Loading...
HomeMy WebLinkAbout3282DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -2 -5 BOX 26 m 19 yf r;I ir 16 L1 i a ma 03282 77 'PUTN Rev i0ii-, Divielow P P.,QMD. . . . . . . . . . . . C&E OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM o r, V M_ Ut Tai, Located P_ A-V SibidMilonNium 11 ' Lot # 7 Owner /app t Name :o;000 _M 23P Date Permit hiiied Separate Sewerage System. Melling Address &kegs OA/ —0 M-C"Z x GaUon So tkTaik' P and WaterSFPPIYt Addriss From Addrmt or " ": Private Sapply Drilled �y 1926- '.7 Grinder 'NICU112wr of lii� -, v �7� lnetslledY eqqI"mpnt9 Other e const, sole �kally a o 1 �s, this -ccmpleted work copies certify t ru&ted a .h 'p I ad and,in,acq?r.,an ro4iditi6iii in an An 6. �th %Jitandaids, rmit issued by the a vohi6h are tech cord _.w a I' P d the,pe Putnaim Jun "'If Health'.' CaftifieWto R.A. Address d Al i-Icense No.. '(511 St action asm y a n Any person occupyino premises c n a b sa►y to secure the correction of any unsanitary Y11 !17 n'�ilf and jllo� as.:ao6n'as_ a puW': unitary i"er becomes ,ions resu"Ing,, rom� A conditions f v�itai­siji)lill ble. z - Such 'approvals are . and -th4'&pp'r0vP(0f. t�pl.pr,!Yat!�.�!litiii.iuoo!i�,kshall. 'iiiednid-Ihbirand' becomes avaiia available 1 void when public t". of�, ner -0,4406ith, such Jaw t 0 'modifi6tl". ri: 66s lon, modification or change Is necesury. subject t -or. chapqa.-Whej;. �tht; jud 9!r n G Title Data i' s S =� b PEEV T = 3-*3 � zM Q OR.s u7T=Drv=lm Lena a - -I r - .moo•: r.. - - _ .se.ira. -�:c G% _,: ......-.. >:.•. ..• -- �'{+, -. - m.?-.eVt,.us..i. azr:.i Yn. .w.rii y7'•. a_ SDS area locates as per a=roved plans b_ Fill sectam - Date of placeemant . 2.l barrie- _ I= W-= AVG_DP H c- Natural soil not s trirced L d. Stone, brush, etc-, create- t'-= 15' from SDS area.sK e. 100 ft. fran water course /wetlands L_ Sr r DISPOSAL SYSTEM a,. Sentc tank size - 1,000 ,250 . b. S=.mtic tank installed ed level c_ 10' rain numu fran fcuncat?on d_ No 900 be_nAS, cle=rlcut within 10 ft_ of d5° bend e. D , S=L'TICN BCX 1. P! 1 outlets at s -me al-eVctlan t°5f.-ed 2_ Protecam be-T cw frest f. g. M .3. Y1n == 2 t=. or? c n =_l so i- l be =we=n bcx and trenches I I JUNCTION BOX Z. I�ngth re=T-ed - Z Length inst 11 e I 4` I 2. D? S t? r1C = to w'ct=T'CCLr =c f t. 3 . Las a 11 e^- ac-cording to Dl an I I 4 Di5 ta_nC° - Cemt,-e_T tO C---1L °T 5. Slarz of t_ =-hch accentable 1/16 - 1/32 " /fcot. I I 6. 10 fit fran nrcce."v line - 20 feet - four---=tiers 7. Death of tr `ncz < 30 inches from ss ^ce I 8. Roan Zlaaed for eY - F—risi on , 50% s 9. Size o= Cl z 3/4 - lz" dia-netear I ( I 10- D<otn- of �_ vel in tre_hch 12" mi nines++ I 1011L I L - . Pite e_hcs came d _P--,MP OR DOSE SYSF-EY-S ....Size of -r ,am ch tC} =r 3- AJ-a=, vis`1 /auca-:wo 4. P= e=_s4? V acca-sible r-annole to cache I I 5. First box b =led 6. Cbcle wit-lasSed by Health De sn't I I I estimated- flag oer cJc-le 1V. HOUSE a. E--Le looted peer a=reved plans. b. T =LII of bemoans i a. wen located as r-,--- a-coroved plans b. Distance from SDS area a==sur ft_ C_ C_s?nq 18" above grade. I i d_ Surface der dun -ace around wall acceutabIe. I VI- CV= -O`er, WCRRAAs� a- axes vroDZ! y arcuted I "OF I b. All pines Iacicied I �+ c. AL-l1 ioes flush with inside of box d. �ctcfill raterial contains stones < 4" in diameter i e. C -tin drain i- ista11e3 accordin to elan f . Car' a ; n drain cut =all, oroty-t---d & dire to odSt- wateTcoursid I . g_ Footing ins dlscr=ce away fran SDS area I I h- SLT =ace water Protec -tien adeo_uate . i_ =--_os�an crn`o I prcvide —d on sloces crzt�r than 15 %_ �000,�, , , ____ �6 -7 '�.