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1 1 , .
03401
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♦1: 1
PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER TO ,PROVIDE °PERritr..#
I ON CERT FICAT OF CO PLIA C
€�Ib Division of Environmental Health Services, Carmel, N. Y..10512 PERMIT
CONSTRUCTION PERMIT FOR SEWA E DISPOSAL SYSTEM
Town or Vilxe
T Locatetl a . yt . _ _. �_ clock;
Tax Map
Subdivision �r��' G� /7 r3 Suhd. Lot it Z Renewal _❑ Revision _❑
owner /Address ! L�/r^�M 10" ��'' -3 ✓ Date Of Previous Approval
i
Building Type �s Lot Area /�' �� 9 C Fill Section only ❑
a ' P. it. H. D. Notification Required
Number of Bedrooms � Design Flow G /P /D ' "'' 9
Separate Sewerage System to consist of �y•0, 19 Gal. Septic Tank and
To be constructed by s Address
Water Supply: Public Supply From
r Private Supply to be drilled by
Address
Other Requirements
I represent that I am wholly and completely responsible for the design and Ideal
above described will be constructed as shown on the approved amendment t6 e'
County Department of Health, and that on completion thereof a "Certificate;
be submitted to the Department, and a written guarantee will be furnished'
place in good operating condition any part of said sewage disposal system
ante of the approval of the Certificate of Construction, . Compliance of the
will be located as shown on the approved plan and that saidwell will be Installed
County Department of Health.
Date 49 Signed
Address
APPROVED FfOR CqNSTRUCTIO N: This"approval expir o Udered m
revocable for use r may be amended or modified when .c es r requires n v per pproved for disposal of dome w 9
Date ( /° By
Rev. 6/85 ..__
Ion of the 'pro osed system(s); 1) that the separate sewage disposal system
to and i �a�a�h the standards, rules an regu a ions o e Putnam
of fyc n p'�{s cell satisfactory to the Commissioner of Healthwill
t ra�of rs or assigns by the builder, that said builder will
d nng,N% $t• Fko) ears Immediately following thedate of the issu-
;g,sn �stem'or an pairs ereto; 2) that the drilled well described above
disc 41t11. tf .'sta ds, rules and regu ads of the Putnam
�
[ P.E. R.A.
L,� License No. i y '77 ;
I of the building has been undertaken,.and is
h. Any change or alteration of construAlon`;;' „.r
tly.'��.��
Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property o
Located at
(T/jf Section �}�, Block Lot.
Subdivision of
Subdvo Lot #
Filed Map #
Date
Gentlemen:
This letter_ is to authorize O C
a duly licensed professional engineer V 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 145 or ~`
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
X ", X
Address
c7,1�
ol
Te]lep one
0
Very truly yours,
r S'i n e d
Owner of Property
-- spa- - Address
J.
Town
��. F - 3 l �
Telephone
Date
Subdvo Lot #
Filed Map #
Date
Gentlemen:
This letter_ is to authorize O C
a duly licensed professional engineer V 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 145 or ~`
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
X ", X
Address
c7,1�
ol
Te]lep one
0
Very truly yours,
r S'i n e d
Owner of Property
-- spa- - Address
J.
Town
��. F - 3 l �
Telephone
PUIMM COUMi'Y . DEPARTMENT OF HEALTH .
DIVISION OF ENVIRONMERML HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTER FILE. NO. -- - - -_ -
- Owner' e fie, i e: Le ,*rc Address
-Located at ( Street) /�� ± G Pv' j, Sec. `� l:: Block Lot
(indices nearest crossstre /et)
Municipality '00V Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMr= WITH APPLICATIONS
Date of Pre= Soaking � . Date of Percolation Test'
HOLE
N�fl�I$ER CLOCK 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
ll
�r
0
4
5
4
1
2 VVbJ e',e_
-1:
3
,?
4
NOTES: 1. Tests to be repeated at same depth until appro metely equal soil rates
are cbtained: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 DATZ
UUM TO
OF SOILS
DEM. HOLE NO. HOLE NO. HOLE NO.
G.L." Xez
2' 1 7 A lory -r-weplov fen
31
14'
INDICATES -LEVEL AT. WHICH GROUNDWAiM 'IS EN00UNTERED . We;.
INDTCAIE *VEL twm WATER LEVEL RISES AFTER BEING ENOOUNTERED.
DEEP HOLE OBSERVATIONS MADE BY: DATE
DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable, Area Provided
No of , Bedro a ns Septic Tank Capacity j 67 -Cle' gals. 1)rW
Absorption Area Provided BY 3� L.F. x 24" width trench
Other
Name 7 Sig
V2
Address
Soil Rate Approved sq.ft/ . gal. Checked by Date
E
"t-1 4,46 3 12/ 78 �-APPEKDIX B
"SHORT MMIRONPUKTAL ASS E§= FORM
JNSTRL St
In.order to answer the n this 'short EAF is is assumed that the
e questions
1. use .
freparer wil, currently.aveilable iiiformation concerning
*
the•-project'and the
1k 1
01 e action" It s' not
impacts of th i expected that: additional studiest research
0r.0tKer investigations will be undertaken..
