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04574
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04574
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Diviglan of Envir9nmental Moeith frvkm
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COUNTY OFFICE pUILOING - CAI#iI,i §L, R4 YORK
r�lw'��1A'�F /!% G Rf3 }.U(iijJ16 #f� �p 747II t11� A unu syiamittew to Count y Fiaa4ch DORartment tgoeOer ►Kith lah�tat ryl BRI fR I�f
�rl�lysla c►# wsl3lar sample indicating water is Of satisfactory bacterial quality before gertificate of construction pmplion 111 ,
DEPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
6�CATIOIS Mp, A StFg9U gtTn
(fill Nvo
gap
(�� tluslNESS ('"'�
1= 'Si<IC ESTAf }Li�MRAEMt 1:1 FARbI El im 1NCkll.
PI�IC �j""""�'� (('''' '7j AIR 1�� OTHER
WPM 4..1 INDUSTRIAL 1:1 ONDITIGINiNQ 4_,.I f cifrl
PtatLlEfdt9
E 41Pi t�1
COMPRESSED CADLE (� OTHER
I3 TAY t J AIR PERCUSSION El ?9RCYSSION LJ (SPOCIfy?
CAtflme
POTAIL$
>:If1ITM /feel&
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RIAtdITP(Inchca)
',
WRIGOT PER jO4T
l s
� THREADED � WsLDPD
;
. YES NO
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TRS lt1�i
Y1011,01,
T@gl
((''"^ jj ((—""�� ��jj "OUR$ G.P.M,
L.J NAILIEp L _I PUMPELI '�`i COMPRESSED AIR 7 4—
6
VJA
tAE¢N9.9 PROM LAND SURFACE —STATIC (SpoCilyteat)
PURIN4 YIELP TEST, /avt)
Depth of Camel @tad Well �
In feet Iaolgw Lonel turfpsgl 02 L3
D
IVIMP
LgNgT114t'sN To I�IPAa (Weil
B4O SI ,
PIAMETER lln4h)
IF CaRAYEI
PACKED,
Pipmatgr of wall inOudinD
gravel pack (Inch ®a):
pr pTN PROM tAliq SURFACE
_. ,. F9RMATION DESCRIPTION.
oN
,
Patch exact location of wall with dl&topRge, to pt It
two pormangnt landmarka.
FRIT to FEBT
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a .rte. -.- ., a - ... -. ..+,. ..
lee Remm.,
N yield wb8 =d of 6I1ggrent depth& during 'dril►ina, liat balpvf
FEET'
GALLONS PER MINUTE
P41:1 MIE cu .Isis
wig
%
Ea9T awe f1gPORT
_ t.:.....
W FRILL I= lane ra)
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MEer or Furehaser of uild ng Municipality
u lldif* Constructed by
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Looa�an --Street � � > Boa
u ng ype Lot
GUARANTY OF SEPARATE; SEWAGE SYSTE14
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
constructer! 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-
sops, 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-
vt.ea of the .-Putnam Cot -ity D®partment,of Health as to whether or not -the
failure of th7e system to ope a was aaus�cl y the willful `or negl��ent
act of the ocoupant of the building utilizing the system.
44 Dated this day of r4-t4 • 19 Signature
Title 2BIAAC
corpora on, 'give name
and address)
- - - - - - - - - - - - - - - - - - - - - - - - -
THREE (3) COPIES ARE REQUIRED WITH TME (3) COPIES OF FINAL PLANS. HEFOR,E
CERTIFICATE OF COMP MION WILL BE ISSUED.
GUARANT2R IS AgQUTRBD TO FILE LOTIC4 Qom' DATE OF FIRST USE OF SYSTEM.
- - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - -. - -
Division of Environmental Health Services, Putnam County Department of .Health
PUTNAM COUNTY DEPARTMENT OF R!ALTH
:.... nrVISION .Or rnVTRONTME`ITAL HE. ?.,mTt:. -S!,
VICES-:- :....
COUNTY OFFICE BUILDING, CARNll?L,, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM, FILE NO.,
Owner Address 0 ,6E,-ej:P�7%�
Located at ( Street fM�P6 % Bl ock lot �?
6aicate nearest cross strett)
Muni cipality�T,�: , / Watershed /L/ X G�.
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH' APPLICATIONS .
..5
•
l
Hole
Number CLOCK TIME
-
PERCOLATION
PERCOLATION
Yhm apse
No. Time
Start -Stop Min.
Depth. to -,a ter
From Ground Surface
Start Stop
Inches Inches
Water Level
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
1 3n- po
5
.
2 �t,:So
4.SS ' S %f1U
S�
c2S6
r�
..5
•
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-
2
5
.
Notes: 1) Tests to be repeated at same depth until a roximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) D-;pth moasurements to be made from top of hole.
o
PUTNAM COUNTY DEPARTMFN T OF HEALTH
01+' �i G C RVTd l i� -A x :.
kL'PFi .��RTCES
Date �? ,e/ v
Rea Property of e_81 `/
Located at
�!
Section 67 Block Lot
Gentlemen:
This letter is to authorize
a duly licensed professional engineer l/ or registered archi ct
(Indicate).
to apply for a Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as.promulgated 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
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
Signed
r pr groper
Countersigned: Address
P.E., R.A.,��'O
Telephone
'S. co �,�5�$`�'�T);;'•. ,tea
Address I.;V'`
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Telephone y == r�``'rr S „�WOO��