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HomeMy WebLinkAbout2807DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -36 BOX 24 02807 er -A lm or J ' N ' Y I 4C o f 'o '. �'' r T: �. o , i+1 7 1 1 ' h 1 ', �F 02807 Y LO-�. z 3 C Y ENG I.NEER MUST. PUTNAM COUNTY DEPARTMENT OF HEALTH P.ROV IDE Division of Environments/ Health Serviasa, Carina/, N. _Y 10b1 ?. // PERM`I T� r CERTIFICAT F CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM. /a �fT/ Tovrri or Village / — 'Located at tGQn(A�Q'%% 4%J4t7, .Tax Map '. .�'..�' - Block ' ..s ..... ........... -:.v Owner � �j�,�� 1z L -y e-4 / Formerly - - Tax Map Lot ll % Z Subd Lot H .. ►9 Ai9 � u-1.5 10 Separate Sewerage System built by Addr, /d o o Consisting of Gal. Septic Tanrk d Other requirements Water Supply: Public Supply From Private Supply Drilled By Address Building Type`s ttt!!! Has Erosion Control Been Completed? Has garbage grinder been installed? I certify that the system(s) as listed serving the above premises were constructed essentially ast'shoNn *,An the plans of the completed work ( copies of which are attached), and'in accordance with the standards, rules and. regulations in•accord"ca,,rith ti)e filed plan, and the permit issued by the Putnam County Department Of Health. e: 7 �f y �..olt! P.E. R.A. Date e Ctified by Address d M ' License, NO. Any person occupying premise; served. by th above systems) ShSIFpromptly; take weh set as may ba nepssary!fo gcure the eonection, of any unsanitary conditions resulting from 'such usage: Approval of the separate sewerage systsm;sha�h0ecom� nuil�andAvoad`4s soon as a public.tanitary sewer becomes available and the, "approval of the private water supply shall become null and' void wnena putilk` water supply become •vatlabh. Such approvals are subject to modification or change when, in -th6.Judgment of the Commissioner of Nealth;v,iiieh revocation, modification or change is necessary, Date 13 Tills 0 Rev. 6/85 I. 357 YK. 004,5-D LAB # (orktown Medical Laboratory, Inc Collection Station Used: ­- Yorktown Heights, N. Y. 10598 rm . e ­ Fe ek . s k-ill Mt. Kisco New City (914) 2453203 Director: Albert H. PadovaniM. T. (ASCP) Date Taken:' Date Received: 14 1 2, r Date Reported :'14- j 3,-9- OAAj6f Collected By: IV��S 1_67ir-l? /* ? Referred By: Sample Source: L V LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA V_�Standard Plate Count per 1.0 ml (Agar plate @ 35 °C) M-71•IBRANE FILTRATION TECHNIQUE (MFT) Total 'Coliform ner 100 ml Fecal Coliform per 100 ml Fecal Strentococcus per 100 ml PRORAELF 11 UM B F R T E C IITNTOUF (VPN)_ 0 X! C),r.lrr. .L11 d e-x 6 — Fecal Coliform: VPN Index per 100 ml T.-'-';'SE RESULTS INDICATE TFfT THE WATER SAMPLE 07 A SATISFACTORY SANITARY QUALITY ACCORDING WATER STANDARDS, FOR THE PARAMETERS TESTED, A � Gam, �� Albert H. Padovani, M.T. (ASCP), Director S)l (WAS NOT) (NOT APPLICABLE) 0 NEW YORK STATE DRINKING E TIME OF COLLECTION. LEGEND RDS = Recommend Disinfect- ing Water Source < = less than TNTC = Too Numerous Too Count a Ai�l�OII. TTIT ATT WL'LL VVL1rLL11Vly �rVa�l �.� ly .t +' DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION METAOSIURESS: WN /Vll 1 Y TAX GRID NUMBER: ` WELL OWNER E' ADORE PRIVATE D PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED ❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL 0 INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT �— gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON 'FOR DRILLING NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ' ❑ TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH `I� D ' ft. STATIC WATER LEVEL ' P ft. DATE MEASURED- DRILLING EQUIPMENT 19CROTARY O COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING. XOPEN HOLE IN BEDROCK 0 OTHER CASING TOTAL LENGTH tL MATERIALS: XSTEEL O PLASTIC O OTHER LENGTH .BELOW GRADE / ft. JOINTS: ❑ WELDED