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04622
` PUTNAM COUNTY DEPARTMENT OF HEALTH
;Y D, i visi bn of Environmental Health Services, Carmel, N. Y. 10512
CERTII=IC6STE- 'OF'COI` STEE,UCTIORi6OMPLIANCE FOR SEWAGE DISPOSAL, SYSTEM % 0 ;,41si y �GG4W
- Town or Village
Located at �i(JM k'i i% �.'c SeCtinn 62 Block
Owner ,S. J/_ c 4',d`" rt;,+i �Tv4�C✓ 'ors :i Lot Job
s�
c ,�
Separate Sewerage System built by'�!QV,4T7r`%' P�y"� li�%�tl ��r Address A °' >/t "�F� � , �4 A Q/
Consisting of Gal. Septic Tank 414 lineal Feet X IY6 I'll width trench
Other requirements
Water Sunnlve P..Kl;f Cnnnly I=-
Build
Has
�LS
attac
Date
Any
condl
ava i la
s ubje
/ Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental• Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL 'SYSTEM 0/0 wTN'JANJ
/Ax 44p '`0 (O 7- f 3 yvn or Village
Located at ` /Nn// T P-4 A Ci5 Section Block
Subdivision
L 4/ -0 %4 - 4l✓REAIA Owner
Lot Job
Address es TNU2 r% lN &�RS /l /
n vo
/GS���NT2/ Lot Area `� " -9
Building Type -�+G
�3
Number of Bedrooms 7
Total Habitable Space Square Feet
3` n
Separate Sewerage System to consist of 9019 —Gal. Septic Tank 37S lineal feet X fo width trench
, �y
O@ �L,y_ S
To be constructed by t / // /✓ /
Address � ' •
Water Supply: Public. Supply From
XAIDg/Q spa
_�ZPrivate Supply to be drilled by
�vrnlA
4LL
Address
Other Requirements
I represent that I am wholly and complete) design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as sh
ndment there to and in accordance with the standards, rules an regu a Ions of e Putnam
County Department of Health, 'and, piki r
"Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, a e g a
furnished the owner, his successors, heirs or assigns by the builder, that said builder will
the two immediately following the date of the issu-
place, in good operating condition o wag
I system during period of (2) years
ance of the approval of the Certi
e o Com
II
a of the original System or any repairs thereto; 2) that the drilled well described above
1 installed in acc rdance with t e standard and regula ions of the Putnam
will be located as shown on the app
vMh plan ;
,rules
County Department of Health.
J
ian P.E. R.A.
G,,
Date O
)
o-
A WAZ 14 _ License No. .1l 'ZOO
Addre
APPROVED FOR CONSTRUCTION: T Ptglfal ire's,
_
;year from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or Sider ecessary by the Commissioner of Health. Any change or alteration of constructn-
reqruires a(rlbw pe mit. A /pproved for disposal a estic s W y sewag3e,, pr' to water supply only.
Title
e-e -1i li
e results indicate thct the water
CROSSROADS
)VA,4,fl':,M,: 4 SOP)
7
N:
N, Ml N A T 10 �"O F� W
RESULT -W X WATER
.0
U, TAM-ORENA;,-:- F,,,oD o,,�
"s 'sk 10GER"I T i;IR
SAL LABORATORY
.'2
F.�Rjk -PER'-MtjAcf"dt,61ate Cq
GROUP
s RECORDED AT ", -J
e results indicate thct the water
CROSSROADS
)VA,4,fl':,M,: 4 SOP)
7
N:
N, Ml N A T 10 �"O F� W
RESULT -W X WATER
.0
U, TAM-ORENA;,-:- F,,,oD o,,�
"s 'sk 10GER"I T i;IR
91'
T
F.�Rjk -PER'-MtjAcf"dt,61ate Cq
GROUP
s RECORDED AT ", -J
?POINT, TREATMENT,
iRIDE F)
e results indicate thct the water
CROSSROADS
)VA,4,fl':,M,: 4 SOP)
7
M
PUTNAM COUNTY DEPART NT OF HEALTH :.
-DIVISION OF ENVIROM ENTAL HEALTH SERVICES -
I
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO
. Owner c�A'To -Address• 2 447-ifyA 05'7:, }�„�, '�,Qs
Al-
-4
x 67- .7
Located at ( Street ) �L .4 c4 Sec . Block
Lot
(Indicate nearest cross street)
Municipality- law' Al Z y Watershed b4x?,6;e c
- SOIL .PERCOLATION- TEST DATA REQUIRED TO BE SUKII -TTED WITH .APPLICATION
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Slater
(dater Level
_
No.
Time
Fron Ground Surface
in Inches
Soil Rate
Start Stop
'Lin.
Start Stop
Drop in.
Min/in.drop
Inches Inches
Inches
5
- 2 21 q ��
3�
A, 17
4
S -
2 _ _ 3.2�
4
S
5
Notes.:—
1) Pests to be repeated at same depth until approximately equal soil rates are ob-
tained at each percolation test hole. AllVd6ta to be•submitted.for review.
2) Depth measurements to be made from top of hole.
TEST PST DATA REQUIRED '-0 BE SUBi1ITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED I`i TEST HOLES
' -5..._ .y, ;.. — s'..... . .u..: .,, - .C'- e. .: ^ - >=Vl -.: .. _ .. }'f ��t•Y . Y: rea 7
DEPTH HOLE h'0. P� ;''`, "" .HOLE' NO. HOLE NO .A /, joG •..
