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BOX 24
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3 .. 8 PUTNAM COUNTY DEPARTMENT OF BEALTH
Re
1 Division of Environmental Health Services, Carmel, N.Y 10512
t Engineer Mast Provide Pr 2 j I-
Jr
. P.C.H.D. Permit
li,
CERTIFI TIE. OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Located at
TazMap
f•W / /[� �:/JJd? G ia✓/'Jr`° .
Block Lot'�i
g6 �n C! Ib � Formed Subdivision:Name Subdv., Lot H
Owner /sppllcnnt Name Y p � .
Mailing Address J ¢ X y' zip_ 1 O. �7 / Date Permit Issued
�/ s�
r i r / 7 OJJY) /' !: /
Separate Sewerage System built by F° -4 Ir - - Address � i
Consisting of / Z s on Septic Tank and e y 2 f n W%° GyIG
Water Supply: Public Supply From 1 Address
or: '✓ Private Supply (Drilled by /{�' /!d sb✓W�rr� Address
Building Type - �/ C�Has Eroslon;Control Beeu, Completed?
Number of Bedrooms Hag, G age Grinder Been installed
Other Requirements
AM
I certify that the system(s) as listed,serving the above premises °were: construct s all ahc t lans of the completed work ( copies
of which are attached), and in accordance with the standards rulesyapd regulati s,' cc ith d plan, and -the permit issued by the
Putnam county Mepartment Of Health
Date rtifietlbY P.E. R.A.
Address ` �� License No.� yy fs
er• sea
Any person occupying premises served by'ths ove systems) shall promptly..tatki, s60':
ch act >�� to secure the correction of any unsanitary
conditions resulting from such usage. Approval .of the separate sewerage system shall bsicoefas soon as a pub!': sanitary ewer becomes
available and the approval of the private water supply shall becon►e_:riut void when a public wpply becomes available. Such approvals are
subject to mod�ca ion or change when, 'in the judgment "of the mmi or Hof N�eatth ehh revocation. modification or change Is necessary,
Date _ BY 4 Title
a7
Owner or
PUTNAM COUN If DEPARVaM OF HEALTH
DIVISION OF ENVIRO1NMEMAL HEALTH SERVICES
of Bui
Building Constructed by n
C:!& S r
Location - Street - Subdivision Name
e.
Municipality l Subdivision Lot #
i(00 aA - -�— a'cJI-VK43
Building Type
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
QL-_R
Lot
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 Construction Compliance" for the sewage disposal system, or any
_ •• .. whar.. - f A] 1— e to n C t p e
repairs ti�auc by .rte.. w su.;.. 5y8.ca'it; '"�."Cqt.. the ..,.. p_ta= prc2�Yly. 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 a day of 199-) Signature
Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
I CES �n a r e,
Address
rev. 9/85 0 S `1
mk
Corporation Name (if Corp.)
SPT-ov I- Q
ess , c, p tet j I
`rU�V�. w� V Y V
o 37CI
1
TTTT T ^AAdnT TTTALT 1']TT AT)T
k
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VV 1;1 JjL VVt'" LL" 11 VLY LtiL VA1
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
r- iiNA'ri COLl3TY DEPARTHEidi aF-ii —T11-'-_ ....
Office Use Only
.. _ .. :.._ . _ ..
WELL LOCATION
STREET AOORESS: VIL I I Y TAX GRIO NUMBER-
r
N ® Aooa s: bKP81VATE
❑ PUBLIC
WELL OWNER
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑. PUBLIC SUPPLY ❑ AIR /COND.JHEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL Q INSTITUTIONAL ❑ STAND-BY. ❑
MOUNT OF USE
YIELD SOUGHT � r
gpm.lNO. PEOPLE SERVED ==EST. OF DAILY USAGE � gal.
REASON FOR
DRILLING
19LNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH KOO / ft.
STATIC WATER LEVEL 3fir ft.
DATE MEASURED
DRILLING
EQUIPMENT
)<ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
"❑'WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING, OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH O ft.
MATERIALS: ''STEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE fL
JOINTS: O WELDED XTHREADED ❑ OTHER
DETAILS
DIAMETER !' in.
SEAL: O CEMENT GROUT O BENTONITE WTHER
WEIGHT
PER FOOT I'X' lb./ft.
