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74.06 -1 -18 & 74.06 -1 -19
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03578
OWNER'S NAME
SITE LOCATION
PUTN AM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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MAILING ADDRESS V u- 3-IV&I;K
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PAID Canplaint #
Name & Relationship U.e, owner,tenant, etc.)
TYPE FACILITY
,cYJ�l1 (rs yLab.r� PHONE S' Z 6 ,5
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REGISTRATION # I ,:5q
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.____-
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Proposal approvedC oposal Disapproved
Inspector's Signature & Title
15
X14 V
Date
roposal approved with the following conditions:
1. Procurement of any Town permit, if apple able.
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 6' diem. 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, r reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
OPW: Miite (POND): Yellow (An HE); Pink (Applicant)
PC -RP 97
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TO NAM COU1�1T�' DE�.�It'�'-NgEi . ®lE HEALTH `
S _ r Division of Envi�onmenra/ Hea/rh Sewices Carmel, , N Y, ,10512 .
'CONSTRUCTI.ON PERMIT FOR : SEWAGE DISPOSAL '$VSTEnN 4,0
u
;Town, or Uillag`�7
Located_ at 6'7" d.flCuI r
Block I
Section ..
:'Subdivision Lot �° Job
/, ff i
i _ ` Address a .� f-,r
Owner LC : Q ti
j `. e , ciaol�� of Area C3 cnd lloiy e- r,
. .Buildin 9` T /§�. �/' • - .S(7 jt7 f
t YP.
s f Bedrooms Total Habitable.5pace �EiC%,C3. Square Feet
r
,!,.o,
,Separate Sewerage System to consist of %� °'a Gal Septic Tank ��`o ;Width trench
j F t ` r ..
:,.
To be constructed .byL� -�� T %��;^°� �dne (_ ' "Address - al e� X�
line
Water SuPPIy: Public :Supply''From �Ml X4i� _
Pnvate 'Supply to be drilled by ��
} d/ y�
-
I
Other quire Re
{ ments
i�I represent thaf Pam wh¢Ily and 'completely responsiblefor the design and location :of the s�j�,. m(s) 1) that the se paratesewage;disposalsystem 3
=: ye, de'scrWed� will be constructed as.shown -on - e,approved amendmentafieie fo and o nb�Wtt `standards; rules <an raga a ions.o ' e: u nam
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County. Department, of Health; and that on compietion._thereof a " Certficate ;of:C rfio�dCq�mpl ar f, tisfactory to-.the-.Commissioner of Health will Il
be,'
e submitted .to' the Department, and' a written guarantee MW 6e furni ;hed..the ; gt>3'successSr;a, e(is 'assigns by the builder; that' said builder will,
place ,in good operating condition' any part of .said sewage disposal system du n�p e'perio f two 2 y immediate,) followiri the date of the issu• .'
ance of -•the _approval of. the ;Certificate of Construction;'Compliance of the or iril! sysfe off py.repairs t o to; 2) that .the drilled9weWdescribed .above '.
pwUl be;located,as.sh"n on-the. approved plan and that sai&well will be installed •i Man WJtF th` itan ail rules and ,iegulations oof _-:the ,Putnam ,!
County Department of Health yy I
Sri- ti x ;<�� ry a �� x' w •{
Date Signed �T R.A.
P E 1
ddress
A �facense No r
bb. ��c•
APPROVED FOR CONSTRUCTION This approval expires one year from the --date' is Qpf� sS i io of the bwlding has -been .undertaken and is
revocable for 'cause .or may be amended or modified when considered necesse;ry by the 'Co eaIth :Any change or alteration of, construction
requires'a new permit Approved for disposal of domestic sanitary sewage a nd/ or pnvate water supply only
f;7 ate BY .Title I
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PV N COo_ --
•DIVIS i ON OF 7C S
Date ,� �°. 1171-
Re: Property ofr -aOt� _
Loca,ed at �M2�Oa.®6
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2-
. Section 7�k<• K3 B_oc�_ 2— Lot •.,`�`
Gar_tlenen
This le tar .s to a:.t o ^_✓ �— �e�C.
a .dul.y l_c ._J .e'-_. _�:'^i :. :JJ_��:�_ 'e or r.�v_Jv�h.�. ��'.. :•_��.�j- .
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Depa „=-~ens o' Heal "n, and to s, -n �_l ne:. ✓ssa -p ayers
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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.
Owner 1' 1 &nk T eZ Ak q0fte. Address ® Oq
Located at ( Street r'! />�,•..�
Sec. 6 - Block �- Lot
6—d—le--aT-5 nearest cross street)
Municipality Qm f-ma^A VILI * PJ- *atershed
SOIL PERCOLATION TEST DATA REQ IRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse p o a er water Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
1
2
3 O C. It vr•�J �o
4
5
2 Ire of
3
i
5
1
2 NY
3
4 �.
5
Notes: 1) Te'�ts 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 from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G. L.
6"
12"
18"
241'
30"
36.. OD
42"
`t8"
54
60"
66"
72"
78„
8411
} 10i C•
\A PIN
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INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WH5WATER L WSES AFTER BEING ENCOUNTERED
TESTS MADE BY C Date Z g,
DESIGN
Soil Rate Used d° 5' Min/l "Drop: S.D. Usable Area Provi___, 0 ® ®
or tic ..y
No. of Bedrooms 4— Septic Tank Capacity D ®® Gals-',P o ' �� aj0A
KI
Absorption Area Provided By L.F. x2411 "— `� /,V.K_dth fi c
ffl "r . - S her *
gnature
,
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTPENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by
Date
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