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HomeMy WebLinkAbout3395DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.08 -1 -39 BOX 27 03395 0l`�7 iPUTNAM COUNTY DEPAItTM ENT OF HEALTH ENGINEER TO PROVIDE PERMIT # ON CERT FIC 0 COMPL IANCE. Division of Environmental Health Services, Carmel, N. Y. 1 512 PERMIT CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM own or Ilage .'.i �etiie nat'E..cT'!r��— > < -__ _ -� rT.a -'R1ap ; Subdivision 6 / 9S&;&TLC.__ f� Subd. Lot a Z`7 Renewal _� Revision _[] Date Of Previous Approval Y'S 16 Lf/0/'77 A Z AD A 17-AA, e. a , 14C— __ Fill Section Only 0 Design Flow G /P /D. 1900 P.C. H. D. Notification Required Separate Sewerage System to consist of �pc✓ Gal. Septic Tank and 46 ga- _�/s'1 ig og ,0i *y Address To De constructed by Water Supply: ✓ /�hlic Supply From r Ile Private Supply to be drilled by����1•' Number of Bedrooms ✓e Other Requirements A/VW I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulations of e Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years immediately following the date of the issu- ance of the approval of the Certificate of. Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be installed in accqrdance with the standards rules and regulations of�Putnam County Department of Health, c Date // Signed ,�t� P. E. R.A. Address !r' L /w Yl License No. 49 2,IP-VI APPROVED FOR CONSTRUCTION: This approval expi s one year from the date issu d unless construction of the building has been undertaken and is revocable for cause or may be amended or modified when on red necessary by the Com ner of Health. Any change or alteration of construction requires a ri per �t. Ap roved f . disposal of dome is san a sewag and /or priv a ter su Y. Date —ff 13 Sy Title Rev. 6/85 \lam " - - a` .• wtNNtlY \WTt�. i�'t VLF C �\J�' �9 'v�KX.(L'� V• s `� \ Pl. bA- GoCAr w co I / REVII1•1 CIR,'CK SIEFT _ D�rE �_ , rIrI.D CHECK I;CST. IA DOCL9,20TS ) M(II' L6CJ) 71o� 'rouse plans O.K. Design data sheet Peres presoaked? i -in.� 30" pert test depth Const. results for 3 runs D. Hole log O.K. - Corporate Affidavit for of Authorization for engineer Tatter from Water Supply i If variance requested -such on planes apps Meets Std. Remarks es 0 Date: I / Insp.by:� L :;JGIJATUM% E bCRL - O!J PEA DOTAIIS � FILL D6pTH j RREA' SNc _W( r_'0 Nom 1,PLAM io 6F PROX)MED Existjng c shown (show new contours) Slopes fo driveway cuts, etc. shown I.later ser 'ce ocation Footing drain, etc. location I S: Top slope, bottom slope of fill :AJF- Percolation tests and deep test pit location- Septic tank size and conformance to std. ✓ I v2 3 B.R. housa minivium r gl House setback shown Distribution box ft, below below frost AU I All water within ;4iw t. of..PL shown 41E1L_ CASING IV' i)zova GP_A•DC of Plan and profile SDS All other wells and SIDS closer 0' 'shown or reference made Property boundaries (metes and bounds - �E aDiv is lo�� P� ,_T'f yF D 6 i T't SEPARATION DISTANCES SPECIFIED ON PLAN 10' to P. L. 201 to Foundation walls ia0 to Nearest well OW to stream, march, lake, etc. incl: ,W to Curtain drain 10' to water line (pits -20 5' to storm drain 101'to larse trees 10' from foundation to sal'tYC tan: 5' to pie from leader drain LC.1'oo iTe; 125 TD CRTCN 2,Rs1la I15' WELL ro Eo' emc. -6tov_ rp • .3e, -9— I �-19'- 3' -nqF.tu' (* = So , spoyn ../� X11 rj ;.Ttt-5g J _ r ' .._ _—'_ - -, ­-4—­_.I. _.... . -.. '- - -.'