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HomeMy WebLinkAbout1476DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -3 -8 BOX 14 01476 ., r�T i i. � , � ' - „ r 12 rr 01476 4 Lj re - .. 5. Bul uTdIth 12 0 Other glrequ!reTen la s Ur �iyAte ij Drilled By' 7. suc an 6ecome.nu e_, /�!o . b, We Oar f �' $AETERIOLOGY PA�2ASITOLOGY VI RO LOGY `4 . s ANTIBIOTICf USED W2 -27 SOURCE of M_ AlERiAI ' RE4UEST <[�' a p ', El Blood Q - SMEAt2 ._.. CULTURE �- Q. sputum_ p_ Roiti e , a Martin Spottl Q T ❑N e guile} a Rd r - Q - Throat Q Diphthena _- -? CarIRer- NY -' p �Ui oe"- c = 3%28/74 Water � T -s;t - • .p> Pus: from = PUTNAM DIAGNOSTIC LABORATORIES O- Oya and�Parasites -; _ iral 'Studies '" 1'0: STONELEIGH AVENUE­-. CARMtLi :W Y - SENs Q.SENSITIVITY :RESIST STAPHLOCOCCUS b 'Aeiobacter. -. Non =Herio :Cobg. To Follow ' Corynebacterium .- Co istin Sulphate "- 1: 'I 'Hemolytic•Coag: To Follow l Escheii €hia _' Declomycin "; ::, .. , ,.,'• L❑ Coag. Positive -, '0-,Klebsielta Qihydrostreptoinyc�n (� ' "" �. Negative . []: Paracolo: Bact: , ! Erythromycin :: :STREPTOCOCCUS; HEMOLYTIC Q P'roteus - Neomycin ' Alpha' ', -Q Beta Q. Gamma ' :Q: Pseudomonas ; -; Witrofurantom :., ,. ` `_ , „ 5 Q.'En #erocuccus .. - - `, Entei c',P.gogens, 0kacillin :, a o- occus — =[].Found. =Q P.neurn - Panalba :' ' `. , _<.. , `;4Q Neissq is _: - . Q- .Not'F.ound Pemcilliri : ': , _ '• Q Hemophilis`; .Tetracycline a "'' =`TUB ERCULO,S[S °.SMEAR. TUBERCUL''OSIS — nacefyloleandomyuq E n` ,• �..,2?', „r a L5� il _` ..Q, Acid Fast = Not - Fou "nd _ Q Weg 'F..or Acid' fast • -. ° :v A'mp'icitlia_. _ ❑ -Acid, fasfi = >Fopnd .. Pos. ®3Siriears,,Roufine Neg.r Q,, "O &P N of Found* ` Guires Q. opt P Positive For . H : „ r : - a �� No baciMll°�isoalated spe�men submitted. At tame coliform £fr.`om vw µ ity z' of exaiia}iratioz.,aterwas of good qual . J � Y DEPARTMENT OF HEALTH WELL COMPLETION REPORT PUTNAM COUNT 3/71 Division of Environmental 11981th Services COUNTY,=OFFICE BUILDING - CARMEL, NEW YORK he with la -_N_s­—repo_r_'t- is '_to_bi"c6rfi0l66d"by *Well driller 'and suibmitied t6 Cduifty'Heaftti Ddoartment 6oritiolry­ -repo f I. 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 mart,tyl ADDRESS '` t LOCATION OF WELL (No. & Stre . ';_-!Town (Lot Number) e:r 4 0 1 e- PROPOSED USE OF WELL BUSINESS , 1A DOMESTIC [—] ESTABLISHMENT ❑ FARM ❑ TEST WELL PUBLIC 11 AIR ❑ OTHER SUPPLY ❑ INDUSTRIAL El CONDITIONING (Specify) DRILLING EQUIPMENT R COMPRESSED CABLE ER OTH ROTARY [] AIR PERCUSSION ❑ PERCUSSION El (Specify) CASING DETAILS LENGTH (too t) DIAMETER(l has) WEIGHT FOOT r7 DED DWELDED THREADED 12RIVE SHOE 1-1 YES 19 NO WAS CASING QRQUTED ? YES El NO YIELD TEST HOURS G.P.M. ❑ BAILED El PUMPED LW COMPRESSED AIR 1­9 1 YIELD (G.P.M.) 1 ��— WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) O DURING YIELD TEST fleet) 3 U Depth of Completed Well in feet below Land surface: SCREEN MAKE LENGTH OPEN TO AQUIFER DETAILS SLOT SIZE I DIAMETER (inches) IF GRAVEL I PACKED: Diameter of well including gravel pack (inches): IGRAVEL SIZE (inches), FROM (test) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET L 3,v ro-n If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED //- 1,5 DATE OF RERZT. 1 la-- /o-- %7 =WELL DRILLER (Signature) L "�► ,TOTE Pre sent S st t ,�._ea..a . D(gna1 t.._en.