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01258
' �Y GGGIVV
PUTN ,COUNTY DEPt
AM ITMFVT 'OF vHEALTH
e. I iwsion :of Environmental Health r ices Earmel N Y. ' :10512 G
v
' CERTI�I69�TE .O - tONSTR!lCTION C011APL1'A'N E POR'3EYdACI== ''D,ISPOSAL SYSTEM
r ilia —
'`, �f. e
Located at 6: "1 o nco V�gFW
14"',
:. rB lock
w
Section t
Owner': 1 Lot C] z�9 Joti S I'Z SSO'l
_
t_
Separate Sewera e S stem buiittiby
9 Y Y Address
u Consisting 4of �_+ Gal Septic Tank lineal Feet X
width trench
9.
° I"Oth&, req.`Uirementsf`
v Water supply Publ {c ISuppry From :,
t
Private�SuPPlyi
Drilled ° BY A 1
Address �� s
1 . r
Building TypeNo of Bedrooms T ry -' Date Permit
$ Issued
_Has Erosion Controi Been Completed? Ll `
4:a I certify thatAhe3ystem(s) as listedaserving the „above premises were constructed'esser Bally as shown,on,,,the..plans of.;tfie.completed work co les of:which are
-� .. ..,c P., ,
.'attached) }anil "in accordance with the' standards; rulestandlregulations Mplans filed ;;an h ermit .issued.`'bY the utnam - COU:'Wo epar,finent of Health.,
Date ertrfled by^ E. R A•.
4
#1 s w } Adiiress } a : I }cehs No
1 ;Any poison` occupying:wpremise5served by the above systein.(s) shall�prompfly take'such action as may be necessaryto�. ur the correction'of any unsanitary.
'conditions resulting from such - usage. :'Approval of the ,separefe: sewerage systerri shall ;:Deconie null and`void asisoon a a public •sanitary _sewer becomes
available and the approval of'the ` privatewater- supply shall become null and void,,Wlien -a 'public ;water supply becomes-� available. Such ,approvals are .
u sub)ee .;to modif}caUonu:or, change when, in Ahe: Judgment of thl iCommiisioner -of Health such reyocatioh modification`,or change is necessary.
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WELL COMPLETION. REPblT
3/71 r
y
This ;report is to be completed by well driller and submitted to
.analysis of water,. sample indicating- water•as -of satis#actory bscteri
REPORT MUST -BE SUBMITTED WITHI
PUTNAM COUNTY DEPARTMENT,.,OF HEALTH
Division of Environmental Health Services'
COUNTY OFFICE BUILDING • CARMEL, NEW YORK
;ourity.Health Department together with laboratory report of
• quahty-befor ..e:certificate-of•construction compliance--is-issued.--, "
30' DAYS OF WELL COMPLETION
OWNER
NAM F„% 1
ADDRESS 1
LOCATION
OF WELL
(No. B eet). A (Town) (Lot Number)
•. PROPOSED
USE OF
WELL
BUSINESS
DOMESTIC h ESTABLISHMENT FARM D TEST WELL
PUBLIC AIR OTHER
INDUSTRIAL CONDITIONING F] (Specify) t '
SUPPLY El'
DRILLING ".
EQUIPMENT
COMPRESSED CABLE a OTHER
XCI T ARY ,SIR PERCUSSION PERCUSSION (Specify)
CASING
DETAILS ,
LENGTH ( feet)
-
DIAMETER(Inches)
WEIGHT PER FOOT
C THREADED ❑WELDED
DRI
E SHOE
'ES ❑ NO
�jS CASi�PfG D?
LJ YES NO
TEST
:BAILED I 'j ! PUMPED !I COMPRESSED AIR HO G.P.M
S
YIELD (G.P.M.) _^
WATER
LEVEL ''
MEASURE FROM LAND SURFACE —STATIC (Speclfyfeet)
DURING YIELD TEST fleet)
�j
,�--
Depth of Completed Well
in feet below land surface: O J ., ,
'
SCREEN
MAKE i
LENGTH OPEN TO AQUIFER (feet)
DETAILS'
SLOT SIZE
DIAMETER (Inches)'
IF GRAVEL
PACKED :'
Diameter of well including
gravels pack (Inches):
GRAVEL SIZE (inches)'FROM (feet) TO (foot)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
Dk
II '
1
If yield was tested at different dept'is during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
DATE OF REPORTS
(.�
WELL DRILLER (Signature)
t
�llir�l�a r '
REPORV
E1tARf WATION OF POTABLE. WATER :
APP. COL.
