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BOX 31
03975
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03975
V!k�3
;PUTNAM Cdi
Division of :Envvonmenr.
s
y�.,f4RTIFICATE •OF GONSTRU TIE1N: Q0M_ P AJN.0 FDp
ts� .Y :r•u A tl... WW+'• tpRt4cl�sN¢. >.n�+4
7
a ,�1�L��� LS.
Located 5t A 1
Separate Sewerage System bwlt :by (2: `
Consisting :of �- Gal.' Septic Tank an-,V
I r
Other requirements'' `
Water Supply Public Supply From
Pri4ate ,Supply Drilled .By
Address WILT,.
rT
ji Building Type e
r Has Erosion Control Been Completed?
1 cert�f that the s
y y se
stem(s),as listedrving the ab er
tit
94tached), ands in' accordancebwith --the •stand_ 41) +and
c r' Address
0.1"
f '''Any person occupying•premises served by the above s q�s �
�9� 'condit`ions resulting from,.;such,,usage ' Approvaf ?of th t
n ,`available ,and the approyal•of• theprwate',water supply shall;
subjecttEo modifecatio or change" hen 'in the judgment` -of
� wr •1
r S
3� =,1
PARTMENT {OF HEALTH{
cii Sef Gices; . Car»e% N.-'-Y.40512
AGE DISPOSAL SYSTEM A
Tax Map I -� Block
` LOti ° Job
Aaa�ess • �P�T �.A°I'!1 i. A(,t:,�L %l. > �%_
Fof Bediooms Date Permit Issued
�y_ 3 •�
tiall 'S-," r on the plans of the completed work (copies of which'are
s; n he permit ass d, by Putnam County.•Departmen $ of Health:
P.E G. R A.
License ,No .32
;r _t
ke such action =as may tie necessary to secure the correction of any unsanitary
,•system ihill become null and void'as soon as,.a public sanitary sewer•becomes
it vq1d :, en a publ Ater supply .beconies 'available. Such' approvals` - are
one of` ch evocation;; modification or change 'is necessary.
w ti ti
,_. - co .°lam'''"•' can �ngiii+e� � "ln ; it1�C�
f .... r.
r .
10RKTOWN MEDICAL LABORATORY`S Co
r> P. Box 99 32� M4T Street
,,.
Y4o� n .l�9ei I�tS �;Y. ���
5
�,.; 2� 303,
rl�� r.
DATE COLLECTED:
i2ESULtS OF EXAMINATION OF ,WXTER t
OWNER k k;. DATE RECEIVED '.
x
CITY, VILLAGE, TOWN & /OR NAMir OF SUPPLY-1 f DATE REPORTED
Ro�a3;a 107D �loo�o JeaF �o 9°°
,AMPLING POINT
BACTPERIA PER ML. (Agar plate count at 350%.
COLIFORM GROUP (Mostrprobable _N6. /100m1.)'
: HARDNESS, -,TOTAL - ppm
2,2 ,.
DETERGENTS - ppm
NITRATES.(as N):- ppm ':
IRON, TOTAL - ppm.
FLOURIDE (F) - mg. /1•
These results'indicate that the water was 708 oi, d satisfactory sanitary quality.Vihen the s pie ed.
P.ADOVANI, M. (ASCP)
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�f7� LIT V 6�a�i� �w y u %v .4a,1 IMC"
Owner or Purchaser of Building Municipality T
�AZ ✓r?'-�zagr
Building Constructed by
Location - Street
&--S!b�,oJr 14 4-
Building Type
/i3
Bl ck
Lot
GUARANTY '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 guaranty to the owner, his succes-
sors, 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 undersigned further agrees to accept as conclusive the-de-
termination of the Director of the Division of Environmental Health Ser-
vices.-of . they .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 LSD? -- 19(o Signature f
r.
