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631- 589 -8100
24. -1 -97
BOX 9
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I represenCaMt'I am wholly ind completely responsible for the; design and location of. the proposed system(s); 1) that, the. sa crate sawaie dis oxt s stem
above described will b• constructed as shown on the approved smea talent there to and in accordance with the standards, rules an regulations , o e
county ,Department .of ►IMltli, and that on completion thereof. a "Cartificate of Construction Compliand" satisfactory to the Commissioner of Hesithwill
be subinked to the Department. and a' written .quarantee, will. be'furiiished ten owner, his success ors. heirs of anigns by, the balkier, that said bulkier will
Wca in pod .operitklg ealditfori any, part of ,a sewage disposal systanl 'du►flp the period of two (2) Years Immediately following the daq. of the Issu-
anoe of den appovail, air the Certificate of ConAiugtbn' Cori�plianee' o(,.t • original'syAem or any repairs tMreto; 2) that the drilkid well detalbid above
WO be located ae showmen the Opp@ove0 Plan and.that sakl will will bi inst in accordinoa with the stand& I s eTON-USTMS of the Putnam
;.
COUrItY DipeAnleoM of. luelth. p.E. � 11;A,
Date' 3 1- 9 Srrpb
Address s tj ieenae No 5� 1 ?.�
APPROVED FOR CONSTRUCTION: This epprovil expUes two years from the date' issued unless construction of the building has been undertaken and Is
revocable for cause or may be anierwae of modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
requiressaa ON p- er`mit. APProvtooAgfor disposal of domNtk sanitary and /or/pjriv�atte water supplyy cony.
l�.CV,• oft h�7 ..._! -J BY `:�-- T�- ��.1�` Title S
10/88
n
DEPARTMENT,OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914)-278-6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Address
own Village City Tax Grid Number
WELL OWNER
Name Mailing
per' °Z5
Address
L,,Am jLvAp 011
)efPrivate
Y O Public
USE OF WELL
�- primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP.
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL b INSTITUTIONAL O STAND -BY
[3 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT _gpm /4E
13 REPLACE EXISTING SUPPLY
VNEW SUPPLY NEW DWELLING
PEOPLE SERVED C'� /EST. OF DAILY USAGE jpV Sal
❑ TEST/ OBSERVATION Q ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
'
WELL TYPE
®DRILLED
DRIVEN
DDUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES !✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_
Lot
WATER WELL CONTRACTOR: Name t72 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _/ NO
NAME OF PUBLIC WATER SUPPLY: 01A TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: k�/A
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
SON SEPARATE SHEET
3 -11- ?3_
(date)
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
thirt -y (30) days of the completion of water well construction, the applicant shall:
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 Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: i�G�G S 19
Date of Expiration 19 % S Permit Issuing Official---
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PC -1
Q U T NAM C OUNTY D E PARTMENT O E;' H EA L TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1 . Name and Address of Applicant:
2. Name of Project: Location V /C:
4. Project Engineer: [ALA AT A5-4,o6. rt; 5. Address: :1! I -t7 L��►�E
License Number: 5(!� (24 Phone:
6. Type of Project:
_ V Private /Resident
Apartments
Office Building
T. Is this project subject
Type Status (Check One)
iai Food.Service ...Commercial
Institutional Mobile Home Park
.Realty Subdivision Other'(specify)
to State Environmental-Quality Review (SEAR)?
Type I.. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? .............. tad
9. Has DEIS been completed and found acceptable by Lead Agency? ........... /A
10. Name of Lead Agency n.1J
si. ,Is this project in an area under the control of.local planning, zoning,
or other officials, ordinances? ......... ............................... &jp
12. If so, have plans been.submitted to such.. author 'sties .) ..................... I 1A
13. Has preliminary approval been granted by such authorities? W A Date Granted:
t4.. Type 'of Sewage Disposal System'Discharge...... Surface Water
Ground Waters
15. If surface water discharge, what is the stream class designation ?........ 1JJA
:6. Waters index number (surface) .......................................... �11A
T
?7. Is project located near a public water supply system? .................. 130
8. If yes, name of water supplyT Distance to water supply
9. Is project site near a public sewage collection or disposal system? ..... WD _
0. Name of sewage system 0/4— Distance to sewage system —
1. Date observed: '7 1214 23. Name of Health Inspector: . h6.
4'. Project design flow (gallons per day) ...... ............................... P1&
R
2.
