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Rev. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N,Y.10512
Ir' Engineer. Most Provide s ,
P.C.H D t Q
`e Permit
..
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM°r�t.�•l':
Town or Villau e
Located at . I r'1 C7 �•(i W, 7 IINd - F—Y7+ 1
T� MBP , Block Lot
Owner/app litmt Name Formerly G SubdlAslon Name : Sabdv. Lot kq
Melling Address ' o• f 615 7P 16 5 ,1-1 Date Permit leaned
Separate Sewerage Syetem'bnllt by �OMr� -�1 S� _!'�� . Addressp�Ij�p_ by./�F -1�0
Consisting of j2 0 Galion Septic Tank and &0 � AVEOP t
Water Supply: Public Supply From �, , Address .
(oor::' � PPrrivate Supply Drilled by �lf� SA 4 `�Ad�drrees's �9M0" V-
i� ,(
B.,dlug Type d Has Erosion Control Been Completed? b"'
Number of Bedrooms 4 . Has Garbage Grinder Been Installed?
Other Regailrementa �� -
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department of Health.
Date Certified by P,E.V R.A.
Address Ct� � ' In License No. 61T51
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. 'Approval .of the .separate sewerage system shall become null and void as soon as a pub('= unitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner of •Health, such revoca n, 'modification or change Is necessary. ---�
Date Y �� �\ Title
t _ __
AE..
a
►�
W �j04
WLLL L,Ur rLL 1 iv1N AzrvAl
DEPARTMENT OF. HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: WN /VIL I Y TAX GRIO NUMBa.
290/t' `�
WELL OWNER
N E: ' ADD ss:
- /L'ct_ ce,-, r zr, r1� ✓�
❑ PUBLICS
USE OF WELL
1- primary
2 - secondary
'C�. RESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP b ABANDONED
0 BUSINESS 0 FARM 0 TESTI OBSERVATION ❑ OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
`B. NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH ft.
STATIC WATER LEVEL ..-'�/_ft.
DATE MEASURED
DRILLING
EQUIPMENT
0 ROTARY `.COMPRESSED AIR PERCUSSION O DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING. _tMPEN HOLE IN BEDROCK 0 OTHER
TOTAL LENGTH ft.
MATERIALS: @-STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH.BELOW GRADE _q 9' ft.
JOINTS: ❑ WELDED 'In- THREADED ❑ OTHER
DIAMETER & — in.
SEAL: 0 CEMENT GROUT 0 BENTONITE `®=OTHER
WEIGHT
PER FOOT 17 1b. /ft.
I DRIVE SHOE O YES 'B.NO
I LINER: O YES ❑ NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
❑ YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST ; If detailed pumping
METHOD: O PUMPED t tests were done is in-
t
• COMPRESSED AIR , formation attached?
• BAILED ❑ OTHER ❑ YES O NO
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
D'a-
In
FORMATION DESCRIPTION
COOE_
tt.
ft.
WELL DEPTH
(t,
DURATION
hr.
DRAWOOWN
it.
