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HomeMy WebLinkAbout0837DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24.18 -1 -16 BOX 9 00837 :` I �. .� L=, I j rd I kP lr. i JL 00837 w, Y;t! PUTNAM I D ivi sion ,O n'n ` Rx CERTI;FICATE 0,F, CONSTRUCTION , LIAN -". 2 -�Q'al. Septic; ; 66nsisnjg Tank -.'Otherj.,reOuir `�;t` vyater '. Y From PA" sup ply Private' SuPPIY Drilled - 'BY J -Address J f -P,"4BUIldirig�T I ';Zf. s -Has Efosiow. Co,fftroI,.,-Been :,CqrrjpIp 4 t6ait-Ah6 iyA4mjs) as listed servjhgAhe,above.premi t ittil-the a tachecl) and , re' X, VV OF :HEA;LT:ff,,,;:�,9.`-- hne Y JT ' .Sv. SPSAL"SYS, - ,O P-) E1 T 0, --n-- oc-ml ligb" �7— 4 ch Or v, 1-t rooms- EN ' e ands t omoidie'd work (copies of .4vhIcti are COO am County -, epar*i,*m,-,e,,nt,oi,,Heifeh,.-, P E ftoz rt 77 A ivins& 40 Kac secure the 'correction "of any unsanitary hall p5 soon as Jiie - �omes hen ;6,a,- �publ Is are s n 'rev is necessary,. L BACTE- 10OLOGY - PARA IT, 4L J►�Y YII "Q .4±G . A i IC�US D� SOURCE OF 'MA*WAL 9 REQUESfi p 544 ❑ 8140' ❑SMEAR ❑ Sputum ❑ outine . Wank e q Nose] ,T. B.;;." ,Goudi ❑ 'Throat Dpht prig erii Ridge." 4 .Pine, ui "da • -Wine p �. c: e/o ` COrrii sIi' Pharmacy . • L7 us From {] hey. -0 PUT IAM D41�, 00,0lC:lAb OA*ORI Ya, and ams lies'_ cl Ylm. to io's 1,© STONEC6IGN A1/I;NUE - ."CARMEL, L$SENSIiIVITY. mss. n slsr.: $T�4Pf3hb� CCUS Aeroboeter Chloramphehicoi "'N -61 emo: £oag.'Tp follow : J Co:" tldlracterjum o istin Sul ate` p " . i'ieinioly"t�•£oag. To.Foli4'w.fsc ,erfchta p clom i:in POStitjV46 Dihydrostreptomycin " ' N 'attx� ., '� ,Pa t'��o Bif�t '. E hramytin' TRt4 1, ,3 - epm ein f -Iq p ii d Beta Gan/ma ' : s .` onronas „ itrofurantoin E_� ._: p nrotoecus - •Enter�c:Pathogons Oxacillin (TQ .houmocaccus -- "' ,�(..qund Papal a ,. Ul.'No. sseria Faun Penici tinmophills Tetracycline T,IdB, RCULQSl3; S. EAR T.IIBERCU. gSIS 'CUtTL1RE'tio- riacetyloleandomysin Arid , . sf� Not found.' ". [}".Neg.>> pr." eicJ ast -- Abi'Mpici hn rA4 fasf:Torid `] .os.' , { MoOis Routine "Nei, .Q, i?`NO . Quid �'�_ufutes - ❑.�a& ;.Pgs �ye'FOr No, col ifar>tt "bi cili'i sol�.tod 'from the " specimen su�bmi. :l'y °.. + -a. 41�iY:i'.L, )wd 1(..)i!i i'S )_�l�)'! 1 1' �.+ n IVA ^nib'i bl%Liiti ..n. .n ,.. ...`� , � _., , . • '3/71 Division of Environmental Health. Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be;- completed by well driller and submitted to County Health Department together with laboratory report 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 Vm . .' 1 p ` 3 a'/ II ( ( �luS(�FV! f0rV ADDRESS LOCATION OF WELL (No. ti Street) f� (Town) (Lot or) %G �� �- iQ jo r BUSINESS ❑ ❑ ❑TEST PROPOSED L7 DOMESTIC ESTABLISHMENT FARM WELL USE OF WELL ❑ El INDUSTRIAL ❑ CONDITIONING SUPPLY (Specify) ❑ ❑ ❑ EQUIIPMENT ROTARY LJ AIR PERCUSSION PERCUSSION (Specify) CASING LENGTH (feet) DIAMETER (inches) IWEIGHT PER FOOT C�'.THREADED ❑ D VE SHOE El CABIN D • �NO DETAILS �3 l7 ,�ja WELDED YES NO YES YIELD `� HOURS G.P.M. ❑ ❑ YIELD (G.P.M.) TEST )>i&'r'. PUMPED COMPRESSED AIR f �¢ WATER MEASURE FROM LAND SURFACE —STATIC(Specify test) DURING YIELD TEST fleet) Depth of Completed Well LEVEL 23© in feet below Land surface:. .95 At MAKE LENG H OPTS TQ�UIF,ER (feet) SCREEN DETAILS SLOT SIZE DIAMETER (Inches) • IF GRAVEL Diameter of well including GRAVEL SIZE (inches) FROM (feet) TO (feet) PACKED: gravel pack (Inches): DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. _...FEET to FEET. 0 20 #640a/ : %wCde".. 