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BOX 35
04657
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04657
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTKM
DIVISION OF ENVIRONMENTAL -HEALTH SERVICES
^PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION ) 4_YAe '45 VXI a0'
MAILING ADDRESS v2 kf 6n Sal.
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lley i)
PHONE la 3- e-7d (a
TO
PERSON INTERVIEWS) O w n. tK ,7 'PCH
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER 1, y (S- c tZ r Ac, A 0 Y
Canplaint f -R -e X
be�QYI o,�
PHONE 73 Y`" 2. F X.5
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
01$rRi6vr1vN"vFFFDiH6 8. N601 JNF1LrP..Xr6[?,&
Proposal approved
Inspector's
& T
Proposal Disapproved
Da
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
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 (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner reported a ent of owner agree to the above conditions. ,,or
C TITLE DATE 6 41,h-7
.W: V&te (PC D); Yellow MZ n Ht); Pink (Applicant)
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PLJ T_NAM COLJN'I'X, DEPAR'I'1VIE1�1I ®F giEAL'� I� rr
Diy�sfon. of Ent!ironmen;al Health Servi ces Carme% N Y 10512
..... .-s`..
±•-�aG (1 =t 4 :, �c�'v Nso .ftuulvs' n i✓ i_Ao &IA -aeE'3 fs .`L4� �tf+y c i i'Fsf is
or ,Village ,
Located at "T���✓ E T��/ �` 2 Block
Awner ! / ��/�� �%�� z/i/G,. Lot , Job!
' -` Separate Sewerage System built •�by �� � G�6L;/�,�CJ - Y���'• Address �- �/�/i<�9i �LL�w
Consisting _of /�� Gal Septic Tank. r "'t��Qjj lineal Feet "X ` - width trench i
Other regLirements° �������� IA}ST,dL L�'!.► �OtiAlii`�!> �A�>�iA
Water; S u
ppty: ' ` Public "Supply :From -
PrWate' Supply Drilled. By
Ad
dress /�ufiRlX�/z7LL�
Bwid�rig b` ',B `Date erm
P
of d Issued
3` •o
Has 'Erosion :Control ,'Been Completed? :,
J
`i certify that -the systems) as listed serving the above premi w e . B rite lly. sh non the plans of the completed work (copies of which are i
attached) and :in accordance with the standards, rules an s p _ s fi d t r it issued by t e Putna �COUnty Department of Health
Date lib P E R A
Address z�° rd License ;No
< t i
r,.., d
Any person "occupying'prem�ses served'tiy the_above system(s) sfiall. promptly take,! action as may be necessary to secure the correction of any unsanitary ,
conditions .resulting ,from such ,:usage Approval of. ,the.:separate�'sewerage syskem .shall become null' and void'as.soon as - a public sanitary. sewer ,becomes
'.available -and the approvalaof the prrvate:watersupply shall become null and void �when:a'pubI water supply becomes,.available Such approvals are
subJecY to modificafion•'or change when; m thetludgmert of the Comm' ei 'of Heap `such cation modificatioh or .Change is "necessary.'
Date Title
K.
RESULTS OF EXAMINATION OF WATER
DATE RECEIVED
OWNER .'•
ROBERT RI 2 SHRUB: OAK N: Y. it 71
CITY, VIL-- LAGS, TOWN - & %OR NAMP- OF_sUP-PLY � DATE REPORTED .
SMTR ()AK >,
-15-71
AAMPLING POINT.
BACTERIA PER ML: (Agar plate count of 35o C)• =
=COLlFORM GROUP (Most( prole able No.. /l00inl.), :
: HARDNESS, TOTAL - ppm
DETERGENTS,- ppm, N
NITRATES (as N) PPin I
IRON, TOTAL:- ppm
...... .....
.... .•� — ..cr. .w .r...
K
aSlng IOV
Amt ab �@7 grow'
Draw, a well diagram: in
casing,* the -well_ sga!-�4' _.ki:
bearine; formazi -, o - ne , :diaine,
casing(s) with-s- lid lin6
elt vv, r -unc
n
e
%e":':spdc
:,_provi
I and thib,1a5'dss'-'.oJ
..,yes no
41 #2
in
Prade- -
grade
t' -IF UST
ikdy Turbid-J-1-
O'd.depth of pump in
v'6rade
PWD. & GRAVEL:
icy rEf =fo size
if -
f 'keen iil
red -so.
6 f _s�c.Ve en -
p anin x
Oompleted.. 7i
a
1 .
'ix,L' i ���L'�1�s,��5 .�"lv� o��'v� °'i�rrii>Asil "�`�'�`Z.•�`�
Owner or Purchaser of Building Municipality
Building Constructed by
Location - Street.
Building Type
/Z2
won
Block
-1 7
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 grade by me to such systerm, 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-
Tsi ..