YIELD
9Cm
Land
Surface
)
� J
p_min,
(P
/0
WATER ''O, CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? —OYES ❑ NO
ANALYSIS ATTACHED ?`0.YES ONO
STORAGE TANK: TYPE W'f_l j fbL
CAPACITY �vt';L Q-5 I GAL.`S
PUMP K�.%F MATION
TYPE - A'A ll i 6 k )CAPACITY
MAKER Ift ER-i S DEPTH
MODEL 25 VOLTAGEHP
WELL DRILLER N ME DAB
ADD E t� J IGr RE
It. I }
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: Albert H. Padovani M. T. (ASCP)
F
TORLISH WELL DRILLING
PO BOX 271
Armonk, NY
10504
L J
..LABORATORY REPORT ON THE QUALITY OF WATER
LAB // ° -- - -- -- -
Date Taken Time:
Date Rc' d : Tim-e: 2
Date Reported: SEP .'201989
Collected By: Duane Torlish
Referred By: IF5TI 0aee -1 A.Zbi2 -C
Sample Location:
Phone # 273-3W48
Phone # - I Sample Tyne:
Reheat Test? (check one)
INORGANIC ,ION- METALS (mg /L) MICROBIOLOGICAL (CFU /IOOmL)
_ Acidity
_ Alkalinity
_ C'- loride
Detergents,
MBAS
_
_ Hardness,
Total,
Nitrogen,
Ammonia
litrogen,
Nitrate
— Phosphate,
Total
Sulfate
Sulfide
Sulfite
METALS (mg /L)
Cooper
_ Iron
_ Lead
Manganese
Mercury
_ Sodium
Zinc
MISC=L LAN EOUS
pH (units)
Color (units)
_ Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA -
Standard Plate Count
(CFU /1.OmL)
MEMBRANE F IL T.RATION TECHNIQUE
Total Coliform
Fecal Coliform
Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A =
LT =
GT =
TNTC=
CON =
NR =
Not Applicable
Less Than ( <)
Greater Than ( >)
Too Numerous To Count
Confluent ( =T ?ITC)
:Ion- reactive
,REMARKS/COMMENTS (For Lab Use)
_Potable
_ icon - potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
0Utt7'0 1 - W
HNO3
_ HC1
H2SO4
_.NaOH
ZnOAc
Na2S203
Other:
_incoming
_ LE L °C
GT 4 °C
DH LE 2
nH GE 9
_ pH GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH NE YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE OF COLLECTION'.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (D,IDN'T) (N, /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT NKING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
•( - 2 /86(Rvsd7 /87,)RWE
�� n;,.o� +.,,.
Owner or Purchaser or u ng
Building Constructed by
Location h r == Street
1 tLY
Bui ing Type
xTe_pzsotil
Municipality
i
Section
i
Bloc
)9
MOR
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-
vices of the Putnam County Department of 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 OG'r. 19F>i Signature
Title %4s ,
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 Heald
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT -
No.
07
MAILING ADDRESS 6+ I
P.O.. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE� TYPE FACILITY TIME ARRIVED 1: Q� /J/}�. TIME LEFT �f 4�i /)m
INSPECTOR:
WAVEM 041 M"URAME
Signature and
PERSON IN CHARGE OR INTERVIEWED: '
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
Sheet _4 of
INSPEr -TTON
Orig. Routine
Orig. Canplain
Orig. Request
Compliance
Canplaint Carp
Final
_ Group Illness
Construction
_ Reinspection
_ Field, Sampling Only
Field Conference
Other
TELEPHONE:
Explain
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet'_ of
INSPECTION
NAME �C.(,�i�'ti� �l,tiVIC`1 Orig. Routine
Orig. Ccmplain
ADDRESS ��[l� I S _ Orig. Request
No. Street Town TM No. _ Compliance
_ Complaint Comp
MAILING ADDRESS Final
P.O. Box Post Office Zip Code Group Illness
Construction
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED
DATE o
TIME ARRIVED
6T-0
Name and Title
TYPE FACILITY �/► �.�' ,
TIME LEFT
_ Reinspection
Field, Sampling Only
Field Conference
_ Other
Explain
FINDINGS: �
�•1 .Ut44
•�
nl
INSPECTOR:
SictrALture
6A. 1 �
and Title
TELEPHONE:
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
TITLE:
vI4
b ��n� Divldlist�alefaaMal Bssd� Seevless. ®Qw. PI.H. Y6t$Y?