_- . $'�•`t:1iiQ E� — Z Wk 3 C• 7'•-r �n «.... ,a INITIAL SITE INSPECTIOII Zot _ Xcs No Comments' Property lines or corners found Gan estimate house,location . . . . . , Will drivctaay need cut . , . . , , Must trees be removed -hote these Is deep hole representative of entire SD3 Brea Additional deep holes needed. . . . ✓ iDtit �� �ry71^ � - Sufficient SIB area available considering driveway cut,house location,separation . distances, etc. flP� �L ISM. WELL>�SEPTIC� 777 Y DERP HOLE DATA Dspth : 14ater el.evation:. Rock elevation: Soils descr:iDtion: - Date: _ FINAL SITE IINSPECTION lIns . by: -- House located where shot :m on approved plan SDS located where approved . . . . . . . length of trench measured Width of trench average Slope of tile line and trenc .ucceptable . i Room allowed for expansion trenches Over "5 . ft. from swan, p, watercourse It'atural soil not . stripped or SIDS area iuuiecessarily graded 3.0 FL-. maintained from prop.line and 20 ft. from house . . . . . Separation of trench from house, well ._.. etc. - follows plan .. _.. . - --- �'- - ......._. _ , __ , ; -,- - - . . . _ - -- - - - ------ —. Number of bedrooms chocks . . . . Stones, brush, - stumps, rubble, etc. greater than 15 ft. from nearest trench . . . . 15 FL-. of peripheral soil horizontally from tronch _ ,y Jw7ction boxes properly set Could surface rtui off from driveway, roads, ground surface, etc, channel near SDS ,.. . area Doos lot drains :e anpdar O.K. in area of SIRS FINAL GRADING OF SITE ACCEPTA= PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ...� - ..� _....C..... �. 1. nlOW T.ua,. uY' _. .i'.' •�� _ .. ,� !s tiM•o��y l'w� _•I. -. ....I� Date Re: Property of Located at y—c'wAwr (T) /�7W,4$4 �Section 2 Block Lot c Subdivision of S- CL) I(.C, 6-T i/fY� Subdv. Lot # 27 Filed Map # / Z 3 P Date 7 -30 °71 Gentlemen: This letter is to authorize IGGr �C/ Lire. a duly licensed professional engineer Y 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. =- s3Tstem- .;or:••�. , m•s••an` conformi.ty- wish- -the prcwis'ions of- Article •.145 -o "r; 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. 0. of NEW rOR Very truly yours, 4 PM F. IF�`��'t' ?� Signed Countersigne �,; '? Owner of Property P.E. Address %FeSSIDOX,/ Address Town ool 73 /W Telephone �® ECEIV Telephone. SEP 3 0 X985 PUTNAM �pU'TY DEPT, OF HEALTH PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... a :} --- - � 17 i i 1 ' - ^ . i -. - - , .. , < , i .. , .., � • _ a .., � . , , ,... i ✓ .- '. _ i Y i < , . - , COUNI`Y OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM �y .FILE NO. Owner�G''DZ6Gr ®�U Address J24A)iP% b,-9, �y >��� �� Located at ( Street Sec . 