THREADED O OTHER DETAILS DIAMETER in. SEAL: O CEMENT GROUT O BENTONITE'DWTHER WEIGHT PER FOOT Ar Ib. /ft. I DRIVESHOE,:'5<ES ONO I LINER: 0YES 0 SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (it) DEVELOPED? FIRST ❑ YES ❑ HD _ GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE. DIAMETER OF PACK _______ in. TOP. DEPTH fL BOTTOM DEPTH It. WELL YIELD TEST If detailed pumping 00: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? O 8AILE0 ❑ OTHEA ; ❑YES ONO ELL LOG It more detailed formation descriptions or sieve analyses W are available, please attach. DEPTH FROM SURFACE Water Bear- In9 well Oia' neter FORMATION OESCAIPilON coot . ft. ft WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Land WATER ❑ CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE _ ;5be—G p ; CAPACITY G L. 14 0 WELL DRILLER NAME•')�y jse_,, � OA ADORESSf/� i9W, 304F- SIGRXTURE -- , PUMP INFORRMATION � TYPE `3 CAPACITY 4' MAK DEPTH MODEL --- YNOLTAGi� . H le r;76* PUTNAM COUN'T'Y DEPARTMENT OF HEALTH -DIVISION OF ENVIRONMENTAL_.HEALTH SERVICES -_.- _ __ . -. Owner or Purchasef of Buildinef Cl Gr v,s•, s L. � Gf ire �y Building Constructed Vy f'd Z B )e 528 '0.scew4?nu LL . kol Location - Street / / Municipality /- I"tr m e. l Z_ S/z v... Building Type Section Block Lot .��e_,Idwaw Subdivision Name Subdivision Lot # GUARANXEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workQnanship, 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 _2r... }} �GCS�l, �Y � ?y Ccins truGL Tan .^ompliance "� for . :. Y 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 building utilizing the system. Dated this / 3 day of 19 8 Geher Contractor (Ow-der) - Si .9,fature Corporation Name (if Corp.) Rd Z. 13� 5zb 0,5caaoio Lk P,-� Addrrs 7 rev. 9/85 mk Signature Title AAA 44 Corplloration Name (if Corp.) /Vest,? s 4 / biz U Address s 1_ e / ®r,`� " �� /` `� PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. 3/86 1 Division of Enviroamentsl Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit # on CERTIFICATE OF COMPLIANCE W DISPOSAL Permit #��`� +'.� 92 CONSTRUCTION PERMIT FOR SE G SYSTEM (� �Grr yY `�Iry/% A,,n J 6 � own or vIDage Located at e / _ .,,,r.._�...., Sabdiviston Name Sabd. Lot # � Tax Map Block � Lot `�J� �. �/ � � � � �G�9'r Owner /Applicant Name � x Renewal_ ❑ Revision r��� fi �� g ^ Date of Previous p%val�� Mating Address PT Town— �[, 71P -Se Xy Building. Type / Lot Area • mot/ s� Number of Bedrooms Design Flow G /P /D Separate Sewerage System to consist of % lied Gallon Septic Tank and le-, To be constructed by Address Water Supply: ,/Public Supply From Address or:_ [! Private Supply Drilled by _Address. Fill Section Only " Depth Volume PCHD Notification is Required When Fill is completed Other Requirements I represent that I am wholly and completely responsible for the design and location of 1W system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendmerit there to 0 ✓Q o {ran the standards, rules an regu a ions o e . u nam County Department of Health, and that on completion thereof a "Certificate �4, staglok".Caor�gt e" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished Mvgif p@jftc sag rs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal syste tluria'%t period YI{p (2) ears immediately following thedate of the issu- ance of the approval of the Certificate of Construction Compliance of t or Sys r an - Bgairs hereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be I stall i ,Socor n 'th t rtls, rules and regu a i1 o� ns of the Putnam County Department of Health. .40 - 5P' �Q / i �_ e P.E. _ R.A. Date ii� j ` S' ed a t a AAA- '/ L License No -,PPROVED FOR CONSTRUCTION: Thi pproval expires one year from theVfA , cable for cause or may be amended, modified when considered necessary °O ��hg •es a new permit. Approved for disposal of domestic sanitary sewage �1 .o ��/L�� By of the building has been undertaken and is Any Change or alteration of construction Y• Title -00000 '00� PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONT24TAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS iN-S EYmIO��, ?.E_Pnw_ p'i' .:. _ . ri - . s �_.,..:.,i _ .. r i DATE: ... ,l INSP. BY: (Name of (honer) (Street Location) INITIAL SITE INSPECTION YES NO CAS 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 rte, cut, house location, separation distances,etc... Itt Adjacent wells /septics ............................ G 'l� • t D.H. 1 Lot Depth to G.W. Depth to rock Soil DescriTDtii 0 ft. I _f`* V �Irlu i D.H. 2 Lot Depth to G. W. Depth to rock Soil Descriptia 0 ft. d�;;: D.H. - Deep Hole G.W. - Groundwater D.H. 3 Lot Depth to G. W. Depth to rock Soil 0 � �" ' 3 ft. 3 ft. YES 6 ft. ft. 6 ft. 9 ft. 9 ft. 9 ft. Width of trench average Z d�;;: D.H. - Deep Hole G.W. - Groundwater D.H. 3 Lot Depth to G. W. Depth to rock Soil 0 ft. 3 ft. YES 6 ft. House SSDS located per approved plan ............. Length of trench measured -30-6 L � 9 ft. Width of trench average Z DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS located per approved plan ............. Length of trench measured -30-6 L � Width of trench average Z Slope of tile line and trench acceptable......... Room allowed for expansion trenches...... .... Over 100 ft. fran watercourse .................... k Natural soil not stripped or SDS area unnecessarly graded.......... .... ........ X 10 ft. maintained from property line and .......... ....`e....... 20 ft. from house... >o y-v 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 from trench ..... ............................... Boxes properly set.— ........................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear�OK in area of SDS. a..... FINAL GRADNG OF SITE ACCEPTABLE......... PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SFXAM DISPOSAL SYSTEMS _ DATE REVI W4 / DD �cW4 c` � BY: (Name of Owner) (Street Location) COMMENTS YrkS. NO DOCU�MM Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log �- "� ► �� O- - - 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 N. 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 Perc & Deep Holes Located Representativey of Sewage & Expansion_ Area If Pumped Pit & D Box Shown & Detailed House - No. of Bedroans 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 45° 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' fran 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 l A-)" , i fi " �P CO "�•• ., ,DAVID D. 'BRUEN � '�- _S �n� 1 -�,.� ` � w . Y • ' R r Y" � JOHN -'SIMMONS M.D. County Executive rt, O` Deputy Commissioner DEPARTMENT OF HEALTH Division Of . Environmental Health Services October 30,.1986 Joseph F.. Sullivan 2972 Ferncrest Drive Yorktown Heights, New Yorke 10598 Rem Proposed SSDS. Legrady Oscawana Lake Road It t d' (T) Putnam Valley 4rr 60 -1- 64.12. Dear Mr. Sullivan: 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: submit'2 more copies of well permit application due to steep slope u Pg radient of SSDS area propose a swale to "divert surface runoff. € ( , - '" -' ".- '- u�'liri" ".irrc:EiFi'� o�"'ci-•su1:,Yi1s5.Gii; - iCVib�Ctl -.. is v""' i' t'"1CC:' C..:.- CPle-. �i .�ci "Ve;.�:f5lliIlleriLB.:�_"`_� _. _.