I DRIVE SHOE:AYES ONO
LINER: OYESWO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(It)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
❑ YES ❑ NO
HOURS
SECOND
DIAMETER TOP
OF PACK -in. DEPTH ft.
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
BOTTOM
DEr T}I it.
WELL YIELD TEST I If detailed pumping
METHOD: '❑ PUMPED 1 tests were done is in-
COMPRESSED AIR , formation attached?
❑ BAILED ❑ OTHER i 0 YES O NO
IAIELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
well
Oia-
meter
In
FORMATION DESCRIPTION
cane
ft.
It.
WELL DEPTH
it.
DURATION
hr, min.
DRAWDOWN
ft,
YIELD
gpm.
Land
r
d
WATER ❑ CLEAR TEMP.
QUALITY O CLOUDY ONESS
O COLORED ANA YZED? /YES ❑ NO
ANALYSIS ATTACHED? Y ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAP ITY
D
VOLTAGE HP
WELL OR ME p /�
J
ADOR �G rlxfirHE
l
b
t
Yorktown Medical Laboratory, Inc. LAB # -87.006052
321 Kear Street /
Yorktown Heights, N. Y. 10598 Date Taken: / � -� // Time: . �7
Date Rc :d c 4 /d,"? i Time,:,. T ...!T -
Director: Albert H. Padovani M. T. (ASCP) Collected By : r. tor- e
T_
//aa��
C.U2D 1/0 #7j
.�3 Lvc-�- 'f 17404C d,e
�� > �✓ , v iUC , Al y • /oj—' S
L
Referred By:
Sample Location:
Phone # r2_4 7729�'�
Phone # Sample Type:
Repeat Test?
p ._ (check one)
_LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
_ Standard Plate Count (CFU /1.OmL) 130
(Agar Plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
Total Coliform (CFU /100mL)
Fecal Coliform (CFU /100mL)
_ Fecal Streptococcus. (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
_ Total Coliform: MPN Index (per 100mL)
L•' - ' CalifsriTi:
OTHER ANALYSES
REMARKS (For Laboratory Use)
b! Potable
_ Non- potable
_ STP INF
_ STP EFF
Other:
Sample. Status:
(check each)
Outgoing
_ Na2S203
Incoming
ALE 4 °C
_ GT 4 °C
_
Other:
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of Source
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LT = Less Than (C )
GT = Greater Than (> )
N/A = Not Applicable
LE = Less than or equal to
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T NEW ORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT' TIME OF COLLECTION.
Albert H. Padovani, M.T. (ASCP), Director
12 /85(Rvsd7 /87)RWE
For Lab Use Only:
H/C to
LAB OFFICE HOURS (Main Lab):
9AM -5PM, Mon. -Fri.
9AM -NOON, Sat.
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMmAT. RRAT,TR SERVICES
INDIVIDUAL K1TER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
FIELD INSPECTION REPORT
bi INSP. BY:
(Name of Owner) Street Location)
INITIAL SITE INSPECTION YES NO COMMENTS
Wetlands cn /or proximate to property..............
Property lines or corners found ...................
Canestimate house location .......................
Will driveway need cut ............................
Faust trees be' removed - 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 ............................ s�
Access to or000sed well location for drilling._... �C
P. H. 1 Lot
Depth to G-.W.
Depth to rock
Soil DescriDtii
0 ft.
3 ft.
6 ft.
9 ,ft.
._ ...
2. ft
D. H. 2 Lot
Depth to G.W.
Depth to rock
Soil Description 1
0 ft.
3 ft.
6 ft.
Gtr) `
D. H. - Deep Hole
G.W. -Groun &,pater
D.H. 3 _ Lot -
Depth to G.W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 ft. 9 ft.
12 ft.-
_. ...._, 12 ft.
Soil Description
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
CCMMENTS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable..........
Roan allowed for expansion trenches ..............
Over 100 ft. frati watercourse ....................
Natural soil not stripped or SDS area
unnecessarlygraded ............................
10 ft. maintained fran property line and
20 ft. fran house ..............................
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of peripheral soil horizontally
frantrench..; ......................... ; ........
Boxes properly set .... .... ........... .........
Could surface runoff fran driveway, roads,
ground surface,.etc., channel near SDS area....
Does lot drainage appear OK%in area of SDS::.....