6 'Z B1ock__9 —Lot 4dicate near es cross street) Municipality �{/;�rdi /!/ LG�`/ Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole / . Number CLOCK TIME PERCOLATION PERCOLATION RM apse Depth to Water a er ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 ? '.yo /,sue 2 t/ lie :3 7_2 2 3:yo 3,Sr /S'" 3 3; srr Y: I r . �o z za 3: 407 5 3 �✓` /.3 �' 2 � /,sue 2 t/ z.7 � .fo 4 1-7 ZSd Z? 5 1 2 4 C) AJDj . erN014 Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test, hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. DEPTH G. L. 6" 12" 18" 24" 3011 3611 42" 48" 54" 60" 66" 721.1 % t TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION - .�DES�`RIPTIOI,,QT,.;SOI_L`� -- TyTC- OUNTP.D_,IN, TEST:.:HOLES HOLE NO.(� HOLE NO. HOLE NO. INDICATE LEVEL AT WHICH _ GROUND WATER IS ENCOUNTERED INDICATE -` =L- o- j�i' i C "ri' ,vdA 'ER • * ... ISES -AFTER -BEI-iifi&- E�1i COTJNTERED = TESTS MADE BY /�'U /L�!/�e /�. EGr7G--' Date DESIGN Soil Rate Used Min/1 "Drop: S.D. Usable Area-Provided d"o No. of Bedrooms l�AD /rg� (t' eptic Tank Capacity 0,0 Gals. TypeC6 ,tJG Absorption Area Providded Byeoj2 L. .x24" 'r- width trenc . —.Qthe r A)O Address THIS SPACE FOR USE BY HEALTH- DEPARTMENT ONLY: Soil Rate Approved Sq.- Ft /Cal. Checked by a� i Q o� n o� t. G sm 19� c y ti �I I Y �-4 a y �.P�.r /-)P/ V16 .ln k �+ tkq �.�, � �u see► °� �� �� i'"��p� �y 1� � 'V A J a� i Q o� n o� t. G sm 19� c y ti �I I Y �-4 a y �.P�.r /-)P/ V16 .ln k �+ tkq �.�, � �u see► °� �� �� i'"��p� �y J a� i Q o� n o� t. G sm 19� c y ti �I I Y �-4 a y �.P�.r /-)P/ V16 .ln k �+ tkq �.�, � �u see► °� �� �� i'"��p� �y XPUTNAM� CO Ds',vision m Enwron, 'CERI'fF „ICAT,E OF 'CONSTt#UCTI,ON COMPLIANCE; 0 t, Owner t r Separate Sewerage System built by rConsist�ng of�_ qe� Gal Septic `� °` Other requirements.•` � ! Water {Supply r Publw Supply,�From Privete'iSupply 'Drilled B Address wyBuilding TYPE - <. <Has Erosion Control Bein=Completed� {- r I certify that the system'('s) =as Ilsted servi attached) and inxaccordan "c kW the: Date r A 3 Any, person occupying premises'servecri ,con dltions resulting from such usage available and the -approval",,( f "the' priJa, subject to `modification L ..or tchapge whi v Date • s 3 a �i t 3 I t J. PARTMENT�, OF :HEALTH , '! i WE DISPOSAL Town or'.Village I Block lineal Feet X6'�' width trench JF T 1 , q + t: ,�of5z Bedrooms Date, Permit I `slued y as ;shown on the plans of!t a completed work (copies, of'which are ' he "+permit is su by ah Putnam ;County',DepartmanL of.,Hean, f P F. A' y t uc ction as may be necessary to secure the correction of any, unsanitary >, ZStir s I- become null and votl as soon as , a; public. sanitary aewer'.becomes >; - en a`•public w supply:becomes. available Such approvals, are. I. fi H'eelth such r' cations mod' icatlon or change' is necessary Title ` •r . ����G� / 6 {j ' /� ��r,✓'�o� ���` 41 tr, Owper or Purchaser of building,, A-inici.pality q � - '-'�- %��� ©�.,:�� "...�:� /: J.