25. Is State Pollutant_ Discharge_.Elimination System (SPDES) Permit required ?.. x.1O
26. Has SPDES Application been submitted to local DEC Office? ............... u/Q
27. Is any portion of this project located within a designated Town or State
wetland? .. ............................... ............................... h10
28. Wetland ID Number ........................ ............................... 4/4 -
29. -Is Wetland Permit, required? .............................. ................ . 06
Has. application-been made to Town or Local DEC Office? .................. 11 /A
30. Does project require a.DEC Stream Disturbance Permit? ................... },Lo _
31. Is or was project site used for agricultural activity involving application
of pesticide$_ to orchards or other crops, solid or hazardous waste disposal,_
landfilling, sludge application or industrial activity? .........YES or NO
32. Is project located-within 1.;000- feet of existence of, abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ..... ".........YES or NO 0/),
DESCRIBE:
33. Is there a local master plan or file with the Town or Village?
34. Are community water, sewer facilities planned to be developed within 15 years? Q0
35. Are. any sewage disposal._areas, in__excess of 15% slope ?..,. .K ...................
36. Tax Map ID Number ......................... ............................... �i:- 1- u
37. Approved Plans are' to'be returned to: ................ . Applicant Engineer
If the...,a'ppl4cat,ion is signed by a person other than the applicant shown in Item.1, the.
applicat on:must be-accompanied by y-a Letter of Authorization.' Failure to comply with this
provision may=be grounds for the rejection of any submission.
I hereby. - affirm, under penalty of perjury,. that information provided on this
farm... is :t .rue to the best of my knowledge and belief. False statements made
hereIn are punishable as a Class A Hisdemeanor pursuant to Section 210.45 of
the PenA',T Law.
>IGNATURES & OFFICIAL TITLES:
AILING ADDRESS:
Bedroom
12' x 11'2"
50.0"
I / Wood Deck
Living Breakfast Area 1
12'4" x 11'4" Family Room
Room 13'2" x 21'4"
13' x 23'4" Kitchen
10'2" x 7'8"
Foyer
DiningRoom
12'4" x 12'
N
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE. (914)278-6108-(FAX) 278.2658
HARRY W.NICHOLS. JR., PE. CONSULTING SITE ENGINEERS
March 11, 1993
Putnam County Health Department
Route 312, Geneva Road
Brewster, NY 10509
Att: Mr. William Hedges
Re: Proposed SSDS
Lot #16, Big Elm
Courtney Road
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -9 "Proposed SSDS - Lot 16 ",
dated 3- 11 -93.
2. "Application For Approval of Plans For a Wastewater Disposal
System ".
3. ".Construction Permit for Sewage Disposal .System ",_dated
3- 11 -93.
4. "Application to Construct a Water Well ", dated 3- 11 -93.
5. "Design Data Sheet ".
6. "Letter of Authorization ", dated 3- 11 -93.
7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count
Only ".
8. Money Order in the amount of $300.00, review fee.
We would appreciate your review, approval and issuance of the
Construction Permit at your earliest convenience.
Sincerely,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W.
Nichols, Jr., P.E.
HWN:bd
88044 -16
enc.
cc: Mr. R. Alan w /enc.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of JZDGYv ALAO
Located at �,DL.( Y�TiJ�i 1h1
(T) �� ` l��1 Section Block 1 Lot
Subdivision of 41 ��
Subdv. Lot # 1(o Filed Map ## Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer 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 pro.visio.ns of .Ar..ticle..145 -...or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Co
Counter
P.E. , R
73 Fairfield Drive
Address
Patterson, N.Y. 12563
914 - 278 -6108
Telephone
Very truly yours,
Signed X"4
Owner of Property
25 r�YI�;�M �Ar--F- 12dR��
Address
Towh
Telephone
Pr-",M.CCC= DEPARTMEW OF . y r.
r OF r •: E v HEALTH SERVI
DESIGN DATA a DISPOSAL a R FILE NO.
