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03227
3 PUTNAM COUNTY DEPARTMENT OF HEALTH
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t Diliis�on of Environmental Health Services Carme% N Y 10512
,CERTIFICATE' OF CONSTRUCTION COMPLIANCE FOR SEWAGE 6I - -'-SAL SYSTEM, T•VJN OF �t)°IIVAM= �A �-LE�/
-- _ __ lr/� < x -! I T fo or Village _ /
t Located at, Fy R £s Aw "� !-ANA Section Block
a 11 .STA11�1�f00 D�U1�L `��s< F ` Lot' %`� Job - ,
Owner `_ r :;
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Separate,'Sewerage System built" by Address
l ,, � - � � .
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�2'�'f� o�. �t 0 width" trench s
` Consisting of Ga( Septic Tank lineal Feet X
X F T -
-, Other requirements 4 1.
'� a '. *t.ti ''`•� r .z { t ''�sv e } ry, "~x r't r .,„. r �,..
, ';Water "' P" ''� rPUblic,t -upply From r - ;�.
.- _ _ Y' s 4 - _ -
Prrvate: •SuppIX_,66Iled < BY
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Addr: ---
r .Building,vTy'pe NW A/`'I'l'LUle�S:� + N of Bedrooms '' •Date Permit Issued~ Has Eroswn Control Been Completed
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z l certify, that the system(sy.as listed sere ng'the above premises,were, constructed es Tally as show a ,plans of the completed work (copies?of which are `-
':attached) and in- accortlance with the standards ules and regulations, plans fil an t perm t iSs by. the Putnam County Department of Health. 11
s e 5 �� l J - 4 r o �7i �y ' *, f p,r,., 3• P E pry / R A 11 rl�
a .y Certified by.
_Oats _ Y #
A` ?.� 3 < -rvry g N , �E 1�.4 ron�.a /, . �, i8 3
ddress License . ? Q
ttAn erson occu ing1p r.' emises >servedkby.-•the:abovesystem(s) shall, promptly take'such action as . may be. necessary to secure the correction of a'ny: unsanitary,
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'conditions, resumagg .froF'�such ;u4j6e 'Approval', of the ,separate,;sewerage syste hall become null and void as soon as a'public #sanitary sewer becgmes'`,"
available "'and the approval of t�lie pnvatepwater supply shell become nu`Il an,x id whe a ;public water' sub� Y, comes available Such <r,epprbJals are;' 11
_ =s subjects to" modification_or change when,, in the - judgment of the Com" stoner Yof ealtfi; s ch revoca'i5n drf cation :or necessary
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` PUTNAyM COUNTY DEPARTMENT OF HEALTH
11 � 4: 1-6._ vision of Enwronmenta/ Health Services, tCarme% N Y 10512
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} "t.GilNf� r,kLJZT10r4 PlrrRi 7 T ^�R S ti1ACE QI O., L STEM' t!
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Located ` a v �� � A.
Y Section Block rrr
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Subdivision � _ Lot Job
S �r +aC Y� 11l5'Vh , �Ci�l; !
^Owner rv����, pp�� :j Address
Buildih9 "TYpe Cot Area )Q ��
Number of Bedrooms Total Habitable Space Square Feet
Separate: 5ewera'e "System to .consist of �` Gal Se tic Tank Z-° lineal feet -X 3',' r. g �__�,qq P width trench 11 r To `be constructed by' f�: ' - Address
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,Water, SupP)Y < ' 6 Public. .yppiy From''
" Private, Supply to be Ari1lnA�v. ���
.r Address ,irce�,. `
Other Requirements _ 51 ' 1.
z. ;I represent that 'am wholly and completely re�ponsibleforthedesignand location of the proposed.,system ( s); 1) diet. the separate_sewage, disposal system.
.11 above described `will be constructed as shown on the;approved amendmenYthere to arid in accordance.with the standards;.rulee and regu a ons o _ _, e' u_.nam
'County `Department of .Health;_.and that'on completion thereof a; ",Certificate of Construction Compliance "._satisfactory to the Commissioner:of Health will 11 be submitted `to the Department, and a written "(guarantee will be furnished the owner -his wccessors, heirs or assigris by the- builder,;`that said bI iider: will . 11—
place iri; good_ operatipg'conditon ,-- any;part of said sewage disposal syste dur�rig the period of:two (2)_years immediately:foilowing the.date of the ` issu. -'f
-,
ante o r 'the approval.• of h'e Certificate; -of Construction ;Corripiiance of `t a riginal system r ny..,repair ;;theretor;2) that, the drilled `well descriDed;ai `i %
;Twill be located as shown, on the approved plan and That said well will be install in . ' ordahc the standards rules and,.regula ,i` ions of -the f?uthim % % County Depa tment of ,.Health `
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Signed `P.E��. RnA = I, I
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PAddress� L _ @ACA l� \ C!W Vl/M1 ®� c.� O r.