__. this application will be considered further.: Very trul ,yours, Anne Bittner AB :pt /J Asst. Public Health Engineer cc:AB ✓ JK File TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 PUTNAM •• DEPARTMENT • Y. -DIVISION; OP . DESIGN.DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE I Owner h -5 e- rz� Address _ c J. °.1 Located at (Street) z..ye % d Sec. G Block. / Lot (indicate nearest cr_ oss street) Municipality. �cfC/i . �'ti Watershed Date of Pre - Soaking %O mot' Date of Percolation Test 162,1 i -e HOLE NUMBER CLaX TIME PERCOLATION PERCOLATION Run Elapse No. Time Depth to Water From Ground Surface Water Level In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 4 5 5 l 2' 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 suhnitt.d for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT_ IN TEST HOLES DEPTH HOLE NO. HOLE NO., AL HOLE NO. G.L. lu. - 2, j7 >�•� A4M. A4 AV 4° 5' 6° 7' 8' Z 10, 11' 12' 13-' 140 INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: %�i/ O��' DATE: DESIGN Soil Rate Used e7---5-'Min/l11 Drop: S.D. Usable Area Provided�di No. of Bedrooms Septic Tank Capacity (e/ a gals. Type v/o oo r Absorption Area Provided By L.F. x 24" width trench Other Name Address siir c::.. son aasc +, Soil Rate Approved sq.ft /gal. Checked by Date DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ..._.l�PQLICAT.IQN..T0 CONSTRUCT A WATER.-- ..._.,,:.._.�..... ._..... ._....- .,._.....PCHD .PERMIT # WELL LOCATION Street Address Town/Village/City Tax Grid Number e-5aov n a e Ty e- z 4eo 64.12- WELL OWNER Name G S �� Address pct SdG ��' IV. Y. C AX ate ❑ Public USE OF WELL 1 - primary 2 - secondary SIDENTIAL O BUSINESS 0 INDUSTRIAL D PUBLIC SUPPLY CI AIR /COND /HEAT PUMP ❑ FARM ❑ TEST /OBSERVATION O INSTITUTIONAL ❑ STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PFOPLE SERVED -14 /EST. OF DAILY USAGE gal REASON FOR DRILLING EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN ODUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES A-00- NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:' m p Lot No. Z. WATER WELL CONTRACTOR: Name I_ ,-,W f 57 �, ��t /3O� Address: �i6l" A'rn rae�12 V IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY -DISTANCE- TO PROPERTY` F? O11 NEAREST WATER-MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED � ON REAR OF THIS APPLICATION �N SEPARATE SHEET - _ t (date) ( ' 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 Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: lVe41 l-, 19 �G �.�s e Date of Expiration: rL od /2 19 Permit Issuing f Permit is Non - Transferrable 8/86 z� IV. V. Vi. FINAL SITE INSPECTION Date o P Inspected by TION OWNER T9 # OR SUBDIVISION IM # ,..8:XAGF, - DlSl�liSA AREA a. SDS area located as per approved plans ca-2-nil IS b. Fill section - Date of placement 2:1 barrier- LGTH WIDTH AVG. DPTH c. Natural soil not stripped d. Stone, brush, etc., greater than 151 from SDS area. e. 100 ft. from water course/wetlands. SEWAGE DISPOSAL SYSTEM a. Septic tank size - 1,000 1,250 b. Septic tank installed level v6;4- c. 101 minimum from foundation d. No 90' bends, cleanout within 10 ft. of 450 bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX —properly set lnee-6 Y?-DZI 9- TRENCHES 1. Length required - -�60 Len install ej,�.�.O 2. Distance to watercourse measured- ft. Y. Installed according to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 "/foot. 6. 10 feet from property line - 20 feet -foundations 7. Depth of trench < 30 inches fran surface v ,c 8. Roan allowed for ion, 50% 9. Size of gravel 3/4 - 11" diameter 10. Depth of gravel in trench 12" minimum ll.' Pipe ends capped h. PUMP OR DOSE SYSTEMS 1. Size of PM—, 2. %)vEitfi6i tank 3. Alarm, visual/audio 4. Pump easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed b Health Department estimated flow per cycle HOUSE a. House located per approved plans. b. Number of bedrooms WELL ' a. Well located as per approved Tans b. Distance from SDS area measured IZ) ft. C.. Casinq 18" above grade. d. Surface drainage around well acceptable. OVERALL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All pipes flush with inside of box d. Backfill material contains stones < 4" in diameter e. Curtain drain installed according to plan f. Curtain drain outfall rotected & dir.to exist.watercoursE g. Footing drains discharge away fran SDS area L h. Surface water ppo ection adequate Ui C"; i. REosion controi provided on slopes !3rester than 15%. 