TRU COQ
'ODOR (De cription) (Deg.
SAMPLE . � ®.
`PH
=�r
�
x.20
f %RRis WATER LABORATORY
Mab 'I Ave .r DanburP ; Conn. 06810
e
3350
EXTENT OF ANALYSIS
OTHER
t
❑'PHYSICAL;. ❑ CSMPLETE ❑BACTERIAL •
NITRITE (as N)
NITRATE (as N)
NAME OF.M4TFB..SUPPLY
®%
PR -SS
JOU
TOWN _.
DAT REC'
DAT TES ED '.
COLLECT BY
DATE OLLECT D
PUBLIC -, SEMI - PUBLIC PRIVATE
O
IRON, Fe)
. '
ALKALINITY (CaCOj BICARBONATE
ter /i
o
ALKALINITY (CaCO,) CARBONATE '
TOTALHARDNESS (CaCOj
�•"' `J t
J
u
!*C +r1LM1/�a.rO4�r��p• iN_,•`-"s.``C'*P' ^#
k fir L1.W LJP! c*
NL•
LOGTION AND /OR ADDRESS ,OF SAMPLE COLLECTION POINT
Cv
NAME AND
.ADDRESS OF .
ZVIC
"
P ERSON TO / f ?
RECEIVE LAB. /�� I1� /p'
- TREATMENT RESIDUAL
El NONE 11 CHLORINATE CHLORINE
REPORT
J
...
(TEST)
r
g
I
El ❑.. ;OTHER (SPECIFY) .
MEMBRANE FILTER
TEST
"ON
SP.
.01 ee
coed one colony per 100ml. Coliform colonies per standard sample .shall not exceed 4 /100ml. in: (a) two consecu•
if lonies
COM.
TYPE F WATER (At Sample Collection Point)
Raw or untreated- ?2. Treated water at
❑
3. Water from distribution ar . El 4. Water from distribution;
❑
water at source treatment. station
(One
source only) (Mixture of.2 or more sources)
REASON FOR EXAMINATION
:t: ,
COMPLAINTS OF
1. The results of the 'analysis of this sample are satisfactory., and. nieet requirements for a potable water.
❑ COLOR ❑ SEDIMENT.
❑ ❑
IF SUSPECTED OF CAUSING DISEASE GIVE DETAILS
are as follows:
G
a
ODOR FOAMING
group in a sample of potable water is undesirable and; while::noJ. necessarily indicating the presence of any disease-producing organisms, does
indicate that such contamination might survive to the same extent', The presence of organisms of the coliform group -may also indicate that the
❑ TASTE ❑ OTHER '
ur
APP. COL.
TRU COQ
'ODOR (De cription) (Deg.
TURBID
`PH
=�r
IL
t
NITRITE (as N)
NITRATE (as N)
AMMONIA (ef N)
ALBUMINOID (as N)
CHLORIDE (C)
O
IRON, Fe)
. '
ALKALINITY (CaCOj BICARBONATE
ter /i
o
ALKALINITY (CaCO,) CARBONATE '
TOTALHARDNESS (CaCOj
�•"' `J t
J
u
MANGANESE (Mn)'
FLUORIDE (F)
DETERGENT- (ABS),
SULPHATE(SO�j`
v
.
The .arithmetic mean of all standard samples examined per month using: _fhe „membrane filter technique. shall not.. ex.
MEMBRANE FILTER
TEST
"ON
SP.
.01 ee
coed one colony per 100ml. Coliform colonies per standard sample .shall not exceed 4 /100ml. in: (a) two consecu•
if lonies
COM.