(b) If - any question has been answered Yes the project maybe significant and a,
completed Environmental Assessment Form is.necessarys,
k
(c.). If all questions have been answered No it is likely
that this project is
pot significant.
(d)'" Environmental Assessment
d
.,I*. Will project result in a large physical change
to the project•Site or physically alter more
than. 10 acres of land?
Yes No
2e Vill.there be a major change to.any unique or
✓
unusual land form found on the site?**
Yes No
3• Will project alter or have a large effect on
Yes No
an existing body'of water? 4 0 .6
4'e Will project have a.potentially large impacb on
No
groundwater quality?
59 Will project significantly effect drainage flow
'Yes NO
on adjacent sites?
.6. Will project affect any *threatened or . endangered
Z No
plant or animal species? .9
.708
7e Will pro ect result in .a VAJOr.adveres effect on
air quality?
Yes No
8. Will project have a major effect on visual .char-
• - alter of,-the-community. or scenic..views.-or vistas_
-to _t m
k-tb ei iiip6itaA the community?
known
0
9* Will projectadversely impact any site or struct-
ure, of historic, pre-historid, or paleontological
importance or any site designated.'as a critical
environmental area by a local agency? e 0
Yes. NO
'Vi4 project have a .ma jor effect on existing or
tpukirecreational opportunities?
Yes• v**' No
(11., Will Project result in major traffic.problems or
cause.a major effect to existing transportation
".0 6
Yes No
systems?
Will project regularly cause objectionable odors,
electrical distur
noise, glare, vibration, or
.
the p
ance -as -a result of roject's
Yes No
Will project have any impact on public health or
-safety ?.
Yes V/ No
14* -Will project iffect the existing 'community by', .
directly causing a growth in permanent popula-
tion of :more than 5 percent over a One-year
period or have a major negative -effect on the
0. EEO,,
character e community .-,r:h'eighb6rhOOd
h of th
No
the
Yes
15* 1 .:there'.public controversy'concernihg proji
s
P.
T
j
F
REPRESENTING: e
'b
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEfi M DISPOSAL SYSTEMS .
REVIEW SHEET - CONSTRUCTION PERMIT
_ DATE
(Name of ) (Street Location)
DOCUMENTS
-
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
If PWS - Letter
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
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
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
Expansion Area;shown;gravity flow,suff. size
If.--Pined-:Pit. & D Box, Shsizv & Detailed - „-;`
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & 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
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains- Curtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Eft- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
1
PUT'NAM COUNTY DEPART OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
rmff"LIVS C`If& 'REMRT
DATE:
�(0 le INSP. BY:
(Name of Owner (Street Location
INITIAL SITE INSPECTION YES NO L COMMENTS
Wetlands on /or proximate to property..............
Property lines or corners found ...................
Can estimate house location .......................
Will driveway need cut ......................
Must 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 ............................
D. H. 1 Lot
Depth to G.W.
Depth to rock ----
Soil Descri tion
0 ft.
3 ft.
6 ft.
9 f�.
D. H. 2 Lot
Depth to G.W.
Depth to rock
Soil Description
0 ft.
3 ft.
O IG-
6 it
9 ft/.
D. H. -Deep Hole
G.W.- Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
Soil Descri
0 ft.
3 ft.
6 ft.
9 ft'.
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
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. fran watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded...... ..... ..............
10 ft. maintained fran property line and.
20 fti from house... .........................
Distance well to SSDS (ft.) ......................
Number of bedroans checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. fran nearest trench ................
15 ft. of peripheral soil horizontally
from trench ..... ...............................
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 ..................
ti
ONE]
SITE LOCATION
0
IR
PHONE (7 �i/
T!#
PERSON INTERVIEWED —PCM-Eemplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE TYPE FACILITY
Pwposw i%TALLER PH= 6 2k- S7 3
' 24 - YV (e CP
Pro (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.
Proposal approved Proposal Disapproved
Da _
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 ccmponents 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
drywetls 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,r rted a of owner agree to the above conditions.