��.,�i -"L� -r - .:.._.."._._.. ... ".. .. —... -. .a.r e�•� ti���i- s��_.�.: �.rj .z��... ...c •`"pV.-ce..,,,. r.. _. - -_•. . -.. .... !3Lii•�l�ding Constructed by ° Seet-on � ,fin j�.�L'� Location - Street Block Building Type Lot GUARANTY OF SEPARATE SEMAGE 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 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 initial use of the sewage disposal system, or any 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.,utilizi.ng 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 .oiler. ate was ._caused b3� -.- the ,,-willful.:- or „ne-ligent. act. of the_.occupant_- of�tb,e bgilding..uti izing the system. _ .r x :, Dated this G( da y of t/ 19 Signature TitleGJ:z�� (if corporation, give name and addres, THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION 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 r .r BREWSTER LABORATORIES t�1'..'.WTQ'J.nW'Y}+a`sc11.�..'.i Ll yYi b:V4w�- r....i: ..w,�'.��..s♦ ul.:..' - .. .. � .i ..4 N ..0 . >.,i� +. � � .. .. 1 � ^..,i q•. w;.�y..: =' _ R - �Z�..rfL 1! :.�.. u ,, ......4:.....,rt..J.....ty�,.... h \'.�r. �1- .^6-w \.. WATER ANALYSIS REPORT SAMPLE NO. 3015 SOURCE: George Nurphy - hose b ibb — well supply Peekskill�HoZZow Road Peekskill, N.Y. COLLECTED: BY: Frank Carroll Well Drilling, Inc* BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 0 per 100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. C_ August 4, 1973 Boy Bickwit P. E. Director WILL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK 4iisl Lei r iw it to=be^ completed -ty� weh Tdt ilfer -and �strbmitted -'ra otinty Fteatttt' Depar riiIiift t6gether'vaith'iaboi'attsry' rep- 6rr?)f' •'` -- analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME George Murphy ADDRESS LOCATION OF WELL Peekskill (No. & Street) Hollow Road (Town) Peekskill (Lot Number) PROPOSED USE OF WELL LJ DOMESTIC ❑ SUPP Y INESS ❑ ESTAB ISHMENT El INDUSTRIAL ❑ FARM ❑ AIR CONDITIONING ❑TEST ❑ WELL OTHER (Specify) DRILLING EQUIPMENT El ROTARY COMPRESSED � AIR PERCUSSION CABLE ❑ PERCUSSION ❑ ((SSpe if ) CASING DETAILS' LENGTH (feet) 120 DIAMETER (inches) 6 WEIGHT PER FOOT 19.45 n 11XJ THREADED ❑ WELDED D SHOE YES .A NO C G ? YES � NO YIELD TEST [I BAILED El PUMPED � COMPRESSED AIR HOURS A G.P.M. 18 YIELD (G.P.M.) lU WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) 30 DURING YIELD TEST jfeet) 90 Depth of Completed Well in feet below land surface: 12 SCREEN DETAILS MAKE LENGTH OPEN TO AQUIFER (feet) SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL SIZE (Inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACE FORMATION, DESCRIPTION Sketch exact two permanent location landmarks. of well with distances, to at least FEET to FEET 0 90 Hard pan.boulders etc. 0 125 large water bearing rav J. If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPORT WELL DRILLER (Signature) a `f u � `r ✓; - r. t � ti i!•„•a gJa ISAZ. .SEP%lc f6.n.FL` � S. t""�s•..i 1 t t �' yy t �• � 1,�,: :: � s _ . � � � F: do ry � "..