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License No-
APPROVED FOR CONSTRUCTION' This approval expires one year from the date: issued ,unless coristructiori` of the building 'his been undertaken and is :3
Y - y he Comh, Any change.or. alteration of ;construction '. r. ;revocable for cause or ma be amended or odified when considered necessar by t
requires a new permit' .Ap roved for d s posal of domestic san a , T�_�__�.- nly
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Date B Y Title a _. _ '
- PEF- KSKILT., MEDICAL.,LA80RATORY
1879 Crompond Rd. Barclay Tisza Bidg. A, Apt, .1 ,
Peek "skill, New York 10566 PE 7 -8777
DATE.COLLECTED"
RESULTS OF EXAMINATION OF WATER .. -7
OWNER DATE RECEIVED
CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY DATE REPORTED
SAMPLiNU PUINT
BACTERIA PER ML. (Agar plate count at 35 C).
COLIFORM.GROUP (Most probable N6. /100ml.)
D ES , TOTAL -ppm.,
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg. /1.
These results indicate that the water was ! I of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASCP)
1
PUTNAM COUNTY DEPARTi�NT OF HEALTH
DIVISION OF.ENVITONMENTF-T NE?�T.TU -SERV . rc_
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Date
Re: Property off�iiQ,Q�
.Located at
Section Block Lot
'Gentlemen:
This letter is to authorize !9`U`U-U &M
a duly licensed professional engineer _or registered 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 construction of said
system or systems in conformity with the provisions of Article. 14S or
1.47, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
Signed
Owner of Prcp rty
Counter ig
Address
t,'lt��. Telephone
Address
Telephone ��
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-.d_ .- ...:or.� _ � .. �GSrt.. °��� _ -' - -�:..:.�. -iw r .- ._r -- .. � ,, w.._....v �� �.. ciLq: °� »_.�:. d:e �- .u.d..: ws�• n.. - -.r» ..
or (it71✓fI M 4L&
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Owne o Yurc aser.o B ing Municipality.
Building Constructed by Section
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Location - Street Block.
Building Type. Lot !°
GUARANTY OF SEPARATE SEWAGE- 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 guaranty to the owner, his succes-
sors, 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 initial use of the sewage disposal
system, or.any repairs :Wade by me to such system, except where the failure
to operate properly is caused by the.willful or negligent act of the occu-
_ pant_ of_ t.bp_ jbiiild:in _ ..utilizing the
system-
-The undersigned further agrees to accept as conclusive the de-
termination of the Director of the Division of Environmental Health Ser-
vices 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 neglig nt
act of the occupant of t e bung utilizing the system.
Dated this day of 19�q - Signatu
Title
I orpor ti.on, give nam
and addres
- - - - - - - - - - - - - - - - - - - - - - - - - - - - (-
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP.TTETION WILL BE ISSUED.'
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
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PUTNAM COUNTY DEPARTMENT OF IEEA.LTH
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V Ori :�1V`VIKC�NM�IVTA�, HEALTH ~S�'RVIC�S+ ,,.
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSA(LL SYSTEM FILE NO.
Owner{W�titjddress
Located at (Street LA. Sec. Block Lot Vo
indicate neares cross street)
Municipality IkI.;�-"10M Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO'BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water a er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop . in Min. /in drop
Inches Inche Inches
4 R'-10
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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.
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TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DEPTH HOLE NO. HOLE N0. HOLE NO..
G.L.
6" 1V
12"
18"
.2411
30"
3611
42"
`t8"
54
60"
66"
72 ti
7811
'.'TESTS MADE BY 1�--2Z -�"$ -� _�V�XZC-1� t� Date
DESIGN
Soil Rate Used l:0 .Min/1 "Drop: S.D. Usable Area Provided..
No. of Bedrooms ��. Septic Tank Capacity M&O Gals. Type
Absorption Area Provided By `2,'2 (o L. F.x2411 widthtrench.
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Address (A- <S� W ,Pt- 1nnZ SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Elate