1I poevedis
ad 1Z
MNUMM P®1®1' FOIL WWA4W WFOSU s Flooillill p
Li>aslsiit Meot.Amy 1-aii.L F.o^x:�, oil MAnIOQ - Town or ire
Vw Nrs - AI9.111e~1d M.ot.loe, SAL Let t IS Max P&P I 1 let _ 19
Owwss /A}�artNs� 4- 4oMESrt� .���oGt.�-rars Yee:ewd_p won p
Dots of Piravlo e A ffmd
ram Adilre so P o - i3 S"N 18G. gown T � F.A.-r- Zip io s 94
patg Subdivision Approved Fee Enclosed [3 Amnnr,t
adming TYP let Ann, FM Seefte, 0 D.Fa Wabsoo
Nt>slrar at no&— 4 Doo4p Fbw G P D Soo PC® NolBf md= k Reasibed Wbm F® k oatapkeed
Sava mb Sowmw System b maedst erg 1 210 r� Tastk so,t Boo L. F. AB��fa7Yo.✓ /cN
To Ib esmhadod by -75' Address
Water Ss t pia Sop* FIB Address
an _terteob Sew Dodd by T Bo- l>c
Otlnlr Rlnn(ekeoiwts
1 represent -.that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sew di sal s atom
above described will N constructed as shown on the approved amendment there to and in accordance with the standard; rules a reeu ns o norm
County Deportment of Health. and that on completion thereof a "Certificate of Construction Compliance' satisfactory to tho Commissioner of Heelthwill
be admitted to the Department. and a written guarantee will be furnished the owner. his successors, heirs or assigns by the builder. that laid builder will
pbce in good "seats" condition any part of said sawage disposal system during the period of two (2) years Immediately following tledate of the bom-
once of tha approval of the Certificate of Construction Compliance of the original system or any repairs eto; 2) that the drilled well daortbed above
wile be located as slldrra on the approved plan and that void well will be installed in a e:ordance w the eta rds. rules and rogu a�TfTons of the Putnam
Date rt To b /���"� 1 X_ Signed
Address P.E. RA. —
Address `-+"`^'141 License No Uzroofs
APPROVED FOR CONSTRUCTION. This approve$ expires two years from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
Rev. reOUNe�a Per It. Approved for disposal o< domestic sanitary end /a pi too pp��`�'^
10�88 oet�
.
a. -`° /- .,. �c--. : �i -'-• - t .--a, ra .. - . c- ...... -- i�_. �: :ti— ,.m..ro..,.o:....,..- R...�m. ,.._.....- ...- ..... -�-.,. ---v- �.- a....�... .v .zc::,x.., ,..........__ - _ --
\
6x
YU224 l[ COU fff DlAl22113 ' OF H6AM
Dlalia[)�tketaealslBssMSelnb Caaod.Ii.F.14W bFm"a!malts/
sea CZRTMFW/118 OF C011KLA B
!IWei POlet >NOIt WWAOE DIIIMU ST
v - - t�.e- t-Tvozao d
I.eeod ttt Moo1Ja,r VA I L.L. ! Matigg , Tamm ass Vubp
le oNpa Natar _sidii& W p IS Tbx M 1 Dls& 1 f.: 19
tlte.eiad o Zevbilas�
QaasdAPPDpsat Nataig I-�o M BSI TE .� o GA"[Ss
Dais et Ftevlso App wd
161re Bon 186 Town T"owJwbojn k zb. 10594
Date Subdivision ARDroved Fee Enclosed ❑ Amn„nt
veil Tj,N ae-g-. I = c-e W Ara 1- S Co F® Seedso Dab LJ Deph Vekaae
Ntat I Of Issi+r■ 4 Daelp Flow G P D 800 PC® Nad8tedw k l Rath red wisest F® k comelided
SepaaM Sswwess Sym m M Quaid of I192 GWI ft Seple To& astd 1900 L.. F od %eMcd
U be eastsmaelei lry -7—, BB L�c3T�KM) s� Address
water Stadr: tout.. Sib, Fyn Adiseas
an rata Se*pbr DtWsd by '70 Agareas
OdkWNe�iemsak 171 1�s uT1 01.1 le>C"c
1 represe ic.that I am wholly and eompietely responsible for the design and location of the proposed systein(s); 1) that these ►ate sew di sal stem
above described will be constructed as shown on the appr� amendment there to and in accordance with the standards. rules a regu ens or nem
County Deportment of Health. and that on completion thereof a "Certificate of Construction Compliance satisfactory to the Commissioner of Healthwill
be submitted to the Department. and a written guarantee will be furnished the owner. his Successors. hairs or assigns by the builder. that 'said bulkler will
place in pod dperatbg condition any part of said sewage disposal system during the period of two (2) yews Immediately following thedate of the I=-
so" of the approval of the Certificate of Construction Compliance of the original system or any repairs theredo; 2) that the drilled well described above
will be located as shown on the approved plan and that old well will be Installed in accordance with the standards, rules and regu aeT fgns of the Putnam
county Delpartnment of Hlaelth
Date Ut I I J� � Signed P.E. R.A. w,dress C... b,--14IhJ t!:� L.. IJY License No 6161 '
APPROVED FOR CONSTRUCTION: This approval exPles two years from ((We date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction.