• i r j p• i r• yo{9 �''�> >- y t � tf i'�� e � t Y f a lI r '� \� . . {\r t 7 ',y x.� 1i '� i t,"�. nt ~�t , � . �' 1 r Y :a. { s♦ . 4 . ` y t .� �. � � f r = ••mac•._._'. Pr��f �?,' � i IJr farce f'ron'' . . Al ;,A c t �• k. ( r�. ��y. ✓� . R ', -i - a.�' "` ,.gyp r. =, 1 tiara. �.' e "'C`a'— • 1• � .:�, � �1ti7e.4>!�•�G;,,�iE.Gi"' �,� ': ,r .wa"•yar 1. t 'Sy„ S, ` , i. . +biers. -'4 Jie.�'+'t Vasa � S:m">'z k..C�w w•e� - r Y' vY � !SY`m ..Jst +/rL�':-+easa i-- •'2.4M•' .'aA ab`".+S!`.w s - R.k..._•viw; v.+�.. wi.e«..J'Ses:x.ip .''(,: x 1 cl a `f u � `r ✓; - r. t � ti i!•„•a gJa ISAZ. .SEP%lc f6.n.FL` � S. t""�s•..i 1 t t �' yy t �• � 1,�,: :: � s _ . � � � F: do ry � "..• i r j p• i r• yo{9 �''�> >- y t � tf i'�� e � t Y f a lI r '� \� . . {\r t 7 ',y x.� 1i '� i t,"�. nt ~�t , � . �' 1 r Y :a. { s♦ . 4 . ` y t .� �. � � f r = ••mac•._._'. Pr��f �?,' � i xa, �p +f� Exf Ate. t PArJ$t0� A APPROVED.- S E P' 1973 '� r`= •, i WTN COU OF'.HEALETH ... ..VISION, 0 - {t VIRONMEtiTA- NEALTN,SERV100 2 j �. c � � � y i• � r �+�,nit UYi•'�IWLi NI.L+"il : 1 '� ' t z •�� � 1b9�.tES3i if3� (E'� tfidu Red#, ?, 2 Tnn rs p b y • rea,a'' .rL r_ J, 2 w If 7 ip t 7 Y fr h i. J� �4r��e rY 6w, ��ii/�Yi� • r t/, s k s \� r �• � v� z � ` '. .m'fP «Q ,:.�'.a�,�'r , "'S- ".rJ, �y2�� 5�P �^` f?t./,�ii(.�t!�J' � �r'C J�`� l'�i�,. ., ..a.:`'t,..,. q•r^l ' ,• .'tG..a`rn. "f IJr farce f'ron'' . . Al ;,A c t =, 1 tiara. xa, �p +f� Exf Ate. t PArJ$t0� A APPROVED.- S E P' 1973 '� r`= •, i WTN COU OF'.HEALETH ... ..VISION, 0 - {t VIRONMEtiTA- NEALTN,SERV100 2 j �. c � � � y i• � r �+�,nit UYi•'�IWLi NI.L+"il : 1 '� ' t z •�� � 1b9�.tES3i if3� (E'� tfidu Red#, ?, 2 Tnn rs p b y • rea,a'' .rL r_ J, 2 w If 7 ip t 7 Y fr h i. J� �4r��e rY 6w, ��ii/�Yi� • r t/, s k s \� r �• � v� z � ` '. .m'fP «Q ,:.�'.a�,�'r , "'S- ".rJ, �y2�� 5�P �^` f?t./,�ii(.�t!�J' � �r'C J�`� l'�i�,. ., ..a.:`'t,..,. q•r^l ' ,• .'tG..a`rn. "f � Q54 "J COUSIR T. fT r 11 Xot tide, tn or d r4 birtaken., And is � � . � | � | ' � ~ r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date ,�a4u5� 7, /972 Re: Property of A,� C /'°'�y,� AW �4 Located at J C- AN�QF -D P �! •s A %�c.��p Seetran- O L- Z- Block Lot U Gentlemen: This letter is to authorize STANLEY 1e WIDER a duly licensed professional engineer L,-Io-r registered architect (Indical-e-�- to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County Dcpartuiciit Of nealta, aiid 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 Iaw, and the Putnam County Sani- tary Code. Very truly ours, SignedUw Owner df Property 644A� G1oo '0CR46Sr �P,q�r/%�.a�i 4,/ Address 6 -z8- 4,76 Telephone 1 L PUTNAM COUNTY DEPARTMENT OF HEALTH I0R"OF`"E1�CTIFtO1VNNl�1AT; "fi,Zfi�S`iS"° ..: •:.:�.:a : ,� :_,•::. ; :� �. ;.-.� COUNTY OFFICE BUILDING, CARMEL,.N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner e?