`G.L.
6 rt A
12" Ar �, y
18" X%x r otc �g+v NX7 lye
24 j Ir
30�
if
36"
42'r
48" y
5 4"
6 0 ='
661; y
fi
INDICATr, I,rVr L AT t,{ICI[ GRGU \D t'aTL'R IS E \'COU \iERED /�� �'�
INDICATE LEGTL TO L�HICH WATER LEVEL RISES AFTER BEING E\'COUtiTERFD
TESTS BLADE BY �S; �,4 � ,e Date 9 -A /- %O
I
1JLa1 U:\ /
Soil Rate Used 3v Min /l'T Drop: S.D. Usable Area Provided j.a"
No. of Bedroo s - o
Septic Tank Capaci -y..900 �y� Gals. .Type �o•�c, c
Absorption.. Area Provided. By a57` L. F.x24''". 36 k width trench. Other. -
/i _
Name
Address I
PUTNA!•1 COUNTY DEPARTMENT OF H 1LjZ
Soil Rate Approved Sq. Ft.
3i
laF jgiv L -e d by.
Date _
i UTNAM COUNTY DEPARTNIN T OF HEALTH
. }.DhViSION OF.'IRWIRCNfg2NVAL HEALTH ;SERVICES .
Date /q7
Re Property of Si [.,Mliy'E
.Located atinr,J�r-;� 4C �yN�: e>
Section Block '. Lot
Gentleten:
This letter is to authorize STAKE . LP�iM1), FO
a.du.ly -licensed professional;'engineer j/'or registered .architect.
( Indicate)
to apply for a Construction Permit for a separate -- sewerage .system; to.
serve.the above noted .property..ir_.accordance.with the.'.st:andards, rules
or regulations as promulgated by the Commissioner' of the Putnam County
Department of Health, and to.sign all necessary papers on my.behal.f in
connection with this matter'and to.supervise the construction of said
system or systems in conformity-with�the' provisions of Article'145 or
.14. , Education Law', the P.ublic'Health Law, and the Putnam County Sani-
tary Code.
Countersi g neck!
P.E., -R-;., # .32723
STANLEY I LAN DM (seal)
Ad reqftV 2fi7
AMAWALK, N. Y. 10501
245 -2645
Telephone
�f IdE�iO .
Very truly yours,
Signed. _J11- A1
Owner of Property
Address
Telephone
�.
s•
t..i.!%L Ofi� dA Y - 'A`j�jo -mil y a�p}��`/3✓�� . R ..la Al. Gr /z' „ f'
Owner or Purchaser of Building Municipality
Building Constructed by
Location Z Street
Building Type
W
Set o j ,,f 1740
Block
Lot
GUARANTY 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 guaranty to 'the owner, his succes-
sors, 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- _A
_�viue .af:_.th° .L L_. _Co�_Yaty_D,epart^:ent off' Health -as to whether or not the
failure 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 19
3/ Signature�G�%t�`— xa
Titlei.��rt;
If corporation, give name
and 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
�I
ti�
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 ® Division of Environmental Health Services
ti
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
; ..,jh7s :report.,is to. be, coml?1eted.,4y.Lpll, driller,.,an¢ submitted „tc. County yealt�. Department togi<ther with.hbgratory repprt.of; �;.
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
A R
LOCATION
OF WELL
(No. & Street)
_
(Town)
(Lot Numbe
PROPOSED
USE OF
WELL
-DOMESTIC
PUBLIC
❑ SUPP Y
BUSINESS
❑ ESTAB ISH NT
11 INDUSTRIAL
❑ FARM
AIR
El CONDITIONING
❑ TEST WELL
ER
(S(Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED
AIR PERCUSSION
CABLE
❑ PERCUSSION
OTHER
❑ (Specify)
CASING
DETAILS
LENGTH (feet)
DIAMETER (Inches)
WEIGHT PER FOOT
/
THREADED ❑ WELDED
DRIVE SHOE
YES ❑ NO
SC G EDP
� YES LJ NO
YIELD
TEST
❑ BAILED
HOURS
❑ PUMPED IR COMPRESSED AIR
G.P.M.
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC (Specify feet)
DURING YIELD TEST [feet)
l :LDepth
of Completed Well
feet below Land surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches) FROM (feet) TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
t. r,
y
Ic
PUI'NAM OOU[ITY HEALTH DEPARTKW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FM ^ S30M DISPOSAL SYSZE2I REPAIR
OWNER'S NAME <�Z/ �' �' ci pw ole -4 PHONE
SITE LOCATION S-0 ri n TM# Let 3 6Ikk. �]
MAILING ADDS 4 4q '-
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY i lF M i
PROPOSED nsTALLER T 1o•is,('� $ S1ylc . PHONE
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NME: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect.
,r'92 STi9 L ` ICU D y / L 601 PRO Fit-
Proposal Disapproved
�II
's Signature & Ti
with the following conditions:
1. Procurement of any Town penult, It appllcable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
Z O
Lat
(e.g.,house corners).
three precast 61. diama. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, orreWrted a t agree to the above conditions.
SIGN TORE / �'�`� TITLE DATE.
PIE: ftte MD); Yellow (T= BI); Pink (Apptiamnt)
PC -RP 97
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5, 14 �- A
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4�4
"CIL c Z'
7,
A/'
PC' 1971
PT. OF HEALTH Ad 77.
- R Di SION OF
v, m
HEALTH SEWICIES
14
laW
54
—04, 9
.eta +old as in
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