Owner f 6- /-9-L 4 AI- Address z sBY� 'A M G,4 --A-Pm o ,U"Ir / y-, 1.o -To ¢
a/- D /20.919
Located at (Street) / ✓,: z Z Sec: G 9... Block -5- Lot 7.2-
(indicate nearest cross street) 2� , 1 11 C N�
Mini cipality y A/
Watershed
SOIL, PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITS APPLICATIONS
Date of Pre - Soaking 712 i7 f c?
Date of Percolation Test
HOLE
NL1-1BER CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse Depth to
Water Frcm
Water Level
No. Time Ground
Surface
In.Inches
Soil Rate
lG Start-Stop Min. Start
Stop
Drop In
Min /In Drop
;% Inches
Inches
Inches
4
5
l.S-
3 Z.' /7 - z.¢% .,.?o 20 f/ %�,r Zr
4
5
1
2
3
' 1. Vests to..be repeated at same depth until approximately equal •soil rates
are obtained at each percolation test hole. All data to* be suhnitU�d
for review.
2. Depth measuremnts to be made from top of hole.
rev. 9/85
TEST PIT DATE - PMQUIRED TO BE SUBMITTED WITH P"nLICATION
DESCIM )N OF SOILS ENCOUNTERED IN TES. OLES
DEPTH HOLE NO. A HOLE NO. B HOLE NO.
G.L.
2'
5'
6'
7'
8' /(/o AD
9' 1 C//�TE \1_14 T ,�f
10' ...
x.:•.'12
14
INDICATE LEVEL AT WHICH GROONUAATER IS EIOOUN'I M
- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENMUNTERED
1
DEEP HOLE OBSERVATIONS MADE BY: e A9 tC A) C A/C d G ,i DATE:
DESIGN
Soil Rate Used l /' /.S" Min/1" Drop: S.D. Usable Area Provided 6_00 0
No. of Bedroans Septic Tank Capacity /ZSo gals. Type Cv.lc_
Absorption Area Provided By Sao L.F. x 24" width trench
^ 1
Other 01.r, O F NEW
i u 01
tkk
Name G/Iv�rT i- '/✓c�itl,E�i�i /� ?C Signa
f
/l, S 5 c /
,
i
Address /09. ... SEAL , cr
N
194 %T,6/ ?S L /✓ IVY /Z SG 3 � ° No. 0451'6\
THIS SPACE FOUR USE BY HEALTH DEPARDEW ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
_lam � h •
Iv
v
t-
ati /
of
D
U0 /
IL
JA
INIA
N, Joy
'�s�
Conelsting Of I-- /� U, Gallon Septic Teak and '
ial
Water S plys Public S lytFrom Address
aP dO
or: Private Supply MrDled by Y� �%O � I� — Address �l) ( 12 5.2, WA 50o N Y
_T_ .:
! Building Type< Has Erosion Control Been CompletedY
Nmnber':ot Bedrooms Has Garbage Grinder Been In�stalledY N
Other Regalremente
jI certify that the system(e) as'listed serving the above;•pzemises• were constructed essentially es: shown on the plane of the completed work (copies
of which are attached), ;and in: accordance with the standards rules and re u ations iri a cordance•with-th file ;,pla • and the permit issued by the
I@utnam,County Department Df Health
; '\
�3
Certified by P.
Date IE 14 A.
Address IV Lieen a No.