� .,,.,, c t,:Lon -state ,ylici3 ant e.e signed by the General- Contractor t-lie SeotiC c ontr. actorrf . ' ' T., ~Tt74ry�i1 0.1 l'aGtG°t s Owner or Purc aser of Building Municipality Building Constructed by �I l n-t 11;1l ^ r"n!a(i 1 riG'':t.� "'. chit side o.L % Location - Street -1, 'a `1=i 2 -, 0as'] 2( -11Ce Building Type LP T. L ''laly '17 Section Block Pare aJ e = ,stirs:_' Cal 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. SA , I +. AY SYST E1,. .� � ,� 5'L AL�l:,1: R 1. . Dated this day of 19 Signature ±at.faro Hsu- ui c:> ° a{�~ -cav �o-r GRIME :AT (,01'0 'FACO: T r Title 'Pullet :Iola Road Pat (,erson IT t .,.. u, l,�la tin'-T',' � h1'�..� d = <.cr If corporation, give name as.(:a 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. Qper 'r),elon! 19'74 Division of Environmental Health Services, Putnam County Department of Health 1z r. ai'; J.AL(;,If11. PROFESSIONAL. ENG I NEER ., ..._ _.. ., _.. M I I LT _ OWN ROAD.. RD.. NO. - B.. - - BREWSTER. NEW YORK 10809 , ?14� '79_G98G February �., 1974 iutoari Count-, ": 3..ti..- .�a.,..�.. -u .y,. rrn- •..«+- •w...,...,w.i..._ a.a. -.., >� ��-- w»�...�- ,- s".�., aa.nedq PS� ,� ..y�,,,,.�•,�?,.�. .w, -.Jta .°, a. eq�,,., t,* a.^' u„ t�� .�- ..�.*,u- ,��i.•ex#•- �.". -`w , k 1 t J. r t% �t�•p f�a i xx u � � Pt. � , 'try T F, *P •i � x �6 x + j � a x E i � � ,1 P+ _ TABLE or OFFSETS . .i -U.L 'EL arm • 8{.G t0.t 76.'_1 SOX cs,3• Fez:• aG.l �e �L . • ° i'4ai5 la tc e�trtx °v t, -_f� kt� s8�ma?, �s Cor3TMi• as ri•3ie sa on *. . the V.vS e"'7t•wa in&_)801' I b,- 4 1c, b • _ DTJ 1' - ? ?,. . '['3•c/; 3,ni'a eT:t 41tEt 6Ok'6t?":i•G.¢r')d -all the rik as 'r' • .: �'�a a t�e':t ai �S•L.e t 1 n R El ? 1 .5EPRoo.M -v R p0 M _ "A9 BUITT It Sanitai ) D sioeal .; F_p.Fe_para5d for Joy ,.. x P p�w� s i o N SILO TL Pax grip t 7 Mock 2 --�5 1 Lot h.k mwrr o g t� 1 x'cPrT. AP"i n tw .ti 1� r_4: tt _ 5 a w yQ 1. k 3 GVRrk tU 9R.A 11J - _ (LP P A Kt N LTE �.o OAT t0 N� - 'a a A,.r� Qua`" y5 THE me NE S: 3` WIDE 'TYPICAL z p 41.2 1p �� —_ �— .. 1 BpafiS t. 4 4;,.S Lf A e __ 51.3LF DICV i GENERAL CpNYRACTpR = owu.ER MARS 1 N � L. 1, • F , �'- Qwisin of Envrron �+ OTMs REDq'uesL via vi °T o ' s 0 m n:: et �ONSTRt TION„ PERMLT F R, SEWAGE D1SPO$ Y$TEI Located at "Bul• le t E611e road <' (Bout hears t s_ c subdi�isien Div s l on :_ :of Pr.o pert ._ ..Ros J� J c Joy Owner �. & P1lartiri L. Spool i BuilGing Type �' far y Y'e,si denC�ot 74rea 1.1303 L ,( Number, of Bedrooms J_ unfinished On SG'COnC I Separate.Sewer_a9C. ystern o consist%bf If,$- Gal i� : to be` determined To 'be constructed :by Water Supply putilic Supply From X Private Supply to 6e drilled by t0 bE F d 1 : Atldress • G as„ per plans provide fc Other Requirements.. o` e . `es gee ors :u use County 'Department of Health and,.that on- completion thereof a 'Cart be1,submitted to the' Department anq a written guarantee will be furl - - y -. r ". place in good operating condition any part; of said _sewage disposal. t .ance of the',approdal of the, - Certificate of Construction Compliance i will be located a shown on the approved plan and that said we11;wU( be;in: County Department of Health.