`- "•/fj WZLL UUrlrLrjiLUn J.j A rV Office Use Only CIO DEPARTMENT OF HEALTH Q� Division Of Environmental Health Services U'PNAM COtJ NTY- DEPARTMENT "'OF -•REA--''H:: --* ST ET ADDRESS: WNi 1 Y TAx GRIO NUMBER: WELL LOCATION � WELL OWNER ME: ADDRESS: `] BIVATE ❑PUBLIC USE OF WELL 'RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ABANDONED 1 - primary O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE, °O gal. REASON FOR NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST/ 0BSERVATION DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL ! DEPTH DATA i WELL DEPTH �dd ft. STATIC WATER LEVEL ftj DATE MEASURED DRILLING ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING. X OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH r fL MATERIALS: $'STEEL ❑ PLASTIC ❑ OTHER CASING LENGTH.BELOW GRADE 4 Y' ft. JOINTS: O WELDED THREADED ❑ OTHER DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE ..'OTHER WEIGHT PER FOOT 15 lb./ft. DRIVE SHOD0,YES 0 NO LINER: OYES WO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ❑ NO DETAILS SECOND, . ....._ . - _.. _- .. ... HOURS GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM O NO SIZE OF PACK in. DEPTH ft. OEM ft. WELL YIELD TEST If detailed pumping P P 9 It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. METHOD: O PUMPED tests were done is in- DEPTH FROM water Well OMPRESSED AIR , formation attached? SURFACE Bear- Dia- FORMATION DESCRIPTION coot tt ❑ BAILED ❑ OTHER i ❑ YES O NO ing mete In . WELL DEPTH DURATION DRAWOOWN YIELD Surface ft. hr. min. ft. gpm. r S WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES. O NO STORAGE TANK: TYPE CAPACITY GAL. PUMP IMF, RMATION t �- TYPE �� /CAPACITY s r 0 DEPTH � WELL DRILLER NAME DATE ADDRESS ' Y SIGtt1(TURE • ,'�r /C /�' ` r.., VOLTAGE >d HP IMOD ��� -/ • Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N..Y 10598 Director: Albert H. Padovani A•1. T. (ASC.3) r ANDERSON, NORMAN RD 3 BARGER STREET PUTNAM VALLEY; NY 10579 L J I LAB _ ___ ­ Date Taken: 12/8/89 Time: 9 AM D at Collected By: H. WEINENMAN Referred By: Sample Location: HOSF_ mTT,T,F,g unAn,w TOP L,EFI) PTTTNAM VAT.T.F.Y, NY Phone P28-T803. Phone J# Sample Type:, Repeat Test? _ (check each) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC,NON- METALS m777 MIC.RQBIOLOGICAL CPU /100mL Acidity _ Alkalinity _ Chloride Detergents, MBAS Hardness, ,Total Nitrogen, Ammonia _ Nitrogen, Nitrate .^ Phosphate, Total Sulfate ~_ Sulfide Sulfite METALS (mg /L) Copper _ Iron Lead Mercury Sodium Zinc GENERAL BACTERIA _ Standard.Plate Count .(CFU /1..OmL) MEMBRANE FILTRATION.TECHNIWUE }� Total Coliform < �. Fecal Coliform Fecal Streptococcus MOST PROBABLE. NUMBER TECHNIQUE Total Coliformi Index - Fecal Col form Index KEY FOR TERMINOLOGY CFU = Colony Formi ng Units MISCELLANEOUS CON.= Confluent (q.v. TNTC) LT =.0 = Less Than GT = > = Greater Than. PH (units) N/A = Not Applicable Color (units) S /A See Attached Odor (TON) , ) TNTC= Too Numerous To Count _ Turbidity .(NTU) REMARKS /COMMENTS (For Lab Use) it Potable Non.-potable _ STP INF STP EFF Other: Sample Status: (check each) Outgoing, _ HNO.4 HCl' _ H2SO4 NaOH ZnOAc _ Na2S203 Other: Incomings y LE 4 °C GT 4 °C . pH LE 2 _ PH. GE 9 PH GE 12 _.._ Other: ELAP No. 10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (Was) n (Was't) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE ORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (Did) (Didn't) (N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK PUBLIC (DING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. x . 