Any person' oecupying'premises s"ed by. the above -system(s) shat) piomDtly take such action as may be.n to secure the correction of any unsanitary
conditions resulting, from. suen.iu`saye. Approval ,of the separate sevverags; system shi0 become, null and vold•as soon:•as a Dubt% sanitary power becomes
m
avaltable and the approval of the pri4ate -water supply shall becoe null and ;void' "when a public water supply •becomes available, Such .approvals are
subject to modificatio or change when, In the judgment 'oi the GonMlssioner of-Nealth such revocation; modification or change Is necessary.
Dote G..: ' BY. Title
Q, .t
4V O4
wTSLL t,Vl "1rLl;ilvty nr.rvnl
DEPARTMENT OF HEALTH s
Division- Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
'
_
2=2
WELL LOCATION
STREET AOORESS: M nn' WN! I I Y �(� # . TAX GRID NUMBER:
n1FFaF be
WELL OWNER
NAME: ADDRESS:
a ,� T I
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
dRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP p ABANDONED
O BUSINESS O FARM ❑ TEST /OBSERVATION O OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT --5:— gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE 66D gal.
REASON FOR
DRILLING
❑REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY
(f NEW SUPPLY (NEW DWELLING) [] DEEPEN EXISTING WELL
DEPTH DATA
2 WELL DEPTH �DtJ ft.
STATIC WATER LEVEL �.ft.
�^
DATE MEASURED 17-116
DRILLING
EQUIPMENT
O ROTARY WCO MPRESSED AIR PERCUSSION O DUG
0 WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING 1 9/ OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH _ _ fit.
MATERIALS: KSTEEL O PLASTIC 13 OTHER
LENGTH BELOW GRADE _ 1t.
JOINTS: O WELDED THREADED O OTHER
DIAMETER_ in.
SEAL: O CEMENT GROUT BENTONITE OOTHER
WEIGHT PER FOOT 1 17 lb. /ft.-
DRIVE SHOE YES O NO
LINER: ❑YES END
SCREEN
DETAILS
\,
DIAMETER (in).
;SLOT SIZE
LE GTH (It)
DEPTH TO SCREEN (ft) ..
DEVELOPED?
FIRST
...
d-YES ONO
HOOPS
SECOND
_
- `,
'
GRAVEL PACK
"02W
❑ NO
GRAVEL `,
SIZE: ` -•=
DIAMETER ��
OF PACK In.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: ❑ PUMPED i tests were done is in-
rYCOMPRESSEO AIR , formation attached?
O BAILED O OTHER i ❑ YES ❑ NO
'WELL LOG if more detailed formation descriptio s or sieve analyses
are available, please attach. .
DEPTH FROM
SURFACE
water
Bear-
ing
Wen
D'a-
meter
FORMATION DESCRIPTION
CODE
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land
Ifix
3
- t rinirl
) 6 c7
WATER CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES ❑ NO
ANALYSIS ATTACHED? ❑ YES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL _._ VOLTAGE HP
WgLtitKl WE
WYATT &SONS, INC.
ADDRESS Vdell Drilling 5101ATURE
Rte. 311 R. R. 2 Box 171A A/- PATTE RSON, NEW YORK 12563
3/89 /
PUrNAM COUNTY DEPARTKENT OF HEALM
- DIVISION OF ENVIRORMgr L HEALTH SERVICES
'pwn or Purchaser of Building
Ross .'A/C 1'L1_- LI C,
Building Constructed by
Location - Str
) g; —,,e74, � y
rinnicipality \
X- &f' 1dr, 11 )LQ1
Building Type
.:2-t f j
Section Block Lot
/0 -7
��
1'!� - E Ll
Subdivi ion Name
Subdivision Lot #
GOA.RANI'F.E OF SUBSURFACE SEWAGE DISPOSM 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
standaDepartment rds, rules and regulations o£ the Putnam County Depar of Health, and
,hereby guarantee. to the owner, his successors, 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 approval of the
"Certificate of -Construction. Compliance" for the sewage disposal system,` or any
repairs made. by me to such systen, except where the failure to operate properly is
caused by the willful or negligent act of the occupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environirental Health Services 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 Jej 19 t3
�oss Alan. rv.G
i Geneial Con actor (Owner) - Signature
�-
Corporation Name (if Corp.)
