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MUNvL iL �k �xOx „. .-u+ �`� ,� •`k
CO .TY ;DEPARTMENT F'-HEA�LT11
e� _ 1>
• - . ;. ;Divi�JOn of Environmental Health Services Carm N Y� 0512 ,
s CERTIFFCATE OF CONSTR'UCTtQtV CONIPLIAN'CE, F,O,R tSEWAGEDISPOSA 'L,.Si!STEMllIOTCJ`,
' r �'�r -�' �; t , :Town or�u111a
s a
Located ;at Section
�� lock
Owner
Lot,-., O ii 7.
e _ Job`
Separate'Sewerage System built, `by Address i r.?
Consisting of Gal; Septic Tank /v lineal Feett X e�V width trench
.. .. 4 -i.
Other requirements
Water:Supply. Pubhc,'SuPPIy''Fro n
1.:.
Private ;SuPPIy_ Drille ^ By
dd ress~
s
B
uildingType No of Bedrooms'' 'Date Permit Issued
HasE"
rosion Control Bee Complete 7 _ N ,�tllltlllJ,J
'� r : }i j; � `���. '� • :i; `Y y iii ,.;. ` ': u. • -
I certify ,that the systems) as listetl serving the above prem4ses were constructed ✓plans of he completed work'(copies "of which -are
.4. ttaced); and . in -accordance with the standards rules and = regulations plans fi Pie pe ^rmi�A Putnam. County `Department,oi Health.'.
'Data ` Certified b
Add f fis f
r r ,
e
ressr � license
Any person occupying piemises servetl by the above systems) shall "✓promptly tIk�.;u "ion ar, f e Q�ce. nary to secure the correction. of any unsanitary -
conditions resulting from such :usage: Appro3al" of the °separate sewerage�..systema ip�``````�il void as.soon as 'a.,public sanitary sewer becomes .
available .and the approval of, the:private water supply shall become null and void wh�Nq'" 1iJater supply1 becomes; ,available. Such' a prove ls,Care ;
subject to mo ' 'cation or change {whe - "inzthe judgment of th :, C,Qmrniss�oner rot Ith suc1h revocation, modification or change,; is necessary,
i h li
Date Title.
f4_ _ ��._�� _ _._ _•<.s , _� _ _.._.�.�_ l _ ,__,., , . t. _._ _ _ _ _
WELL COMPLETION REPORT
3/71
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
_..This .report ..is.to be. completed.by_ well. driller. and submittedto 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
ADDRESS
yH-•
LOCATION
OF WELL
6 Street (Town) (Lot Number)
e "' t b° S 0 ri
PROPOSED
USE OF
WELL
BUSINESS
DOMEST C ❑ ESTABLISHMENT ❑FARM ❑TEST WELL
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (spHEB
❑ )
DRILLING
EQUIPMENT
1.4y
COMPRESSED, CABLE
ROTARY ❑..A R PERCUSSION ❑ PERCUSSION ❑ (S(Specify)
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
% 7 THREADED ❑ WELDED
Lztm
0
❑ NO
Li
SIN
YES NO
YIELD
TEST
❑ BAILED ❑ PUMPED
HOURS G.P.M.
COMPRESSED AIR
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
�—
P;7 C b
DURING YIELD TEST fleet)
G
Depth of Completed Well
in feet below Land surface: 6
SCREEN
MAKE
LENGTH OPEN TO Ap FER (feet)'
DETAILS
SLOT SIZE
DIAMETER (inches)
PACKED:
gravel pack (inches):
EL SIZE (Inches)
FROM (toot)
TO ( lest)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
I
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
�j
TE W LL COMPLETED
DATE OF REPOR
�i
WELL DRILLER (Signature)
tir®
d:
BREWSTER LABORATORIES
Box 224 - BREWSTER, N. Y.
WATER ANALYSIS 'REPORT
SAMPLE NO. .3255'
SOURCE: Emma Spaulding - faucet - well supply
Troy Place
COLLECTED: August 11, 1974
BY: Edward Savoy
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 m1.
