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Home My WebLink About3404DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.08 -1 -50 BOX 27 Iry a .�; it Ll •, fir. :if, ` .,. 16 ` � r f I r r i4f-ILL -L Nit 11 03404 . . .. ! % 'LL, : * Ldeated' at . - t ! - - . x --Bld.k. 7, a Tax : , J � 'T MS Lot Lot OWnir built,: by V, "'I.— Address Se"Oaiate, -Sewerage System :nk and ,COnsisfl pg of Gal. Sept Ta a Other requirements " "°' 4", Water Publlc( 6pply From S'u ply; �+�' -Privaii:"Suooly 'Drilled y ddreii Building T pe No. of Bedrooms. Date Permit Issued 7 Has Erosion, Contiol :6ean: iboinpi"?. 'Has garbage. grinder. been' installed? listed- serving �h� th. completed work copies i certify that the syAsm(s).:as_ the lAns, o e of which' "are aiii6hed);L '"d `1�' accordance d t by the in ac6oidancowith,,,tfie f d"plim' h Putnam. C OU n Departmen t Of `ty Date Cert fled by P.E . R t V Add License N, , o. M? --, Any person occupying prerhisds,served ,by thi,ib640iiVitiM(s),ihall oidO6otly',ta e,"suc h fctlo _ necessary to' cure the correction of any unsanitary -conditions resulting ig fio m , such , diige t 7. ` A Pprova ;,OfA he sepaq e:s"qre, _ 111 ' ' i '' - "i. - ` Y A i s t sewer b ecomes available. and the approval of th ii , "Aq. public water supply becomes available. Such approvals are subject to Mod if Icai ion or nge'wIin, In the Iudgnent,othe Commissioner ,of4H alth,7su fi r vocato" , modIf Ic— ion o change -is necsury. Date Title Re 13 ,0 ►� p• 1� ¢. .ty.. WP�LL t�Vl'1rL�liViv L \�rVl�r DEPARTMENT OF HEALTH Division QOf-Environmental Health-Services m-r.:♦ :qs.: w. v..i .c r It ... -,.. 'IOF^: •..tiL -'^w C't'�'ti3 a .N. PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only _ Oe.s � «q \.:'h `Y "' i.... P t t ti 11WELL LOCATION STRE' AOURESS: WNI t Y TAX GRID NUMBER: C WELL OWNER NAME. nooaE MIA U. t bd,,.l �j (IQ kT O PRIVATE O PUBLIC USE OF WELL 1- primary 2 - secondary °RESIDENTIAL ❑.PUBLIC SUPPLY ❑ AI /COND.IHEAT PUMP O ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm.INO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY O.DEEPEN EXISTING WELL DEPTH DATA L � WELL DEPTH ft. STATIC WATER LEVEL ft. ` DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH fit. MATERIALS: STEEL ❑ PLASTIC O OTHER LENGTH.BELOW GRADE ft. JOINTS: O WELDED 'f§S THREADED O OTHER DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE )&bTHER WEIGHT PER FOOT __ lb./ft. I DRIVE SHOE2"qYES ❑ NO LINER:0YESNqNO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO SECOND .._ , _,_ . - HOURS GRAVEL PACK O YES O NO GRAVEL SIZE. DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM OEM It. WELL YIELD TEST pumping If detailed METHOD: O PUMPED ; tests were done is in- COMPRESSED AIR , formation attached? O BAILED Cl OTHER O YES ONO It more detailed formation descriptions or sieve analyses try �LL LOG are available. please attach. DEPTH FROM SURFACE water Bear- ing weft O,a- Meter FORMATION DESCRIPTION COOE. ft WELL DEPTH ft. DURATION hr. min. DRAWOOWN ft. YIELD gCm. Surface 0 WATER CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? ) YES ONO ANALYSIS ATTACHED? "YES O NO STORAGE QTAN�K : TYPE�� CAPACITY h �X c�.5I GAL. PUMP VFO MATION TYPE X101 e � RAPACITY MAKER V I DEPTH�"a%® MOOELj - �"� �� VOLTAGE HP WELL DRI ERN E E . jo AD S stcr JAL 2J I w, 32. O i'�4L i -Yorktown Medical Laboratory, Inc. LAB # i 321 Ke]r Street Date Taken: 10-14 Time : l i.0,)AYVI .T. 0' T A� (914)245.3203 Date Reported: OCT. U 0 7988 Director: Albert H. Padovani M.. 7. (ASCP) Collected By: Duane Torlish Referred By:.. I— 7 Sample Location: 'T TORLISH WELL DRILLING eAA PLjNA ht r- 14 ; ,OV PO Box 271 Armonk, NY Phone #'273-3h48 10504 pe1 r i L : J Repeat Test? _ (cheer .one) L?.BOR . ORY RE?ORT ON THE QUALITY OF WATER !NORGANIC..NON- METALS .