FINAL GRADNG OF SITE ACCEPTABLE .. ....
L
�-
7,7 . a ^' -.ski 'T +o?x•+' '.!�'^"cGr {.""9'°•" °. -`R "'T� "'C `•.• -:. yic 7 ^v c'ip�.'�'•�Ty -Y� `• 4 '"'^'fq.` "4 Y: ^°- Gxy.."
.s PUTNAM COUNTY DEPARTMENT OF HEALTH
RerV. 3/86 Division of Environmental Health Services. Carmel, N.Y. 10511 R eeeEr.to P'° rmit
on CE A OF COMpPLLANCE .�
CONSTRUCTION PERMIT F R WAGE DISPOSAL SYSTEM ermlt N.
Subdivision Name - Sabd. Lot N ,Ta: MapBlock I of
Owner /Applicant Name ' • .
• .L �" rJ. � C !+c! � �' � ' %;;. Renewal_ E3 Revision p
Date of Previous Approval
Mailing Address /✓ /T Town l'v
Building Type � /d e Lot Area C%•3 � Fill Seed on Only Depth -volume
-
Number of Bedrooms Design Flow G /P /D C%tJ PC ID Notification is Required When Fill Is completed
Separate Sewerage System to eonslst of Gabon Septle Tank, and
To tie coustraeted by Address
Water SapPlj:.. ' Public Supply Feom
Address
or Pilvate Supply 'D�rilled by
iNr.,: 5V
represent that I am, wholly and completely responsible for the design and location 01 the proposed sydtem(s) 1). that the separate sewage. disposal system
above described will be constructed as shown on the approved amendment- there ?to'and m,�ceordSnce with The standards, rules an regu a ions o e • Putnam
�A
County Department of Health, andthat:.on completiomthereof a "CertificateoFof CQ,ns't r(dl'c�nBGomplianceV satisfactory to the Commissioner of Healthwill
be submitted to the Department,' and a written, guarantee will be fuinisherthe }pwlrter, his succeskri, heirf or',assigns.by the builder. that- said:.builder will
.place in- good,.. operating: condition. any part of said sewage 'disposal systemtduryngpthe peOod of t•`M70�;2i y ars immediately following the date of the isw-
ance of the approval of the CekGficate of Construction Compliance: of the originriF systemsV orfahy repairi�t ereto; 2).ahat the drilled well.descr.ibed above
will tie_IOCateC "as shown on the approved' plan and,tliat said well will be,ipstalled in accordaice' with the ndard ,;rulers and iegu a ons of.. 'the Putnam
County Depa tment of Health. y?a t•
�..
Date C Si9n� ? �k _." �6 P.E._ R.A.
Address ��""-� ''^ ' License No _
APPROVED FOR CONSTRUCTION: -This, approval,expiresa year fromthela4 �S'ed�'urtfessr�cconSt�: e ion of a Duilding nas been undertaken and is
revocable for cause or maybe amended or modified when.considered necessary *,by th Ccl �nJ ;siorler of" Health. Any change or alteration of construction
requires a ew permit. ApprdeC for di osaI of domestic sanita sewage; a- /o° w•�0teuor6``r supply only. .
Date By Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
nU('Tiil DTi'DMTT J� %�����7
WELL LOCATION
Street Address
Town/Village/Cl y Tax Grid Number ,
WELL OWNER
Name Mailing - Address
rt'hE' A0 j�'
EMrivate
13 Public
USE OF WELL
1 - primary
2 - secondary
OIRESIDENTIAL'
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
❑ OTHER (specify
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE ge'C) gal
REASON FOR
DRILLING
EW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN E]DUG
[]GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES k-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Alc Lot No.
WATER WELL CONTRACTOR: Name A7jta - Address: ������✓ .P 9�
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES J,-' NO o .
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
_ -•: DISTANCE TO PROPERTY ,FAO11 LAST: FIAT�'R.
LOCATION SKETCH & SOURCES.OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION
(crate)
ON SEPARATE SHEET
J(sigyihtu
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 provide by the Putnam County
Health Department.
Date of Issue: 19 go
Date of Expiration :_ . 19 '�--Ierrnit rssuing f icial
Permit is Non- Transferrab White copy: H.D. File Yellow copy. Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
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
April 28, 1987
Mr. Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, New York 10598
Dear Mr. Sullivan:
JOHN SIMMONS, M.D.
