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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512 Permit
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM / �10//
Town or Village
Local ed //t / ��"� Tax Map : /� Block '7
Owner �'i -.� /Formerly Tax Map Lot A Subd. Lot it ,.3 U
Separate Sewerage System built by d 11� Address 41>°f a J/
Consisting of %S v Gal. Septic Tank and .3 9!� J 1, -1 e'/ /
Other requirements
Water Supply: ublic Supply From �5� ` '> �% / 6�
Private Supply Drilled By
yAddress
Building Type r' �" j� n- No. of Bedrooms
Date Permit Issued /
Has Erosion Control Been Completed?
.-
I certify hat the system s) as listed serving the above ` "
y g premises were constructed easentially,'> as'.. ahown,on the.:pl'aris'of the completed work (copies
of which are attached), and in accordance with the standards, rules and regulations, in accordance.,`wi&�fhe' filed- .plan;; and the permit issued by the
Putnam County Department Of Health.
?1 ��•;':
Date Certif ed by
P,E. R.A.
f7
Address
=' "'License No.
4 f J
Any person occupying premises served by the /9.%e systems) shall promptly take such action as may; tie n, sser'yrto securo the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null'and void as soon asr a public unitary sewer becomes
available and the approval of the private water supply shall become null and void when a public waters ('be 040; available. Such approvals are
subject to modification or change when, in the judgment of the C n of Health, wch ocatlon; "m "" 'iflcatlon or change I necea y.
Date
IS _ BY!'�"' Title
Rev. 9 -81
� PUTN
AM COUNTY DEPARTMENT OF HEALTH Permit —!
Division of Environmental Health Services, Carmel, N. Y. 10512
CONSRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM l �i firi a"'�'%
Town �o►r^ 71lage
S�tv9 Tax Map Bloc
k �7 Lot
Located at J 0
Subd. Lot R 3 Renewal _ _ Revision El
Subdivision J � p / S�
j__ / a -,...G J� , / 1 I /• Date Of Previous Approval-
Dwner /Address 0 '1
Building Type Lot Area ��
�a
Number of Bedrooms Design Flow G /P /D
Separate Sewerage System to consist of
/ Lf� Gal. Septic Tank
To be constructed by
Water Supply: Public Supply From
Private Supply to be drilled by
Address
Other Requirements
Fill Section Only
P.C. H. D. Notification Required j
.3-s- L. > `� b✓i�� >Giit
and
Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules aregulations o e u nam
County Department of Health, and that on completion thereof a "Certificate of Construct ioJbCG?fl i# ��tisfactory to the Commissioner of. Health will
be submitted to the Department, and a written guarantee will be furnished the owner, t)v�Pcc e r. assigns
mediately following the date otitherissul
place in good operating condition any part of said sewage disposal system during thQ'@ ?iodpf<two,(2�)/
ante of the approval of the Certificate of Construction Compliance of the original, stargeoPiAhyQI }(s t ; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be installed in accSitdanEe'w{th the sFse dyerds, ules and regu a ons of the. Putnam
County Department of Health. d n y'Y c v J✓y
Fes/ Al /� a P.E. R.A.
Date Signed a c
° /
° ` License No. Z
Address a7iR"t o,
APPROVED FOR CONSTRUCTION: Thj approval expires one year from t e date issued unless con ione the building has been undertaken and is
revocable for cause or may be amended or modified when cons' sear by the Oottimi`ene of"- ly Any change or alteration of construction
requires a n w perm' Approv d r disposal of dome .ic san' swage, ''�t�e°'.M. 0 ly ly.
Date By J
"A'4
Owner bY Purchaser of Building Section
i�
- :-Biz iding Constructed by
Location - Street
Municipality
Building Type
B1"o c k
3a
Lot
Subdivision Name
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-
ation.. of the D_ i.re.ct.or. of .the Division of Environmental
of`�the "'rutriam Courity"`Department Health Services
of �
-thb— f'd11 -' -" -' � `"
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 day of 19c Signature lam, )�Q;k.;� �f
Title. -tom,
Corporation Name if corp.
1A 1A 5�k� N�AV �) ,1 164 aA
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
b PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
. , _ • _" _F.. s_ b'; - , r' -• _ _. - .. +. -F %�' cam. I: P' .i• _ -
Date
Re: Property of
Located at(� it C
(Tj�s?G�y �/ ` Section Block �� Lot
Subdivision of
Subdv. Lot' # Filed Map # Date
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 irr- conformity with tYie' provisioris of Article 145 or `
147, Education Law, the Public Health Law, and the Putnam .County Sani-
tary Code.
Counters e :Laws..
P.E.,
Address
Telephone
Very truly yours,
Signed
Owner of Property
Address
to �+
own
sz (. -5 f �g
,Telephone
•' . PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
`0:bUWT UFFICD BUILDS- 0,`-CARMEL, N: Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner s Uj.. �° a Address
Av
Located at (Street Co Sec ,/2,0 Block Lot U
n ica e near cross s -ree
Municipalitq Watershed
SOIL PERCOLATION TEST
DATA nQUIRED TO BE SUBMITTED WITH
APPLICATIONS
.Hole
-Number CLOCK TIME
a' PERCOLATION
PERCOLATION
Run Elapse
pth to Water
a er ve
Na. Time
From Ground
Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min. /in drop
(Inches
Inches
Inches
92Z:.
. ;
5 -
r
Notes: 1) Tests to b1'e 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 .
DEPTI, HOLE NO. HOLE NO. "A-
HOLE NO.
G.L.
6"
12"
18"
2411 .
3011
36"
42"
48"
54'1
60"
66"
72 fl
781
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED�'''L
:...
INDICATE LEVEL TO WHICH WATER LEVE RISES AFTER BEING ENCOUNTERED
TESTS MADE BY �a '� ✓�
Date 7.
DESIGN
Soil Rate Used Min/l "Drop: S. D. Usable
Area Provided.
.No. of Bedrooms_Septic Tank Capacity
Gals. Type Q
Absorption Area Provided BLqW L.F.x2V
Uli trench.
33 -e �g ab. °.�., ��\er
Name t.4
%
Address
wt
CA
THIS SPACE FOR USE BY HEI AL`I'H DEPARTMENT ONLY: A jg�S���Pd �•
Soil Rate Approved Sq. Ft /Cal. Checked by Da-to
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