Title L')W^/&,,Z-
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
RUTN:AM CgUNTYEP�cMENT`.OF HEALTH
Division of„ Env►rgnm H
ental ealth services, Garme% N. Y .10512
CONSTRUCTION, PERMIT FOR SE WAG E:DI$POSAL
4 U'
i. own or, valage - -
{' a I'�a T fl y ` .k.b_,..^S � :.:s fl ,`, �a � .?'°.e' .. •�{3 �/�� __ i _ i'"Q.:P.f79 _�.i�. -.s . .:JEocp
4
SUbdrvislon__� Mg Lot ° `' Job
Owner e Address
Building TYPe J% Lot Area -
( Number, of Bedrooms ry Total Habitable Space / %�� -�� Square Feet
Separate Sewerage System( -,to .consist of r` Gal Septic Tank �� a lllyn°eal feet ?rX !o� width trench
To be constructed by
Water Supply Public y5 jpply From -
r'M ;Private SuPPIY,16 ,,be dr llpd nv
y y
Address 6.• s f
Oche► . Requrrements I
''represent that l -a_m .wholly and•,completely resp esI _
`above•described;
on, of ,;the proposed system(s);; 1) that ,the separate sewage disposal „system• ,
„`
will be constructed.as shown on;
and ran acco ►dance wyth the standards rules arf regu a -ions•o -'. the, ,.0 nam
' County” Department'- of Health, and that on: c "re ti„
Construction ,Comp) ;lance "'satisfactory to the Commissioner of Hea.lthwill
be submitted 16 the Department, and•a wr, ara' ish
owner h�ssuccessoF.SIO rsior assigns, by the, budder,, that•said builder will
;:;place in;'good, operating 1condition' any ,part sa se, s st,
ring the pei"iod of two.( ?) .years immediafely following.;the.date of the issu-
ance of =;the' approval of ;the Certificate,of, ctio of •t
in al system':or any repaus (hereto 2ythat the drilled well described above
_
will be located a "s shown onahe approved plan a sa sta
accordance with the a,ndards rules and `'regulations. of • the Putnam
_
County Departments of Health 4 • . Q
< ti
z ° ®a
Address
- License
7 ,»
APPROVE FOR .CONSTRUCTION This approval expire ne ear from the_
sued unless coitistrefeLi of the - "building has been undertaken and is
revocable .f r taus or may be amended or_I' defied. when ons red necessar
by ie�Com of Health A or alteration of.construction''-
on)y
requves aew p' mi Approved for disposal of';do sanitary sewa a e t supply s` ►a '
yOate.
- Title
_
OL/Yi-I
Tmvv'rAT. RTIVIi! '1111111,117MITMI
Inup. by
Ye, -.0.
'P.ro�)prty linas or corners found..
0C,
n
Will drivev:ay nz-,:od cut
V,'•u.,t trees be -mmoved-note the: -
Is c1cep hole of antirc 3 D 13 area
Addition.al dc._T) holcl" nccdod.
9t1f,.f,J.cient F)DS area avai'lablc consj.derib,,
drivev!,ay cUt.,house locatj.on,,,.,;cparaLion
distancels, etc. V/
JETIT ROLE DALPLIA
Mpth':
I-later elevation:
Rock elevation.*
S 01 Us descrin -L U-ion:
-Date
URAL SITE DISPECTION, Ins T). bv.-
ouse located i. -here shown on approved plan
M lo,,.ated•where approved
oom allo,,•;ed for expansion trenches
ver 50 't. froim svaiim v.,atercourse.
loi,.-a or ti .le. -lin.6'and tiench acceptabi
atural soil not stripped or SDS area
unnecessarily graded
FL-... maintai.:ed from prop.lin.- and
n1paration of trench from. house, well
etc. foll o-%..rs, plan
riber of bedrooms checim
;cms., brush., stumps., rubble, -etc. greater
t=han 15 ft. from nears st tre-nch . . . . . .
PL. of Poriplacral soil hori4zontal.ly, from
trench
Lnetion boxes properly set
iuld surface run off from drivevay., roads,
(round surface, etc. cl-nnnel near SD3
'area
as 16t car. ainare annnar 0.1".. -in area of SnS
RA GRADING OF SITE ACCEPTABLE
f
0
REVIL�(1 CIIL,C3� S � � T
Meets Std. ► Remarks
_ es No _
r5 ti - Z . w.....a v.Sl f' 'II v i_...... � . r. - S:x. ..M - _ .. is r[r �� -SC ..af , .n r �•. K h. _ . � "r„ "T Q :.'h. � "tt, . _ .v F.y- wvas'N var-4 .+•... v � 24!Y.: n.'Y.ot'^O._...i.0. ww? . iwr.t � -. e+ e^ ,
0
DOCUMENTS
House plans O.K.
Design data sheet i !
Peres presoaked? i i
Min., 3011 perc test depth � �
Cont. results for 3 runs I j
D. Hole log O.K.
Corporate Affidavit for.other than individual
Authorization for engineer I J
Letter from Water Supply if applicable i M
If variance-requested-such noted on plans & apps. j'
DETAILS
if charge is proposed.)