SIGNATURE TITLE
TI TF& Mite (MV; YeUc w (T v n BI); Pink (Ani icant)
DATE
t r,• r f _ -- , " � - fir¢
_ w .w- ..+yA- � -m-c -. ..ara.� .p.� _a ' _,. .;.�- ...�..,- ,.a..._.,.._.w....., _,.. �.�...�.e_ ..gin -_•,�. y _.. //, �._
.... .._. - -. . —,;��• — <j _ , ... .: _. .. v- ...,.. __..._ ._ ._ 'jN � �� � y . �% - ,fir
;a
Yv
Yl
is 4. ! �° 14
NA
i
�1 J
Enr•.. a r= _ .. n•.:._.. ..•.F,�n . _ .� , , c_n,.ti•- s.an. r .. -
.._...... ...,.,,,.,� -'��1? ��ir a aril S✓ ............. � : t
Rev
',Located at
Owner /applicant Name
Mail .Addeeee
`.r
Separate Sewerige SyeI
pate �� —� —T—
Anv. oirson occuoVO4:0remises'si
M
_Addri3ea �_
ra �
✓v,
of -lthe plena of the completed work ( copies
filed. `plan
and the .permit issued by the
R.A... .
a N
Cliena o. '
v �o t6eu►e the cdrreotlon of any unwnitaiy
noon as a pubs Unitary paler become
6 d,haeo Mai :iwallable Such -aoorovals are
i
Wkto�vn Medical Laboratory, Inc. ,AB - - --
321 KearStreet Date Taken: It)- Time
Yorktown Heights, N. Y..10598 _ __ Date Re I d - Time •
x(914) 245- 2800"..
Director: Albert H. Padovani M. T. (ASCP) Collected By : So NAG
_ Referred By:
T 1 Sample Location:
l� U�� d ��7so•� �,� , is ��✓.�rn. V�L�
Phone #f
L IIOP�s�t' �/ Phone' # Sample Type
/ J Repeat Test? _ (check each)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC'--NO-N--METALS mg -.L
Acidity.
Alkalinity
Chloride
Detergents, MBAS
Hardness, Total
Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
Sulfate
Sulfide
Sulfite
METALS (mg /L)
Copper
Iron
Lead
`! Marigahe`s'e "
_ Mercury
Sodium
Zinc
MISCELLANEOUS
pH (units)
_ Color (units)
Odor (TON)
Turbidity (NTU)
MICROBIOLOGICAL CFU /100mL
GENERAL BACTERIA
Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIrQUE
Zotal Coliform
Fe.c'al-Coliform:
F.ecal.Streptoc.occus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Col-ifdrm `Index _ - • :T
KEY .FO .:
TERMINOLOGY•
CFU =
Colony Forming Units
CON =
Confluent (q.v. TNTC)
LT =
< = Less Than
GT _
> = Greater Than
N/A =
Not Applicable
S/A =
.See Attached
TNTC=
Too Numerous To Count
REMARKS
/COMMENTS (For Lab Use)
_ /Potable
N -on- potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
HNO3
HC1
_. H2SO4
_ NaOH
ZnOAc
Na2S203
Other:
Incoming. =
✓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) (Wasn't) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING.TO T NEW. ORK STATE PUBLIC DRINKING
WATER CODES, FOR THE'PARAMETERS TESTED, AT TH E OF SAMPLE COLLfCTION.
THESE RESULTS J NDICATE THAT THE WATER SAMPLE (Did) (Didn't) (N /A') MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARRS'OF THE NEW YORK PUBLIC DRIN NG WATER
CODES, FOR THE PARAMETERS TESTED; AT: -THE TIME OF SAMPLE COLLECT
Lx l L.� %i i�z� 1ell,
Albert, H. Padovgni, M.V' (ASCP), Dinectcr
2 /86(Rvsd7 /.87)RWE
j.
PUTNAM COLUEY DEPARIMENr OF HEALTH
DIVISION -OF ENVIRONMENTAL HEALTH SERVICES
AV S 19
Owner. or Purchaser of Building Section Block Lot
i`
Building Constructed by
Location - Street
l uon/4
Municipality
Building Type
Subdivision Names
Subdivision Lot #
GUARANTM 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
"Certificate of Construction Compliance" for-the sewage _disposal system,; or any
made- b m-tc-=such•-s stem eXCe t where --the =+fai uru -to- o er`att2 ro eYl
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 Environmental 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 he buil g utilizing
the system. .
Dated is day of 19
General Contractor ( ) - Signature
�OIV /DV* -C,
Corporation Name (if Corp.)
Adair ,�6 ��iCc.�c y ss
rev. 9/85
mk
Signature
Title
90s f4 A) 4 [f�AtCt-
So 1�fi7tfi - .
Co ration Name (if Corp.)
(f9L F,X c__
Address
r1
T.TVT T fInAMT LMTTnTT DVnnDT
��ti ✓� YYJ;AJ.JL VVL "LL L1L 1. 1VLY L \LPL VL \L
`1, .• DEPARTMENT OF HEALTH
- Divisign Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
.
., .
Y
a..w.ura.