2 /86(Rvsd7 /87)RWE Albert H. Padovani, M.T. ASCP), Director PUINAM COUNTY DEPAR' MUC OF HEALTH .Ei1VIROi .NrAL IIE , SERV OS ... .. er or Purchaser of Wilding" ilding /Constructed by Location - Street ,tee Municipality Building Type ,�-�2 Block Lot Subdivision Lot $ GUARAN= OF SUBSURFACE SEWAGE 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 immediately following the date of approval of the r- cif -ic of -� hrur°t oar= om l ante "�- f.or_::the se,-4aage, disposa. _system- j- -ror.. ny 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 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. Dated this 1,� day of ' / G 19� w A. (Owner) - Signature Corporation Name (if Corp.) Id • 6 Il � Address e rev. 9/85 mk Signature IlWk , U11 tfk' Title y f(t. p � iV Corporation Name (if Corp.) LA/A Address eoonplat ©Iy voapovisiblo tos t W Oasign;aM beat on of elw woo0 ays4 ®in(s) 1) tiwQ tAe -23 rato ` owa if ral stem. b ai ahoWn Or1 thospwov®a;amanemant 4hsv® Yo an0 in acoar®anoa wtth tho stanOaiAa, rulealn r®gu sl dons pY � na anA tA84 oe�CanpOmtbde thoeoo4 0'� Cortiticato ; oP ConaQruetlonCOmpliante' m4fafietorg Qo;4ha Com�isalonsmo9 6ta+91B11�i11 'OR6 0 'wrttQarot gvarahQOa' w10 N 4uvniahca9 tha Oa/OW Ais tldCd?aa8t P8�')1®Irs Or'a i8oes bi%'EPO ®ulBalm 4Aaf: 6� buti ic T,)will In rang Dart of s+�ie aaw0®O�AhpOQDI ayatom 6urirq tRe ttaaioA;ot two „(Y) your, m�s76pQ ®Ig 4o11OnriRp Qho�to 09 tla0'.is�e- Rilttate Ot ConaQrudion t omplNnce o4 4hs original ayatom ov pny re�okra Q ®S ' 8) th t, t110,6vi11®tl wait iia ' ciodv: plenrano that ral0 well will tlo InatallM =in a nC® with Q ti va8 ' .ruaas on6: ra�u s 04 :the t➢u@nam 5igalas8' P.E. ' Ov,neomNiN1 wAan''eonWd®ied Ovom tAO ;Date ialuo6 unle$s tonaQruet o4 tha bui0lsirig Fier b¢®n ueu)artElcmr mii0 is GgDPI:TAia Opwoval oapuol tlroo ya�sv� by tA® Comiaiist8on©v oo; It1i. Any ele�ieego or aitwatdon oe.sonaQvuctbn 9pom1 of;. ®Omragtlt ariltavy,'s¢xar /or pr to voter age Onlg. rpubea a �eou+ pwmit' dApwo 4or ®i / ff PUTNAM COUNTY DEPARTNaMOF OF COMP CO UMONTERAM FOR SEWAGE DLSPOSAL SYSTEM ti SabdlvlWon Name Y- n6, f7 Tea irivibiiiii A' MaUlag ddniomw, /0&1r Town r mi il ?BW FM,Se J 14 44a isUdIng Number of Bedrooms De ign `P6* G P `MiD N6tffle " When Flll Is cdm Separate Sewerage System to Ciqziusbt of j P, tk Tank aml Tube lconstructed by Water Suppb,:. Pttbllc $apply From Address or: Priva�tle`Supply Dllled by B81 © — Address jV men­ Other Rpq dve = -that' -the 1) . ;fist separate sewage:, ispoul iSys am is Or h� J_ above described wili;bi constructed tshowq, on"t, t stand" n d. r e.g u a will the d i1fil ,:= of County Department, 'of Hialth" nei hit' oh:corno!e! ion "Iii#of. be .submitted: tot`hi'Departrnafit, -and -a rqttjifi:g6ira juccistor*�-tioirs,o-riisilgnl-by thi-bu �will Ce" I o- a'fji0i.:co'niilii6n' any immediately following ihe,dati Of the l,fsiu YI.TT Per.". 01 the ,apoli4al,�'Of system V repairs jherstq; 2) , `the uii4rn issu- ance i�l I Il b 'tailed 'in `4`"t `cats' i; Jtli'rit ufis and rag that the drllled,wiii�:ciiscri6eif above will beI64timaisi own on;the�appr,6�vQ'Ip6 5 ulations. of r County _4 Address ..... ..... APPROVED .FOR y!44is_,f- iOrn I revocable fq!, cause or may be amentletl or'motlitied when considered necessary _qby the C I ►iiluvres a new .6fiji6it: 'A'ppio4d`f6r. dn lieu. epz,— 1/87 date px.— R*A- License N -,.