Existing contours, shown show new contours)
Slopes for driveway cuts, etc. shown 7—
Water service line location
Footing. drain, etc. location I
Top slope, bottom slope; of fill !
Percolation tests and deep test pit location
Septic tank size and conformance to std.
3 B.R. house minimum c i
House setback shown i
1i-L -L wa Let' /1LI11l1. ,V 1 6. U1. I-L -jilu v1i
All other wells and SDS closer 200' !
shown or reference made I
Property boundaries (metes and bounds - clearly she
SEPARATION DIMANCES SPECIFIED ON PIA1
10' to P. L.
20' to Foundation walls
00' to Nearest well
50' to stream, march, lake, etc. incl.
15' to'Curtain drain
10' to .water line (pits -20
15' to storm drain
10' to large; trees
10' from foundation to septic tank
5' to pipe fro-m leader drain & footing
ansion )
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PUTNAM COUNTY DEPARTMENT OF HEALTH
t?F
•�a�= yRONMEty1'A;
Date
Re Property of. C d��- t TZ °-c7 0-
'. Located at S4 a AD t, ti g r� U T tild�a) At,L, .
y`1+ MA `
1 Block b Lot 0 �% ^Z
Gentlemen:'
This letter is to authorize �sf' STANLEY Jo LANDER
a duly licensed professional engineer L!_' 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
14:7, Educ.ation. Lac, the Public. Health .La and•
'� w. d... the_ Putnam- Coun. Eani•=
tart'. Code .
/a.���?
1"U'.l'1' M COI1;"l'i'Y nl?.PAItiT,P T.1Qr!' Ole'- 1)I-AT,'1'11
DTVTt IOid OP F';VTIiOT,Ii•il Al'PfIT, 11EAI T11 S)!'.MTCEF)
CgUI1'h1'_.Or' UM, B1;.T.LDiIa�r
N. - Y. 1E14�1.2:... _ --
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DESIGN DATA SLIT' T- SEPARATE SOv,AGE DISPOSAL SYSTEM FILE NO.
Owner(:!FC 1QjA L 172ROvi Address!?D 3 G1a4i6y Ak
�J -
Located at ( Street 6ndic Os:,awatir� ZAk'e K „Ap `fie . /l Block 0�=s' a tc nieares cross stME.”
Municipality b o %r �:it9 �,4�� - �latershed.es���z.c
SOIL PERCOMTTOt' `i"_ES`I' DATA REQUIRED TO BE SI u1ITTTED ldT.T", APP1.,TCA'.11:1 T:::;
/0-
5
4ye % - G
11
1
e
2
;r
Role
--
Number CLOCK TIPS
PERCOLATIOIN
P} RCOIATi ON
i Elapse
Dapth to water 1.1ater
1,evei
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Miin.
Start Stop
Drop in
Min. /in drop
Inches Inches
Inches
/0-
5
4ye % - G
11
1
e
2
;r
5 ..
holm : l) Test; to be repoated at same depth ' iin t,il a nnrr�roximatel.y equal. Soil
rates are obtained at each percolation tc: >t hole:. A11 data to be siibmJ.t.i;cd
for i,oview. .
2) D:pth moan iremcrits to be made from top of hole.
'TEW PIT D.PTA RRIQUIR'E'D 1110
IT! TE""T Wj
DEPTH 110111, RO.� ITOLE m. IC22'.
G. L.
74
611
1211
e-
4211
4 8 it
5411
6011
66
..7211
7811
8411
INDICATE IZEVEI A'-" l . E111COCIVITET 7,
IINMICATE LEDVI ' -L TO VIE= 1,,'ATjIR 127;VEL RISE�S AY-91"ER
TESTS M�ADE By
'I) SIGN
fj
.Soi-, Rate Used) 1"Drop: a. D. Usable Area Provided
No. of a:adroo;,s '4---------Peptic Tank Ga 1 s . �pe
.Absorption Area Provided B� :� Width trench-.
L - F. x24-
Othy
-4,'1 o a N nFR
uro
Address; wo a a q a-i
TIMS SPACE, FOR USE LY Ilaum 1).1!-,F.
Soil Rate Approved Sq.
by
Date
.1
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14P
OCT25197�
' MRAM DEPZ
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