Address N_ y
rev. 9/85
mk
Signature �• ��wy -o /�L� �L�� .
Title
Corporation Name (if Corp.)
Address
I
PUT'NAM COWN DEPARTrSEW OF HEALTH
DIVISION OF ENVIROWiNTAL flEALTH SERVICES
Own or Purchaser of Building
R o s ,..
s A�c.�
u —lding Constructed by
C& y T
Location - Str
Municipality �I
_ X 161f t dr, 1, )L
Building Type
Section Block Lot
1
Subdivilsion Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SERAGE DISPOSAL 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 oamer, his successors, 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 approval of the
"Certificate of Construction. Compliance" for 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 occupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the detennination of
the Director of the Division of Environirental Health Services 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 jaa 19 �3
�oss Alan,
Geneiak Con actor (Owner) - Signature
�-�-
Corporation Name (if Corp.)
a5 13 Zip.
Address N_ y
rev. 9/85
mk
Si nature A�Ita4
Title
�,► �T, I,)
Corporation Name (if Corp.)
/li d s-v
Address
N
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
_.._ _ -_... PATTERSON, NEW YORK-12563
RANDOLPH W. LAURENT, PE. (914) 278.6108 -(FAX) 278.2658
HARRY W.NICHOLS. JR., PE. CONSULTING SITE ENGINEERS
July 8, 1993
Mr. William Hedges
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Proposed SSDS Lot #16
Big Elm Subdivision
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing S -16 "As -Built Plan ", dated
7 -1 -39.
2. "Certificate of construction Compliance for Sewage Disposal
System ", dated 7 -6 -93.
3. Three (3) copies of "Guarantee of, Subsurface Sewage Disposal
System ", dated 7 -1 -93.
4. Well Completion and Well Log Report.
5. Water Analysis Report.
.6-. Check in the amount--of $200.00 payable to Putnam County
Health Department.
If there are any questions concerning the enclosed, please call.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichols, Jr., P.E.
HWN:bd
88044 -16
enc.
cc: Mr. R. Alan w/1 copy each
PUMAM COU171 Y DEPAR'IMENV OF HEPME
DIVISION OF ENViROMMAL $FALTH SERVICES
'37n or purchaser/ of Building
Building Constructed by
Location - Str
��;��� / y
jdunicipality �I
A%-5- J6 o h )L Q /
Building Type
24,
Section Block Lot
y7
l
Subdivi ion
Subdivision Lot #
GUARAWEE OF SUBSURFACE SEDGE DISPOSAL SYSM
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 successors, 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- approval of the
"Certificate "of Construction. 'Compliance" for 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 occupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environia-antal Health Services 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 l day of c% 19 �3
,�oss Alain. vv,,
�2Ad,-J 6 L� .
Geneial Con actor (Owner) - Signature
. )& :55 Al��
Corporation Name (if Corp.)
. asp 1& a
.Address N_ >/
rev. 9/85
mk
Si nature
Title
Corporation Name (if Corp.)
N� ZO s�
Addr ess
Y YS
J.f
NORTH AMEREC AN
LABOR TOM ESo ENC.
ANALYSIS DATA SHEET
TYPE:
PW
LOCATION:
Lot 16, Courtney Lane, Patterson, NY
(Big-Elm)
REPORT TO:
Ross Alan
ADDRESS:
25 Byram Lake Rd.
CITY, STATE, ZIP:
Armonk, NY 10504
DATE COLLECTED:
07 -13 -93
TIME COLLECTED:
9:45 AM
COLLECTED BY:
Ross Alan
REPORT DATE:
07 -14 -93
SAMPLE:
93 -3076
SAMPLE SOURCE:.
Water tank _..._ ........
Patterson NY
DATE
ANALYSIS
RESULT UNITS METHOD ANALYZED
Total Coliform MF Absent SM 17 (9215D)07 -13 -93
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
oratory Director
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754
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