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04472
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04472
PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER MUST
Division of Environmental Health Services, Corm% T
N. Y. 10512 PROVIDE# y, ,
))PERMI
CERTIF CATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SY STEM �rs/7Jgrr, �rrf %•�i
j Town or Vlllsg
Located Ot / / Y Tax Map Biock
Owner C Formerly Tax Map Loth Ay s'Z d Subdr�Lot q
Separate Sewerage System built by �/ WA, � Address , i � / � r•
Consisting of 20Q (dal. Septic Tank and
Other requirements
Water Supply: --.�G re Public Supply From ��+ °✓ ��� r��� y �t' }
f L-
Private Supply Drilled By F;
f� Address
Building Type ✓ ��
Has Erosion Control Been Completed?
No. of Bedrooms Date Permit Issued &CAV
Has garbage grinder been installed?
I certify that the systems) as listed serving the above premises were constructed essentia}
of which are attached), and in accordance with the standards, rules and regulation-, in
Putnam County Department Of Health.a
d
a
e°
Date ertifled by
Address, 3`
Any person occupying premises served by t above systems) shall promptly take such actio5
conditions resulting from such usage. A proval of the separate sewerage system shall becu
available and the approval of the private water supply shall become ull and void when a F
subject to modification or change when, in the judgment of the Co Issloner of Health,
Date _I By
Rev. 6/85
gh �— Tsplana of the completed work ( copies
the plan, and the permit issued by the
P.E. R.A.
u G
c` a License No. 7 O 9S
�lie the correction of any unsanitary
Vs a public sanitary sewer becomes
fines available. Such approvals are
Cation or change Is necessary.
Title
Owner 'o Purchaser of Building
Building Constructed by
,Location - Street
Municipality /
Building Type
110?U
Section
Block
V
Lot
> ' - 09
Subdivision Name
zG
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 undersigned further agrees to accept as conclusive the determin-
atl-or o-f tIxe• Director of. tl�e Division of Environmental- =Health,-,Services:
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 Af day of 19JF� Signature" r:. v,,,•,M �__® .�
Title (g�,s..
Corporation Name if corp.
V.
�\� I
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
t�`t�'✓� ' `` s E 4 Division'of Environmental Health'. Sorvices Carmel ry j
`�i N Y 105.12 z
U�
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM 3 w e$..� i
Town or Village,
Located et - x �_ ' , Tax lAaP A1ock t Lfiit - f
}
SubtlivisiOn / Subd Lot H-V Renewal ❑ " Raysion ❑
Owner /Address -� /' �/ �J� -FDate Of Prevloua Appioval .f
- /S� • __ -_� Fill Section Onl ❑ t ;
Bu ng ype lid, T Lot Area y
f
rNumber of Bedrooms Design Flow G /P /D " N 3\ P C H D NoQiflcatlon Required i
' Separate fSeweiage35ystem , to consist of / U Gal Septic Tank antl �i
To be uc
constrted k
Water SuPPIY� Public SuPPIY From 4 e i
TrPrrvate SUpPIY t0 be drilletl by i
((
Adtl ►esfn: a Diu viz m..�
r tt Y -,�� fs �L- S^ °� ,,�.'� 4 sx r a { Yt� °k n ,,,,,`,.e ,., J'�.,Y r x '� y `�'n l J; ` l� yJ ; .�, a� �r s•u'` }�sw ''1 :?
Other Requirements Yle
T7 •.t s C .x a�C 7x .,;.;i• y '� a sy a 7 } 4 s s'{"c p z.,, �., ya rw s M spa a a
.; a., 3.. �. «3. s,;5' a'f �� "c�'bsro. A� ��.� s ,�;;- 4'?,�4 'YP., k^ ��'�;..� .�,"S � n;. � d 3 '3 �
y >
c
u.
