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3t ?t plv)Alpn of Envlrpnmontal Heelth -ra, . lcree
CQUIVTY OFFICE 9UIkDIN4 • GARMEL,..NEW YQi6iK
Thla report 1$ tg pe Famplated by well. driller and submitteq to County Health Department together With I44oratory tapotR'pT
gngly(8Is 91 water sample indicating water Is of satisfactory bacterial quality before certificate of 06ristruction •cainpijpRGp
REPORT ,MUST BE SUBMITTED WITHIN 30` DAYS OF WELL COMP4E�IOM,
i?YVNI�1
o t �
yes+
rn
LOCATION
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� �� @STIR , .. (� 1 ESTAtsLISIfM�NT Q PARS �1 t�sT wEl!
PUUIC
f'1 (('''''''1� AIR t "1 OTHER,
�. $UPFIT' INPUSTRIAI, L__1 CfaNRITIONIN4 (6Padf0
DRILLING
EQUIPMENT
(�
L_.► ROTAOY
COMPRESSED ' CABLE OTHER
AIR QERCUSSION q 't?ERcusslow. �. (Specify)
CASIPlQ
PETAILE '
LEV914 (Iffl)
�j
GIAMETEB(Inchge) WEIGHT
PER fOOi
(
( TItR ADEI? LD WElvsn
YES
NO
WAS
�f,ASj�l
.
L�J
HQ
YIELQ
TBSF
(�j
L-J 4A 114P L,.J PUMPERi.. IAJ
HOURS G.P.M,
COMPRESSED AIR �..
)(190 (Q.P,v ;1 '
WATER
„• Asa
MEASyRE FROM LANR a4RfACE��= STAT14(Spggllyfeet)
V Eel
DUR)NS. �fIEID TF,sT (1egtJ '
alJ
pepth of Completed Welt
In feet Is 'ow Lana surface,
SCREE" .'
PETAILS
MAK$ ...
IENAT„ C?i'gN TO Af?Vlfss (!Qo(1
491 11114
QIAAMgg (Inoh tsa
IF. GP.AYEI
PACKED;
Dtamater of wall including
gravel pock (inchoa)r
GRAY L SIZE (IM ? of (fQef) ' TQ 090
PKRTH FROM lANq SURFACE
FQR(yIATION pt SCRIPTl01t(
Sketch exact location of well with distances, )o at (9a$(
two permanent landmarks,
FEET to FEET
w(A R�C)
91a�3
C3UNTV
HE:ALI � ..
1 -A—g_ .
V
[DEPT. O
If yield was fasted at different depths during drilling, lid below
FEET
GALLONS PER MINUTE
PAT{ WfiIL CaMP!s TEp pA� OR I111PORT NyQL L faRlLl -t=R (Slgnt►turol
I
tO
A1' COUNTS EE 1
3, -B3
w D/wstoA, --of Etrvironmental1 1/ a>Wtli Serl%ices 'CRrme_% N Y 10522
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CERTIIFICA7•E OF ONS,T
_ RIUCTION G M�PUAJVCE FORS ;SEWAGIE DISPOSAL_ y'sT,EM•,,
4 -
Towns or Village _
%. Located 13
at Y
Owner dWti�1�� tim �(,d��. V�br� E3�sl�r1 --- 3 1' 2
�� 34
_ — Lot s
x �* :,�� Elul -- -t �ir :17z {.. s , i
rbuitt
Job
.170'1
Separate Sewerage System by —� Address K�ns�a NY
a
1 a, is ,•.tr m.ti
rronsisting toi b�0 'iGal �Septic�T+ank�£ . rk aFeet
�4r lineal X
B �
-Width .trench'
-? Water `Supplya P.lfb',lc, = 4r
_ SuPPIy
Private SUDp(Y W ,8Y
a
e
l J Patbn,; �lY
w Address k s
j - x
�Fl^a�eY .zti
-
: err u` �''!i/'j:w- t�- '�i•4y R' g�'i4s � -r 'a` � � .,�`�.. � '"41J
:Hasa Erosion COntr01 Been }COIMlpletediF _1��"�} T7 �';� T` " e?' "
I, certify that ttie systems) as lisfed serving the above premises' were., constrveted essentially as show f on the plans of the conipletedhwork (copief of which are
_attached), ano' in accordance with the standards; rules,,and.reguiations,, plans fil_ '; sand the pe`rmiL: ;issue the .'_Putnarrm ;County',, - Department of Health:
�loaa r June �'
t 983 Y
!- Certified by- - p E
R A
e - (Licensel!Fo
yAny person• occupying>>p`reitilWS served'b,.y the above systems) shaYl promptly take such act(on as may be necessary to;secure tne,correctlom of any unsanitary