�.ozCE /i'Id�2vf�5j AddresSA- lov,oC` esr e-^eor`',rl,A,075 Ar "Ot' -'a 10,9dor9C. JC-a #J�� T�ee�. o6a Block ©9 Lot Located at (,Street �L +�� U � n ica e nearest cross street) Municipality- ��`i�3 APA J6 LL + Watershed PCt1G �` GGy cam+ ®� SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION apse Depth to Water Water LeveI No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 2 3 i; Z - 3lO:os' 5 .:ZY :.`_ .: . ...,5��" 4 5 1 ... . 2 3 • 4 Notes: 1) Te'gts to be repeated at same depth until apppproximatelyy equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. r• TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION _ �....._ ..... _ _DESCRIPTION OF SOILS ENCOUN�['ERED IN _ _ TEST HOLES _ DEPTH HOLE NO. PI No. HOLE NO. G.L. 7 e),P`�co /�- '1 8" `F 6" 54 N 60" Ably z4cc 121, a,v� Vic€ LG.9 72" 18•• 781 2411 30" 3611 4211 .y '1 8" `F n 54 N 60" 66" 72" 781 84" _.INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED 00 �Ee'� ''INDICATE L�Mi;'TO-WHICH WATER IZVEL RISES AFTER BEING ENCOUNTERED '.TESTS MADE BY Date --/✓e >, /.4 72 DESIGN Soil Rate Used 10 Min/1 "Drop: S.D. Usable Area Provided -!5� Z No of Bedrooms F SSeptic Tank Capacity U Gals. Type /yy,9 SoN,2 Absorption Area Provided By i 7'7 L.F. x24 " 3b''— ,,/ 7 width trench. QTANI I_ D 0. . ,J:% �ti-��. �.. Other- Address THIS SPACE FOR USE BY HEALTH DEPY Soil Rate Approved Sq•. 'ONLY:y^ Checked by Date M 1 ivir VJ ti hj h \9 J �3 t fi ddjN Z W H 0 to Q. :-t67c r- �+•z- ;v.m+..s_�rs �m`::i��- +- ^V�uy�..y��+#fi•. saa %sE.�e.Y Nr.oasa .. 4i 3. �. S.. S�$r 0 IN I O ORi� E N aO • 0 1c.' mm� •r Q0 7 to g ^/y67 c�^ o V � �l ry LI, v 'dnyd Z �\ z m o i 00 `r a- 0 � n j a Q 0— ih �S -� 7 h� W� 7- W �@ W 0 � .. obi W � ivir VJ ti hj h \9 J �3 t fi ddjN Z W H 0 to Q. :-t67c r- �+•z- ;v.m+..s_�rs �m`::i��- +- ^V�uy�..y��+#fi•. saa %sE.�e.Y Nr.oasa .. 4i 3. �. S.. S�$r 0 IN I O ORi� E N aO • 0 1c.' mm� •r Q0 7 to g ^/y67 c�^ o V � �l ry LI, v 'dnyd Z �\ z m o i 00 `r a- 0 � n j a Q 0— ih �S -� 7 h� W� 7- W �@ W PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES �,:..T•A:'i�!4Vrtl .!� �i YY."�".i'N�'s'+Mv'e...+oT.�+^ ri:�-+3 ^- �ri'.v:?'t.i%tfCRM :r......r r. -. j++..f Y.FW'un � «�.... -�.. .- _rve�7='�+�.� �C � SS�Pf.+Y+�W�fJa'Wio+p iiF%' -t.'AI PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR U f- Jq e.-P SITE LOCATION ,3�4 / .J iA lT OWNER'S NAME P&y R-t c* 4 G Lt MAILING ADDRESS 'P�j 1-q4fl-41 V +4 OFFICIAL USE ONLY TM# '73.8 —t —3I Toj,/ PHONE S-2& -75-V--2-- PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE / TYPE FACILITY `PROPOSED INSTALLER �" PHONE 6 ADDRESS REGISTRATION# �� 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. © u, &" ._,► _ as_o Pp orted;a g ent of o�imer__ gtLe to_+ e: con0it1gIS 3at_01%thi�.forii:: .ma - SIGNATURE TITLE o /� ►�'�l Proposal 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 DATE v b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved A Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NIL DA J .� Sheet of * . ,TUTNAM COUNTY DEPARTMENT OF HEALTH 4= �� ID. ISION (��% E� "?sRON�EI�T��, HEt�TI�II;��R�1I�CES'. 'FIELD ACTIVITY REPURT F h „1TAMF;l f 1n'S, TT PIa Street Town - State Zip PERSON IN CHARGE AJI) b -OR TrNTRRVTF_WF.T) �. Name and.Title ` TYPE:GF FACILITY. _ t ' arl " - y - . 