WELL LOCATION
STREET AOURESS: wwwl I Y TAX GRIO UMBER:
PEEKSKILL HOLLOW ROAD' PUTNAM VALLEY, N. Y. 10579
WELL OWNER
NAME: ADDRESS:
m PSIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
0 RESIDENTIAL O PUBLIC,SUPPLY O AIR /COND. /HEAT PUMP. ❑ ABANDONED
❑ BUSINESS .❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY 0
MOUNT OF USE
YIELD SOUGHT 5 gal gpm. /NO. PEOPLE SERVED --- / EST. OF DAILY USAGE 500 gal
REA90H FOR
DRILLING
0 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 240' ft.
STATIC WATER LEVEL 2L— ft.
DATE MEASURED 5/8/89
DRILLING
EQUIPMENT
q ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG .
❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING, OPEN HOLE IN BEDROCK 0 OTHER
TOTAL LENGTH 147 ft.
MATERIALS: 8 STEEL ❑ PLASTIC ❑ OTHER
CASING
LENGTH..BELOW GRADE 1452_ ft.
JOINTS: ❑ WELDED t7 THREADED ❑ OTHER
DETAILS
DIAMETER 6" in.
SEAL: O CEMENT GROUT 0 8ENTONITE ®OTHER
WEIGHT
PER FOOT 5 Ib. /ft.
DRIVE SHOE:ffl YES ❑ NO
LINER: ❑ YES 10 NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH
(1t)
DEPTH TO SCREEN (it)
DEVELOPED?
DETAILS
FIRST
o YES._,❑ ND
_ » _
SECOND.-
__
_.. .......
- - -
_ .. a ».,.
- , _ti : F .- r...._
HOURS ^` T
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER TOP
OF PACK in. DEPTH
ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST It detailed pumping
METHOD: O PUMPED t tests were done is in-
l
® COMPRESSED AIR ,formation attached?
O BAILED ❑OTHER i ❑YES ❑ NO
�IFLL LQG 1t. more detailed formation descfiptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
I "9
Well
Dla-
meter
FORMATION DESCRIPTION
CODE,
ft
iL
WELL DEPTH
ft,
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
137 v
hard an overburden
137
24011
1
bedrock limestone
Op.
7+
none
10
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE LM.r x TRnr. #302 tank
CAPACITY 220 gallons GAL.
PUMP INFORMATION
1 phase 3 wire
TYPE cAPaclrr __�.
MAKER GRUNDFOS DEPTH A 220'
MODEL 5S0513— VOLTAGE 2M HP .1
WELL DRILLER NAME DATE
NORMAN ANDERSON INC r "d /b
ADDRESS 152 BARGER STREET slGfnMRE
PUTNAM VALLEY, N. Y. 10579 � ,
u� nw
SIRS ICC4- IC)N' �S)Ce, —10 C4vi1� R �/ �✓
21 p OR. Su`EDIVISICN LOT z
� YF.9 NC]
CCYkS
•
1. SLS.0 -c� DISPOSAL ARF-lk
_
b. Fill Date of Plac--nent '
2:1 barrier . I=- W== AVG.DPTH
c. Natural soill not st=n =De3 I • I I
d. Stone, bra--a, etc-, create-* than 15' free SLS
e. 100 ft_ from water course /wetlands_ I�-I-
II_ S�� DISPOSP.L SYS T _ i
a_ septic tank size -UAOO 1,250
b.
c.
d.
e.
f.
a.
gestic tank inst�= I I eval
10' mi n in= from four_: anon
No 90° bergs, cLe_snoLt wit= 10 ft- of 450 bend
DISTRIBLTICN BOX
1. Pal cutler at saw el evation - water test ea
2 Prot-t.� below f_cst
3. M.inittIl t 2 ft-- cr_c? r`l soi? b=— -We= -n box and t= *e lees
JUNCTION BOX - vro�iv set
MS
1. Izn h reru? rea - V I+C ^_�i_rl II15ial V r
2 Distance to wap = rsc
3. Instt.�l l ea a:' crdinq to plan
4. Dis tanC°_ csnt,---- to c- -it --r
5 Slorz of trench ac=t able 1/16 - 1/32 " /foot. ,N-7
6 10 f=-t fren prcce"v line - 20 feet - four�a'a crs
7. Depth of t=anch < 30 inches fran sar =ace
8. Roan a-1-1 a4ea for Er..arGion, 50
9. Size of c__vel 3/4 - li"
i m= I
10- Deoth of crravel L'1 trench 12" minim=
�•I
I
(�)
h ( I
L
I I
L! . • Pipe e---ds Ciip -
h. 1-i_ ClR DOSE' SYS -S
1. Size of p= ch=bar
--
3. P1ann, vistr? /wad o --
4 Pc= e=s'! v a= ^e_c=ible manhole t0 arc0.e
5. Firs' b=c haZflea
6. dole w. mes_1t by Emssa th Ds. Ent-
estt_ZIISat� Z! cw �.-z Cdcl-e
IV. Ec; ..:,
P-- F -curse locatea ver &morGtied plans_
b. Nmhsr of be'?rcc s
I
I
t
I
i
I
I I
V. , .r
a. Well lcC}t= as rg--r approval plans
b. Distance f,cA SLS a=ete msms'ared
I I
C.