`condltions resu'Iting froml wef usage , ;Appyo'va_ "l� of the separate. sewerage system thalli'becorne null and., void aii soon as, a public sanitary sealer becomes
'Vvailatrle; ands the apprgvpl of the prPvate wate►�tup -, I s" "hall become, null' and. 'void when, a iputiI c water supply' becomes available.. Such approvals are
_ ange when; Ar 'ttie y)udgment of ttie C– Ommis ones cf Health, sueli ,revocat i'on motllfication'or change it .necessary,
subject, ,to . modificatiorn _or cti
t
a
rr Y
Von s z.,
Own or' urc aser of Building
Building ConstructeA by
Ica► :r. .�.
Location — Street
rpa �-2rs o�
Municipality,
TAX Mab,3
i
Block
34. 2
Lot
Subdivision Name
LY�e
Building Type. Subdv..Lot #
GUARANTEE 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 guarantee to the owner, his success-
I. heirs or assigns, to place in good operati4g condition_ any part of
said system constructed by me,which .fail's 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 operat -e pioperly'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 determin-
ation of the Director of the Division of Environmental Health Services
of the Putnam County Department of Health as to whether or not the fail-
ure of the system to operat.e was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated.this day of ✓Note 19 S3 Signature/,t %,jL ,_ ��• � . VI�
Title CrZt Vl t ,jam
JUN 1a�3 Corporation Name if corp—.T
Pi11 ' AM COON Y
OF KPP0, Address
E
DEPT. ` '
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
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❑ SVyIM PQbL. r"�, ���„`��;� �` t�, �,s P r;a
RES1D�PiC1E��a,
❑ TEAIPOp�iY
❑ �f�## FLER
4_ _�, .. •'tia
_ a .. ,:. L -.. is ,..... ^^`I•. _.,.. .._: r5.[r_. ...... _N':... ..,
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or urc aser of Building
it �U: ( . • ( .yY✓1��.ni►ti
Building Consaructed'by
Location - Street
Alift
21'a�•l
Municipality
Building Type
Section
Block
Lot
Subdivision Name
Subdv. Lot. #
GUARANTEE 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,guarantee to the owner, his success -
ors, 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 determin-
ation of the Director of the Division of.Environmental Health Services
of"-th -6' -' Putnam County Department -of Health as --to- -whether or -not -the fail-
ure of the system to operate was caused by the.willful or negligent act
of the occupant of.the building utilizing the system.
Dated this 00 day of /" 19dff. Signature
Title
WN
ECEIVED
Corporation Name if corp.
JUN 9 19,3
Address
PU Q -,,AM C ".)W',FY
----- --- ----- DEPT .OVHE-A,'.-4;:T------------ - - - - --
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 o'f.Health
i }
+,Owner /,Applli�
le
Maw�gAaa
•'Nambei of B
$SB�'sy�rp` .f�Qq�$eWC
Ax ya k�
WateroSuppl�;
,t
''Other}RegWre
• I }represent kh!
'above�doscritii
County wDspa
e submitted`
:'place -fin! gooc
ancer ofAne}a
.twill be.locatec
\
! County .pe`par
•APPROVED F,
j�rev ocaDlejlorertor .,
requsres)�.a ;riei
w
'Date
}
i.C, fiU'^�.rr m t�h .`$a«, a.:f, � S �,' , .�..y, � of � 3, ; ! {'�'3: .•
OF HEALTH 4 t `
-°• ^i
toPvlde.,_
Carmel�N Y •10511 �-�nx'a, r Engineer 'ro�Peemit N�,,
onYCERTIRCATE
Ne
�,Qy +,. p .O>,;k �lY{,IUBgC
L 1 8Z MBp�' w.