4 se �S' - v _ mmy,RFC'T(1R; Signature =and Title ". -n RFPnRT RFE:FTVR RV: I acknowledge receipt 6i* report , SIGNATURE: F ` > Title, 02/96 = Rev. PM CO PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ ...>:.s•'v� T... ; � ;7� - ai.+e�in'r�s`.rsin:Ydu.n+r. �..w�i*vr a`i�- sti%c�� .va'^i+ °.3 =:.,- ,+ice+.:.- .::.;nar•'..ner.: oT- °aa. :...r.a. t:!r;:i� -imr"j - .ii:u:�e""wr..vs. %wi'r:yin PROPOSAL FOR SEKAGE DISPOSAL SYSTEM REPAIR OWNER' S NAME J L L iL� A g ° L) lZ P N y PHONE J- SITE LOCATION t e.1 CeL A) AJ e- r • TM# �;2 MAILING ADDRESS M U14 iC- A,/• i/. PERSON INTERVIEWED _ n iuy 2, - . TL yN I ty) of—p H Y Pa M Canplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 0 )C I PHONE a E 17 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 fram licensed professional engineer or registered architect.. e7 Z:2 -/77%17 111n 1-/11 3 'Z-i Proposal approved Proposal Disapproved Inspector's Signat & Title /Pdte Proposal 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' diam. 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, reported agent of owner a ee to the above conditions. SIGNATURE TITLE DATE LPBS: KAte (PAD); YeUcw (Tam ED; Pink (Applimnt) ¢.. w� - � �i�i.;;" p�'•" �^+ i+ syevsw* csi�v% wiRx.: �. v_-- r�i �= u-t �. sse:-: r.:.:..; .. �.. s... u' y' w` i:.w..:;��ya,..+:c,nsa�i�r� -w' sum-. r' a... sCtk�%ir�s+�►ei: >`�%.�a�e-a -:,: r,�<:;�a.a- ti�o•z_�r..:� PROPOSAL FOR SEMkGE DISPOSAL SYSTEM REPAIR 0 ° S NAME PHCM S Y SITE LOCATION R- MULING ADDRESS PO+ Ur8'kI wx PE Lc,CN INTERVI3qEb d �1 �e2 PCOD Complaint # - Dame & Relationship ( i . e, owner, tenant, etc.) DATE I6 n c TYPE FACILITY S S PRU WED IRLSTALLER y922a CJ 6)(C. .2.— r _ PxCNE REGISTRATION # _ Z. Proposal (include sketch locating all adjacent wells): RATE: 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 engines or registered architect. _. !�'ac/S ✓ s- // ye V I House F^+-or ..�.� .. ...� ..s .. .. ... .... .. ..p _. p.eq.,, ...•.. v-r.� .i'>`-.^. _.�...a..- - .- .'1`,�,'.�9. +..ems '^.w•.+s. ^.. ...-^ .w. ..�.^ .r ... _gip _.., p•w -. +�.- •_�-- r....va�....^. ^�.. -^T _ � Proposal armed °s Signature & Title Proposal Disapproved I //,/ /?" I alte proposal 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 components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 60 dwp 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 reported agent of own agree to the above conditions. SIGRtAUM TITLE DATE OPUS: 6tite MGM; YeUcw (inn HE); Pink (k is mt) -Ijj� pRoc Z:I . ........ ............. . ................ ........... "Y "of '.7 V, PA ED; R, C 3t J �S E R, .197 OF H.EALIH:- fNj AL wo-za ae sarago 62 syra cm m 'was construcle, rubs V4 rK.. .. ...... fu= goo De e iwl 7 l "` IV T17 c ... .... . ..... - .... .. ... . .. T:�..ao .4/c7: �17 vow SEX 891 F CA NOW pal ngtuV sera Ildn! �uokN SPA M PM uqd tm wmp. SR P=m m -raft. omb� ou"'n Ba m fag Q 04 CL61 d 3 S - -:09A08d .41 N')A 2-1 v4Y." T a .41 N')A