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02649
Rev. 3/86 PUTNAM COUNTY DEPARTMENT OF ,HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
A-D l�
C)
U �� /%% �e P.C.H.D. Permit
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Town or Village
Located Tax Map 15 Block
. �-.. Let •– (�. - .:.
Owner /applicant Name C21 C21,L» 1T--1/y Formerly Subdivision Name Subdv. Lot #
Malting Address �f -�?�' l " LJ ZIP- Date Permit Issued -7
Separate Sewerage System built by 1 _U WAa4 U Address
Consisting of 100c;` Gallon Septic Tank and Lf
Water Supply: Public Supply From Address Address GG��''��
or: _Private Supply Drilled by�TrM'=0 Address __� �L�f I
Building Type i f,� -Has Eroelon Control Been Completed?
Number of Bedrooms 1 L Has Garbage Grinder Been Installed? -
Other Requirements t..? I`_�1 IL
I certify that the system(s) as listed serving the above premises were constructs use 1 as shown on he plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules a eg ons, n e with filed plan, and the permit issued by the
Putnam `CCo ty De rt:ment Of Health. //��
Date ` 15Lt"iM b(ry +fied Dy P.E. V R.A.
Address l02 QEA1 :lam License No.
Any person occupying premises served by the above system(s) 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 pubis: 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 Commissioner of lath revocation, modification or change Is necessary.
Date o,
y� _ Tit
(pONg1RUC1i0N PEBMR
1ti}11ifAM COUNTY DEFABTMENT OF B( a= m Provide Peaolt /
'`.Dm law di Ohl Health Seevloes, Carmel. N.Y. 14S12 Eughwar
w CE RMCATE OF D�LA�+NCE 7
SBWAOE DL4MSAL SYSTEM Ptremk M o
Srtlbdlvldw
Nam c•�_ Lot Y T. Map d�� gbek r°f
h 60// Reo1i_❑ > o
Date of Previous Approval
Town CE f/of /.a 1! ZIP
Date Subdivision ARproved f ,y Fee Enclosed ❑ Amnunt
Bdbftg gyrpe Lot Arcs / • <JG �f /t' Fad Section Only Depth Valame
Number of Bedrooms Design Flow G P D PCHDANodGeMloo b When FIR Is completed
Separate Sewerage Syllbem b =mm of Gabon S• Tank ®� y } P r
To be oana4wetsd by
Water Sw*: - PdflBc Supply From — �AAddizams
ert 11Agate Sup* DOW by
1
represent that imam 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 a regu rons
OT • nom
County Department of HMlth, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said bulkier watt
place in pod operating condition any part of said aware disposal system during the period of two (2) years immediately following thedate of the issu-
anm of the approval of the Certificate of Construction Compliance of the 0/ 1 em a any repairs thereto: 2) that the drilled well described above
will be located as shown on the approved plan and that aid well will be Inst ccl dap with the standards, rules and rev ons of the Putnam
Date � � % `iA'rAIA'+s >��.N1Cr' n P.E. R.A.
f�— Ile I crss-C ngl 1 � f� A !� 11#S' i License No ohlyqc
APPROVED FOR CONSTRUCTION: This approval expires two years from the data issued unless construction of the bui ding bas been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Com Health. Any change or alteration of construction
requirZ;z Tille(
Approved for disposal of domestic sanitary sewage, and/ r' onl .
MV.
10/88 Date --
PUTNAM COUNTY DEPAR241W OF HEALTH
DIVISIOi4 _.OE!:- ENVIROkZ=AL..HEA.LTH :SERVICES
Owner or Purchaser of Building Section Block Lot
Building Constructed by
Location - Street
Municipality
Building Type
Subdivision Name
Subdivision Lot
GUARANTEE OF SUBSURFACE SEE -AGE 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
"Certificate of Construction Compliance" for the saiage 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 Enviror*ental 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.
UatL�d this _30 * d:iy of 19aL
General ntractor (Owner) -,Signature
Corporation Name (if Corp.)
L-'t-M U LA,-4,,L
Address
rev. 9/85
mk
SignaLura z
Title C.A ItGa a.
B
Corporation Name (if Corp.)
Pr3dress
PUTNAM ENGINEERING, PLLC
102 Gleneida Avenue
Carmel, New York 10$12
914 -225- 3060.. ..
Fag: 914 -225 -2955
To: l�
Letter of Transmittafl
Date: 1A �•►�_ �� , 9 `7
_ _
RE: U5 H Ls Lc_. 1'I`l All 1 Y
WE ARE SENDING YOU Attached _ Under separate cover via
the following items:
—Shop drawings "' Prints _ Plans
_ Copy of letter e Change order
Conies Date No_
_ Samples ._ Specifications
Ddherriminn if
AYIE. TRANS�I1� °PEI1.as:checkedabelow.:. -: - - - .
