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HEALTH uT- -.,COUNT_ MENT -OF= '�' ju
5-Divisi^-of Enviroijrned6i Health
Services, _
r mel ,N..,. y 0512
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CERTIFICATE 0E-b0NStF&Tlb N_CoMPLIAN.CE,F R SEWA G E DISPOSAL
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Owner*
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Separate s4�,werage,,sygte!n,-�bMIlf-by�,��+ Address
Cons�st�ng of width tierich..
A
il. Septic w
-.,Other -.-jr
Water s 6 p f�.
Public _Supply
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x.-'N'S
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Address'
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.,Bbil.d.ldg�jVp , 0 ,A _446 of Bedrooms p Date UCAd
'Has Erosion Control Been Co
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i �cerufyfqa the - systems) :as, us
-at . tached) and in accordance Department of Healfh.
4�
Date E'.
a a. -..—
sl
72—"
_(License �0`.3'
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_�Mddr
Any person 9ccupying p r a '.
qqs. served f - ..............
3'0 v fe- "s y -
�cibnl! 4�e i
of. ahy'un'sa'nitary
i 66rditiors resulting from_ ikh usage ,Approval bAi�o e� ,r nd- v 9 1 d a public sanitary ei%becones
available a hal t supply eco as avaitable 'Such approvals :are
'sub)ect: to ,
I Wr
e,' j,ucmqn V-0 ltqn,R_r., chan e ii 'I s necessary-.
Owner or Parchaser of building
Kunio ipality
x�e.:..r:::, °.n -.�' • - wn. .gym .
..
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Building Constructed by
< '-�A .,`
MAP' -:._
P•.it
Location - Street
Block
Building Type Lot
GUARANTY OF SEPARATE SE-VAGE 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
ic'. nai.iS' ri -b t. -File+ wi_l 1 -Ri.1 nr nccrl irrem.i- ant..nf _tho.. nnrmnnnt _n f tho hi1i 1 riinrr rnt.i lA.7incr
The undersigned further agrees. to accept as conclusive the determination
of the Director of the Division of Environmental Health Services of the Putnam County_
De- partment of Health . as _:to -- whether,.or :not. -the- -failure- of the system_ to. oper -a -te- w.as.. -
" caii "sed - "by `the' "wil" fuTY "o`r``negl gent' act -of t` & occuparif -of the 'bui`ld ng`uf lizi�zg:.fhe
system
Dated this day of U G 19 Signature
Title _ �GJ.r/ER-
(if corporation, give name and address;
----------------------------------------------------------------------------- - - - - --
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
PUTNAM COUNTY DEPARTMENT OF HEALTH '
._.....•. :.r _ .. , .: N - ENVIRC3NMEN�A�;-
1 Date���
Re :_. Property of . �.s.�10
Located
Seel-Iren 68 Block Lot c6
Gentlemen: fl
T
ER
his letter is to authorize / �\' ��H `�= LAND
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
UU1111t:f1: L_1U11 W L Ldl L11J.5 MdLLev ,UIJU LU. Sl1Pel-VJ_Se. %he consrrucrion oT. sal
system or systems in conformity with the provisions of Article 14S or
_� 1:47a:'Educ_atier Law,:�fitre_Puhl7_ Neck} i:. I�aw ; :ando�the.:::Plufizam.:Coi%r►t� Sarii q 4_.:
tary Code.
. Very truly yours,
r7
Signed_
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Own4f of Pr6fi rt~y-
Coun ersigne: �4 ° 4-'f-
Address i'
.,€ #i 2� /
P.E 's � 1
e one
Address
STANLEY 9e
BOX 267 -
245-2645. ��. 3�1z
Telephone �' g�
1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION _ OF- ENVIRONMENTAL HEALTH SERVICES . - - - = - - - -- -- -
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM r FILE NO.
Owner %J,0i'�, -,W /"//c.f.t ZI .1�'E11c ,.I:L ��c%, A Qa -1 •s ' ,��,.c� `Y�,k1__
Address a ALL � a
iAAM-r4P J
Located at ( Street , ,��� - � �,� a w c, Block _5 Lot r
k Indicate nearest cross street)
Municipality ��Jn.) Vge7 Nr#%yG41_jA- Watershed ,.�;,�-Y`Gt ZXAe -gelo
SOIL PERCOLATION TEST DATA RE UI14D TO BE SUBMITTED WITH APPLICATIONS
Q --
Hole
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth
to Water
water Level
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
f
5
2Jsj= - Lx3 51 % r a
34,;4 4,
5
1
3 ..
Notes: 1) Te'�ts to be repeated at same depth until approximatelyy 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
?,ESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. 107 HOLE NO. /01' HOLE NO.:
G.L. liar'? 1- 6" �1
fj f,
12"
18" 3i,
24 �
30..
36"
42"
48"
5411
60"
66"
72"
r
t,
/) A
:"+
78" n..
84 l
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
n %y INDICATE LEVEL LEVEL TO WHICH WXTER ,LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date //
DESIGN
Soil Rate Used %ice ,Min/1 "Drop: S.D. Usable Area Provided
n
No . of Bedrooms Septic Tank Capacity �> Gals. Type
Absorption Area Provided By L.F.x24" � ° -width trench.
7 Other �
S,
ST 1e NDER _�r���fl�._ i;
Address
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved .. Sq. Ft /G °C _c'l y Late
k
t,
/) A
:"+
78" n..
84 l
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
n %y INDICATE LEVEL LEVEL TO WHICH WXTER ,LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date //
DESIGN
Soil Rate Used %ice ,Min/1 "Drop: S.D. Usable Area Provided
n
No . of Bedrooms Septic Tank Capacity �> Gals. Type
Absorption Area Provided By L.F.x24" � ° -width trench.
7 Other �
S,
ST 1e NDER _�r���fl�._ i;
Address
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved .. Sq. Ft /G °C _c'l y Late