C?s?nq 18" grove orzc =_
_,,
C.. Surface dr-a nn.ce a=cL�r..d well acceo -tile.
ocE�LL woRsLLI�
a. Rmes propp-nlV crcut=
b. Ail pices ra*=`aLy b- 26Ciled
( i
�
c.
Pid flu-=h with inside of bc�
I SZI
d.
iackfill material c^nt_ins stones < 4" in diameter
I I
e.
f.
0 -`t ain drain install--d `ac- ordinc; to plan I I I
Curtain dam= ri cut=a11 wrote Led & di r. to eYist.wate- -=Ursd
g.
Footing drains discrtrne awa fran SDS area
h.
Surface water orot., c—ticn adeo- ate
�
i.
E csi.on c--n=o r)r.zv--,c.ed cn sloLes Qreat_-_r than 15 %-
I I_
.; a �S i � 3- � E `, v J,,,l -.� `^ r "t�-F„ * c,,T 5�. ti r�,.`G s 'ta" c 3 t '�' l ,�, � <? a a �' • �. g"``" '; i •
-
�, 1'I 'b • "` � ; , x ,� PVTtvAM cour>� DEPARTnn,�rrrroFHEAr;Ta
e Dlvlsfon of Envlionmental Health ServlceB Carmel, N Y 10511 rs ` Englneee to Provide Pecmit;N
o �' yy1f� } r on CERTIFICATE OFTcOMPL1AN� `
q A�
a CONSTR CTIONPE FOR SEWAGE DISPOSAL SYSTEM rz
F
s .,-. YaRZi�ON at Y�Z/ '�Y� .� �4Pf 3>',� yti. rt n ^-.+ ✓ {••. ,+- „>�TOMII,«rOL.- �,11^^ a � xi r •' .. � .. -'
SQbdivl ®ion Plsme f � dii?
/ / Renewal ❑ t Revlelon
Ow"F,v pUt�nt Flame /iL. f
1� r Dote o ,jkL ioa ®-,Apfprova�l/
Mol11uS Addr®ss S D�� a��'o✓9j� Towns =/��/7 (/�;.�j
�� `
Bvlldhtg rType ,Lot Area v FW :Secdon OWy Depth'Volbme
Rlambee of Bedrooms Design Flow G P D PCHD PloHticatloq ig Reataired When FW le �tnpieted
Se crate Sewe e;S stem to,ironsist of Gallon Sepdc Tack and
To be constiaMed by. ° Addres®
Watee Sttpply Pabllc Sttppiy Flom Address
oat Private Sopply Dewed by Addree®
1 re0resent that I am wholly ands completely responsible forthe design and IOCaUon of the propose i.Q'F) ipjhe separate .sewage disposal system
6DOVe descnbeG wilLbe constructed as shown on the approved amendment there'ato and m accords �t .a6este ®` {du an regu a ions o a ..0 nam
County a Oepartment of Health and that on c mpletYon thereof a i Cert�fuate. of COnstruetio 0 8A�4 �ia4ior tho Commiss�oner.ot Hedlthwlll
bo submdted Mto the 'Department $and -a written .guarantee will be furnished the owner hH ice heirs or astiell
y: a Du�lrler` that said builder will
place ,n goodtoperatjng conddion Rany;`;part of ia�d sewage d�sDOsal systemxtluring the pe fF o'(2 "t; im e$fatel following thod'a of the issu-
onCe�Ofz the, .8pprovat of the Cert �f mate,of ConstrucUon_COmphance of the;OngmalY yste or, re - -• s - Ito �a%it ''drilled Well, describetl',ebove
arils :be located as shmyn On the approved plan andAhat ssid, well will De Insta11' i Ordane w`;i he-� rules u -a i�'ohs . i<-:t o, he : `Putnam
COUnty De `tmont o[ Health'.`—
Date' ���7 Signed
l
i PE RAr
? Address /y� ense No
APPROVED FOR CONSTRUCTION Thad approval expuas two y rs h the, date issued unle c tl*jj ®6 '3h ding has'.been undertaken and is
revocable for.'Uu' a or,rniy ie �a'mendeo of motldied wnen cons' Bred, - ec ssary" by the ;_Commission - j h nge or'alteration- of-construction
requires a w permit. A proved fordisp sal of domestic sand wage -an /or to er s 8E3 °floc
Rev:: '
Title
-1/87- Date
.. p.. ...87 -�' .a. -.-,o .. ..... r,- ..�.w:... �.- t . -� -o _..7 �,,.,�..,. d .'•.. «.. f w ;.� r. _..ia- �p0.._e.,. -. s,.— +P- ,.:..w...a..r.. .d.-. �..- v. «..-.e
In
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N:Y. 10512 (114) 225 -3641
AEPLIrAT.ZON. _T,0 CONSTl2LTCT.._A WA'PER WELL -
_ ... r -
PCHD PERMIT`# vi
WELL LOCATION
Street Address T wn /Vill e City Tax Grid Number
WELL OWNER
,.Name f Address.