- c . o . A . st ru ction ­ O't the buildini'has been undertaken and is ner:.iif iq"ith -•-Any change or alteration of Construction :,er DPly'. Only. PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION OF HEALTH'. SEMCFS DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. ,...z :.,:- �- .-,-�: :-:-: -- ..: .va. �\-v: -. r :� h .. _.. x.. �,.; .�z...;_-�`«`..<.:c„ - ,.y..,. _- ^'--- ; we. f.- .„r.';.,�..,.nr .r..' -d d;- .--Sy:.r'^ii �- =;•a=a OGmer' t qr� 5 e; J .O Address Located at -(Street) y Zec. /� Block Lot (indicate nearest cross street) Municipality II i( Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED. WITH APPLICATIONS Date of Pre- Soaking ,T �"IO 1"� Date of Percolation Test HOLE NL14BER CIAO TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches / 1 9'o e - 9•�0 � �v /� lam% //� �.1� 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 submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS NCOUNrERED IN TEST HOLES DEPTH HOLE NO.. ( HOLE NO. HOLE NO. _ r _ :`� .._ - y� �.vi.;r n.+...'>.,an �i �' ���- -eE"2 :r.ao. <vvi.u:-+- _.�,... .- r.'c,a ir«..:�: ;- •.•..ac.•a:_. s=+: x=- .r- +rn.a�. -w -- A- vv...c. a,.:.S�R G.L. -� -- .�-�Od��Oi�- �UOb�� a 1' 2' 3o 3' 41 P4 aelt ,4_ LPG 5' 6' 7' 8' 9' 10' 11° 12' 13' 14' -AT i'I7WATER S ENMUNTEREb, INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 3-6/ DEEP HOLE OBSERVATIONS MADE BY: i DATE: �Q , DESIGN Soil Rate Used s Min /1'° Drop: S.D. Usable Area Provided (01 ��a4i No: of Bedroans Septic Tank Capacity ���} gals. Type Absorption Area Provided By L. F. x W widch Other Name f m C 2Qkto, Signat Address RW '7� SEAL Ge THIS SPACE FOR USE BY HEALTH DEPARZMENT ONLY: Soil Rate Approved sq.ft /gal. Checked- .by Date l DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ;.._ APPLICATION TO CONSTRUCT A WATER WELT; _ PCHD PERMIT # WELL LOCATION S r t Address/ T /Villa J/ty Tax Grid Number WELL OWNER Nam Mai ing Address 4 / �l d rwmeev rivate D Public USE OF WELL 1 - primary 2- secondary or RESIDENTIAL 0 BUSINESS O INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify, O AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED C /EST. OF-DAILY USAGE 464) gal REASON FOR DRILLING EW SUPPLY O PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING 14400 JVOLIC4 WELL TYPE 026ILLED DRIVEN ❑DUG ®GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: No. WATER WELL CONTRACTOR: Name 7'.-6-D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L,---NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ` DISTANCE "TO °PROPERTY' FROM- NEAREST - WATER rIATN:" LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION all 1z P E S ET, (date) gnature) 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,byc_the Putnam County Health Depart lent. _ Date of Issue r �� 19 <::;!5r_< Date of Expiration: 19' Permit Issuing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 Oranqe copy: Well Driller APPT;W. nT,Y R Pu1mmaM COUNT"' _ DERaRDU TfI' OF HEALTH - DIVISIGN OF RWnRCMAE= HEALTH SERVICES INDIVIDUAL WATER SUPPLY & S'JBSURFAL'� SENik DISPCSAL SYSTEMS CONSTR=ON PER' MIT DATE R�� V'rEQ D: ���'' BY: e'r. (Na-me of Cwne_r) (Street Location) C - 1I5 YES ( NO I DCCtTMOUS Permit Applications Corporate Resolution --r' Plans - Three sets Engineers A- uthorizaticn (, Design Data Sheet (DCS) SiJPEDIVISICN Deep Hole LCr , Pere s°- Consistent Perc Res,ats (3) Fi11 3 Perc Hole Depth cd /moo ,� a 1-7. t2'enai.. provLd requires ma:c. eilel to contours r - - FML, SYSTEIS clavharrier notes red sue. qov- 100 vr. flood elev. -� I I I 200 ft. reservoir, etc. 0 ft. tr H ��.