,
W
U
.. ..
five samples; (b) more than one standard sample...when less than 20 are examined per monte; or (c) more than.fice -per
m
cent of,the samples when 20 or more are examined per month. tk`=
1. The results of the 'analysis of this sample are satisfactory., and. nieet requirements for a potable water.
The results of the analysis of this sample, are satisfactory for a'poiable water but certain of the chemical or physical constituents are high. These
are as follows:
G
❑ 3. This sample is not satisfactory since it does not meet the bacterial- requirements fora potable water' . The presence of organisms of the coliform
group in a sample of potable water is undesirable and; while::noJ. necessarily indicating the presence of any disease-producing organisms, does
indicate that such contamination might survive to the same extent', The presence of organisms of the coliform group -may also indicate that the
U
treatment was not adequate at the time the sample was collected.' ;
O
to
❑4. This sample is unsatisfactory as a potable water because certalh'•'themical or physics( constituents are above acceptable limits. These are as fol-
Iows:
E-1 The. coliform content for this raw surface water is ❑ 5.., Low= " -'- :❑ 6. Moderate ❑ 7. High
F] This sample. -was analyzed for fluoride. The fluoride concentration' was ^ ❑ ,B High ❑ 9. low• ❑ 0. Satisfactory
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F7 .O 1', Z'u!'C iaGw D L }:Li'. t'.i_I'1__ a' ��l)a.11LC].ILy
.00.6 tlon.
1c71<ion�` Stree`It.
F , , i , .'�
Bu � 1, i n , . Ty e --- �--- -� ---- �'` ---- ---w
,
� Tt r -, RAT" -�5 ,� ,
:f -UA, ���r�. 0, SEgip }��.rr, s�:rAr7r, sv�TI,,M: `
a,
' I
-epee ,e>>t `th:xt ` i girl t,�h.olly arld cor,i a.etel � rc:s,�o�� sib l.e J'�,r. t!z�' i
location -, VIOr�ts^1 .n'�hip, nlatc:rial, conStluc t. it, c^::'c�'��.r "r'.c'. 3 Of �;hG':Setd�lv'ri
;di §- p;osa,l s`Ts-t-In1 s�rv`ir' `:trio. ^��J'OVi' clesc l;'ed t�r.o'perty- and :th,a:t it' has hp' n, l
:. constructcd `'2s . sroL•ri1 on the pprov ed plan or. unproved amendlnent t}ie.reto,
and :in acc.orczance. :rich 'the standards, rules.. rl.rict: regulat: old;=. of 'the Putlrrl�lll
County Dcpar.,nleif�, o'f Hea -lt.i, and: hereb�r �uara ~it;� to• tie otinzer, his succe;;
S0I's r :or assisigns., - to place. .iI1 g v �'.ODr ?'c ^.'t'rl Condition •anj' -p rt of 1.
said system `cons +.r —d �y r_e.w,hich fF11�i_s to' on�ra,t for' a ;.�cz,.iod ;of .l;l'r:o
Y fo'.low- J.r_ the' d.at:e of initial :usc of? t sera. di, csal
::.ystcm, or.-, .y r ;:a rs :nude 1:)y .�1Ie to :�,'rcii systoi�; ;�. cept'x'i,There the .fa- I ura
to over u. ,c. a. otiE:� l i s cuL,�ud r�r the , �I.lf.tzl '' :r�,ne ligent •a.c,t of the' 0"' C ciz-
pah rOf.thc; buildi'1f,° ;ut'iliz!nrr the syst;m
1.iiL : lucsl':i q.0• �L%CFpt as-..&b r1 1 " "U�'; G L "IZG CiC:
tE)'7'r'11I: }1 v'1.0 "n' Cf vrle D ll'� ct „' /�f. T . c t. �] l n 1' ) ,,�� e
e o_ z t.: J] .�.�iozl ,a r�vi� o. _� Ie.1 .,al Health Se
vices of t11 P►ii:ri �i- r. "CoLU�ty' Dc-,, tlr_�nt -. -di' Itealt: �.as to it lethor -•.or. not t?ie
�''E1 ll:llX -e 0 , i:}�t S`ISteI'1 to C:)T) -ra, o was c3.'.i5`:'C3 'C1�' t't`�1C , 4,r; r r,
,, ,
ac.t, of thc, occupant. of the buildin '-, ut, l z, -1n
day or
'Ti fi J100
l 0 -p'bi t_ton, give rlaiin ,
and a.ddre'.ss;7.