i N
rivate
O Public
�. ,�!/J!•' /'d t �'�
USE OF WELL
W6SIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /CO D /HEAT PUMP
0 ABANDONED
1 - primary
O BUSINESS 0 FARM ❑ TEST /OBSERVATION
❑ OTHER (specify
2- secondary
0 INDUSTRIAL U INSTITUTIONAL O STAND -BY
0
AMOUNT OF USE
Y ELD SOUGHT. S"' gpm /# PFOPLE SERVED 4 /EST. OF DAILY USAGE dot) gal
REASON FOR
NEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY
❑TEST /OBSERVATION
DRILLING
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED DRIVEN DUG ❑ GRAVEL
O
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Y NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name 1jewl A ---> Address: % /Yi!✓,3 '
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 91' NO
NAME'OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
rDISTANCE�TO;._ ROPER Y FROM --- NEAREST -WATER -MAIN
LOCATION SKETCH & SOURCES.OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION ®06N SEPARATE SHEET
(date)
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 by the Putnam County
Health Department.
Date of Issue: 8- 3 19
Date of Expiration: - / _19 Permit Issuing Official
Permit is Non - Transferrable
8/86
DIVISIU4 OF EM11UZil-NrAL 1it1t All SUNICES
DESIGN [BATA StiEET- SUPSUEACE SEWAGE DISPOSAL SYSTR4 FILE 'ND. � ,
„ § e, ?70
._.. ._'�ler. ':>" � "'w. -- .;ieSS.- �f ti'� / /�ts': ✓+? c;/4".!r !.•I
Lxatc'. A at (Street ! Seco Block
(indicate nearest cross street)
}
Watershed
Son TEST DATA RT-"'YJIM TO BE SUMMED WI'.[ii APPLICA7.`IONS
W+I. Y
Date of °x >_� rr�g _ Date of Per a est
MUSF ' C S _a�X TIl E PERCOLATION OL.ATION PE RC'b
Run El i;; Deptl to Water. From Water Level
No. Ti'M ' Groand Surface In Inches Soi.l�'
Star :- Stop Man ;' Sta i Stop Drop In N11nf Ii^
,z
_ fiches , Inches Inches
S /
---- -- 0
43
5
✓f
4
t � � + R � •Y�� 1
t r
� s
H
5 E
6y' r t
w
Tests to 1,P.. F eFeated
at �Ck z'�YJt:r iiCBt i � a�?prC34�ikitP��i
E! "�Lkix .Soli ,fit f�
art: obuti.nal at E�>ch
percolation test hole. All data
to be
,ept n"
f lc... -top of Ixal.e,
R-
TEST PIT DATA REQUIRED TO BE .SUBMITTED WITH APPLICATION
a
DESCRIPTION OF
SOILS ENCOUNTERED IN TEST HOLES
j DEPTH
HOLE NO.. !
HOLE)T NO.
HOLE NO.
3'
4'
5'
6'
71
8'
g'
10'
11' �
12'
13'
14'
INDICATE JaUEL AT. WHICH GROUNDWAR.:IS : FNCOUNTERHD,.:-
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTE/R %BEING ENOOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: " et // / r DATE:
DESIGN
Soil Rate Used All. Min /1" Drop: S.D. Usable Area Provided g:sl6ac?
No. of Bedrooms Septic Tank Capacity /-> 4 gals. TypEeG </-_17jo'y
Absorption'Area Provided By 9*0. L.F. x 24" width trench `!
Other
Name
C
Signature 'L ••NE �E�
W
Address i// ° SEAL
9
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
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
Mr. Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, New York 10598
Dear Mr.. Sullivan:
August 31, 1987
Re: Proposed SSDS
JOHN SIMMONS,_ M.D.
Deputy Commissioner
JOHN KARELL. Jr., P.E.
Director
Sonaro
Peekskill Hollow Road
(T) Putnam Valley
TM #62- 9 -P /08
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:
1. House plans submitted include a utility /storage, room.. with
h-obb �,r'obifi �&nd- 1zoft-- rbom: _: _-
s y
Any of which can be easily converted in' the future to a bed-
room, it is the recommendation of this Department the SSDS
design be based on 5 bedrooms.
Upon receipt of a submission, revised to reflect the above
comments, this application will be considered further.