C.�tra.r.y'..,rexart.mbr�t. of '.�i:al'th as `to' whether car. note tre
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the syste
Dated this day of 1921_ Signature /-
Title
ii corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP.TTETION 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
k 'PUTNAI� COUNTY DEPARTMEI�IT O� I.�LTI[
- Division of Environmental Health Services, Carme% N. Y 10512
'. x s ;
'CONSTRUCTION PERMIT -FOR SEWAGE - 'DISPOSAL SYSTEM
Town or:' ;ViIlaqe
lyp 'i
�`.J!XYY,�,w':g.:: -'./-� 'rC� "x' .n :',;g C• a:rfiCa' ,,.G' -ca =;
Located a �eciibt� Blo k
r -L - p�
s �
Subdlvis one ®'�sjrC ifi � OP / - -'�� - 44 Jobc,
rtt Address l4�C
Owner ¢ �
_ , 7
k Nu'mberg ofy Bedro ¢ L'ot ;grea `
r _
c oms 1 Total Habitable Space ��� ,( quare Feet
t 9
Separate - :Sewerage System to cAskt of a Gal Septic Tank' ` lineal feet X width trench
To be- constructed by�r - ®-� "�� Address
T—
Water Supply Public Supply From
r x;. private Supply to be drilled by
I AA-
D ErC Sa /i'
Address' V .4, Aso ',-O
Other Rouirements.
o Gid✓ �Lli
s
I represent that I am wholly and coinpletel 6 s_I nd location of -the proposed systems) 1) that the sepaeate sewage disposal system
'above described will be constructed as sho prove 1i6-R,,,. t ere and yn accordance wdh the standards, rules an regula wnao e • • . u name
County- Department of Health,:and t `f�cate of Construction Compliance satisfactory to the Commissioner of.Healthwill
W be submitted to the Department; and ar W shed the owner his ' s cc6isors hers oi ass�gris by the 6u11der; that said ;builder will'
place in good operating.'condition` an$ of spo e`m duri the period of two (2) years immediatelyfollowing _thenat'e of the issu -.
ante of,;the'rapproval of the Gertifica of Con _ :`y lian tfie or•i n'I- system'or any repairs thereto 2)''that. the drilled well_`de$cnbed >above
will be located as shoewn on the approve and 1l ill m Iletl- m cordance -:with he st mils rules and regulations of the Putn,
County Department of Health a ;:
s
' Date P E s
a - , Address D'. License No F
r_
gPPROVE'D FOR' CONSTRUCTION This;approy- a year'from`t a date issued unless construction. of the building-'has:been, undertaken and -is
_:revocab.le'for, cause or,may be amended or,riiodified, when considered necessary. by the. Commissioner -of Health, Any change 'or alteration of construction
requires permit < Flpproved; for disposal ofdomestir andary sew ;' and /or; private :water supply only
�Y :
•Date: -/ / ey Title Q�iLL
,..
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PUTNAM COUNTY DEPARTNIN T OF HEALTH
'e
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Late'
Ae : Property..
Located a tdo Ve "2-Wiv
JA H
-'Block Lot
Gentlemen:
STAEY
This letter is to 'authori'ze K
.:
a'duly, licensed prof b'ssional-engineer r registered architect
_1Z/o
.-(Indicate*)
to apply for a Construction Permit for a*,separate. sewe . racre system; to'...
serve .the above noted property -in accordance with the* standards,rules
or regulations as promulgated by the Co=,-issioner of the Putnam County.
Department.'of Health, and to sign all necessary papers on M Y ..behalf in
--connection...with this matter, and to supervi se the construction of said
system or.systems in conformity .with the pr.o*visi.ons.of Article'145 or
147$' Education Law,'the Public Health.Law,.and the Putnam Coun'7.Sani.-
tary Code..
Very.truly'yours$
Signed
Owner of Property
a-:V, J/az�'
z'
Countersigned., Address
32
in Telephone
Sea
RIAN' AN'
RUPtn"
BOX 26.7
h,
MAWAK, N.. H8561
24--645
Telephon5e
PCiTNA�I COUtiTY DE?:.?T'fU `T OF 1 —LEA
.. }�. .i.0 _ -�.:" •" .. y:'. _ ...?!'.:r_'.'., r, x.. , .�,. : -.,� -^ _:.. `..C�. l:ai`r c•^:;Yyt:ir'icio:
DTVISIOy :OFr`E \VIRO`�,L TEL HEALTFC- _1ViCES
DESIGN DATA SHEEN - SEPaRATE SE.:AGE. DIS=OSaL SYSTE_ FILE .NO.
o�
Owner C.tic.�c'S�� Address X26, nrif�'v� tO,�c'
Located at Otre2 t L�r�y�til :cJM�re�. , �q i !/ Vie . Zi Block �" Lot ° �..