10 f P . PUTNA ENT M COUNTY DEPARTM OF HALTH.Pe:mic:r " E W,- 0 �- Q =• 4 x DNision of ,ryEnwronmental` Health Services, Carmel N ` Y 10512 CONSTRUCTION PERMIT 'FOR SEWAGE DISPOSAL SYSTEMgr✓,;' �• /l .p i -uOWn— Of V tlpii Lccatcd at/ fr✓4r1�? Q �d !f�Z i� n 1 S ::8iaf'/ . LcJ ,? `y� . "� '�P Subdivision �� subs• Wt N Renewal ❑' Revision Q° -Owner /Address -��''� ��•'� Date Previous Approval Of Building :Type Lot Area �' Fill• section only ❑ SG .Number of Bedrooms Design Flow G /P /D _ �+ Q P C x D Notification- Requires / Separate Sewerage System to consist of -� Gal Septic Tank antl To be constructed by Adtlreis '-_' Water Supplyi PU41iE:Supply From A ^Private 'Supply to be ,dgtled by Address Other. Requirements,, - t.' sea } 'I represent that'I dam wholly and completely',responsible for the design and location of the proposed systems) Afiluda . t _ wage. disposal system above describetl will be constructed as shown on the,approved amendment there, to and~ n accordance ;with the' dns o . • u nam County >Oepartment 'of Health. and that on completion'thereof a '.0 <ertif� cafe' of ConstructionCOmpliance" fi Cg onerof. Health will ,�ti_e submitted, to .the Department. "and a written "guarantee :will be..Iu►n�sheclAhe owner his successors he "'or S. the . ,,,t- t said builder will g �..., place iny400d',ope►atmg''c6hdrtion any, part of said sewage disposal systeT. du►ing' the perioA of two (2 m`d fol t tlate °:of the issues anee of 1110'`approval of :the Ce tif"ta ot<Construction Compliance of the ongina6[system,'or any copa� t►► �i;, e: di Nbd rYe11':gsspibed -above will be located as shoyvn'on the approved plan and that said well wilfbe installed �n accordance'.- :with the st $a, s, rul u s. of the Putnam County Department of Health Date °ch bt •�'y I R.A �i��1f.9_S�, _ Address Liednse No. APPROVED FOR CONSTRUCTfbN This app►oval °expi►es one year ;from the. date isa d unless' on uction of thn'buI— rl has been - undertaken and as revocable for cause or may, amentled or modified when consider `n essary • by the' Comm Is ei of Health.: An Change or alteration of, :construction i requires a new 'permit ;,,.Approved` for disposal of doniestl;= mta' sews pry �_�ppiyleTite Rev., 9-81 Cf PUTNAM,COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of cx_cia-'� Located at (T) - )aySection ZO Block t Lot J W. / -2 Subdivision of Subdv. Lot # Z Filed Map #, Date Gentlemen: This letter is to authorize a duly licensed professional engineer or registered architect (Indicate to apply fora 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 system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. V • 4 Countersigned: P.E., ., Q Very truly yours, Signed Qianer of-Property/ ,SDI- c A9'4 5'+` • X 31 Address Town (2%2) 772 - 312 jNo;�e � I rNeiLepnone r :n Telephone S E P 17 10-889 PJ-MAM COON-1Y DEPT. ®F HEALTH v DESIGN DATA Owner :3Q! Located at PUTNAM.COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. U'4 ddress (.® & +� ( Street ��c Spec . tj O Block_ jLot nd` ic ca e nearest cross street) Municipality, TION TEST DATA Watershed i TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION. Elapse Depth to a er — Wat e ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches �l � _ 31 -9-3 'l/ 3 Ig 6,y a HEAL Notes: 1) Teets to be repeated at same depth until approximatelyy 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. " DESIGN Soil Rate Used MirVi "Drop: S.D. Usable Area Provided -s-VOO No. of Bedrooms Septic Tank Capacity Gals. Type Absorption Area_ Prov. ded .By.71t!�V L.F.x241' . width trend . •' Other Name Z dt t 1 , v�?i,/ signature Address 72— '�(ilr� S THIS SPACE FOR USE BY HEALTH DEPART NT ONLY:` Soil Rate Approved Sq. Ft /Gal. Checked by A +0. oases -:5, t � 1.� Ot 3' C��) 4 A'7 C��) fr 7771- 7Q 1� e 6:1 Jo 003, A"? C��)