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BOX 24
02905
z
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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ^
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM
PHONE
%`cam
Complaint. #
Name & Rel ionship (i.e, owner,tenant,_etc.)
DATE -�- TYPE JWILITY
PROPOSED INSTALLER ; .b h �i� �'%� ` . PHONE
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Z..
Proposal
Inspector's Signature & Title
Proposal Disapproved
41116
Date
roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair,to be performed in accordance with the above proposal'and conditions:
I, as owner, or
SIGNATURE
TP1E5: White (FCC); YeUcw
agree to the above
conditions.
r V'
TITLE
M
PUTNAM COMYY yEk"ARTMENr OF HEALTH
IVISION OF EtiVIRONMENAL HEALTH SERVICES
Building Constructed by
Location - Street
Municipality
Building Type
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEDGE 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 imnediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs :made .:by .me to -such system, : except where_ the.. failure- to ,operate properly is
-_... _ caused�by the wlitul o� negi gent acc -of u, uc�.ii�t ci tie u-iiutg utiliiii�g-
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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.
DatTd this day of 10�
General Contracfok (OwnT - Signature
Corporation Name (if .)
/ "'Va
ia
rev. 9/85
mk
Signature
C7syr�r.
Title
Corporation Name (if Corp.)
Address T-
Owner or Purchaser of Bbilding
Section
Block
Lot
Building Constructed by
Location - Street
Municipality
Building Type
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEDGE 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 imnediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs :made .:by .me to -such system, : except where_ the.. failure- to ,operate properly is
-_... _ caused�by the wlitul o� negi gent acc -of u, uc�.ii�t ci tie u-iiutg utiliiii�g-
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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.
DatTd this day of 10�
General Contracfok (OwnT - Signature
Corporation Name (if .)
/ "'Va
ia
rev. 9/85
mk
Signature
C7syr�r.
Title
Corporation Name (if Corp.)
Address T-
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH_ SEFIIT'T'CF.0�
Date
Re: Property of / - 1(
Located at 45, !f i�ry
(T 41 Section
Ile
:- Block Lot
Subdivision of
Subdv. Lot # --�. Filed Map # — Date
Gentlemen:
This letter is to authorizev /� /'
a duly licensed professional engineer" or regist4kred 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 eon. t. Q'C'k'
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.
Countersigned:
P.E. , R /A. , -
/ r�
° i- J] i e-
"�� I l
Aldddr e sus r�
/ /
Telephone
Very truly yours,
Signed pz-/v
l�
Owner of Prope ty
37 .� ` < (� �
Address
Town
( L( y( �a �
Telephone
/• • � 1 D1 • .I' 1T1D, • . 1Y .
DESIGN DATA SHEET Sj�Y+TAGE DISwa?SAL �'S71m k'T GF.
Owner �Ci�/ f`/i c / Address .%�r� ✓�c< /1
l
Located at (Street ) i //r cJCG Sec. Block 4:r'd, Lot
�(indicate nearest cross street)
Municipality / U �f7 n',► ? Watershed
• • • o1' k• •' Yom. • F.AWEVRA11 NO �� • mpipleg-14161y 01 111 r, •
Date of Pre- Soaking Date of Percolation Test �9 C,6.-
HOLE
3>1
NUMBER CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water Fran
Water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start-Stop
Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
0j 1 113a li jj�
z
2--3-
1-2-5
>--
4
5
4
5
1
2
3
4
5
NOTES: 1. Tests to "be repeated
are obtained at each
for, review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made fran top of hole.
3>1
4
5
4
5
1
2
3
4
5
NOTES: 1. Tests to "be repeated
are obtained at each
for, review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made fran top of hole.
V, NUF
TEST PIT DATA
nrCr,0TVrT
OF
TO BE
%
IBMITTED WITH APPLICATION
DEPTH HOLE NO. HOLE NO. HOLE NO.
17a 0, p'al - ,/0
G.L. �
21 = S!
31
41
51
61
71
81
91
10,
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNLUPdER fS EN :OUNaERM'
INDICATE LEVEL To WHICH DATER LEVEL RISES AFTER BEING ENCOUNTERED
A
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used Drop: S.D. Usable Area Provided
No. of Bedrocms 7, gals. lype,1
Septic Tank Capacity ) Oa 0. _ 11-0-�aw
_ -2 22�
Absorption Area Provided By 19 L.F. x 24" width trench
Other
Name
Address
01"
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved
Signattire
OT ONLY:
sq.ft/gal. 'Checked by Date