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04592
PUTNAM COUNTY DEPARTMENT OIFAEALIrH-
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114 .-86 ces., Ciiiii 1, N; Proviae Peiiidt #
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�TF CATE'OF COMPLIANCE
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C19RTEN
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CONSTRUCTION PERMIT FOR SEWAGE DIS OOSA M
ZZ,
above described*will be constructed as shown on the
.
County Department of Health,; 'and thai o . n co, , mr
be submitted' 1:8 - 6 - e depa!tm4nt, aircl'a written . -
Place n 400d operating cohditi6n * any part of s
ante of the approval of the 'Certificate -of Const
will be loca . ted:as shown 0 . on . the I approved plan and ti
county Depart, 770f. Health
Date G9/ .7
id well will be ir
Address JR,
APPROVED FOR CONSTRUCTI 014:.X'.his a pprov a I expires one.)
'when-co!!.'.
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requires pbsal 6udomeitl
Date -
.
7
there• to and in accorag
I iiitq of Construction
ished. the owner „ his k
titim `during 'the perip,
V,the"original,.systim"a
tall , !CI!nqq v
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60%misjioner of. 140alth will
U r, that said builder will
u
atel
li no the date of the Issu-
let
ril well described above
ril
and d
a ons of the Putnam
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.,.:•- -1:......:: ;+- 5- +%hcna.�` "ter. --^. :- :s`.,:�`6a+, -.���, _.b... ......:'ec:.':.�:. -::r :_ :r. t.`::'"::- .,._.�....�...+r.. -.�.. :' 'q'C. e� -���. .. ,....�..'w�.': i.+:.: ��., :.. •'C„
Date `.
Re: Property of / �r7 C' y
Located at
(T )/4L 1 0177 Il
Subdivision of
Subdv. Lot #
Section /419 Block Lot z/
Filed Map # Date
Gentlemen:
This letter is to authorize%
a duly licensed professional engineer 6° 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
sys "tein °or "sy "stein " "" �ri " conformity with the - provisions of Art -icYe 41.4.5 -or
147, Education Law, the Public Health Law, and the Putnam County Sani-
t a ry Code.
C iun rsi e.
P.E. , �;=
Ad1dr a ss /� / / //j
O
Telephone
Very truly yours:,_- I t ..
Signed
Owner .- P:66� #163fot'y
130,e
Address
ez
Town
: F- v Ace
Telephone
1PYAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF EWMON04TAL HEALTH SERVICES
IDIDIVIDUAL MTER SUPPLY & SUBSURFACE SEO,GE DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT
I
( - -- _ - - DATE.... , . /� _
(Dame d er) (Street Location)
CCMMEN .'S YES 40 1 DOCC VOM l A .� A�
Permit Application W"l
Corporate Resolution
Plans - Three sets
Engineers Authorization
AV
l Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
If PWS - Letter
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or .J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located'
Representative of Sewage & Expansion Area
Expansion Area;shown; gravity flow,suff. size
f f,,- Pumped,. Pit, &,D- Box:..Shown' & Deta led
House No..-. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
1001 to Stream, Watercourse, Lake (inc. expan)
15' to Drains- Curtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' from Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
PUrNAM COUNTY DEPAF TMM OF HEALTH
DIVISION OF HEALTH SERVICES
DESIGN DATA SHEET- SU_BSUFACE SEWAGE DISPOSAL SYSTEM
Owner ' ',%�!� " lJ 1 f Address "s� Z/7
Located at (Street) ( t� Sec./ 7� - Block
7 Lot
(indicate nearest cross street)
Municipality Watershed
Watershed
SOIL PERCOLATION TEST DATA TO BE SUffiMII= WITH APPLICATIONS
Date of Pre-Soaking
/C Z/
of Percolation Test
:Z_5 _3,
HOLE
NUCER CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse Depth
to Water From
Water Level
No: Time
Ground Surface
In Inches
Soil Rate
Start-Stop Min.
Start
Stop
Drop In
Min/In Drop
Inches
Inches
Inches
1 70
2 Via/ ,P
/C Z/
2—
:Z_5 _3,
44,'_3 _-S, % i / :?-- . ?-C;l - __�2 ; _:>>
5
1161, I �5� ; C-1 1
4
5
2
4. '
5
NOTES: 1. Tests to be repeated'
are obtained at each
for review.
2. Depth measurements to
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to-be submitted
be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION g E
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. / HOLE NO• HOLE ISO•
2' Gle c' %"
3°
4°
5°
6°. t
7°
8°
9°
10°
� 11°
12°
13°
14°
w ' INDICATE ILEVEL AVWH CH CROUNUQIJ R IS ENCOUN`LEB
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY.: �i� / ��i.a�� DATE:
-- DESIGN
Soil Rate Used J Min/1" Drop: S.D. Usable Area Provided
Noe of Bedrooms Septic Tank Capacity gals. Typello is
Absorption Area Provided By L.F. x 24" width trench
Other /`� /� / c /
Name �a ` �l� / / `� Signature °A 7
b
Address
Z X
4
THIS SPACE' FOR USE BY HEALTH DEPARZ ENT'ONLYa
Soil Rate Approved sq•ft /gal• Checked by Date
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