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PUTNAM COUNTY DEPARTMENT OF HEALTH,
r Division : of ,Environmental Health Services, Cerm %;
N. Y. 105!2
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Patterson,
7', _ _ _c.
Located at Dover; Lane} Tax Map 76 Block
Owner Reil ly. Homes, Inc. � nc. Tax Map wt ii 23.2 su d. # 2 .
Separate Sewerage System . F built by:. dw4H _ Vi'ncent Address 8 Broad Ave., Fishktl l , NY .12.524
Consisting of 1000 Gal. Septic Tank and 375' x 24 ". Width Trench
Other requirements 18" Beep Fill Section x 785'
Water Supply: v Public Supply From
x Private Supply Drilled By H. & B. Well Drillers, Inc.
Address Bethel, CT n
Building Type Frame No. of Bedrooms Three Date Permit Issued 6/4/79
Has Erosion Control Been Completed? Yes
1 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 with the standards, rules and regulations, in accordance with the filed plan; and the permit issued by the
Putnam County Department Of health.
Date 29 October 1979 Certified by ?Carmel w P.E. x R.A.
Address R: D. 9 - Fair S - , : NY 10512 license NO. 29206
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
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 when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commis on of�lealth, such revo ,ification or change Is necessary.
Date By Title
t ":TELL. :COMPI,:.FT: tf'J kVI?ORT PUTNAM. COUNTY. - DEPARTMENT OF HEALi'.i
3%71 Division of .Environmental IIeahli Services
i COUNTY UF'FICE BUILDING - CAR(AE , NEW YORI,
This report is to be completed' by well driller and submitted to County Health Department together with laboratory report of
ana!ysis of water sarnple indicating water is of satisfactory .bacterial quality before certificate of construction compliance is issued.
j REPORT MUST dE SUBMITTED WiTHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME ADDRESS
No. 8 Street)
10CATION
(Town)
Of WELL
f
' f)tSHMENT aU51NE5S
je
1iPGG£D
FARM TEST WEIL
USE OF
.. WELL
_
11 PUBLIC AIR 07FIE2
LJ SUPPLY' l— INDUSTRIAL 0 CONDINONING
lJ (Sprufy)
DRiLLING
COMPRESSED (�j CABLE OTHEP
ROTARY L�1 C�
EQUIPMENT
! 1 AIRPFF.CUSSION. :. _ -. PERCUSSION
J (Spec;fy)
CASING DETAILS
lEN3TH (loot) DIAMETER(inr,Y,xs) WEIGHT PEP P001 --- ( DRS- SHOOj('-� —
' r1 j.TitrPADED uWELDED DYES ONO
\SAS CASLNG Gj( RQUiEO?
.'t�'YES L__ NO
YIicLD
TEST
rEl * HOURS P.A. G :
Ll BAILED D PUMPED LN COMPRESSED AIR 5l
YIELD (G.P.Mj .
WATER
15 ATER
DURING MEASURE FROM LAND SURFACE- YIELD TEST 'eet)
�'
—
Depth of Complete Well
LEVEL
- -- _
:d
in feet below Land swfoce: S
MAKE
LENGTH OPEN 10 AQUIFER (feet)
SCF.fEN
-DETAMS
SLOT SIZE
DIAMETER (inches)
_
1 GRAVEL :IZE (inches) FROM (teat) TO (feet)
IF GRAVEL D.ipmeter of well including
gravel pack
DS•TH rP.QM LAND SURFACE
� JEET
FORMATION DESCRIPTION
Ska;ch exact location of well, with distances, to at least
two permanent landmarks.
to FEET
�8
"
�-
If yield was tested at different depths during drilling, list belowr
- FEET
'GALLONS PER MINUTE
�
• :D ATE \vE1l COASPLETED .
DATE O:° REI•'ORT ..LVEa
-L DRILLER (Signature) �
V % -- —f "I, Vt(f.
ell
fill
a! o g o 9 o a I Or)
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7
IN w � '
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Ck
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v p� �! .