TH.I7EE (:j) COPIES !EIiE R;;QUI "ti?'1J WI'i' =I: TiiiiE- ( COPIES 0•F FINAl PLI:NS ,BirM:iL,
CErZTI1� ICATE Or C61 -%P IETION WILE, B}� TSSUl`D .
Gt1��I {111I`!OIZ LS t;.QtlilZ ?� TO F'�.;iL .AyO LC:, Q,< a�f1J <<t' Pipm. •tJS.?:.0}�'. S1S:aEtt:;`.
Division of Enviranetal 'Helth.Servi:cbs Puti r Count of Heal ti
,
11 1
1 t f 7 a r x i
x�PU AM COUNTYnEPTMENT 'OF HEALTH' k�
{ p F w r
iwsionof�Environmental SHea %ih Services, Carme%
}\
a S,CONSTRUCTION iPERMUT FORE WAGE DISPOSAL SYSTEflA_ k
-MMM7 or.,
r /4 Located . at = ll..E�J i� � •�1.6i z v e.ct
P c5i C -
y.,Subdivislon - �V1��� �- �'rlc'�•�. � ��� � o7C%�`s.
5 on Block
Lot Job
WN
:Owner Address -± -� CO r
Building Type +��a +.� 'Lot Are n7�pCcl R ��.�1�Q.� CO go
Al
Number,,�of Bedrooms " rc a Square:.FeetTotal Habit ce ..
Separate Sewerage System to cnftsist of ��0 Gal .Septic Tank e I �t
lin a wfeet X width 'trench
;tTo ibe constructed' y Adtlress a k± 4 n ��
Water Supply Public "Supply ;From
Privat Supply.,to be ,dulled by f ? "
y �' i •Address a M V
Vin" /;1 T u .•`,� ,!
Other Requirements �t @ �S7r�6i)i� ( ®SAilL P'(��ik
;nl represent that +l amwholiy and completely responsible for the design and location .of the proposed : °system(s) '1);- ,t hat �he rsep5ra,sewa e'dis oral s stem j
above described will be constructed as shown �ontheappvvedF ma endment there to `and in accordahce'wdh' the standards rules+an Yegu a ions;o
;County` ^Deparfinent of .Health, +and that on�completion'thereof a ,'Certifleate of:Construction Campliance< satisfactory. torthe•Commissioner < of Health
rbe su'dirn tted to' ,the Department, and a °written: guarantee will -be furnished the owner, his successors, hells or a" signs_ by.'the tiuilder, that,'said builder• will'
Fe in, ,good operaLmg'condifion any :part of saidysewage' disposal system during the. period of two (2) Years iriiinediately_ following the,date,of'tfie
<,. lowing
erica of ;.the approval, of� the ,CertiUficate" ofr Construction 'Compliance! of ache original system or any repairs ° there to,- 2j,that athe ,tlri lied ,well des_ cribed` °`above r
_..
will be'aocatedtias, shown on the approved plan and Shat said well will be installed in ccordance with 'ahe standar s, rules and'. f u I s rof" :tile• :,P.utnam'
CountYDepartmentrof Heal
Date LL i/ 5lgnetl P
A "ddress _1`
;APPROVED FOR CONSTRUC ?fi;ON Ttiis approval expires one year from,the date. issued: unless. construction of, th'e bulldiri has been un ertaken land -is
revocable for cause or m_ay be amentled o►xmodifIed when consitle';Z necessary by the Commissioner of Health.• -QriY change o'r alteratlon'of•construction
requires =a new ;;permit ;Approved for`dlsposal jof domestic sanitary 'sewage, and %or private water supply
`,only. /F „
Date
U Title T
r
m
--.----;---PU-TKAM-COUTILT-Y—.,,DEPARTMMff---OF-'LEUTH-..-:., .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner 1F P! 'LL CZA Address FAtfF1FL) COtJQ.