Total Count, MF method 32 per ml,
Detergent 0 ppm
Nitrate Nitrogen 105 "
Ammonium Nitrogen 0
Chloride 45
Iron 0
Hardness 8 gpg
ph 701
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
August 17, 1974
I �,:n� % or 1Lrchase., of build:i.lib
�yyM.rYj "J •d.�t?.dFfL� i'�•.yJ`y'.J � __-Zdf�i%;i _ -.
uilcling Constru "ted by
61'oTl �"C'
location - Street -
3uilding Type
I
.......... - ..............
Mu>>acS.�,�,l:i ly .
Section
Block
Lot
GUARANTY OP SEPARATE S0,7AGE SYSTEM
I represent that I am wholly and completely responsible for the location,
iorkmanship, material, construction and .drainage of the sewage disposal system ,
>erving the above described property, and that it has been 'constructed as sho,,m on
:he approved plan or approved amendment thereto, and in accordance with. the standards
,ales and regulations of the Putnam County. Department of Health, and hereby guaranty
:o the owner, his successors., heirs.or assigns, to place in good op�r�:tino condition
my part of said system constructed by me cahich fails to operate for a period of .t:o
,ears immediately following the date of initial use of the sewage disposal system, or
Lny.repairs made. by me. to such system, except cohere the failure to operate properly
('au: (_-6 .ijv 'llle wil.i iul Ul' 71E'j 1 L�tii i ac. L iii ehe Oli:i.ij.,nii a. vi L.,,i; ,.U.� 1...11 ,
• The undersigned further agrees to accept as conclusive the determination
if the Director . of the Division of Environmental Health Services of the Putnam County
)apartment, o-f Htalth° as--to-whether -or not the failure. of- the- system. to. operate was
,aused by the willful or negligent act of the occupant of the building utilizing the
system.
>ated this_
day o 1
Signature
Title
corporation, give nand addres.l
'HREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS' BEI'ORE CERTIFICATE
)F COMPLETION WILL BE ISSUED.
;UAizA\' '.TOR IS RF.OUIP.I,D TO. FILE NOTICE OF DATE OF FIRST USE OF-SYSTEM.
_______-- _...._..- __..______.._-- -_ - - -- -- ---- --- - - - - -- --------- ------ _- - -_ - --
)ivision of Environmental Health Services, Putnam. County Department of Health
1\
t
r
_��'D
PUTNAWCOUNTY
"
Division of E nvirofiMenMl HA
tttGGG AUCTONd","PEAMIT. -FOR. SEWAGE ,DISPOSAL .�-SYSYE
at -, ovo
e
n,
�,:Sub6lvlsio
Area_
rF3uilding. Type .' fi Lot M 4er of Beorqo.T,s,
x .Separate sewer age System to consist of %SO
-6, constructed -
-,�I-To.,b .,,by 7'
Water upoly.,. From','
If -Oiivatii �Supply . to be -drilled't
Acldirdss'-
-Other -ReqUir6merits! L
4
v., vrdpreseni- at I -am,�.woolly, and completely �responsible for the'design -
above, I deschbed -Wil 1,6e constructed as shown'on'the approved j
+ County, Department Hof AHo liii-`,incitfik'�o I t
i tie n, corn r
p e ion the
Cl
-submitted to-the.Depai ment;, an a vViitten'gbarantee
„place in good,.operat;ng -,sk,d.,t wage
d tion,,any.'part,�of", I
.,. f i' , _t" '
of the approval . o he 'Cer iWic'ate oftiConstr6itlon co
d-
r,. �Ws e.. ocated. is: Sh Ci&V h',o h I he:ap prove plain and ,that _.'said ';We
-1-Co6riti,� bepartrin' ent', o"if" 11'4alih.41 -
Address "
o� APPROVE CTI ON: j
Ci FO'k �66NST lilb appr
f or, cause - or � '16e'�amended '' "inod
J-6ay. - 'or.