� ouse P Two - wo sets - Ferchit; F -v;, letter Variance Request CL legal Sabdivisicn Su, =- iision Approval Checked Ex -ap provai SSDS Pd . Lots Checkei -Wet -land (Tcw-n/DEC Psyi`_ R.& D) Data Cn DDS Plans & Permit S-a'e REQUIRED DETA TIS ..CN Pi?NS Sewage System Plan - (north Sewage System Hydraulic Prof '_l_ - Gravicv F1cw F M Profile & Dimensions - Voluare J Box;Trench /Gallery; Pm-9 pit de'.ails .C.eptic Tank - .Size, Detail Well Detail, Service Line if ever Design Data:.perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes C,2t Footing L. Drains (disciarge CK) Perc & Deep Holes Locates Representative of pr; trary and e- =ansion Expansion Area;shcwn;gravity flccs,suff. size If Pmued Pit & D Box Shcw-n & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systen Property M~tes & Bounds House Setback Necessary (Tight lot) House Seger - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /clenout SEPARATION DISTAL'�TC.ES SPECIFIED CN PLAN Fields 10' to P.L., Driveway, Large Treesjop of fi 20' to Foundation Walls 100'.to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, lake (inc. ems. 15' to Drains - Curtain, Leader, Footing 35'to catch basin,stonndrain,piced watercou -r. 10' to water Line (pits -20') 50' intex- n- i.ttent drainage course Sentic Tanks 10' fran Foundation; 50' to well 15' Well t•n vr, q PUTNAM COUNTY DEPARTMENT OF HEALTH Date P J, Re: Property of ot'-7 12 t JU /Ilyz Jyly Located at "e (T 61 )OL,4 T E Subdivision of I I A Section- J- Block. t,/;rj"- Xuvw*4 If;j -Lr- Lo t cl.� rl T pv ) � Subdv. Lot # Filed Map # �Q- ate Gentlemen: This letter is to authorize 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 connec-t1on-wkth this- m-at-ter-and to- sup _gKyj. _Qx'trugl oxk.--.g, -0- 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. Very truly your's, Signed Countersigned: Owner of Property (1, P.E., R.A., # Address Y' Address To Tel phone 0 27 Telephone p c.•,dw:.- .. _ . "✓o .��•►c :..i-:a_= =` �': xtBE( R� 'NSA:;�tit.iJr�rTN:L:1Lih:S.i/• eat. io. :l4.:.'a��fl�'%14it''2(bY.`ai3di aw;�yi.. �'� "it��.':�:. ` . PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services AFFIDAVIT — CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: of I , N/#1V_K ✓,� represent that jI�am to act for T_ ki,, having offices at Noy Whose officers are: President: #K• Vice — President: AIR. F4 �TSecretary: 6 an officer orb► employee of the corporation and am authorized 1 ' k)(� �J�d -C ����� 674g.4. (Name of Corporation) 4,v)— �f ���i'� -gyp t�1J�d.✓dLID%i� -� G'� %� %'IU /Tfs' t k14),�2 Name and Address (Name` and Address)' J� 't )No #1f,S1 ~ Ny le s-?? Name and Address) Treasurer: (Name -and Address) and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval.requested and all subsequent acts relating thereto. Sworn to before me this Z_ day Signed: 4, Z� of 19,r Title: X A s Notary Public MARC 1.. SAIDEL Nfty auic, Steteof New York Pao. 9820275 Qualified in W CW* Commiseon Expires Nov. 30, 1988 8/84• Curpora'te- Seol 4 j. -AP e, Lf i , OV, division of Enviro ental- Heaitjt� ser,vio,w note 0' canfo.man+cs with Ipplicable Rules amd Regulatiort§ of the 'Itn,am,Qunty Health Department(, .1—t— X 119r—,&71Kahl 4, A t air —32' —Go T c THL SYS't,:; I A TI ff R i I 1)• . r "it "A \A , OV, division of Enviro ental- Heaitjt� ser,vio,w note 0' canfo.man+cs with Ipplicable Rules amd Regulatiort§ of the 'Itn,am,Qunty Health Department(, .1—t— X 119r—,&71Kahl 4, i ga A t air —32' —Go T c No I i ga T c No I \A . `=- v I