Located at (Street � A<c-- '&P(Kc D(_. Sec. P4- Block .9 - Lot 7,&1f(,)9
i �'Tndicate nearest cross street)
Municipality T)A:l I E-k-s o �1 Watershed C e-,U:l 0 tj
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Depth*to! Water WateF-EFveT
.No. Time From Ground Surface in Inches Soil Rate
in. Start Stop Drop in
!P Min./in drop
Inches Inches Inches
010 9 3/1
2 12% 3A
3 AX-J*
0 1
511
4
12A34
5-121,34 11 �ffl-
2
.4
2
Notes: 1)' Td,Ats to be repeated at same ;deptti until ajpproximatel� equal soil
rates are obtained at each percolation test hole. All data to e submitted
for review.
2) Dp I pth measurements to be made from top of hole.
4
TEST PIT DATA REQUIRED TO BE SUBMITTED, WITH APPLICA I TIQN
'-DE5CP!-PTI-0N*0P- SOILS --E7N(50V&TERkb' IN tifft HOLES.'
DEPTH HOLE NO. f HOLE NO. HOLE NO.
G. L.
611
121T
1811
2411
3011
3611
42"
4811
5411
6011
66"
7211,
7811
8411
,.-....INDICATE L-AT1WJ-a,--H---GR0UND WATER IS- ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
.':TESTS MADE BY fZC:j S c-- (4 Date �(o ,u.
DESIGN
Soil Rate Used_fl-_
Min/l "Drop: S. D. Usable "Pov, d c. t, 0 o
0 . — . t
Kk�
No. of Bedr(DOMS Septic Tank Capacity C-) 00 A
Absorption Area Provided By OL.F.x2411 nch.
o Z)CL'j- ek%, --tb cou-0-4- a0,
Tame o"r f-t I c.. a- Signature
Address 34 !31,e�?LAt- SEA
THIS
SPACE FOR USE
BY HEALTH DEPARTMENT
ONLY:
Soil
Rate Approved
Sq. Ft/Cal.
Checked by Date
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH.SERVICES
COUNTY OFFICE BUILDING, CARr�--�-Z N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner EL -k-tG 2,A Address
Located at (Street LA14e loo - Sec: mac - Block
Lot-)? )9
n ica e nearest cross istreet)
Municipality �C-}'j jC7i� Watershed IJ
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
r CLOCK TIME
TION PERCOLATION
man Eiapse Depth to ,Water Warmer ve
No.. Time From Ground Surface in Inches Soil Rate
Start- Stop', Min. Start Stop Drop in Min. /in drop"
Inches Inches Inches
2 1') )LI 1a,�a
3 �a: �4
�a•.''a�,
t `� tin i
s�
2
5
F4
3
5 '
Notes: 1) Tests to be repeated at same 'depth until approximately 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.
i
TEST PIT DATA REQUIRED TO BE SnMITTED WITH APPLICATION
-DESCRIPTION OF- SOILS- ENCOUNTERED IN-TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G - T..
12"
1811
2411
3011
361f
4211
4811
5411....
6011
66.11
7211
78"
8411
INDICATE L -AT. WHICH. GROUND .WATER..
INDICATE. AL TO WHICH WATER LEVEL RISES FTER BEING ENCOUNTERED
TESTS MADE BY MaL C Date
DESIGN
Soil Rate Used jL— t \ Min/l "Drop: S.D. Usable Area Provided
No. of Bedrooms .2) Septic Tank Capacity goo Gals!_ Type M A-S
Absorption Area Provided By L. F. x24 5b"
26 th trench.
r,
_
"IV her
A. JcC�
fir.,.,.. I 1 4
Address `54 61,�
THIS SPACE FOR USE BY . HEALTH DEPARTMI T ONLY: STS j 1891913,
Soil Rate Approved Sq. Ft/Cal. Checked by Date
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