For approval _Approved as submitted _ Resubmit _ copies for approval
_ For your use _ Approved as noted _ Submit _ copies for distribution
_ As requested _ Returned for corrections _ Return _ corrected prints
_ For review and comment _ Other
_ FOR BIDS DUE , 19_ PRINTS RETURNED AFTER LOAN TO US
REMARKS:.
:vt
m �,,�� ► / �\ fir`
COPY TO SIGNED:
If enclosures are not as noted, kindly notify us at once.
PUTNAM ENGINEERING, P4LC
102 Gleneida Avenue
Carmel, New York 10512
914 -225 -3060
WE ARE SENDING YOU Attached
the following items:
_ Shop drawings Prints _. Plans
_ Copy of letter _ Change order
Copies Date No.
Letter of a mi 1
Date: J ow � _9I
_ Under separate cover via
_ Samples _ Specifications
Descriation #
3 <•�9-r
�S'DS EXPa►.t5tor�t t�n.1
PLAt l
-1-7
PLAnI
THESE ARE TRANSMITTED as checked below:—
_ For approval — Approved as submitted _ Resubmit _ copies for approval
_ For your use _ Approved as noted _ Submit _ copies for distribution
_ As requested — Returned for corrections _ Return _ corrected prints
Y For review and comment _ Other
_ FOR BIDS DUE 119— PRINTS RETURNED AFTER LOAN TO US
REMARKS:
.151 U_
AtDb 1 -not'l C:L R_EASE FEEL FRS To Goat rl�.ct
"V)A\S O (cam SKav 1.Q you N5a Y3 Atjy Kom I �r �rn2h -tb'C t_orJ
COPY TO
If enclosures are not as noted, kindly notify us at once.
DlePaC f j r Of He- a l
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re CpJd-LO
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1117 -� `YY��"?�►� Q i �U ._�"o. CAS. - (,��P� _ Ll��.. _...._ _. _ _ _ _ .. _
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A-rz�_r-�sc4 agou_)n in )Ode Avqu"��H,
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Box 224 - BREWSTER, N.Y.
(914) 279 -4945
® WAFER ANALYSIS REPORT
SAMPLE NO.7 5 2 0
SOURCE: Bus hell
776 Peeskill Hollow Rd.
Putnam Valley, NY
COLLECTED: g - 21- 8 9
BY:P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
FAUCET WELL
0 per 100 ml.
This result indicates the source of the sample was .
of satisfactory sanitary quality when the sample was collected.
9 -24 -89
i
Thomas May
Director
r
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
.z
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address
Town/Village/City Tax
Grid Number
WELL OWNER
Name
Mailing Address
•,,)SQrivate
O Public
'USE OF WELL
primary
secondary
RESIDENTIAL
0 BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL' O STAND -BY
O ABANDONED
O OTHER (specify
p
AMOUNT OF USE
YIELD SOUGHT
'5— gpm /4i PEOPLE SERVED 3– /EST. OF DAILY USAGE a0Zkal
REASON FOR
DRILLING
PLACE EXISTING SUPPLY O TEST /OBSERVATION GI ADDITIONAL SUPPLY
O NEW SUPPLY NEW WELLING ® DEEPEN EXISTING WELL
DETAILED
REASON FOR
'DRILLING
y i
WELL TYPE
RILLED
DRIVEN
aDUG
GRAVEL.
O
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 /j l/ - Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES / 'NO
NAME OF PUBLIC WATER SUPPLY: � TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST`WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET j gs �,p zy
da of ) (signature)
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 s.hall:
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 Completion Report on a form provided—by the Putnam County
Health De rtment.
Date of Issue: 07 19 /
Date of Expiration: 19 ermit ssuing f icia
Permit is Non - Transferrable
Rev. 10/88
White copy: H. D. File
Yellow copy: •Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
FC7INAM CL'Y]NI'Y MARE' W OF BEAUS
D=ICSN OF EZrTMXZM= HEAD S -cVIas
C-:;-Czjr ur 1= ScWe,C DI;SPOS..: SYSTa-if Z =1 r
Cwme -- 5UIS4 -L-I-- Address PeeV--- >K4L.. HoLL40W fi
qtr at (st=et) P66K�LA ROLt'OW 52. sloe 3 zit-74
-
r�.uz�pzity Wa e'-.he C2o10 Nt
MA= -CN 'T..�' DAM P-m3:rS---= M BE W= APPT ?C3?'TC?i5
L}zt ` of F= -e- Sca�.rS 5 � ��i' �� % Pete of r ^`rcola`Cn Test
7
EOLE
L� ='=CN-
Elapse
De: th to
Water F==
Lever
No.