(Indicate nearest: cross street)
Alz Munid.ipality, lawU of u�qr>. ��1� /T Watershed � /1 X7.QoviG
'SOIL. PERCOLATION TEST DATA REOUIRED TO BE' SOB1,1T' -TED t'IITH :?PPLICATION
Hole
Number
. CLCCK MIE
'
PERCO� ATION
PERCOL_\TION
Ru'n
No.
Start
ElaQse .
Time
Stop Min.
Debt'. to �%ater
From Ground Surface
Star - Stop
Inches .Inches
r,;ater Level
in Inches
Drop in
Inches
Soil Rate
Min/in . drop
5
_ /�'y 1 = -rte � � 6 � �' � � � `•
2 17
Notes
1) Tests to be repeated at same depth until approxi- tel, euual soil rates a,re ob-
tained at each percolation test hole. all data to be submitted ier.revie:W.
2) Deotn mear;;,,re,:ents to be made_ from ton of 11n1 p .
30'
36"
42`
48"
54"
6 0r
a
q
2:.
787 �+
INDICATE. LEVEL A
AT VNI ICH G
GROUND W
WATER IS ENCOUNTERED
-
INDICATE LEVEL T
TEST PIT .DATI PEOUIp D TO 3EE TH aPPLI,CTIO\
DESCRIPTION or
SOILS E` TERED I': _EST
HOLE
DEPTH
HOLE N0. /2/
,HOL N0,
HOLE_ NO. .
G.L.
12r:
cJArrO /R��
47J lo yQ<h:'C- ��i✓�+I
-A� �-G
Soil Rate Used /
/0 M
Min/l" D
Drop: S. D. ?'sable Area Pro - ,ride -d ! /J"
2 4`
— S
Sep t.ic T
30'
36"
42`
48"
54"
6 0r
a
q
2:.
787 �+
�N
7� y�
Name a
'f `�
Address. y7
N. ' U M
��. 1 G_ ':1% v L 1 �
die No, 32�� �'.�' /�'_ " %?
W-2645 `�` �Mh
PUTNAM COUNTY DEPAR'TL%FNT OF HEALTH v 0� q ..
Soil Rate approved Sq. Ft. /Gal. Checke.d `_ Date
INDICATE. LEVEL A
AT VNI ICH G
GROUND W
WATER IS ENCOUNTERED
INDICATE LEVEL T
TO WHICH-WATER L
LEVEL RI?EES AFTER BEING E
ENCOUNTERED
TESTS. LADE. BY D
Date 2 31- 7z
Soil Rate Used /
/0 M
Min/l" D
Drop: S. D. ?'sable Area Pro - ,ride -d ! /J"
No. of Bedroo- s�7 —
— S
Sep t.ic T
Tank Ca,- _cite ao G
Gals . Z�Pe -eeA C_
Absorption Area P
Prcvided E
Ey_/ L. F.x "'` 3b` 1. i
idth trench. Other
7� y�
Name a
'f `�
Address. y7
N. ' U M
��. 1 G_ ':1% v L 1 �
die No, 32�� �'.�' /�'_ " %?
W-2645 `�` �Mh
PUTNAM COUNTY DEPAR'TL%FNT OF HEALTH v 0� q ..
Soil Rate approved Sq. Ft. /Gal. Checke.d `_ Date
oI
o 21'
f
a
NEW YORK
V
/971
,
8B1 a.s•
N/R cSU�✓iNER 1
89'00'/0 F 1797'
5��on�� t --- j�l•SBs� �ZO-E /07, 60'
l9 ati yo /
/-0 ' i 2 V
PREiy/ /SES S.yO`VN HERON B—�/NG LOT G
4.�L, 24' % ,�' AS Ss/ow�/ oN iNFlP E�t/T /TL EO " /�y/PRovE�Y1,ENT
o� f1N PREPARED FoR RUSJ" /C li�7L � .
PROP�RT /ES,"
59/O 4Yl.9P F/L EO /Nr;VE
PUT/VA/y! COUNTY OL�RiYS oFFicE oN
cIULi 17, 1970 9LF iYJAP iV / /BB. ?
V
R -50• oo'
a-
e.. 3.9,
N69 °49'iV
2'3.22'
5 �URV�y of o,4op�,QTy .
s CSiTV9TE '/N
ALL
Pvrivq� �'oUrvTy '
a
NEW YORK
/971
SURVEYED & PREPARED BY
BUNNEY ASSOCIATES
••Atl certificatiaaq'hcreon are valid for the riapaz:d cupiea
i'Ui4s.�,f,:iY:ilit:4t Ltiul',th184t1/Yrr�.
µ -r :;rEQ If arrorearca.�u,tti9
ENGINEERS & SURVEYORS.
thereof only if said map or nlpics tzar the iwpr.�. A
seal of the surveyor wbcxu- si�,•uatme apF-arr, turr.rc:.;`
a� to z, &ale W Fratflea ;or Und
Sv arg.a3oF•���.oYtne Nov, York staft
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20 WOODSBRIDGE .ROAD ,•
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KATONAH. NEW YORK 10838.
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