646iiei new perf'rr`k�.� 'Approved - i6i. disposal
ri '.`iA -
a]
El y
'*6 fUrni
;pRsa �1� g sy
I iaincb- '91
ili'b6-Inst
�.P,-A,RTM,EN'T,,-',IjF,*,.,'iik�kLT,I4
'PS,&-vicis, CqnWel, N. K-'_166 12
67
P
Town or Vinage. 7
Section e6t on Block.
xr
Lot Job
Address
6. —1r.
Total Habitable 'AIC 6 Squl re'Feet
.,
S )ilc-i
eg Tank'* _Wlclth 'trench ,
oca tio - ri 6f ..-t he. proposed system(s);-I) -that.,the separate sewage disposal system j i
ib'ii3',to;,arid ,'-Ih'ac6drdance with e,�s an iard. �61"es= 1-utnarn
th "t d 's.,r. an regulations of , the
cate`. _6 Construction , omp ancel.,"saitlif6ctori t6*ihe.Cc;mthiisioner of Healthwill
fied the !owner ,his !sucjdessorsi.h'e'lrs,qr,,4ssigns,py�thp builder, that sild'b411der will
em �urlrig
6 � 9 � . qL,
., the:.porkid iif' two ,(2) `Y`eari Imrhedla t ely,folk?'wing thaidate of the
,. , ; . ' ' Issu
t�e.orlgna I sy it e m qrany,repaI s ihereto; 2). that thedrillid well above,,;
'6 rules an,�rec.,, 0 utnam
1� Z_d i7u-I4rq_nsVqf icth P
Licen ie No
''the daY i ss66/unless constru dt ion of the':bijMlrij`Kiibe6 undertaken an
Commis er U Wth._ArwchanO or alteration . of construction
priva supply Only.'
Title
a'
PUTNAM COUNTY - DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner AddressS
Located at ( Street Sec. Block Lot
4dicate neares cross s ree
Municipality, , 1'?- 17 - T.�'SQ AL/ Watershed Ax y.G
SOIL PERCOLATION TEST DATA REQUIRED T.O BE SUBMITTED WITH APPLICATIONS
2
3
3
4
W,
Notes: 1) Te'gts to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse
No. Time
Start - .Stop Min.
Deptti to Water
From Ground
Start
Inches
Surface
Stop
Inches
Water v-e
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
2 �: o /�5
/t.?
/� 3
/�
33 -'16
5 J
4/4L
/ �¢
11.3
2
3
3
4
W,
Notes: 1) Te'gts to be repeated at same depth until approximatelyy equal soil
rates are obtained 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' SOILS ENCOUNTERED IN TEST HOLES"
DEPTH HOLE NO. :` HOLE NO. HOLE NO. -
G.L.
6"
12"
18"
2411
3011
3611
42
48"
5411
60"
66"
7211
78'►
8411
..INDICATE. LEVEL .AT WHICH- GROUND WATER IS ENCOUNTERED X/��✓ - -- -
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY G.A /A Date
DESIGN
Soil Rate Used / / /e5 Mi Vl "Drop: S.D. Usable Area Provided
No. of Bedrooms' Septic Tank Capacity Gals. Type
Absorption Area Pro ded By %s-�z L.F. x24" 36" width trench.
Other
Name Signature
Address SEAS
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: P� 6411
Soil Rate Approved Sq. Ft /Cal. Checked by Ptt�FeftEQE�L` ��y Ante
o �T' EtLS
y 1' `{_4'
75
T \lo
ISO Gallor.l 5 �-i(: jA4
R
AUG
2
F j '!"''��tV �•tiX��N� "`( iYY OE HEALTH
i"'
gq DIVISION OF
ENVARINUM l4ow" Smog
f
O F U L -
oQG� E A 5Na. L
LA
PATT
fv uT i..
R
t L
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y'/ r j 2.`6/'/,��4.tr -:`• ..fs J" /LG"�. �1 /i4i �L.../,7 { .L.
1 \ rt F j lam✓ oT •7F .ft1 f t - - '
Z 771c F44D
c � /SJ�.f l jQ BtS,%,t��%•?=Z/t'�.!} 4tfL7 hfi'D.G'Grr"`L' 6`I""
j F -
'
APPROVEG
44
�72 MAR 15 A
`
NULTH Sam=
to
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