Owner or,Xurdhaffer or Building
Bli i in nstructE by
Location - Street
Buil ing Type
ir
Municipality
(f -1 A 4 � �'� i FF Z
Section
Block
of
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-
term,in tion...of ,the- ..Dire.c -tor.. of the Division of Environ_men a- l -- Heslth 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 ac.-V ay of C% 19�e Signatur 7-
Title ,
If corporation, give name
P � g
and address)
_ �L�
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION 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
NANCO ENVIRONMENTAL SERVICES, INC.
P. O. Box,. 10. Hopewell Junction, New York . 12533
Laboratory U.nity*St. & -376 Hopewell Junction, New.York 12533.... Phone 914 -226 -5155
Forward Report To Name: RPi 1 1 Sample No.;jQ_i X03
Address: 'Received
,Sampling Point '& Address: Dover Lane Time Set. 10/29/79
Owner /Buyer Name:
Address: Tel. No..
Treatment: Chlorinated Softened Qther
Source: Drinking Water System X Other
Collected Byi /Reilly
Date: 10/29479
Arsenic
Time: 9:00
RECOMMENDATIONS
Nitrites asN
Barium
BACTERIOLOGIC
'EXAMINATION
OF
WATER Examined !a 30
Total Coliform Count
Fecal Coliform Count
Fecal Strep Count
Total Coliform Count
Fecal Coliform Count
Sterile Blank
M.F. T. Per 100 ML
M. F. T. Per 100 ML
M.F.T. Per 100 ML
M.P.N.. Per 100 ML
M. P. No Per 100 ML
Per 100 ML
THESE RESULTS INDICATE THAT THE WATER SAMPLE
Date Reported /Mailed
MEET SATISFACTORY SANITARY QUALITY WHEN COLLECTED.
e � �
The results of these tests represent a physical and chemical analysis of the -sample as
delivered to this laboratory. This laboratory assumes no responsibility for the identity
of the sample or for the sampling technique or storage procedures employed prior to
the receipt of these samples at this facility.
CjiEMICAL AND PHYSICAL EXAMINATION OF WATER
Chemical Examination (Results in Milligrams Per Liter)
Ammonia Free (asN)
Arsenic
RECOMMENDATIONS
Nitrites asN
Barium
Nitrates asN
Cadmium
MBAS (Detergents)
Chromium
Sodium.
Copper
Sulfate s
Iron
Fluorides
Lead
Chlorides
Manganese
Physical Examination
Hardnass, Total asCaCO
M ercury
Color) Units
Alkalinity asCaCo
Selenium
Turbidity Units
H
Silver
Odor . Units
Zinc
Conductivity Units
The chemical parameters tested (were, were not) within
the limitations of the New York State drinking water
standards when the sample was collected. The results
circled represent those in excess of the limitations.
Reported by
Date Reported
4
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 /Pn er 4. ne . Address 0. .
Located at (Street 4/ trM Block / Lot 2 �. 2
%/ r�►er ..
n i e nearest cross s ree / j,, A+rhes gooe 'eo.e, # L
Municipality, 4�r a mp Watershed cEkAn
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run .apse Dqpth., to Water water Levei
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in + Min," in., drop-
Inches Inches Inches t=
2
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.
Address R.D. 9, Fair Streit
CarMe ; "NY 10512
s
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved ": Sq. R /Gal." Ch
�a
+e!
OF rug
Date
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"
24"
30"
361
42"
.
48"
_.
5411
6o"
66"
7811
84 it
-
INDICATE
LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE
LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS - MADE BY j_�re ri�.f7 j Date ..
--DESIGN" - - - -
Soil Rate
Used'TMin/l "Drop: S D..Usable Area Provided,600D f
No. of Bedrooms 7zepeo lL%�►sen��_
Septic Tank Capacity ., /Odp Gals,. Type,
Absorption Area "Prov ded'By _L: F. x24" 6'-' width trend
Name Jo
n H. Prentiss,P.E. ure
Address R.D. 9, Fair Streit
CarMe ; "NY 10512
s
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved ": Sq. R /Gal." Ch
�a
+e!
OF rug
Date