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01178
4+ PUTNAM COUNTY( DEPA
1 L
Environmente/ Hela /th
CERTIFICATE OF ,CONSTR.UCTION COMPLIANCE FOR .SEWAGE
~Located at
e7J� t/�'%Z/Z/)fd�eii8 y w
Owner
Separate Sewerage System built iby J��l'/ �/'22'rd_�/Lrit/
Consisting of o Qa ptic:Tank and
Other ►eQu(remerits i�
-Water," Supply Public Supply' from
Private Sup,Diy. T lled ;ay
as.,
Building Type
Has Erosion Control Been iCompletedtr
yy
i certify that the system(:) a6;liated serving the above premises were ;cons
of which are - attached)`;; and in "accordance with;;the standards rules and re
Putnam County DeparLaent Of Health �; t )x
+ }� s
• 1 r -�a Y d' 7 " tw
'- Date " , � �'�,.LtwCertifietl by
.t� Address
Any person occupying premises served by the above systems) shall'promgtly to
cond(tlons .resuliing' from such, usage.:' Approvah.of 'the 'separate'sewerageay
,
;available and the approval of the *private water supply shall become null:and i v
subject to, modifi cat lon;.or change when, fn the` - Judgment of the'Commissio
,(� '• � f S X72 � T N
Date n r ti r ' { tirti c BY s c
S
RTME , OF .HEALTH
Services, Calm% N Y 10512 Pe i x'
'DISPOSAL SYSTEMi %T/'2�'a`/
Town 'or Village '
�tTaMap r .• /� / `� l Block
Tax: Map Lot N S, bd Lot p
TBedrooms ._,— Date Permit Issuetls
tructed easentially'as shown bo the.plafi of the completed work ( copies j
gulationa °i'n';acco=dance_ with the filed plan, and .the;•permit_ issued by the
t
J� ;
elo
'L can" Nod
i - ,L Y/C�� . /p
ke such . action as may be heLe6Klry t6 secure the correction of any ununitary,'
stem4hall'become-eufl and; void as soon'as a�vubllc.sanitary sewrer becomes
oid ;whe�,•a• putilic' water 'suppI becomes available. Such ;approvals are
ner of Health,. wch rev ion;: modification or change is necessary.
!Title a ,I
w
tipv � ,G! •Y. � ' '`
i
F.
SAMPLE NO.
SOURCE:
Bon 224 - BIRIEWSTEIR, N.V.
(99 4) 225 -2072
6070
Nick Grazioli
Patterson
COLLECTED: February 17, 1986
BY: P. F. Beal & •Sons, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
Hose Bibb'- 14ell
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
February 20, 1986
Y
ickwit P.E.
Director
i
• 1' .L
Owner or Purchaser of Building
,� z.10 L1,4-
Building Constru__c�t_ed by
C'�q�vM
C'021,1152 49 16-1_5517OR' �iz1vr ° l2a6 o
Location Street
Building Type
Municipals y
94
Section
i Bloc
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 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 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 day of =fer 19JP1C� 'Signature
Title j
(If corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF PINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF; DATE OF FIRST USE OF SYSTEM.
i
Division of Environmental Health Services, Putnam County Department of Health
1 �
QUELL COMPLETION! REPORT
3/71
PUTNIAM 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 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
Nicholas,Gra.z_.ioli
ADDRESS
Box 36, Chappaqua, NY 10514
LOCATION
OF WELL
(No. & Street) (Town) (Lot Number)
Barnard & Lakeport, Patterson, NY
PROPOSED
USE OF
WELL
rV1 BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑TEST WELL
❑ SUPPLY El INDUSTRIAL ❑ CONDITIONING ❑ ((SSpeciiy )
DRILLING EQUIPMENT
ROTARY � e AIR PERCUSSION ❑ PERCUSSION ❑ (specify)
CASING
DETAILS
LENGTH (feet)
44
DIAMETER (inches)
6
WEIGHT PER FOOT
lg
® THREADED ® WELDED
DRIVE SHOE
5d YES 0 N
CASING
YES
NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED � PUMPED ❑ COMPRESSED AIR 6 8
YIELD (G.P.M.)
8
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specifyfeet)
overflowing
DURING YIELD TEST jfeet)
Depth of Completed Well
in feet below Land surface: 1/31/86
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (feet)
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches) FROM (lee,) TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
0
20
Drilling in overburden
clay and boulders
Hit rock at 20 feet
2 0
Drilling in rock,set
281;
—casing.grouted,
k-rilling in Pock granite.
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WEL 486LETED
1/31
DL7�� F gg'ORT
WELL DRILLER (Signature
Lam'
1
N 05 °55'/O "W' 95.00'
7702
d 29. a' ;RO
7701.
1 COMrele 610c*l is i
7700
76' 9,9 .