"Quires a setk
Permit. Approved for disposal of domestk sanitary wa and /or yivate water ! ly only.
Rev. �n
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # z
WELL LOCATION
Street Address
oo"esf 14141. e NIA►jo2 k'C.
Town/Village/City Tax
f/aTraP_%0►J
Grid Number
WELL OWNER
Name Mailing
o"E o ,
Address
15ox 18S _TZ ora u/oo>
®Private
O Public
USE OF WELL
1 - primary
2- secondary
19 RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP.
0 BUSINESS O FARM O TEST /OBSERVATION
11 INDUSTRIAL O INSTITUTIONAL O STAND -BY
❑ ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT1..11jj S gpm /#
PEOPLE SERVED% Fray /EST. OF DAILY USAGE ao gal
REASON FOR
DRILLING
NEW SUPPLY
O REPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
e+vj
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL
E]
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
r^ ► wnh ew M^tjop- Lot No. 1z;
WATER WELL CONTRACTOR: Name am Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL/CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION 1401N� E�PARAT�E EET
,`
Joy's (date) \(s�ig tore) n �ti,
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant s.hall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County
Health De rtment.
Date of Issue 19
Date of Expiration. 19 White Issuing cial
Permit is Non - Transferrable White copy: H.D. File
Yell ' ldi.n
ow copy. Btu. to
g Inspec r
2/87 Pink Copy: Owner
Orange copy: Well Driller
' . • PUIMAM
OCLM Y
. DEPArMM?r CF H.FMV
:•' DIVISION CF 'ENVIRCUMML
)REACTS SEMCF,S
DESIGN DATA SHELT- SUBSUEA+CE SEWAGE'DISPOSAL SYSTEM FILE W.
Owner I —S
Address P O. go11. I85 ` ^�r oR*��JooD �J.Y
Located at (Street) L-
I 20 Q a Sec: ' I Block I Lot 19_
(indicate
nearest cross street)
murn.icipaiity
-Watershed.
SOIL PERCOI,ATICN TEST
DATA .RE1QUiRED
TO BE SUEHITIM WITH APPLICATICNS
Date of Pre -Sg6k 9
of Percolation Test 6 /71 /,57
HOLE IT
NLmam CL= TIME
PmC]Q ION PEEUIATICH . .
Run , Elapse
DepEli to
Wa ter. E r an Ma ter Level
•
No. ''Time
Ground
Surface In Inches Sou Rate
S tart S top Min..
' S tart.
Strip ' Droop In Min/in Drop
Inches
Inches Innches •
� 1 1 8:40- 9: I o 30
23
2(0 -3 1
2 9:10 - 9, qo
12-
3 1o10 30
Z4
2��i Z�z IZ
Q Io: �o -•10 qo 3a
29
'z 1 8 :43- 9'13 30
2q
2Coi 2� 12
2
-
3 q 43- lo: t3 30
23
25 2 1
4 lo, 13 , 10'`4-3 30.
23
5 '
t
2 9: m -,1:-44 • • ��
?
ZS I - �
3 44 • to--IA go
29
4 I o' I q• l 0 44 30
24
25 I 3
5
' T,rsts to be repeated' at same
depth until . aWrcx ma tely equal soil rates
a. re'obtained .at each pereolatixi test hole. All data to' be.suhnittod
• for review.
' 2. Depth measurements
to be made from top of hale.
TJR 'T PIT DATA RD22IRE2 TO' BE 8UBt'1'rr M WrM APPLICATICM
DESCRIPTION OF SOILS EN00 NIA IN TEST HOLES '
AEPTii . '. HOLE NO: HOLE NO. ua NO.
G.L.
4'
12•' ... ,
13'
1 .
