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03745
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PUTNAM COUNTY DEPARTMENT OF HEALTH
Dniisron of 'Enwronmente/ Hae /th : Servfoes,' Carrie% N Y 105 12 u Permit e '
a ;k
CERTIFICA . OF CONSTRUCTION.:COMPLIANCE FOR ,SEVIAGE DISPOSAL SYSTEM
e Town' Or Village
V /
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(p .
LOCated' at -. Tax Map- Block L�
L Ovvner T Q .. - Formerly Tax�Map Lot: # s t R
Separate Sewerage System built byNTVf�' Address ✓�� �L���
i [,�, — 7�%t�%fs� �crOlyU , �y
Consisting of ��/OaL epfle' Tank and ' f
Other requirements ��""'�
Water Supply: Public Supply Frorn
•^ N AMOt s a- ..
Private SuDP1y.Drilled BY
$itie��L ; .rT P,.rM FU.arY:
Address
Building Type �lL�a!! No, of Bodrooms_ Date Permit Issued 3 23
Has Erosion Control Been Completed?
I certify that the systems) as listed seivinq'the above premises were constructed essentially as.shown on the plansof the completed'work ( copies
of which are attached), and in accordance with the stan3ards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health.
Date Certified by. P.E. R.A:
Address
Zdk
License No.
Any person occupying premises served by'the above.system(s) shall promptly take such action as may be necessary to secure the Correction of any ununita►y
conditions resulting from such. ussgo ADProval of the separate `sewerage system spell become null and '4610i as soon as a publk - sanitary ewer. becomes
available and the appioval'of the.`private_wal.er supply. shall become null and':i6ld When a 'public water su' ly becomes available. 'Such - approvals are
subject to modification or
91 ange wher�pe%}bdgment of the Co Health, Such revocat , modification or change �Ge$ury.
,a* f. r— TItN
Date
Rev. 9 -81
t
&ygz s Owner or or urc aser of Building Section
Building /C /o nst uctted1'by Block
Location - St ree Lot
Municipality Subdivision Name
Building Type Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE 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 success-
ors, 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 occu-
pant of the building utilizing the system.
_.The undersigne.d_Xurther_, agrees to accept. as. conclusive. a.l�e_:;d,ete]cmin.- _.
°atkorf 'b �'�ii� "Di �;to-r_.�g __the D`iwvis b i_of E ivYrbri�ijeritaY"rle ]`'cr3 e vice`s
of the Putnam County Department of Health as to whether or not.the fail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated this 7 day of 19 1P�Si.gnatur
Title
Corporation Name if corp.
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
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INITTA.L SITE 111SPECTITT y �IYe No � . Cotrmnni:^
,Properly lines or corn:•ra found . . . . . ... .
Can estimate house location . . ;
Will driveway need cut .
Must trees. be rremovr-.d -note these
Is deep hole represenL"ati ve of entire SDS d.rea'
Additional deep holes needed. .
Sufficient SDS area available 'considering.
driveway cut, hou ,-e :location, separation .
distances, etc. .
DEEP HOLE DATA
Dapth:
14a-ter el.evati.on:
Rock elevation:.
Soils die scr_i. Lion:
FINAL SI M 1INISP1sC`I IG�.i Insp. by: GZ, CIt4�-z
House located when•.- 'shown on approved plan
SDS located where approved �
:lri•Z-i;h of trench mcasarcd
• Width of trench av era �;z
Slope of the line and trench. acceptable .
_..._:_.R6arrL all.otxiod._foz_. � ° ss :oii. ro c ?.cam -.
Over 50 ft. from swamp, watercourse
Natural soil not-stripped or SDS area
unnecessarily graded
10 rib. maintained from prop-lino and
20 ft . from house
Sep- ration of trench from house, tell
_:--etc. - follows plan :- . - . -; --; ;-
1\Ttu ??ber of bedrooms checks . . . . . . , . ,
Stones,, brush.., stumps, rubble, etc. greater
than 15 ft. from nearest trench . . . .
15 r't. of peripheral soil horizontally from
trench . • . . ° .
Junction boxes properly set
Could surface run off from drivowa.y, roads,
• ground surface, etc. charuae l near SDS ,
area
Does l.of. a.rt)ear 0. K. in area of SDS
FINAL GrxhDING OF SITE ACCEPT -hB E
-1 L
M
` lltt�
P-0 Gu v
J, IJsLD CJ U-M,1. hf ST. .
• Date •
4YT::^ ♦.�. . -_.♦ �+- r GG ...:h•rt Y.....� ..? •• - rr .,ge.s.r, .^. '1, -.Y .Y r4. ¢�..rK NR: -•+YI -UU- +�+a.1 yaT �K.•i:..- .�,yn��ne :-�.i W }•..tyk+ f r61: .�
INITTAL SITE INSPECTIM! � �
Yes
No
Comments
,Properl,y lines or corners found . . . . ...
Can estimate house location ... . . . . .
_
-
Will drivcway need cut
Must trees. be remove-d -note these .
--
Is deep hole repres enta-tive of entire SDS area
Additional deep holes needed.
`
Sufficient SUS area available considering
driveway cut, house location, separation
�.
distances, etc.
DEEP HOLE DATA
Dter elevation:
_-
Rock elevation:
Soils descrl -;Dti on:
Date.
FIN A L SITE I. TS P -ECT10 Insp . by:
House located wber.•e s}:ot;n on approved plan
_
SDS located 1.111-cre approved . . . . . .
