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BOX 10
7 ,
PUT NAM COUNTY DEPARTMENT OF. HEALTH
Division W Envii-onmental l-lea(th SerGices, Carmel, N . Y.- 10512
CERTIFICATE; Oe CdNSTR?MCT!ON COMPLIANCE FOR-SEWAGE DISPOSAL SYSTEM
ow
or
Village
Located at l �G I�Qb o- - Section. C 1
=�8 N L-of
'. wrier Jo
N i-
;Separate Sewerage System burlt by Q, 1 ess
Add'
00 iac lineal Feet;X
Consisting of Gal .Tank '
-width trench;-
.
other. requirements �r
'Water Supply ''Public +Supply ;F,rom
-• -- ^^ '
I :Prwate':SUpply:Dnlled By 6iw .7�V6
d�.,Address �2FLU� ?tom .'� � • Q
Building Type T�i� No..of Bedrooms:. 'Date, Permit Issued _ �� `� ,
f. ,Has Erosion .Control Been Completed ?.•
( 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-w.ith the standards, rules anil regulations, Plansfi led sand the permit 'issued y the Pgtnam County ;Department of .Health.
F
>bate �"�i X715 Certrf�ed by P E: r R A L Address `amt -�_�T Lcense'NO s
!Any person .occupying premises served,b,y the above systems) sha11!;promptly take such action as maybe necessary to secure the ',correction of'any unsanitary
..r
conditions resulting from such usage.' ,='Approval of the = separate sewerage;system',shall .become null and void as soon as _a;, public = sanitary sewer; becomes
available and the approval of the private - Water- supply shall become null and void,when'a public water su becomes available. Such, approvals are
su6JecY to modification =.or change when; in the Judgment of the`'Com sinner ' L falth,'such.rceyocat' n, m dif cation.'orr change 15 :necessary: .
Date T dle '
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P. E,.
Dl CT DIVISION OF
(MVIRONMENTAL'HEALTH ERYt
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!UTNtitta, N F HEALTH'
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Owner or Purchaser of Building Municipality
Building Constructed by
Section
00C_1YZL4 4
Location - Street Block
4
Building Type Lot
GUARANTY OF SEPARATE SEZ,JAGE 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 fora period of two
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 Putna, County Department of Health as to whether or not the
" - failure` of -- tlie- syst6mn `t_ _operate was caused by the- willful -or negl gent -
act of the occupant of the building utilizing the system.
' n
Dated this day of OCT 19j Signature
✓t,y Title
cp ( i Cc,(l -Z A . L-k0Z ZIf corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP,ETION 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
v ry LN cn
MR. JOHN MPAOLO 5
CITY,,_ VILLAGE,, TOWN VOR NAME: OFFSUPPLY . DATE REPORTED
OVERLAND ROAD PATTER POtl N.Y. % /8. / 7.
5
1S,'AMPL'ING POINT
BACT8RIkPER ML. (Agar plate count at'35° Q.
18
_COLIFORM. GROUP (Most probable No. /100m1.).:
`-LESS. THA.N 202
HARDNESS, TOTAL -•ppm
DETERGENTS - ppm
NITRATES (as N) =: ppm
IRON, TOTAL - ppm.
FLOURIDE (F) - mg. /l.
These results indicate,that the water was YS of a satisfactory. sanitary. quality when th am e ' as llected.
PER: e� Pao
c
f�
A. H. P.ADOV NI, M. T. (ASCP)
• e
i
n
WELL COMPLETION REPORT l PUTNAM COUNTY DEPARTMENT OF HEALTH
3171 q Division of Environmental Health Sorvices
COUNTY OFFICE BUILDING - CARMEL• NEW YORK
This report is to be completed by well driller and subr.;fitted to County Health Department together with laboratory report of
analysis of water sample - indicating vYater is of satisfactory bacterial quality before-certificate -of consLruction-compiiance is- issued. - - - - --
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
NAME (� ADDRESS
OWNER \—� f4 ( G L.�C�rl i A �
SCREEN
DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL Diameter of well including GRAVEL SIZE (inches) FROM (feet) TO
PACKED: grovel pack (inches):
DEPTH FROM LAND SURFACEI Sketeh exact location of well with distances, to at least
Fcc7 i� ii T
FORMATION DESCRIPTION two permanent landmarks.
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4-
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
MPLETED DATE OF REPORT WELL DRILLER (Signature)
7 �
(NO. 6 Street)
(Town)
(Lot Number)
LOCATION
OF
`�
WELL
oj�f I
k 11. tr C�
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❑ESTABLISHMENT
❑
❑
PROPOSED
DOMESTIC
FARM
TEST WELL
USE OF
WELL
❑
El
❑
El
i Y)
SUPP Y
INDUSTRIAL
CONDITIONING
((SSpe
DRILLING
4
COMPRESSED
❑
❑
CABLE
❑
OTHER
EQUIPMENT
ROTARY
AIR PERCUSSION
PERCUSSION
(Specify)
CASING
LENGTH (feet)------I
DIAMETER inches)
WEIGHT PER FOOT
/
El
❑
DRIVE SHOE((
❑ 0
WAS CASING ROU DTI 1
El
DETAILS
' f
,
THREADED WELDED
YES NO
YES
NO
YIELD
❑
HOURS
G.P.M.
YIELD (G.P.M.)