F '. a s t;t; ±l%i r a BIOCk r : 7--Fr, LOt
.Renewal. '� Reiv�isioa � �p
xL.tt '�uF"c n$'a4•r7 \ C+^'��'l,2�� *1 �.� �1^918�►7 4,P
Datetof Prevlone Approvaii � � � Y ,j ,
TOWn F�r��; '� it i La r)r,•a��r'�D7'1.�. tita '
' : TH v{t 1 1 t�•�Y 7 J a�� ;J '.t 1
t
`++*7r '" Nt '
3
f Y P
v PCHD No ++ (tl9cation le R`egnired When Fill It s,comPieted � � , -
'� } t .> Ewa va wm:' ° v ;• '.c �,�w tS�ay' r� x�, N5a qsk C..�
I
thdproposed system �1)Tthat the separata� sewage disposal�tsystem., '
tamtitl wits the stantla tls ,rules any 1►,egu,a rons o e r� u nam,
istrtu���ctionLCompliance�� stsctdiq to5the Commissioner of,Heplthwill
ner „vhts wceessor�s theirs or assigns by the,buitder •that said -bw'l }ap, ill.
the °perrod ot,two (2)ryears Immedmtoly following hetlate•of the issu-
�syst m or}ariy repaus� ;hereto 2j that the tlnll`W well tlesaiDetl above
ante with the standards rules,antl reyu as onT s, of the +PUtnarri
sued unless�'eonstructwn��o }tthe bwltlmg� has been undertaken andis
pComrmis�s�o ue� otd �IthyjAny. change :or alteration otYCOnst►tictinin.
z a5 t Tale
_s
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date June 19, 1985
Re: Property of Mr. _ & Mrs. William von Essen, Jr.
Located at Fair Street
(T) Patterson Section 73 Block 1 Lot 3.1.2.
Subdivision of
Subdv. Lot # Filed Map #. Date
Gentlemen:
This letter is to authorize John H. Prentiss
a duly liceiise.d professional engineer X 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
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.
C6 tersigned:
R.A. , # 19
✓ � a l�r�.� wJ ,
S i gne d Lc9,[� 11 Qy� �/-
Owner of Property
RD 9 - Fair Street
Address
Carmel, NY 10512
Address Town
JOHN N. PRENTISS, PA.
R09 FAIR ST 914 -818 - 6170 914- 878-4888
CANE' NEW YORK 10512
ephone ,
Telephone fox,
T,
®lk 01y.,
VAJ
r�'
0
PUTNAM COUNTY DEPARTMOT OF HEALTH
DIVISION,. OF - ENiTIitONNENTAL :HEALTH . SERVICES
-- COUNTY,.:OFFICE . MIMING, CARM6L, N.%.-Y.'
. %. Y. 10512:
113Zo 1336 IG Z7
- 2 r33G
3 04; 1A30 17
13K
1362
2
.
.,. -�... i•'•' - ..
Av
_ .. 4;,
1
Notes:
1)
Tuts to be
repeated at same depth until
a proximatelyy equal soil
rates
are
obtsined at
each percolation test hole.
All data to be submitted
for review.
2)
Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED,TO:BE SUBMITTED .WITH APPLICATION -.
DESCRIPTION OF`SOIIB ENCOUNTERED [N TEST IHOLES,
RD9 FAIR ST 914 - 878 -Ej
Address CARKFI
THIS SPACE FOR USE BY HEALTH'DF
Soil Rate Approved Sq.
3a . a by Date
_No• 2920' E
�F rH E SI O
I
0-
,z,601}.
Notes: 1) T6§ts to be repeated at same depth until aroXimatelyy equal soil
rates are obtained at each percolation test hole. All pp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
PUTNAM' "COUNTY:, DEPARTMENT OF HEALTH`:
DNISION OF ENVIRONMENTAL' HEALTH SERVICES;.