14' �-
INDICATE • LEVEL. AT .WHICH GROUNDWATER IS ENOOUNTERED
INDICATE LEVEL TO-WHICH WATER LEVEL. RISES AFTER BEING ERJOUNIEMD
DEEP'HOLE OBSERVATIONS MADE'BY: DATE=
DESIGN
.Soil Rate Used Min/1" Drop: S.D.. Usable • Area Provided,
No. of Bedrooms Sepbic Tank.Capacity gals. Type
• Absorption Area Provided By L.F. x 24" vAdth trench
der
Name �,� J �o� i�-r�s' P. Signature ' i'
Address c? fTE SEAL 1
VoA
GARMEL. �,,- IoS12
THIS SPACE FOR USE . BY" LMALTH •DEPAF24EtJr OMYt
_, ,
Soil Pate-Approved sq . f t/gaa... Checked by Data - --
! ,
t ��
wrA�
APP=LC B
PUINAM Cr,L'i� - DEP_AR'IM.EZTTr OF MUTH - DIVISIG'N OF EWIRCNi�L flEALMc S�VICFS
Pig D./- IDCrPL 4vPTF.R SUPPLY & Si BSE REME MV-A= DISPCEAL SYSTRAS
G
(Name of C me --)
REJ=W S= - CONSZ iICN PERMIT
(St e°_t
c�
I YES
No f
I
I
I
I
{
I
I
I I
i
I
I
I I
I
I
I
I
I I
I I
I I i
I I I
I I
L tenon prcvided
60 f t.
P= r=-L_-- 7 'tc con= s
100%
� I
I
I
(
I
I
i
� I
' I
i
I
F - • ST�nc
r
c_av rr =er I
I
10 ft.
I
f i 11 n t =s
new s-
deoth ca� es I
100 vr. flood kliev. I
I
200 ft reservoi -, et
1 =0 ft. tricall /call.
(
I
I
I
(I
DATE R�'-",T -;+� :
BY: 7[C
Lod. ticn)
DCC'u'V_T;I5
Permit Anpl ica tion
Corrorate Resolution
Plans - Three sets s /__
Encinee_rs Aut` crizaticn
D'esicn Data Si1eet (DCti) Su�Dri! SICK
Deep Hole Lcc Pero
Consistent Pero Re__,i t_ (3) Fi11
Ps--c Hole Depth
Hcusa Plans - T'vao set:.
We11 Fe-m au
Variance Rezuest
G��r.
L= al Sai:divisicn
Succ.ivision Accrova'_ C. =c'c=r
E _,- ac.:rcva_ SSCS Ad Lot_ Clems'.__
Wet?ard (Tcw-p_/DEC P = R & v)
Data Cn DGS Plans & P_=i _ same
RE,== =LMIES CN PL:tiS
S -va e Evst --1 Plan - (: cr-'i azrz, )
�=wcce S_ s t`.'.1 Evdr _:L ied P.- f-41- _ Fill Proz,le & Dime s:c -s - Vci_
D or J Box;'- P=..- .P= pi = ae= i1�
{S e. atic Tahiti — J1 ----, llr71
We l! Detail, Service Line if cJ.a_
C_nst-ucticn Notes (crinder rte)
Desicn Data: rerc and deep ra
Two -Foot Contours Exi sti nc & P_cxs
Drivevav & Sloces Cat
Fccti naC`atter, Ctiurta. i z Drams (d__czzrce C{ )
Pero & Deep Holes L.^cat
Repra=zntative of primary and excansicn
flca-isicn Pr shown;oravitr f cw,suf=..size
If Pmuped Pit & D Box S:zcw-n & Det. -iled
House - No. of Ee^rccros
Wells & SSDS's w /in 200 ft. cf r ocosed .SVs
Property Me -s & Bounds
House Setback, Necessary (Tight lot)
House Suer - 1 /4" /ft. a "0; , /Te pipe
No Bends; Ma:t. Eends 45° w /cleancut
SEPAR.AMON DIS�'L= SPELTFI=) CN PLAN
Fields
101 to P.L. , Driva=,;av, Ia-rae T_ =_._,TcP of f.
20' to Foundation walls J
100' to well; 200' in D.L.O.D, 150' Pits
100' to Stream, Watercourse, Lake (inc.
15' to Drains- Curt=-iz, 1,=-der, Footing
35'to mtch basin, S LCi ,. rG? n, ci ed waterScIr
10' to Wa-ar Line (pits -20')
50' rote_- nitte.*it drainaae course
SecLC Tanks -
10' f_an Foundation; 50' to well
15' well to PL 9
PUI N M COUNTY . DEPAF� U . CF HFALT H
DIVISION CFEWIRCtMVQL
AEAM SERVICES
DESIGN DATA S imr-- SUBSUFACE SB gAGE ' DISPOSAL SYSTEM' FILE W.