Very_ - ,truly yours,
Robert Morris
Environmental Health Technician
RM /jp
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION-OF ENVIRONMENTAL ..HEALTH.SERVICES
Date
Property of
Located at e ev,6 Xz:
(T)
Subdivision of
41.1 ac/1-
/ A/
.Section 12- Block Lot z e
Subdv..., Lot # Filed Map # Date
Gentlemen:
letter is to a
This l' uthorize____ V'Setzv-
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 t4*-s. !Rq�:tpr and to.:.'.Su, ex vise.. the
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 yo s,
Signed aw
Coun ersigne A Mner of Property
ee.eo se
S
P.E., R a
Address
Pr
?A; Ce K S
ess Town
1/4 73 74V 0
Telephone
Telephorie
VAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF E NVIRONMEN I�A I , H h:A l xn ozmv v v
au � �n ►: rt�iY�;�•yi�a�A��'�•'i� : ���t :��+:�+�aia "n.�h��ar.7��:a�ll
REVIEW SHEET - C /ON�ST�RUCTION P T -
REV
DATE IEWED:
(Name of Owner)
CONQ�iENTS YES NO ( DOCUMENT'S
Permit Application
Caraorate Resolution -
Plans - Three sets s/s
Engineers Authorization -
Design Data Sheet (DCS) (� SUBDIVISION
Deep Hole Log j Perc -
Consistent Perc Results (3) Fill -
Perc Hole Depth ca
House Plans - Two sets
Well permit; PWS letter
Varian e Request
GENERAL '
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D) t
Data On DDS Plans & Permit Saner '
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flcw
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
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
�,crtrg; :stter;art?.s -. -L:i rid; (d1s�i�dzge OK) _ ;
Perc & Deep Holes Located
Representative of primary and expansion 1
Expansion Area;shown;gravity flow,suff. size �.
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & 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 fil:
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake Unc. expan
15' to Drains - Curtain, Leader, Footing
35'to catch basin,stormdrain,piped watercours►
10' to Water Line (pits -20'.)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
10
DIVISION OF EMIIUk*NI'AL IUTALV SF.IWICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE ND.
Omer. - Address
'l' c. ... r. _ - .�....... _ it .V J- 7.l -FY A /.. •.f. ar'...wr.- _ —.'.R - - -. _.w. - .•
Located. at (Street) Sec. Block Loth
(indicate nearest cross street) —'
Municipality Watershed
Date of Pre- Soaking
f.��Date of Percola ion g' Test 1�
HOLE
-
NU4BER 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
4
5
/t,//j
c� f
4
5
er
lAr
. 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 DA`T'A RMUIRM `i'O LIE SUI M1'1'1'M W1111 APPLICATION
DESCRIPTION OF SOILS ENCOUNITM IN TEST HODS
DEPTH HOLE NO. HOLE NO. HOLE ND. 1
1'
2.'
4'
5'
6'
7'
8'
9'
10'
I1'
12'
13'
14'
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENODUNTERED _
DEEP HOLE OBSERVATIONS MADE BY s , t�/ DATE: ®4 J dr _
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided
No. of Bedroams _ Septic Tank Capacity A& gals. Type Aoz5,0,0 r
Absorption Area Provided By L.F. x 24" width trench
Other
Soil Rate Approved
_._.:._ k:..�
BRUCE R. FOLEY
__ ... .. , - , -: . -; ;�'ublic��Heahh•= �ecPor= :rr�.,
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509 _
Tel. (914) 278-61,30 Fax (914) 278-7921,
PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY 6r_
r_�C(06(1140110t"INOWN PVVV-114TXMAP#
STREET
4f
NAME i)- PHONE PCHD #
MAILING ADDRESS
DESCRIPTION OF ADDITION
s .
'g
NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS
..(FROM'CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDING INSPECTOR)
*Any. addition which is considered a bedroom requires formal approval of plans (Construction
Permit) prepared by a Professional Engineer or Registered Architect in accordance with
applicable sections of the Putnam County Sanitary Code.
and 'the`fcllcving�toutn i-n•-ounty i�i~alth Dirpt.�eneva'Rti:,
Brewster,, NY; 10509, Phone 278 -6130.
Certified check or money order for $100.00
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
* Non - professional sketches are acceptable
3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #)
* Non - professional sketches are acceptable
4. Copy of survey showing well and septic location, to the best of your knowledge. Include date
of installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
5. Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal
bedroom count of dwelling.
OFFICE USE
Comments
Feb 98
{ +
Q BRUCE R. FOLEY
_�blic - Health
DEPARTMENT OF HEALTH
Division of Environmental Health .Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
November 19, 1998
Mr. S onara
486 Peekskill Hollow Road
Putnam Valley NY 10579
Re: Addition - Sonara, Peekskill Hollow Road
Increase in Number of Bedrooms
(T) Putnam Valley, TM# 62.9 -8.2
Dear Mr. Sonara:
I have received and reviewed the plans for the proposed addition to the above mentioned residence.
The proposal for the addition has been approved as per plans bearing the latest revision date of
November 19, 1998 and this Department's approval stamp.