COUNTY OFFICE BUILDING, CARMEL, N,.:- Y. 10512
a i " z . n,Y
DESIGN -DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM
. Owne r
s ev,, .Jr. Address•
Located at
\ °•TakM•P 'r
- ( Street f\\ 1Q Block 1 Lot 111,
...
/\ Indicate nearest cross s re
_ . _....:....: Me bd.(P d Me 1'ti" to /y
rr'r�'t Qyd�r S'v � 3�T
✓✓
Municipality ♦„�eN Watershed �y
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICAT IONS •',;
- o e........
_. _. ................
Number
CLOCK TIME PERCOLATION �;,_rrPERCOLATION
_....-
..'.. ._ apse .._.. .. - : -.. p .. to,-Water a er.. , ve .
No.'
Time From:, Ground Surface in Incheq,, , Soil Rate
Start- Stop -._ Min. Start ` ': Stop , -Drop -in Min.- /in drop
Inches Inches Inches'..
1139 s Z :3-s
2
17 r j.
l
,
1
2
RE
�
mss. TEB
PLJTNAiVt
Notes: 1) T6§ts to be repeated at same depth until aroXimatelyy equal soil
rates are obtained at each percolation test hole. All pp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQU.-
DESCRIPTION 01
DEPTH HOLE
G.L.
WITH .APPLICATION
N1.,TEST'.H01--;ES-.*.,:
NO.
HOLE." N
1 -1 -, .
0. <HOLE 'NO .
DESIGN...
. oil "Rate 'Used, , 1� 6
XMi 1 Drop: S.D. Usable Area Prov
Septic Tank Capacity. Type -keg
B-6d, 4 �6
rbtibn Ar ..B #4
Abs6. Provided. 5-ae ..- idth.,trenchi."
y.�.,. a,-L.F.x2.�
Other.
JOHN 14. PRENTISSY F-ES X
k2
NY -1 Oil-
L, A-fi M E L. IN
Aadress
THIS SP FOR USE BY HEALTH DEPARTMENT ONLY: 01P
PT14 S1 pit
Soil Rate Approve Sq. -- Ft/Cal. Checked by Date
QF
46
A5 BUILT " .DATA.
Structure Iocated.trom survey by surveyor noted .belowo_____
West. located b y - Surveyors survey,— _., -
.Wolf Qrlllera report
Engrnee.re- maiurel ntHI--
Tank, boxes, pits, galleries $ lat.eralslo•catod. •by .Contractor.
Engtaeera;
H e a lth dept:
Field inspection by: Health dept ❑ date:
Engaveer 1 date c_ L lea 19@
P ut Health
NOTES: �i7r'9 on of > , "vironmental Health Sarei
mss._ �t,
ces
Approved as =: ,1 'or conformance with
app cable Iu ^s Ld EeGulationa of the
°ut Cocnt'
ncalth Department,
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A5 BUILT " .DATA.
Structure Iocated.trom survey by surveyor noted .belowo_____
West. located b y - Surveyors survey,— _., -
.Wolf Qrlllera report
Engrnee.re- maiurel ntHI--
Tank, boxes, pits, galleries $ lat.eralslo•catod. •by .Contractor.
Engtaeera;
H e a lth dept:
Field inspection by: Health dept ❑ date:
Engaveer 1 date c_ L lea 19@
P ut Health
NOTES: �i7r'9 on of > , "vironmental Health Sarei
vv
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Fown:_PA{tg0QV) County P6Mga ,— — State.:
3tlpDIVIS ION: M- krcfz` L-B�cd
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Block: - �— T _ = LOT —
Bull derc t�l —ddam�_ -- _ -- - --
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g
J;Q•HM H P-R- EMTISS
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Approved as =: ,1 'or conformance with
app cable Iu ^s Ld EeGulationa of the
°ut Cocnt'
ncalth Department,
.,ig a
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ldoP .LT .4X)
Block: - �— T _ = LOT —
Bull derc t�l —ddam�_ -- _ -- - --
t ►Own,: R K3r Da.te::5 �l '� j Soate;1 "_ Job
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