Vme
G_cu. *_G
Su-.face
L^ L- es
Sol
Min.
St�Tt
St:D
LL CO
�'}°`� 1 lo:2i
10:51 30
23
25
2
I S
+* 1
2 10:52
l l 22 30
23
2`t 't a
i `12
2c�
311:2.3
[
4
to-4s : -30 2. .....
......-
2 210 :4(p t 1 144 3° 24 25 Y4 I '14 24
311:17 11:1-7' 30 24 14 1 14' 24
Q
2ti0'tls: 1. Tests to be repEetea at same de_-,+h until a,,,-areximately equal soil rats
are obtai_nea at each percolation test role. A11•data to' be suhnitt ='
for review.
2- Deot --h rya. a �n t s to be made fra;i too of ho? e . .
ommki:0 410 . , ; % — 4VA**AKwN"*1,'
41*10Fj"MNW
OF
2'
3`
A
6'
71
9
10
121 _ /�
13'
14t
DjD7 nL
!NOD -T= TO WH� ;C-=, Lv P A= E: INC
DES EC)LE Css=,r-!,=CD;s M-PoE BY:
DESIGN
Soil Rate Used 21 ML-fa/ll" Drcc: S.D. U�le Area Provided 1100
FePL-acs r--,vc->o w
AQDMa4AL- tic NC. cf Bedr-cams -2.c Tar-k Cagacity ooc;, ga-ls. Type colje-
"Ic
L.F. x 2411 w;dt-h t=endn
Absorption_ A-re-a- By
ct.,,.e-- 'Dr3W-tF3L n9rQ -
siam-t=e'4r4
A
P�drzss 43
02- c6tZlIj el C�k- SEAL
Ar 5=j
ti
R 1p
THIS SPA=- FOR USE BY F—E-ALTH DE.-RASM-MiY2 CITY:
F E S S 10
So-',I Rate Apprcvea ssq. f t/gal. , Checked by - Date
-t r •�� pia- • � � •i air w
I SWAP so
7 �- t Y• :I�r• w r�
DF 91GN M'?TM.;. — �'•�JEGUr?iC Sr3vr SYSgi - E'=,�.. 13. _ _ -
OwIn.T' U X1-4 LL- Acdress P sK -ll1. Hod i oW 7j�0N r
Lom—t~' at_ (St_eet) Fj5aK-- I LL. HcLLow - Rou=>. Sec. rJ. 2 . aZo,--k 3 ict %4
. U r,�:4Crtr ne =- es;.. (=css street) -
mu^uc=a —I, ty
I'ztr of Pr scarc S Date of F°T- _cola4ca Test 7
EOIZ
RL;r1 Elarse
reoth to
Wat= F-cm
`',c-..°_*• Levu
Min.
St?_ --t
Stct3
r r c a lh
M�'?��.: LicD
L*:c.:es
L ^.c-:es
-n=es
Houma 1 10 : 2� to : 51 3 0
23
25
2
I
10 52 l l 22 30
23
2.A1I2
I `f2
2d
2
1* 53
2 3
2`f'!2.
I `l2
2.D
4
5
1-1 .-
4-2. 2 (v :4Co la° 24 25114- I ' �q- 24
311.17 (VI -7 '50 24 25 `�� (`l4 Z4
NO=: : 1 _ Tests to be re_po---te� at same de -*nth ant11 arprcxc mmately em m l
are obtained at each perc=lation test hole. All. data to* be
for review.
2. Depth t;�a_� r e-�en is to be r frcn too of hole. .
soil rates
Suter .ttw^
pia
A
5'
6'
74
8'
9' -
apt
1 � f
12'
13'
LE = P= 'Wrr' C^ C rMN-11 jU==--,Ts5 E`; L= TO We ' C: LC =: LBS A- — EBLtiG E~ C�+
DE- EOLE CBS c T_1'T! MiS WOE' BY: CA=
Soil Rate Used 21�t �jp Min/I"
No. of Beoa5 •�• �DDfT �,�L
Absorotior_ P.ror Provi" E
Other- 'B t��i3 �eS
;SIGN,'
S.D. U�ahle Araa Provided 11C O
REP�.AcE Sao w /
r'cC;tV ®Q ga?s . Type COI�1G_
.F. x 24" width. tra nCt1
NP—ma FIAII ,Lr..m N rN�NG ��� Signature' Mac
pc
Fr'.r3ress ID2 Cam- JL 1 c t��l s � n �,: 4, o
�PJ'v►�2 NJ\/ 10X12
TnIS
SPP.0 =. FOR USE
BY �ALTH DEP3�M,� Ct�Y:
Soil
Rate AcnrcvC -d"
sa. f t /gal .
