill material contains stones < 4" in diameter
�
e_ drain installed accordinq to plan
I I
_Oi*tain
f. C-rtai.n drain cutf-al I urotectea & di.r.to exi st_watecourse 1 I
g. Footing drains dischzrce away from SDS area ( I
h. Surface water- orot_-Llcn adeouate
i. erosion on=o proved- on sloces areata- than 15 %.
'l-
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
:-APPLICATION TO CONSTRUCT< -1�' WAfiEI2' WELL
PCHD PERMIT #Aiq-'5�'
WELL LOCATION
Street address
Town/Village/City Tax Grid Number
z6
WELL OWNER
--N e
®%a
Mailig Address
/ %G�/�v.f'
Ur/�'�%r /�''
rivate
.O Public
USE OF WELL
1 - primary
2 - secondary
ff RESI:DENTIAL
® BUSI:NESS
® INDUSTRIAL
0PUBLIC SUPPLY
O FARM
U INSTITUTIONAL
OAIR /COND/ _AT PUMP
O TEST /OBSERVATION
O STAND -BY
0ABANDONED
O OTHER (specify,
AMOUNT OF USE
YIELD SOUGHT___f _gpm /# PEOPLE
SERVED_ /EST. OF DAILY USAGE60Gl gal
REASON FOR
DRILLING
PIEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
jkPRILL8D
ODRIVEN
ODUG
OGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES 1,'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ---
Lot No. f `
WATER WELL CONTRACTOR: Name /�A�s''%D �r �� ® -Address: va e/
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: ""' TOWN /VIL /CITY
- - -- DISTANCE °TO- - PROPERTY - ROM.' NEARESsi ' WATER- MAIN : `
LOCATION SKETCH & SOURCES OF CONTAMINATION
_ []ON REAR OF THIS APPLICATION
(da e)
PROVIDED
..__._�_ — ON S PARATE SHE
(si at ' - "
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
County Health Department attached to this
3. Submit a Well Completion Report on a form
Health Department.
Date of Issue: 7 _iq'�O
Date of Expiration: `Z 19
requirements of the Putnam
permit.
p i oyi ded by the Putnam County
Permit Issuing Offl-eiaq
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange COW: W011 T)ri 11 Pr
JOSEPH F. SULLIVAN, P.E.
eonsuL'Etny �.�.gtnut
2972 FERNCREST DRIVE
Y(jRKTOWN HEIGHTS, N. Y. 10598
(914) 962 -4248
J, the 13, 1.988
Putnam C'ouhty Health Department
110 Old Route 6
Carmel N.Y.. 10512
R,&z Proposed sewage disposl
system property of John
Forte on Peekskill Hollow
Road in the town of Putnam
Valley N*Yo (35 -3 »P /0 4) .
Gentlemen 8,
. From a field inspection of the above lot there have been no
changes to adversely affect the proposed sewage disposal system
or location of the proposed drilled well,
Very trul�yj yours
Joseph F. Sullivan P,E,
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.... : _ ...... Date � +��'✓� ���
��Re: Property of - ' ° ✓�'7 .��
F
Located at �j G0 r!
(T) -/ � 'ea Section, g Block 3 Lot "Vlo
Subdivision ofc'C�! /G%i'
Subdv. Lot # Filed Map # Date
Gentlemen:
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
"'' sy'stem"or ~systems I -.n conformity with the provisions of Article 145 or
147, Education Law, the Pub Health Law, and the Putnam County Sani-
tary Code. �
®'V0000ame" . INAI 1 7 g �ery truly yours,
t Of ��rh °r�,r POW
114 C
<� S pbaoso• d' °p n 8t , pp
s
o N " _ ®p �FC� O er of Property
Countersig
P.E., �j Address
Address Town
o
Telephone
Telephone
i , a .
PHILLIP CERADINI ARCHITECT A.I.A.
1 Babbitt Rd.
BEDFORD HILLS, NEW YORK 10507
(914) 666.0547
TO L-A {`
cr�i�M �L N
[LIE"TTEa of T"MUSEDUML
DATE
JOB NO,
ATTENTION
RE:
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items:
❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
`T .I
' THESE ARE TRANSMITTED as checked below:
❑ For approval ❑ Approved as submitted
M-/For your use ❑ Approved as noted
❑ As requested ❑ Returned for corrections
❑ For review and comment ❑
❑ FOR BIDS DUE 19
.REMARKS
COPY
• Resubmit copies.. for approval
• Submit copies for distribution
• Return corrected prints
0 PRINTS RETURNED AFTER LOAN TO US
SIGNED:
-318 k
CERTIFICATE OF C(
Located
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
P.C.H.D. Permit k
(
s-2 . - 3 - ,;fk
COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Town or Village
Tax Map Block 3 Lot --,P/—<,
Owner /applicant Name. -Tb 11 IF. Ir _Formerly, _ Subdivision Name Subdv. Lot M
Mailing Address 6 W I3 o c• cA Zip I O Date Permit Issued
n h a-r� I;� �C 1J • �� � _ _
Separate Sewerage System built by �' YY]!, ddress
Consisting of (i �• Gallon Septic Tank and F 2A
r e- vtv`t,�s
Water Supply: Public Supply From Address
or: Private Supply Drilled by A-11 A- ew'S V-7 Address a ✓ e er- �`� �. i/• I.i. �1.
