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Home My WebLink About2644DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -65 BOX 22 1 ru rm Le 1. 6 02644 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM ,� �, -- 01 - d I PERMIT Locata �z'� %�f /Y� /`�''n/�a Town or Village Subdivision name Subd. Lot # Tax Map Block Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name p �e_ f Date of Previous Approval Mailing Address YG 4 /�GG%f% ��1 /�� ry' add / ��ti /�� zipJoj'7 Amount of Fee Enclosed /!i d -4- � Building Type /4�o �� eXe- Lot Are - O7- No. of Bedrooms Design Flow GPD Sari Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of % 2 -U gallon septic tank and 4' r D ;7— ��`aelc Other Requirements: To be constructed by Water Supply: Public Supply From Address — Address or: Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director 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 treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: P.E. i/' R.A. Date P/ Address �yc License # Z 1/ APPRO D OR CONSTRUC xpires two years from the date issued unless construction of the sewage treatment system has been c d by. the PCHD and is revocable for cause or may be amended or modified when considered necessary b Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge v , sanitary sewage onl B Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Z/,Q1;)V Address Located at (Street) Tax Map Block T Lot edo-' (indicate nearest cross street) Municipality 00�� Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking vdvz Date of Percolation Test J_� -, J . I I .1 _-__ I - --- , J NOTES: 1. Tests to be rer)eated at same depth until aDDroximately eaual percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review, 2. Depth measurements to be made from top of hole, Form DD-97 Depth to Water From Ground :Water Le I Level .... .. >Elole -N .'Run N ....... t::' top. jl� s Time V11 -face ies) J Surface nel Start Stop Drop In. -lot es 2 TIP- 3 4 5 1 Oa ofd- 2 3 3; 2— 3 4 5 41 J_� -, J . I I .1 _-__ I - --- , J NOTES: 1. Tests to be rer)eated at same depth until aDDroximately eaual percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review, 2. Depth measurements to be made from top of hole, Form DD-97 DEJ91.1 0.)" 1.01 2,0' 25 3.01 3.5' 4.0) 4.5' 5.01 55 6.0' 7.0' 7.5' 8.0' 8.5' 9.01 9.--), 10.01 TEST PIT DATA DESCW.rj-, - - - JONPF SOILS ENCO-UNTER'll"D tN TEST HOLES IJOLE N0. HOLE NO._- -1> HOLE NO. 2 lnd'O;J,; level: at which groundivater is encouintered Alezl e Ind I'C", ct at which nioUling"s observed, Iml, lcailclevcl to which muter level rises after being encountered Detpk()IC, '--)bservation . s made by: Date -------------- Deslg,tj Prof'cssloilal Name: Desigullrofessiou'll's Seal PUTINAM COUNIN DEPARTMENT OF HEALTH DIVISION OF ENVIl O1®"M 4,N'TAL.HEALTI-I'SERVfCES LETTER OF AUTI-IORIZATION .R.E". PI-operty of -'11."/'V Sr.rbdi��i.siorr of Subdivision Lot 4 Gen.t.lun-jen: S Tax. Mup -8 fflocV- 3 Filed Map # Date Filed Lot z � lis, Icllel- iS to authonze SLV Le— I v 4-hj to apply Sor the required -trCatIncilt a� )ted property in accordance od/or to serve theabove-m -Wikh VW- ,-taadavds, rules OY ytgr.Aeffions as J-)romvilgatecl by the. Public Health Director of the Putnam .0cpartment, and to sign all necessary pa us on my be,[vaffin coi�ectio» with this 11-latin., a.nd to Supci-Ilise the consin./c/.1017 Ofsald I'llastel.-YdIff ILVtIVICIlt �117(110r water supply systems in con-I[omilty wiffi tht pi,ovisions of* Aj-[)cJc 145 and/or 147 Oft))C ECILICtItjon Law, the Public Health I-JIVI Z-111d the Putnam COLUItY Sc'MI'MI-V Code. Md,ling Aciciress - ------ Zip V S PSLw NICIIIII Ad inns-. A --- elj —Zip lc7 Forin LA-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # [J ziL�i' Located at ��il/ /�.5 C /� Z5 dTown or Village /e�' yg�ee YAA' J Owner /Applicant Name %G lifl/ �.S Tax Map Block Lot Formerly Mailing Address —T �� 1'01111 Subdivision Name J /Subd. Lot # �' +t/�� /��y ®�' Zip le—'r7? Date Construction Permit Issued by PCHD 17 Separate Sewerage System built by Bhiyl �%�' Address .5;ol'ev C Consisting- of - - `� `� .Galion Se tic Taiik- and = e Other Requirements: Water Supply: Public Supply From l Address- or: Al Private Supply Drilled by Address. Building Type O W04f Has erosion control been completed? Number of Bedrooms 15*4' Has garbage grinder been installed? _ I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issu struction Permit and approved plans and the standards, rules and regulations of the Putnam Coun W ealth. Date. G Certified by Address � Any person occ ymg p�re ses serve by * 11 P.E. k' R.A. BEM shall prom]- ce such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system "shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such rev cati _�uodafic c' ans ecessary:....... s .. -. By: Title: J� Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 P UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Location - Sireet Subdivision Name Building "1'ypz._ Subdivision Lot I represent that 1 am wholly anJ cornplc:,�,ly respor,5ibi, for the location, workmanship, material, construction and drainage cifthc sewage tc catment system serving the above - described property, and that is I- a�+een-- mastruc ec-as �Ytrwn�n�'� ��r��.�l �,�in ogdpprbVed ~ain�ii�ir�cni= tli�reto; accordance with the standards, Hales and rf yLdations of-tlre Putnam County Department of Health, and hereby guarantee to the owner, l<is successors, heirs or assigris, .to place in good operating condition any part of said system crmstructed by me which fails to operate for a period of two- years immediately following the date of approval of the "Certificate of Construction Compliance" for the sett � ge treatment system, or any repairs made by me to such System, exceptwheii6the faiiute.�to operate,. proper -ly_is- caused by-1e ,willful or.negligent.act of the oecuppnt of the building utilizing the system.Y The undersigned further agret:s to accept as conclusive the determination•-of the. Public. Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the w llful or negligent act of the occupant of the building utilizing the - Dated: !Month Day Ycar n _ Signature. Title: General Contractor (Owner) - Signature x ...w Corporation Name (if corporation) Corporation Name if corporation) Address dr s St .�A e .State lxtp t Sr;1e r t :Zip , `e. +r- r,t.f,S? __rCr•f e,� � .Q t t S � r n� i � .. �! « •..,. , `1 { .;.:. .. , r.. t t i ., u* - . .; T ;i,, C' a , > , al de, A -pi �t, w-� o sf, 'Ila 77 d4 7Z 40- 7% OWIMon. ErMionfroo �47 J ww fat donmm wmancmw M"s and Regulations !O the s WMW4 16 Tme N al de, A -pi �t, w-� o sf, 'Ila 77 d4 7Z 40- 7% OWIMon. 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