(mR /L). MICROBIOLOGICAL D o` e -oc to - e — STF EFFF - Acidt Y GENERAL BACTEF.IA: Other:: a ..__ 1 1 n i t y 3 C lor.ide.:. Standard Plate-Co unt. _ Detergents,:'.MBAS (CFU /l.OmL),:.. _ Hardness, Total — Nitrogen, A.-.:aonia MEMBRAIIE FILTRATION T ECH ?1_IQUE 'di trogen, :nitrate / f P: osj'.7ate, Total t/ Total Coliform Sll_1fate —. Sulfide Fecal Coliform Sulfite Fecal.Streptococcus METALS ( ^Q /L) MOST PROBABLE. -NUMBER TEC'- :'IIgUE _ Corner Iron Total Coliform Index ..j A.a .. ....._ _. _ _ —1- _ - . Manganese T Fecal Coliform Index Mercury Sodium KEY FOR TERMINOLOGY Z_nc '.ISC =LT.: 11-OUS PH (units`). _ Color (units) _ Odor (TON) _ Turbidity (NTU) N/A = 11ot AnoIicable LT = Less Than (<) GT = Greater Than (>) TNTC= Too numerous To Count CON = Confluent ( =TNTC) NR = ;ion - reactive REMARKS /COMMENTS (For Lab Use) r Sample St'a:us'. . V u .. !! Q _ a. .. .. ..._ ... W,:10� _ :iCl� H2SOL _. 11a0:. Z n 0 A c `ia2S2b3 Other: Incominz ZLE LOC OT L0C. _ off LE 2 - o J:. — pH Other: THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS:') (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO T4 N YORK STATE DRINKING WATER. STANDARDS, FOR THE PARAMETERS TESTED, AT THE T E OF COLLECTION THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) N/A MEET'.THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA E D NKING.WATER CODES, FOR PARA ERS TESTED, AT THE TIME OF.COLLECTION. /x/ Albert H. W vani, M.T. (ASCP Director 2 /86(Rvsd7 /87)RWE O. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMMAL HEALTH SERVICES e�mer or chaser of Building uilding Con cted by Ile.e T-, a d2 -Location - Street �on Block Lot Subdivision Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM . I represent that I am wholly and completely responsible for the location, workananship, 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 - Constr-uc:.t on�, Compliance" . for the sewage disposal _- systgM,:_or .any - repairs made by ine to such system,' except where the failure to' operate tirdperly "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 ) &— day of C 191ff General Contractor (Owner) - Signature AiO7.-1 — A/ia M ZPe- Ajel� Corporation Name (if Corp.) Signature Ord- Title 4 I 205_ AlA�%,7 ��✓� Addres oak Ile.,� rev. 9/85 mk Z I-A 12PI JX'c Corporation Name (if Corp.) ,0�jeje �u AddresdV PUTNAM COUNTY DEPARTMENT OF HEALTH . 4\11 ONSTIt Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit q on CERTIFICATE OF COMPLIANCE N PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit q 8— Located at Subdivision Name v i ti11a 1� ALt:�`C Town or Village Lot q Tax ( Block Lot Renewal_ ❑ per_ Revia] 1 h Owner /Applicant Name �- C� Date of Hof Previous Approval {� Mailing Address ii [/�G C tr7MY+�i� V 71 - TbtGli w� zip Building Type �-+ t7a � I Lot Area I `d 19.1 x° FW Section Only Depth Volume Number of Bedrooms Design Flow G P D 00 PCHD Notification is Required When FN is completed Separate Sewerage System to consist of _J_!!