Based on the information submitted, the above mentioned addition is approved with the following
conditions:
1. The total number of bedrooms must remain at four without prior approval by this .
Department.
lie urea of the- existrnb sewage dispm — system ;-arid its expansion area, must be
maintained.
3. All plumbing fixtures must be updated with water saving devices, i.e., new low
flush toilets, restructures for shower heads and faucets, etc.
Any other permits or variances required are the responsibility of the applicant and. the jurisdiction
of the Town of Putnam Valley.
If you have any questions, please contact me at your convenience.
VerytNly yours,
R. Foley
Health Director
BRF:tn
cc: BI (T)
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J -'t .�;v'41' � z1t.YrPh' Ap �� .• .! _.. _......_ ...:- - ...... _ •♦ '.. � � . _ r ...
r e
CLiiTIFICA'PE OF(CCAIJC'' `" °0ci� Tariil y W /Dck ;Garage
Certificate of Occupancy No.......................... `Application No 88 160 4 r
t' i'eekskill Hollow Road - TFi;62 -9 8 F.�
Location of Premises ..... ... •.t ` ..............................
Husein &': Pa it$IEE S'o'n: ara of .11 Qld QreAon Rd. Peeksl.I1�:
...................... ........p....
...
• ,:� .........:::. having
<< heretofore filed ari app lication for a building` permit pursuant, to the Zoning Ordinance; Sanitary
Code .in& the Laws & effect in the Town' of Putnam Valley," Putnam County, New; York, having
paid., the requ>xed; fee., therefor. and the 'undersigned ,Having. by personal..., inspection: ascertained. that
the, a plicant has, Subsequently proceeded`with; the. erection or, improvement of the' propo ed struc
pp
ture , in,;, compliance:; with. the: requirements; of. the; laws as :', aforementioned and that, the said ,work'
and materials met . every,. requirement, of the laws . as aforementioned ` and _that the premises" have
now • tieen, fully com leted and are read for occu ancy 'pursuant to :the provisions of _ law, Now,
pp y p
therefore, this certificate . of occupancy is. hereby: issued under': the seal of .the Town of Putnam
Valley (this 16 ' day; of J a n u a r4r .. , 199 0
Not valid unless signed in ink by a duly authorized agent TOWN' >(fTNAM V , N YORK
of and under :the seal of the Town of Putnam:. Valley,.. i, �i
By
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11
PUTNAM COUNTY'DEPARTME.NT OF, HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'
INITIAL INDIVUDAL ADDITION /REPAIR FORM
I. '. ..
. . . r. _.. . .. b.:_ s1
SECTION A: GENERAL INFORMATION
Name of Project
Year of Construction Size'of Parcel 4-.C- " P S
SECTION B. TOPOGRAPHY (Please check'all appropriate boxes)
t
1. Hilly ORolling. ateep Slope Mentle Slope ®Flat
2. ®Evidence of wetland Clow area subject to flooding ®Bodies of water
UDrainaae ditches ORock outcrop
YES 1-N-0
3. Property lines evident?
�, .. 4. Water courses exist o n adjacent to parcel:
, or J P
5. Existing individual wells within 200ft of the existing SSTS? O.
SECTION C. EXISTING SUBSURFACE SE`VAGE TREATMENT'SYSTEIVI(SSTS)
1. Physical character of existing SSTS area.
A. OLevel Mentle'Slope LJSteep slope
B. OWell drained 0/moderately well drained
OSomewhat poorly drained OPoorly drained
C. Area available for SSTS. (Primary & Reserve)
®Extremely limited ❑Somewhat limited IMequate ft x ft
4, •. Ir.
D. INSPECTION Date I Y I Inspector
.9
No evidence of failure Evidence ;of failure' .(LJEvidence* of seasonal failure
- -- ---- - - -- -----------
- - - -- (Indicate - - - - - - - - - - North) -
J I )
Y
(� . HOUSE
bu <_
"Ibo ?A,
0
--------------------- ------ 0 -----------------------------
(1) Indicate location of SSTS
A. Size and type of septic tank 0 0 gallons
Metal 0/concrete ®Plastic
B. Type of absorption area
-, "
1. Fields' - ft. T. Pits 3. Gallies ft.
(2) In"di666 setbacks, front street, ackyard, and side yard dimensions
(3 )) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTING WATER SUPPLY
DP W S ®Shared well 3 dividual well
DDrilled DDug 'above ground
COMMENTS 'd s
REPAIRS ONLY: Status:
As Built Inspection Required: As Built Submitted:.
As Built Inspection Done:
(nr1drP.n)
Inspector:
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Putnam County Department of Healtn
Avis i o Y E nme4tpl ealth Serdioee
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ipproved as noted YoT conformance with '
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applicable Rules..and Regulations of
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?utnam County Health Department..
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PUTNAM COUNTY DEPARTMENT OF HEALTH
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY;
J _ s�6EDROOMS
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LOWER LEVEL PLAN