Deputy Commissioner
JOHN KARELL, Jr., P.E.
Director
RE: Proposed SSDS
Cordes
Lake Shore Drive
L. Oscawana
Tax map 49 -1 -1.1 & 3
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:
hat- y� 2i i:rabai}�1iOtk' in the pump pit be 'done to
~ NEC codes.
to keep SSDS out of direct line of drainage, redesign trench
layout more narrow, providing 15 feet from end of trench to
curtain drain.
Upon receipt of a submission, revised to reflect the above
comments, this application will be considered further.
Very truly yours
Anne oi�t.tner
Asst. Public Health
Engineer
AB: pt
cc: AB
File
JK
V - ..
a APPENDIX B
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WAMR SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW CONSTRUCTION PERMIT /
REN
Name of Owner) (Street Location
DCCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISICN
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked _
Ex- approval SSDS P.dj . Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED _ DEMILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data: perc and deep results .
Driveway & Slopes Cut `
Footing /Gutter,CUztain Drains (discharge OK)
Perc & Deep Holes Looted
Representative of primary and expansion
Expansion Area;shcwn;gravity flow,suff. size
If P=ped Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's w /in 200 ft. of Proposed System
Property Rtes & 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,Top of fi
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, lake Unc. expa
15' to Drains - Curtain, Leader, Footing
35'to catch basin,stormdrain,piped wa.tercour
10'. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks .
10' from Foundation; 50' to well
15�'/ �Well to PL
O
trench IF . . _.
required
.0
Parellel
to contours
Jam%
IBM_
r
�
DCCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISICN
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked _
Ex- approval SSDS P.dj . Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED _ DEMILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data: perc and deep results .
Driveway & Slopes Cut `
Footing /Gutter,CUztain Drains (discharge OK)
Perc & Deep Holes Looted
Representative of primary and expansion
Expansion Area;shcwn;gravity flow,suff. size
If P=ped Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's w /in 200 ft. of Proposed System
Property Rtes & 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,Top of fi
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, lake Unc. expa
15' to Drains - Curtain, Leader, Footing
35'to catch basin,stormdrain,piped wa.tercour
10'. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks .
10' from Foundation; 50' to well
15�'/ �Well to PL
r• •• •DO ••..r 21 •
D2SIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Addressya •-
Located at (Street) / � �Or' �''� Sec. t G' Block Lot •,V- 3
(indicate nearest cross street)
,I
��
Municipality j�f1'
.�
Watershed
SOIL PE ROOLUION TEST DATA REIQU= TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking el �ss� Date of Percolation Test
HOLE
NUMBER CLOCK TIME
PERCOLATION
PERCOLATION,
Run Elapse
Depth to Water From
Water bevel
No. Time
Ground Surface
In Inches
Soil Rate
Start-Stop Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
2
--
3 3 31?
4
0
NOTES: 1. Tests to-be repeated at same depth until apprcximately equal soil rates
are obtained at each percolation test hole. All data to' be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WIM APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
D2PTH HOLE NO. HOLE NO. 2, HOLE NO.
G.L-
it
2' 4
31
41
51
61
71
81
91
10,
12'
131
14'
-ATP T -ijM j T ATR LS. EN(03UN7MZ7
INDICATE LEVEL To WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: 14 / , DATE:
DESIGN
'Soil Rate Used Min /1" Drop: S.D. Usable Area Provided , '11e
No. of Bedrooms septic Tank Capacity gals. Type
W—j!��e I —I-/
Absorption Area Provided By L.F. x 24" width trench
Other
Name
Address
Signature
I
Soil Rate Approved sq.ft/gal. Checked by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF_ ENVIRONMENTAL. HEALTH.. SN -ES -'
Date
Re: Property of
Located at 2'
re c %jG'x
Section Block Lot
Subdivision of
Subdv. Lot #
Filed Map #
Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer or registered architect
(Indica e
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, w th th 4, ti watter dl:-d lt1 3LiDP.rvj..S.P_ t.he:_r..onatr,,^::'1ic vi 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.
h
Countersigne�di
P.E. ,H°
D
Address
Telephorie
Very truly yours,
Signed___.')
Owner of Property
R o `-k &r, -3-Go
Address
Town
ele hone