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04474
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04474
tEl'F PUTNAM COUNTY DEPARTMENT QF HEALTH \Diwsion of. Environme »te/ Heis h � permit ICATE OF �MNSTRUCTION COMPLIANCE FOR SEWAGE. DisposAL .SYSTEM H�
p � � `. - Town or�Villaya
Sax Map %. Block
w.
Owner y �� ormer ly Tax Map Lot .
Separate Sewerage System 'built by Address
Consisting of.,- L —Qal. Septic Tank and
Other requirements
Water Sup Public Supply c ► ^�*+
Private Supply Drilled BY
Address /^
Building Type No. of Bedrooms Date Permit Issued Imo"
Has Erosion Control Been Completed?
I certify that the system(s) as•listed'serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached),.and in accordance with the standards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health.
'zZe
Date Certi ied by I'd P.E. R,A: -
Address
/ Q ✓ License No.1° y ��
or
Any person 'occupying. Premises served by th ove systems) shall 'promptly take such action as may necessary to secure the correction of any unsanitary
conditions resulting from such usage. AP royal of the seperafe sewerage system shall become null and void as soon as a public sanitary, sewer. - becomes
available and the approval of the pilvate water. supply shall become. null and volt when a public supply. becomes available. Such approvals are
subject to modification or change when, In. the Judgment of the Isslroner of Health, suc revoce on, modification or change is no
Date r, CJ ^ I BY TKN
_Rev. 9 -81_.- -- -- -- — -- - - -- - - -
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Own r or urc aser of Building
il
- Bui:l"dink:
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•�'.
• PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
ft=,
Property of
Located at "'�eA4 �A
(T) �P' 6y21 Section 1,721 Block Lot 2�le
Subdivision of /HIV l elelal / "4;q' ',
-Subdv,. Lot 40- Filed Map # Date
Gentlemen:
This letter is to authorize���/
a duly licensed professional engineer /vim 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
., :....:_;.sy- s- z- em--or -sys•t-•ems -the - p-r�o- i�i:ons --of - ►!-ti-c;lew:, 145`
147, Education.Law,.the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
IMF
Signed
Countersigned: � `�
Owner of Property
P.E. , R.A. , # d, .
amp Address
Address a;v�� „�o�° Town
""ECEIVED e� aoeeco43$�y J Sy q l
Telephone
Tegeph ne
tV 191984
P
Dkil f . OF Hi AL M
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 i ;;/ e �s � Address `. Zol
Located at (Street ZV:4;�� Sec. / Block Lot .
n ica a neares cross street)
Municipality. 7all;�702yv o' � Watershed
SOIL,PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number
CLOCK TIME
_...
PERCOLATION
, .
PERCOLATION;
No.
apse
Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start -Stop
Inches Inches
Water Level
in Inches
Drop in
Inches
Soil Rate,,_.
Min. /in drop
2�� ®�;/
3/0,01
&IV :301
5
_ -....m .. ...wn.o �. Z.f
a/P f���/ �✓ ....`� y,s- ... �
...e e.i +. /tee
.. ..�.. ��^' -..M.• rUl+. t. �.�.
.f ...._ _ .. .. .. ..a. i... .- a.
4
1
4
5 DEDr AM C, IU,,,
Notes: 1) T&Rts 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
- DESCR--P'I'ION OF SOILS ENCOUNTERED IN TEST,HOLES
...+.� �`a�C a. _ .ia.. . ;aw.,: .OVb. n .: i!• v _ �...ryry.. .- �� _ s
. V '•��n�•.+fM1d�w '.Z i'i•iT�-1S'LrT •� "p "N ,_N,�
DEPTH HOLE NO. HOLE NO. t!� HOLE-NO.
G.L.
6"
12"
18"
211•"
30"
7811.
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
: °3NDICATL LEVEL PTO WHICH WATER -LEVEE,= =RSSES 11FTER> BEING= ENCOUNTE
TESTS MADE BY cT -'=� f.,, ,) i .r'rii. .. Date'Y�
e DESIGN "
Soil Rate Used I/ Min/1 "Drop: S.D. Usable Area Provided,® cc,- r
No. of Bedrooms Sept' c Tank Capacity ,_,Z Gals. Type_ro.� r _
Absorption Area Prov ded
By L. F. x2�+" "— ��-!Iti trench.
t,...
- a° Elw( -ro
flame K . gna• ; u>re;'= p
Address ;� ` k'
i, -• �moma0e
THIS SPACE FOR USE BY HEALTH DEPARTMENT.-ONLY
aacna°
Soil Rate Approved Sq. Ft /Gal ;. f -> Checked by Date _
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