Owner
AcUress P O. 86k 185 1 y6k i ooD. N�,
Located at (Street) M.ynsoP
z,
Sec. Block i • Lot j4_
(indicate
nearest
cross street) ' o-r tom'
Municipality
-Watershed.
' SoI L PFROOLATICN TEST
DAM ,PMW1RED
TO BE SUMr= WITS APPLICATICUS -
Date of Pre- Sgaking 4. z-z.: eg
Date of Percolation Test .4 • vs-ea
HOLE l'
NUMER C1= TIME
PERCO=CN PERCMAMW ,.
Run Elapse
Depth
to Water-From mater Level
No. ''Time
Ground Surface In Inches Soil Rate
Start Stop Min..
'Start.
Strip'; Drop In Min/in Drop
Inches
Inches Inches •
1 9 :00 - 1 1 5-i 1-1-1
2 1
2Q 3 59
2 115-1- 1 :r-, 160
X21
29 3 Coo
3 1 s-7
21
r,
1 3:15- 12 zz I'I
Zo
2 12:22- ✓' ZZ 15C>
7-
• 3 !00
3 3 : 180
Z5 3 Coo
'
Q
2
No'rES: 1. Tests to be repeated* at same depth untlil .apprm mately equal soil rates
are 'obtained ,at each percolation test hole. All data to' be • submitUd
for review.
5
No'rES: 1. Tests to be repeated* at same depth untlil .apprm mately equal soil rates
are 'obtained ,at each percolation test hole. All data to' be • submitUd
for review.
TEST PIT DATA REQUIRED TCJ BE SUMMED WTIS APPLICATION
DESCRIPTION OF SOILS E OUNIMED IN TEST .HOLES
DtM HOLE • NO: HOLE NO.'
HOLE NO.
G.L. ,
3'
4
C_c ter-,
61
.71
10/
r 11'
12./ ,
131
14'
.
INDICATE LEVEL AT WHICH GROCVDATER IS ENOO(JNIE
INDICATE LEVEi, TO WHICH WATER LEVEL RISES IAFTM BEING ENOXMERM
J IA.
.. DEER' HOLE OBSERVATIONS MADE BY: ' bs �E� ' �+G ' t�-t,�
IaATE:
DESIGN
Soil Rate Used Min/1" Drop; S.D., Usable Area •Provided- -s000.gd
No. of Bedrecros A Septic Tank ,Capacity ' i z e;o gals. Type _N.,si4mY
Absorption Area Provided By Son L.F. x 24" width
trn'cYi-
\i
Qther J--: s7m1 zLrr,,o.-1 .8o
`
Name
• t r;
'Address s•2.. SEAL
r
THIS SPACE FOR USE BY HEALTH •DEPAF UEM ONLY:
Putnam County Department of Health
.Division of Environmental Sanitation
AFFIDAVIT - CORPOI'NTE aINER APPLICATION
FOR PERTIIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HDILTH DEPARTMENT
TO: .Commissioner of Health - In the matter of application for
I ��cc — '— — — — — — — — — — — — represent'
that I am an officer or employee of the.corporation and am authorized
to act .for — — 1�8 CS % J-C SSOf %G97`eS ,_4iU(. _ — — — — _ — — — — —
(name of corporation)
having offices at /D hoc /« va G�icl �Q TA
Whose officers are
President — ���N�� . /9k Cy �
ic.4C _%D �occ��u1
—
Name and Address)
V1;- e� ent %y IO/U �_/ "_(c u e cr -� 3&lgt5,- eievwr C�;�� Rye i i le
— — — ss-T (Nantt! and
Secretary
(Name and Address) —
Treasurer _ _
- - — (Name and Address) — — — — — — — — — — — — —
and that I..am and will be individually responsible for any or all acts
of 'the corporation with respect to the approval requested and all suoi._'
sequent acts relating thereto.
Sworn. to 4efore me this day Signed
of ' i :/ 1.9�� Title
Notary /Public
KELLY H. WILSON
NOTARY PUBLIC, 62S YORK STATE
QUALIFIED
COMMISS ONOEXPIRES 712110
Corporate Seal
�7
I
I
(3Y6`olA: '
OtlTCE13 � ,
RAN
LI
W 52.90