71:z � o
707C 98 Q o
E>
'05 °55'10 "E 95.00, ' _...
t ' 7697
76'96 �
j
F
1 T r IPA T'd NAM ���JRI'd SY
�D /vaion of Environmental
�orvsTUar,00� � RMo� ®��
-Located at- +rZ�6,�7,�%z,�
f 5 -
- Subdigision =
OWner
Building Type 1. °,L.:� `� /i✓� jLOt Area:
N mber -of Bedrooms Design Flow
Separate' Sewerage System to consist aof
To be constructed by
k Y
Watei SU'p ter, �� Public Supply From
hvate ,Supply 6:b drilled
w
'- Address
Other Requirements * Y
3 r l; represent that l am wholly and completely responsible for fhe desig'9�;
t.
aoove'descnbed will be constructed; as shown on the�approved amendme
county Department of `-Health, and. hat'on completion Ahereof a 'Ce
be:.submitied to -the--Department'rvantl a- written. guarantee will be `ft
place. in good operating ;condition any ;part of said jsewage disposal
ante of -. the approval of,`. -the Certif{cate�of Coristructwn Compliance 6. Will be located ass_"n on., the approvetl plan and that said well will be 1
County Department of Health`„
tl
r
r
z Address °�
APPROVED FOR CONST:RUCT1O. tiThis approval expires' one year f
revocable, for-, cause or may be amended od modified =when tonsidered:n
n
requires'a new permit Approved for disposal of,domesti ca { y
-Date'x BY,
J.[r
-7
l h Serlrces, rmel lN. Y 705Y2
M
Town or i lage 4
Tax _Map f�P :.' Block =
k Address
r
Total Habitable Space Square Feet
Septic Tank and
%°
# - Address
:® }
.. r, w ,
location ofiA proposed system(s); 1) that the separate LseWLage- disposal system.
.:......
here to and?,in accordanceTwith the standards; rules'an -regulations of e'.Pu nam < j
{cafe of Construction Compliance ,satisfactory to tKe'Commissioner of Healthwill` +
w,
shed the',owner his successors, heirs•or.assigns by the.builder, that said builder will
stem during. the period of, two (2) years immediately,foilowing.thed'ate of the issu-
't11e original system_or any, epaus:theret6; 2j that tf e'drhled well descr.iDed above
ailed in accordance •with'Ahe standards rules and regulations of. the -Putnam, „.
License
n the date ;issued- un nstruction of the. building "has; been undertaken +"and is i
;so y by the Co isswne 'of Health Any'change'.or on:oi� construction
4D d /or phv >•e wat itC- ei►tp ----
F'
Y
SA
MIT, FOR
TION, PEA ,SEWAGE: DISPO,
or village
nn
Type
C' Notification R.enii�
7:tb co S Gal. Septic Tank and
a:c-cor'd'a'n*F'9':'rpit�'thd-itandards, rules and regulat ons of ',the
Putnam
�Funeity' tie"
Oved:,p Mons-7
,ij4.,County Department- of- Healtti�.,
Address
License
-6ildlhg has'b6en*,,undirtaken and s-:
RU 6 T approval :eXp ire r -the 4 is:sued Mass construction of the'b
orh
-;revocable for� b -anien'ded oi.*,iiiodified when' Cor, i'dere . d loner of Health.' I 'Any OeL, niiiuctlor'
cause.pr may eL, necessary by !the o Witera on o co
ri
Tit
v
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.
Owne r d6 j <-/_,= Address �.p-
Cd/2��✓✓��i0�' s0 /L7 41 ?76 ,�02
Located at ( Street Kaicate J�9i1��.g2D ,0 Sec. Z92- Block Lot
neares cross street)
Municipalit 7,,y4!-,7 Watershed
O W^/
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
apse Depth to Water Va E er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
2 IJ7 .2/0 ;2
3 2, /U
r
4
5
?
:2- z
4
5
1
2
3
4
5
Notes: 1) Tests 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.
Address . 4 SEAL
THIS
SPACE FOR USE
BY HEALTH DEPARTMENT
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
Soil
DESCRIPTION OF SOUL ENCOUNTERED IN TEST HOLES
Sq. Ft /Cal.
-NO.
G.L.,a
6"
12"
18"
r
301
36"
48"
54"
6o"
= 1 � �• 541�112 y
7211-
,r
7 8"
84"
INDICATE
LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WATER LEV RISES AFTER BEING ENCOUNTERED
..TESTS ..MADE..By...... �� D,S, u!�4jz6y Date
�
DESIGN'
Soil Rate Used MirVl "Drop: S.D. Usable Area Provided Qi
No. of
Bedrooms: Tank Capacity /66 0 Gals. Type
_Septic
Absorption Area Prov ded.By width rent
Other
aC� �.�•�' r " E
j��am
Signature ure / .
Address . 4 SEAL
THIS
SPACE FOR USE
BY HEALTH DEPARTMENT
ONLY:
i
Soil
Rate Approved
Sq. Ft /Cal.
Checked by
Date
••`G of NEW `%
y : p• 'F .
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