-checker by Date
LBO Wtl!;&OkO 1P' Z4 1 •1 :1T 1kh�
• .7 m' r Y• on: I2r is r�
DiFS:G�i' R'r' 'mss ur- .:..Sr°3. v%� DIS' SYST
Address P65I-5ILIC.._l_, }-%t. cw go1&r;;,
qtr el (street) PKs�.i ��. Ro� �isT sr-. �2 . azoc� 3 �� •74
(:.acute nest. ccss street) _
water -She CZO o ti
SOM .M=rCN L'AM F.tXrJ?= M F-v- =L-m-=- w= pin -r� C3 rICNS
]>-t-- of P-ra Scale -T rc . S 4 �� Date of Pe -eclaticn Test 6/97
EOLZ
R -Ir! Fl apse
Eecta to
Nate* F--=
Wale- Lever
NO. Z''
G =eLrG
S= ace
I In=.es
sp:1 ' a
�.
st=T t.
Stclo
Drcc In,
.'V, �iC?
-
^G:'S
-L .:as
1 10:2 IoM 30
23
25
'L
I
I
2 10:52 l 1 22 30
25
112
1 `1'z
20
3 i x:23 [ 1: S3
2 3
24'2
1,12
2.0
4
5
2 2 10:4G t 1:14P 30 2� �5'l4 I ��4 S4
3 11:17 11:17 Sao 24 2S �/4 (`�4 24
4
Tests to be repe—ata' at sa.:)e derma until approximately 'emia1 soil rates
are obtained .at each pere=latien test hole. All_data to be suhritt ='
for review.
2. Dect_h to be rade f rcm tao of hole. .
Yom► M Y• : 7• s f` 39
DE �a BOLL NO • EOI R NO • H= NO.
•
G.L. ............... �..�.._.....__�........� _.- . .._. -_ .. - - ..
1 t
2t
39
a�
5'
6' •
7'
81
9t
ipt
11 t
12'
131
14'
nTD:,C L :J P= Trvr_�C: CCt� Tom? IS EtiCGti
TO W= a- =777 P._S—ZZ E=G ENMU' =
DE.'P SOLE CBS T_'T'ICNS MALE BY:
DESiGY
Soil Rate Used M=r_/l " Drco: S.D. II�able Area Provided
FeFLA=S 500 w /.
No. of Bed.-,ca-,z ?= AODrrOJ,aL Septic Tar!k Caracity I oO o ga? s. T` e GONG .
P.bsorptior_ Area Ptcvidez By 5®® L.F. x 2c" width trench
ather
Nape �uT�t,� r-�N t�1 L-1 N G p[� C S igrature '
Address ID2 �.Ei.1c� l t �V SEAL ."1
Tr.TS SPACE FOR USE BY EZALLTH DEPA.I• ENT CNLY:
Svi l Pat` Aooraved sQ. f tf gal . Che%--. %+ by - Pzte
i
e
s
Patnam County DeparEmove tw Hbsla
Division of Environmental Health Servlon
1pproved as noted for conYdrmance with
applicable Rules and Regulations of the
Putnam q0Un_ alth Department.. %
ft-M ure a T1tla
r
i •
AS —BUILT MEASUREMENTS (I,j FeeT)
1
2
3
4
DRAWING ".j
A5 ^ 1 1 I 1 T
iLrGV L
GJ �G] [�q�)
mac/ . �/ .� . ✓.
6
7
8
DRAWL
I O
II;
12
13
I4
15
16
W/2
22'2
2�
2.02-
33'/2
'36/2-
+4
50
55/z
71'lz
�
I�z
�031�z
TCnj�2
41
+-2
I'
°l2
' 7-
?�
7
7 7
2�-
I
�z
A5- BUILT: e;
i
I. This is to certify that the sewage disposal system Was
constructed as Indicated on this plan and that the system Was
Inspected by Putnam Engineering, P.L.L.C. before It Was covered over.
The system was constructed in accordance with all standard j
rules and regulations of the Putnam County Department of
Health and the NaN York 5tate Department of Health.
c.
2. The 55D5 consists of the following lQ� gallon precast 9
concrete septic tank, L� I.f. of 24" Wide absorption
trench , additional requirements t I)t3T2,g ✓T,0,-1 50>4
,; ii;
55D5 PREPARED FOR:
1y.y1 j� �{ C�1�.y1�eY. i-
JOHN `* KIM ✓U ✓1 ILLL
PEEK5KILL HOLLOW ROAD
•f
ZENLW
�'� ";!
I
DATE
JULY 199i
DRAWING ".j
A5 ^ 1 1 I 1 T
iLrGV L
GJ �G] [�q�)
mac/ . �/ .� . ✓.
PROJEC
PROJECT MANAGER
KH
DRAWL
DRAWN BY
KH
CHECKED BY
PMI.'.
!1
P�
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•
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.yr
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