I represerjt that I am, wholly antl completely, responsible for thedes�gnandlocationsofktheipropo P) that thesepa►atesewpge tlisposalssystem,r
G 1.t ,.s.iw,. .Y . :.yse" ... -.- Nog.. xt J 4
above Cescr� bed will be constructed 'as shown.on thegpproved amendment theieto antl �n actor ah� lards* ►ules an ,regu a ons -o e ; u nam 1. a.'< _ .
County De part men t,o Health, arid That on completion thereof a CerUficat","f sConstr�u ctory'to the Commissioner of'Heaalthw�ll
';be Wprnittetl to the Department rand a writien guarantee will be furnished,Vthe owner s ,- ns•bysthe tiuilder thet said builder, will'' a ;
place in good ope`iatmg conddion lany part of saidysewa``ger disposal *systemilunng 4h per g� o wo_ m e "diately fo,llowmg',fhedate oithe tsw=,
'ante 'of the approval of xthe Cartrficate ot,-Construcbon Compliance of theyoriginal` "s e i any ie' us o; that the'dr.illbil'* ll described above
s - - st
Twill beilocated as -snown on`the approved plan and That said well will be installed' "�n acco' a
it nda, 0►�1 'and regu,aa Ens .of the - Putnam-
,
>Date,--- �!.,f .r d Signed= +r .° P E
Address �S ' ��
, license No Z y 9s
APPROVED FOR, CONSTRUCTIOfV T s aDProval expires one ye5r from he-Oat unlesq gywcEi n he DuUtl�ng has been ,undertaken and is_
revocable for cause or4may`be amends or- modrf�ed.virhen.co' d necessary > -b the =Com sqs q�r�ye? °,Any than ation of construefionc
requires a. new permd ro for disposal of cirn i . sand r se age ntl /or Yprry water isupply��anly: F
�6��
D"ate�� -BY - Ti
ReV 9 91-
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property o
Located at
Date
(T)% 61 Section Z_ _Block Lot
Subdivision of/ %f /�
Subdv. Lot # Filed Map # Date j -1140
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
connection
with this
matter and
to supervise the construction of said
`" system'or`''systems iii
conformity"
wi' �h`" tYie' provisidris ' °'bf� " "t�►rt'icl�'� "1�5-'or "'" "'
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
0 E
C✓
Signed `®�`�
Owner of Property
Count e
P.E. , a _, Address
Address "to'
wkfffl
4�
d%
Telephone
Town
J Lv V QC .
Telephone
it • ^'a
d
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
,COUNTY °`OFFICE "BUILDING; `CARMEL;'
DESIGN DATA SHEET-SEPARATE 'SEWAGE DISPOSAL SYSTEM FILE NO.
Owner jc 641 A Y� .> a Address j a ec,,+ `V' .
Located at ( Street M A�" ; Sec . ' '� Block Lot
kindicate nearest cross street
Municipality T � a v V . Watershed
SOIL PERCOLATION,TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS.
'-Hole' _ .. .;....
Number CLOCK TIME
PERCOLATION
PERCOLATION
apse
-Depth-to
Water Water Levei
No. Time
From Ground Surface in Inches
Soil Rate
Start -Stop Min.
Start
Stop Drop in
Min. /in drop
Inches
Inches Inches
2 l-
4
5
1
2
3
5
Notes: 1) Tests 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. a-- aHOLE NO.
G.L.
6"
30" --
36"
42"
48"
5411
6o l l
66"
72"
78"
F
84"
lv
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED o� �-
INDICATE ,LEVEL 0 _ WATER LEVEL RISE AFTER BEING ENCOUNTERED
TESTS. MADE 13Y y S '► �/� ,` D ` fir+ De t e ` J� .
DESIGN
Soil Rate Used blin/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity. Gals.
Absorption Area P v ded By 0 , L. F. x24
se,A F5�,Sw l h
Address;iq7?_. F—er0C-1i
THIS SPACE FOR USE BY HEALTH DE
mgnatui
rMENT ONLY:
Soil Rate Approved Sq. Ft /Gal.
Checked by_
Type��
dth trench.
Wither
Date
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