Inngth of tranch. mae's ured
_
Width of trench averase
Slope of the line and trench. acceptable ,
Room . allowed -for ey,: rust: -an trench s_-�-
Over j0 `ft. from stamp, waLercourse
- -
Natural soil r -ot . stripped or SDS area
tunriecessarily graded . . .
_
10 Ft. maintained • from prop . line ands
20 ft. from house .
Sep,• ration of trench from house, well
- -etc. - follows plan . -.- • -: - ; - -• -; - -e- ; ; - -; � _
- -...__
- - -. ------ ^-
hhmnber of bedrooms checks . . . . . . •
Stone:,' brush, - stumps, rubble, etc-. greater
than 15 ft. from nearest. trench . . .
15 Ft. of peripheral soil horizontally from
-.
trench. .. • . . . . . . . . . . . . . . .
Jwaction boles properly set
Could surface run off from driveway, roads,
• ground surface, etc. cha.iulel near SDS
area. . •
Does lot dr. a innLr,e appear O.K. in area of SDS
FINAL GRADING OF SITE ACCLPT=_,E
s
(�`••t M x.24 -�A � '�
' SU)ROSotj - CA E , REVIEW CiII ;CK SIERT
j
iMoets Str3 . Romarks •
1yes. No
DOrU�TI`!TS
House plans 0. K.
A-
Dssign data sheet
Peres presoaked.
i
L:i n., 30" perc test depth
Const. results for 3 runs
i iL
D. Hole log O.K.
Corporate Affidavit for other than individual
Authorization for engineer
Letter from Water Supply-if applicable
IAJ
If variance requested -such noted on _plans & apps.;
DETAILS
(if change'is proposed,)
Existing contours shown (show new-contours)
Slopes for driveway cuts,, etc. shown
TZater service lire location
Footing drain_, etc. location
i
Top slope, bottom slope of fill
;
Percolation tests and de::p test pit location
.2� ► i
Septic tank size and conformance to std.
c
3 B. R. house min -i ,um
sC
House setback shown
Distribution box ftg. be=low frost
A-11 water within 50 ft. of PL shoran
-And-prof-t DS
All other wells and SDS closer 200'
; I
shown* or- reference made
Property boundaries (metes and bounds- clearly
sh ;
)EPARATIOn DISTANCES SPECIFIED ON PUN
I
.01 to P.L.
/0
101* to Foundation walls
10' to nearest well
too �
')0' to stream, march, lake, etc. incl.expa.nsion
.
!60
.5' to Curtain drain
.01 to water lire (pits -20
—is-
/0
.5' to storm drain
.01' to lar,;c trees
/O
0' 1'rolu foundation to sopLlc tank
.5' to pipe froc» leader drain & . foot;lE6 c rain
AUK. 'TO
'44fpUi le
PUTNAM COUNTY DEIPARTMENT OF HEALTH.
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Dia t e
Re : Property of
Located at cJ�l1' !✓.'��Li) .41-Afr
�LC6 ' Section ____LL-' L- Block -2 Lot l0
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to author ize�CL /.fi
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 this matter and to supervise the construction of said
tQnas i r_,.cb- „= #`oratity'- .•rich the pro:!-. b s f Ar�icle .4 or, -
._
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
Signed
Countersigned: ���J�� � ``1��,
P. E. , �. # t t
Address Town
xf
y` Telephone
Telephone
MAR 11984
PUTNAM COUNTY
DEPT. OF HEALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SEEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner UC ' � �5�% L i� Address _?q17 r Gil left � �ey'
,L (Street .���' � � ��c� sec. Block . � V
,Located at !�. Lot j�
indicate nea.resT cross sTreeTT
Municipality r �� ;j gs . I/4,66c, Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
H016
Number CLOCK TIME
PERCOLATION
S,
PERCOLATION
Run Eiapse
No. Time
Start -Stop Min.
Deptt to Water
From Ground
Start
Inches
Water Leve
Surface in Inches
Stop Drop in
Inches Inches
Soil Rate
Min. /in drop
C7
3
/0.'171
3 4)
3 A'12
5 /D,`43 le -'0'3
2—
1
FO
4
EIV.E
Notes: 1) Tests to be ted at same
rates are obtained at each perco�t ion
for review.
2) Depth measuremenptss to be made
PUTNAM COUNT Y
DEPT. OF HEALTH
depth until approximately equal soil
test hole. All data to be submitted
from top of hole.
S,
f
S-7
.3
2
C7
3
/0.'171
3 4)
4
EIV.E
Notes: 1) Tests to be ted at same
rates are obtained at each perco�t ion
for review.
2) Depth measuremenptss to be made
PUTNAM COUNT Y
DEPT. OF HEALTH
depth until approximately equal soil
test hole. All data to be submitted
from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS LNCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
6
12" '
24"
30"
.3611
42"
48��
541''
60" .
66"
7
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO RICH WAT L RISES AFTER BEING ENCOUNTERED
TESTS MADE BY r� �ir� /Ni r �lL �r7?� Date
_
Soil Rate Used / / -/, Mi Vl "Drop S.D. Usable Area Provided`.a`wf�clMf'
No. of Bedrooms. Z? m Septic Tank Capacity /',00'0 Gals. Type fP41,3.
Absorption Area Provided By 7S-L.F.x24" width trench
Other 414,Pc 1--
Name.. irwi C z 1z,a/� 6ignature
Address Y
�� � �f c�.i' =�'�' . Cr�".�.� �';,�� � . SEAL, y'�Q qP�, �,
THIS SPACE FOR USE. BY, HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq...Ft /Gal. Checked b � e
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Putnam County Department of Health
Division of Environmental Health Serviose
Approved rX ryrted for conformance with
applicable Itulcs end Regulations of the
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