TEST
BAILED
PUMPED
COMPRESSED
AIR
1 i
G
S
MATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC (Specify feet)
r ��
DURING YIELD TEST (feel)
lJ (s
Depth of Completed Well
in feet below Land surface:
' y
SCREEN
DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL Diameter of well including GRAVEL SIZE (inches) FROM (feet) TO
PACKED: grovel pack (inches):
DEPTH FROM LAND SURFACEI Sketeh exact location of well with distances, to at least
Fcc7 i� ii T
FORMATION DESCRIPTION two permanent landmarks.
�j Lc'L L
4-
If yield was tested at different depths during drilling, list below
FEET GALLONS PER MINUTE
MPLETED DATE OF REPORT WELL DRILLER (Signature)
7 �
�Dews
CONSTRUCTION TERMT; j 'OR ., SEWS
A -Ak
Building Type' Zi4l1CG1 -�
Numberil of .Bedrooms '
A,
'
sb Sewerage ydenn
"§ev to consist; of
To be _ru
Water Supply - �.Publlc Supply Fro
�r Private !Y: to
Other mbnts, -
wrlLbe located as shown on the approved pl
County Departments Health
t 11"
'
Addrdss,�;.L
APPROVED. FOR rei/.ojr-abldLfor..,;:ca,use� o"i �;a�:66,-a-m*en'die'q-,&
requires a`new`,�ipermlt pproved for di
7
In
AM COiJNTY DEPARTMENT OF HEALTH
-.!.,V._�K',l 512-r'':�-11-
e4h 0
DISPOSAL ,'SYSTEM
X
7. "aor
Af
a6 a
Feet
Gal c -a lkea'V
h
Addrew
Ij
lied bV:-
�9-'Ie for ihd'd6si§iv*.'a'nd 166ti6ri. bf-,t t' he ,Ijr . 6 ; p6sed 6iit the separate se _ wai e di posal system
Ipproved nd jt
n, a i;4e'. standards nffr u s 37 -, ffi tnam,, -
h
0
,A
a"'
it a r es and l-, regulations of tthe Putnam,
5
s...!:p n s t -i o n ,o the heibien undertaken ...tand 'is.
loner'. ".'Health'' Any change or; +alteration AM coristruttion ,
bu.
it
1. 4:40 4145 5 14
2 4,415 4,_ G2 o
3
20
3
4
S
Not-es
-es :�--e ob-
1) Tests to be reoe-ated' n't Same d,-;--)-Ll*.-1 unt-11 app-cxf—tely- equ=i S();l rates
`tze' for
c 0 j.;= �. - _'_1 k
taint-� a.t E?E:_-... ID e I _.__ .7. all d=-'-= -�-o '-e subm
D I Vi S i ON' OF N Vi O\ E, LH F-=,
--
DESIGN DATA SHELEIE-Y S P' ►RA 7, E S E 7,.- AGE DI. Q OS I L Sv,ST:,_ Fi LE
NO.
e r 0 P% LA
Add'fl-"3s 3 ZSO e> L,-kc.c Pwg-
Located a r
A Sec 51 Bl Oc
Lot
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c
al i L.y .qTr- Rf Sou
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PE 1-\!�.ATI CN TE, ST, DATA
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Li
AT- Pr ATT,(
RZOU. i D7 n 7 ZZ 1 '--'.'T - - =_D I TH p IC_
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T
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PERCOL.`� C,
a�li1 it Ds e
:ept 0
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Fr o Ground n S f - I I ne s
soil Pa-=
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r Stogy -OD in
St a_
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1. 4:40 4145 5 14
2 4,415 4,_ G2 o
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3
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Not-es
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`tze' for
c 0 j.;= �. - _'_1 k
taint-� a.t E?E:_-... ID e I _.__ .7. all d=-'-= -�-o '-e subm
T.. .., .
.TEST PIT DATA RE0UI D =J 2-7 3U'3LiTTTED
;:T TH PPi,IC�TIO`
DESCRTPTIQN 0� '`OL1 c ,• -� �� ^n T,,
_ LJ. �_ \T, E
^ =cT ROLL
--
DEPTH HOLE \O:. i HOL _ \0..
HOLE. N0.
12•.
1811
241.
3.0 `'
361.
42*. 6
Loa,vy�
49 `:
5 O-Acc-- OC gAN� "
-
5..
60'.
66.1
i L
841
1tLTCATI L- `'c.L aT" IGr vQv' \D WATE R IS ELCl7l'`
I\DIC� T E r = %:�.�, TO ;1HICH v,ATE:, � E„� i R = S -' ; E U 'T ER
EE J �__ AFTER 5E_.�� \CG�`e E�,ED"
TEST'S M aDE 34 GAQ� �-Tsc l-E
Date
Soul_ r�� ��j'� S _10 %: D=v? S. D. T cz'zIE' o'.
Igo. of Ba o,,..s S° tic Ta: ti Cap =o -�Y Od
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Gals. ?�.a� MA
A�S.Or 110:1 cirea Provided ��% ��� L. F.Y2�= it �l ...
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;. _ .
o�cce�R A. _� 7P-:AsSOC a Sic-- a tu re
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Address -�4_ GI3 -=VAIR V7A E: SEAL
PUTtia<< COUNTY DEPART ",L \T OF �lE_,T,T
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