��! Gallon Septic Tank and_1 9 To be constructed by , ° 73,D Address Water Supply; Public Supply From $ Address or: ti Private Supply Drilled by f ,-> - Address Other Reouirements I represent that 1 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 an regu a ions O 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 thedate 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 accordance with the st and , r les tl regu aTons of the Putnam County Department of Health. Date Signed P.E. R.A. - _50 Address l_iconse No APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless const►uctio of the building has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction requires a ne permit. Approved for disposal o domesticskpitary sewage, anti r' a water su ly only. 1/87 Date APPROVED, FOR reVOCabie•for Caul reQUires a n p Rev. _- 1/87 Date w t of •Hoatth 196 i -Address.1:� UCTI accordance With. the standards rules and regulations of the '.Putnafrl' r.uction;Compliance satisfactory to,'the Commissions[ of HOR thW, it. h!s,successor;,`ho { rs o'osstgns byahe Duiltler that ald, builder will a perkid "o4 tvvo;(2) years immediately folloWing thedate o4 the l su• . stem'or, any ropo.Irs thereto; ).that t o drilled•well described above ante with the "stand s„ s an r, egu a ,dons . of. the' puthem P.E. W.A. • Cense Nor fO� ld unless construction" of the building has 'been undertaken, and Is 6mm7asion ®r' of Health. Any change or ane►atfOn Cf construetIon te wete y• ... . ..+ 'Tit. SUM SWAMA um r 6f repr 2. -DEPAIMMENT OF., 74, Ri OFJeO zaq m �21MIJyj Licerh :N will ' �7�_`' ' � . DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #" WELL LOCATION Street. Address AM LLM 904D Town/Village/City Tax Grid Number tit, i 4" VAL W K - I I = 'tom l 9 IA WELL OWNER Name PNOW WVMARWT AFT Mailing Address JM Private WIkwoK 60AA046 (ZoGN44130AIR W,, %PxivW4 W6, 01Public USE OF-WELL 1 - primary 2 - secondary RESIDENTIAL ® BUSINESS 13 INDUSTRIAL OPUBLIC SUPPLY C]AIR /COND /HEAT PUMP OABANDONEID O FARM O TEST /OBSERVATION 0 OTHER (swelcify C31NSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED. P> /EST. OF DAILY USAGE (70)0 gal REASON FOR DRILLING ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY C TEST / OBSERVATI0N OREPLACE. EXISTING SUPPLY ODEEPEN EXISTING WELL DETAILED REASON FOR DRILLING v WELL TYPE DRILLED DRIVEN [DDUG ® GRAVEL Li OTHEI IS WELL SITE SUBJECT TO FLOODING? YES _ ( NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: HMTIW& IOC SEeT(yfA r Lot No. 4 WATER WELL CONTRACTOR: Name T. 6.1 Address: --- IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON REAR OF THIS APPLICATION ®ON SE TE SHE (date)' (signature) 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. Date Date 3. Submit a Well Completion Report on a form provided by the Putnam County .Health Department. •�� 19 Cif of Issue: C- - , Permit Issuing Off icy of Expiration: 19, r� Permit is Hon - Transferrable White ��° Yellcw ao ° 2/87 L'.z Pink Copy-. H.D. File .Building Inspector owner Y_ I' V4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL., N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. .5 2 3 4 5 Notes: 1) Tests to be repeated at same depth until a roximatel� equal soil rates are obtained at each percolation test hole. All data to e submitted for review. 