4ome §i avd.. , 20 ,Xand L l ok- 94een� . 'l la 135 225 _!�ltzch 225 300 X -335 BV. 000me w " If 4ome • n ., If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPORT WELL.ORILLER (Signature f- e AC_14A1?_,D d-T N06S� Owner or urc aser o Building �C0 r 4, � 415 "" ,QP. Building Constructed by 5M. A �Z Ll±/V E Loc t on - Street Bui lding Type 4w D P Municipality Ag -f sP'e r/V/,- 1116:,4 /C) <� ills Section 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- - -i;n- good- operating cond -i -t on any -part of said system constructed by me which fails to operate for a period of F Jl/2 years immediately following the date of initial use of the sewage disposal system, or any repairs :Wade 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 L�� day of (/� ^,M1i�i:�21972 Signature ce3 Title d� If corporation, give name and ' addre s THREE (3) COPIES ARE REQUIRED CERTIFICATE OF COMP+.,ETION WILL GUARANTOR IS REQUIRED TO FILE ---- 4Vav_ - f - _.r -- WITH THREE (3) COPIES OF FINAL PLANS BEFORE y, BE ISSUED. NOTICE, OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health u 5 I n 0. I--- cl tx C3 Li CL .10 rf o5i q, I n 4R. Ala, Z In iy 0 D 0 fy li 0. A 4R. Ala, Z In iy 0 D 0 fy li N" r� r ' PGf ;rtyRN COUNTY OF WHOWHOMR DEPARTMENT OF HEALTH - Division of Environmental Sanitation DESIGN DATA-SHEET - SEPARATE SKWAGE SYSTEM - FIIE NO. Offer- gF E rub S r Address Located A,t (Street) ,S j -Wrepecu Aeg&& dz.Sbc-,—H1=k ,! Lot, Ag (Indicate nearest cross street) Municipality ► ° Watershed Raw w Yea &_�a SOLtL PERCOLATICK TEST DATA REQUIRED TO BE SUBMITTED'TWITH APPLICATION Hole. Number CLOCK TIME' - PERCOLATION PERCOLATION Elapse Depth tto later Water Level No. Time Frcn Ground Surface in Inches Soil Rater Stmt Stop• Min, .. Sta t.1 - Stop.... Drop -in MWin.dropr Inches' Inches . Inches 1 iZ:��� ►�:� a 30 1 2-0-0. 1) Tests to be repeated at sane depth until approximately equal, soil rates ' are obtained at each percolation test hole. All deta to be submitted for review. 2) Depth. measurements to be made from top: of hole . TEST PIT DATIt REQUIRED TO BE SUBMITTED WITH APPLICA-TION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES, um .. 7,20- 78 INDICATE LEVEL AT "iRUCH GROUND WATER IS ENCOUNTERED No NE INDICATE LEVEL TO WHICH WATER LEVEL RISES, AFTER EEING ENCOUNTERED TESTS MADE BY fi&() ASSOef a7JF—.s--DATE- In Sbil Rate Used min11" Drojr. S.D. Usable Area Provided td)(D 0 Metal No. of Bedrooms Septic Tank Capacity lg@D Gals. Maso N EW Absorption Area Provided Byjj(P L.Fx24n 36" . 0 her Name Signat SIB195 ASSOCIATES Address: CONSLILI SEAL GOLDENS- BRIDGE, N. Y. PINFESSO Westchester County Health Department soil Rate Approved sq. Ft./Gal. Checked by S.IY-. 27.6 (Rev. 5-24-66) (February 18s 1969)