Building Type 9 G 3 ., Ae44 C e- Has Erosion Control Been Completed?
Number of Bedrooms 3 Has Garbage Grinder Been In -cIE^
a
Other Requirements
I certify that the system(s) as listed serving the above premises were
of which are attached), and in accordance with the standards, rules and
Putnam County Department Of Health. —
Date _ r , Al Certified by_
Al at
Addrett 1
on the plans of the completed work ( copies
the filed plan, and the permit issued by the
P.E. R.A.
License No. 21 y1"LS
Any person occupying premises served by the Bove system(s) shall promptly take su bs necessary to secure the correction of any unsanitary
conditions resulting from such usage. App oval of the separate sewerage system shall b e null and void as soon as a pub,'.-- sanitary sewer becomes
av a liable 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 modificatio/n'n or change when, in the judgment of the Commissioner of Health, such revocation, modification Or Change If necessary.
Data / / B— ��� Title
PUTNAM COUNTY DEPARTMENT OF HEALTH Permit s �I�V
1V Division of Environmental Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM s
� Town or 4illage
Located at .9' r�•t�r. + I r L° 6�• � Tax Map - -� Block ,, Lot
Subdivision JF r 7. 1 �r t' /r/ ��<� %""r' Subd. Lot a _ ? Renewal _� Revision
Building Type A Lot Area
Number of Bedrooms Design Flow G /P /D
Separate Sewerage System to consist of d� Gal. Septic Tank
To be constructed by
Water Supply:
Other Requirements
Public Supply From
Private Supply to be drilled by
Address
Date Of Previous Approval
Fill Section only ❑-
P.C. H. D. Notification Required
and
Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 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 u nam
County Department of Health, and that on completion thereof a "Certificate of Construction ComplitnfeYtut% ctory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner, his succer -O.- I PrsAl 4-dj%tely by the builtler, that said builder will
place in good operating condition any part of said sewage disposal system during the periodof4t4MO (a2.jdbHD({�i following thedate of the issu" ante of the approval of the Certificate of Construction Compliance of the original system oy �,;��h�3 the drilled well described above
will be located as shown on the approved plan and that said well will be installed in accordance with bh@ standards,yfyPes ant regu ads of the Putnam
w
County Department of Health �°��• .� /
\ Date ! I? " Signed . l ;J ! / /,� .i 5 . P.E. 4 R.A.
r l/ �- 5 .l'M n +L ✓� `—.
Address • Rtt{�eense No.
APPROVED FOR CONSTRUCTION: his approval expir s one year from the date issued unies '„construction ofithr uY�iIng has been undertaken and is
revocable for cause or may be amended or modified when o idered necessary by the s ionerz of FfealLfi'Aiji n' a eration of construction
requires a qw permit. prov for disposal of dome is ni ry se ge, antl /or rivat wat
iDate
/� % PUTNAM COUNTY DEPARTMENT OF HEALTH
(9 / Divlslon 4 Environmental Realth Serwlem Carm®1. N.Y. 10512 weer. to Provide Pamh.d
on CERTIFICATE OF COMPUAKE
CONSTRUCTI PEST FOR SEWAGE DISPOSAL SYSTEM Pellsmh p
®.
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Located of / / / / �/ Fs off �% vet e� /� own or VMaS.
Suhdivlslon Piame C_ , E/' � mbd. I.at # Tax Map �® Block 3 Lot � J
t�0/7i7 /!J% Renewal_ Revlslon 0
Owner/Applicant Name
Date of Previous Approval f -
��'
LZ
Mwft Addreoa�0 4✓ ���� Town _ Tdp
Bnlidimg Ty pe %.eye Lot Area Fill section Only
Depth —Volume
—
Number of Bedrooms Design Flow G P D C/ PCHD Pioti®cadon Is Required When Fill is completed
Separate Sewerage System to corselet of : 4 Go on Septic Took and —3 •, '
To be constructed by Address
Water Suppb,. , /Public Supply From Address
or: y Private Supply Drilled by ---Add—
Other Requirements
1 represent that 1 am wholly and completely responsible for the design and location of the propo em t separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accord .� i ,� an regu a ions o a u nom
County Department of Health, and that on completion thereof a "Certificate of Constructs Co to he Commissioner of Health will
be submitted to the Depaithieni,'and a written guarantee will be fur,niilied the owner, hi " t h ass y t builder, that said builder will
piece in good operating condition, any part of said sewage disposal system during the tl o ) r m tely allowing the date of the isw-
once of the approval of the Certificate of Construction Compliance. of the original syste '� re 2) t drilled well described above
will Do located as shown on the approved plan and that said well will be Installed in ac toJ an w' the : r les d u a ens of_ the Putnam
County Depart ant of Health. V
Date igned P.E. _ R.A.
._....w...__ Address:l / iT ✓'/7.•% /f� �. canoe No a�� /—
APPROVED FOR CONSTRUCTION: This approval expires tw .years from the date issued unt ss pvi6 ilding has been un rtaken and is
►avOCaD18 for G a8 Or may be amended, or mOdifiedwhen c dared f�BCefsary by Commissions change or alter lW onstruction
requires a w permit. Q7(�yp oved for disposal of dome itary wage, / private water s Y. tom/
Rev. Z !J. V
1/87 Date -- fff --- 8y Title
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