2) Depth measurements to be made from top of hole. Owner Address Located at (Street� aV .&Z- Block Lot 2- Indicate nearest cross street) Muni cipality':::]�7u2p,d , Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION.} PERCOLATION RM 1. . I . Elapse Depth to Water , - water -LFv-eT- No. Time From Ground Surface in Inches. Soil Rate Start-Stop Min. 'Start Stop Drop in Min./in drop Inches Inches Inches 1 1 Zo 11 A"5- 2) 17, 3 2 I'Z'16 z � 19 z (Z' zo- 12;,A6 7,S 19 .5 2 3 4 5 Notes: 1) Tests to be repeated at same depth until a roximatel� equal soil rates are obtained at each percolation test hole. All data to e submitted for review. 2) Depth measurements to be made from top of hole. ?2.. .I . 78'f 84" -INDICATE L,F'VEEL; AT WHICH- ,GROLJN 14TATER IS ENCOUNTERED _ = - • _ ,. _ i _ -.:.. INDICATE LEVEL TO WfIICH'WATER LEVEL RISES APf1N BEING VCOUNTERED TESTS MADE BY 'T-'J �i�� -i-i Date oc-+ DESIGN Soil Rate Used_dL2(�Min/l "Drop: S.D. Usable Area Provided cp No. of Bedrooms 4 Septic k Capacity_ I ;, Gals . ,-/ -> Absorption Area Prod L. F. x24 ii 3b" wi ft, Signature Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: �-� _� --•`' Soil Rate Approved Sq. Ft /Gal. Checked by Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRZ 3' ON -Wl z - a0.11�'s IyCOjTIt�`l' RIiD y `.'PEST (HOLES° DEPTH HOLE NO. `�_ HOLE N0. HOLE NO. G.L. IL 12" a 181t b 2411 3011 ko 3611 42" 4$" 60" , 66" �� - -- ?2.. .I . 78'f 84" -INDICATE L,F'VEEL; AT WHICH- ,GROLJN 14TATER IS ENCOUNTERED _ = - • _ ,. _ i _ -.:.. INDICATE LEVEL TO WfIICH'WATER LEVEL RISES APf1N BEING VCOUNTERED TESTS MADE BY 'T-'J �i�� -i-i Date oc-+ DESIGN Soil Rate Used_dL2(�Min/l "Drop: S.D. Usable Area Provided cp No. of Bedrooms 4 Septic k Capacity_ I ;, Gals . ,-/ -> Absorption Area Prod L. F. x24 ii 3b" wi ft, Signature Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: �-� _� --•`' Soil Rate Approved Sq. Ft /Gal. Checked by Date 1 r DEPARTMENT OF HEALTH Division.of Environmental Health Services TWO COUNTY CENTER - CARMEL,, N.Y. 10512 (914) 225 -3641 °APPLTC,ATIO -CPC Y PCHD PERMIT 4 WELL LOCATION Street Address Town Vi lage City Tax Grid Number 1i -Zj WELL OWNER Name. ;. Mailing Address ivate O Public USE . 'OF WELL 1 -' .p'rimary 2 - secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY O FARM M INSTITUTIONAL Q AIR /COND /HEAT PUMP p TEST /OBSERVATION O STAND -BY ❑ ABANDONED 0 OTHER (specify, ® . AMOUNT. OF. USE YIELD SOUGHT 0- gpm /# PEOPLE SERVED 8 /EST. OF DAILY USAGE p gal REASON 'FOR. DRILLING SUPPLY 0REPLA E EXISTING OPROVIDE ADDITIONAL SUPPLY' SUPPLY. E3 DEEPEN EXISTING WELL . ❑TEST /OBSERVATION DETAILED REASON FOR DRILLING ,WELL TYPE BILLED D R IVEN QDUG O GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES IF WELL IS .LOCATED IN A REALTY SUBDIVISION, . NAME OF SUBDIVISION:y�.,TiuG Lot No. WATER' WELL CONTRACTOR: Name j tom, ►7.. Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:. YES L/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY - DTSTAiNCE- -TO" -PROPER`r1 RROM' NEAREST WATEE- *M* IY:-- ___.._' --' -. _;. _.._.._�.._ -. -- "' - „__ > ... _ .... u r _.. _._ -- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ]ON REAR OF THIS APPLICATION EPARAT HEE La% (date) signature) 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: / 4ZivV,,4, "2 19 9' ST' �Date of Expiration: 19 facia White copy: H.D. File Permit is Non' - Transferrable. Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF-ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW of Owner) - CCHMENTS SHEET - CONSTRUCTION PERMIT BDATE REVIEWED: Location) DOCUMENTS Permit Application Corporate_Resolution Plans - {Three sets s/s Engineers Authorization Design Data Sheet (DDS) SUBDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill Perc Hole Depth cd e Plans - Two sets permit; PWS letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc and deep results Two-Foot Contours Existing & Proposed _.._ Driveway & : S open. Cut -: • ., -:. - - Footing%Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's Win 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 0 .w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 2001 in.D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 35'to catch basin,stormdrain,piped watercourse (Street YES NO ` LF trench provided required 60 ft. max. Parellell to contours W _... r,/ FjU SYSTEMS _ \rplaybarrier 1'Q ft. .fi notes new pec. de u es Y 100 yr. flood elev. 0 4- 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL 7 13 PUTNAM COUNTY DEPARTMENT OF HEALTH`' �. -. :::.;':�.., „ A�n�:.:; r..".'=:. i' �S�fi? N�: O. F�.: Ei�I= �I�I:' �iI�fi; �N` I' 1� •'-FI£��''�''�'E]`%�3"�:.,..._ .. , n -._ ..:.,..__.__.�..:..:�, ..... Re: Property of Located at MI IIWUr-b . (T) °z" "41 (o7, Block Lot 2� Subdivision of .J I Subdv. Lot # Filed Map # °l Date 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 ..._ _-,..._.< :--- c-crnnnec�t�icrrrtrv��:ic-�h °taii-•s=_ maw -i; per•= �anciA. �ti�.,,.. s�up�e• rv- i- s�e--- �tYr�'- crsn�Cr��E1��3 'z5ii"'ts.f_.s�'°ic1 .._... wA....,., 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 yours, S gn a d kv. t "' Counter Q Owner of Propert �/°' ? y P.E. > R.A. > � Arit�rr�ca _ Address, i / ex/ - 4./, - 7, p ephone To*n ` q) 7,�s Telephone 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: represent that I am an officer or employee of the corporation and am authorized to act for %Zv y1 kv�koptlkjcc I , AdtWI\, {j (Name of Coffr�poration) k having offices at Uk& 2 0Ll W 614 �� Ud-rit, :�n 1L,� �e PAAI ill lC_ Whose officers are: President: Vice - President: ; Treasurer: Name and Address (Name and Address) �d��Avn 'kin a/! - , 7.I. Name and Address Name and Address X70 to R a en j 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 day Signed: hav\� of 19W Title: Aw � �j'fJ��j�i o t ' y Pub is g/84 f 4743051 @..L- ,, EVk a Mamh 30, 19 Corporate seal tlk7T�: HCU5115% AV40 Y,(OLJ- 1,01,ArIC4 A6 f`M 6LAKVra'( S.Zg>.fM> e4t. TRA14c, ir-leptA� R.D. \t \ A (a is All. Id(/L° IV 4W W OCT 94.1' fi A. ,,&-T t4 AW-C-A -.10i91 AC, 7z q 192. 154 L'F I I1 TA LAX-- 0 1'�CjO CAL- PAf;VKW-j' 1(00 L'F Of TKk- 4, LViSiOrl Of Environmental HealM Sarvioe- pproved as notod for co OrME460 with Lpplicable Rules and RegulatiSlis Of the I dtn-m bounty- th Departmel. lismaturp -TM# TD WIJ Or VWX -?A-S l-:N CA"Te 4)-, its T.& I'l e- 15 goo '1'2- wo:*S 94JO 44 4, LViSiOrl Of Environmental HealM Sarvioe- pproved as notod for co OrME460 with Lpplicable Rules and RegulatiSlis Of the I dtn-m bounty- th Departmel. lismaturp -TM# TD WIJ Or VWX -?A-S l-:N CA"Te 4)-, its