-'-'.,' -. Date :.Tul� 133 .19'73 SSigned :`r � t - Address ��il= lto�°rri Road; =R' APPROVED, FOR CONSTRUCTION: This approval expires one year fr< revocable for: :cauid..or may ba amended or•modifiad when considered nec requires a new permit App /roved for disposal of�clornestW:saniiii' s, Date'' ��i -3 ;f B" nz- s a Q' RTMENT OF HEALTH 5 Services- Carme/ N 1' 10512 `• � • ' � �e`n hoizs e and i elds v dorn t o 10,t per plan —'PattPr�on I T `d ii Town or Village 1 sectwn Block 2-: l I tl wPart - of _exifsting ,ob;PA77r2 G,l Address" 6 eathcot`e Road Gres Yonkers . Neer York 10710: r floors Total Habitable space 1500 sf 'IM Feet' tic Tank 7 89 s n lineal, feet X • f QQ width trench Addressry 1 x - determined ' ' t d st forthree bedroom design on]yA, hank o.ur e oom L Pion of .the proposed systems) 1).'that "the Separate sewage_disposal system__- w i fo and �n accor" "dance with the standards rules an regu a ions o ;, e. , u nam- i- <of-.Construction,Corii fiance satisfactory -to the._Commi ;signer of:•Healthwill' Ir <the owner, his successors, =hers or :assignf 6y the builder that said builtler will .durmgathe,per�q&,of two'(2) years`,'immedjately •following. :thedate. :ofAhe issu= original- system. orany repairs thereto- 2)'that the: drilled .well described' above. , I: In accordance with t standards, rules a,nd regula ions. of the -: Putnam K P Er lyL R A rk 4395a, License'No l date issued unless construction of the building has been undertaken and ;is - F6y the Comrrussloner of ;Health -t'Any �eh5nge orralteration of constructwn- . end /or psi water 3uPPly on a f z t: -utTHUR 1'. Mc 1,AUGHLI\ PROFESSIONAL ENGINEER MILLTOWN ROAD, RD NO. 4 . - BREWSTER. NEW YORK 10908 ,9141 2796986 February 4, 1974 Putnam County Health Department Division of znvironmer tal Tioalth Services ,ouhty Office BuildiwZ 'Carmel, l ew Fork 10512 Re; Construction Permit dtd Aug 139 73 for tipottl, Soy Y. ?Martin L. bullet lHiole Road Tax Map 77, Block 2,'F/0 existirZg lot 6.1 Gentlemen: Flease be advised that the house for -which the above referenced permit eras issued, has been relocated by others from the location as approved by your office. As a direct result of this relocation, the the fields designated A. B, C, and D can no longer, ti:e installed as proposed because of the required offset distances. In accordance with- the clause of your regulations that ''If snore are any major c lances necessitated dLurin�; construction by field conditions, they should i'irst be approved by the Putnam County Department of Health ", A forward for your review, co: .wnents, and approval two conies of a drawing, ent_tled "Spottl- 'I'ield "'hang-es". - :'lease. be advised ghat I have innpected.the current status of the site, and have ° founu t;,e ctiang,-s -mandatory for an approval-of the system from your office. Included is the proviso that both your office, and mine be notified after the 6 foot deep curtain strain, and cheep hole, have been installed. I retret the inconvenience posed by this field c`1an -ea and await your corm_ments on same before the contractor besins the installation of said curtain drain. Respectfullv submitted, r"rthur P. liglL ug na P. . C. opy. to. Spottl c/o Faley (wl 2 prints) & statement FUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL ILEALTH-k5.,�RVI.QES, COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.r r Joy M..'"8c),lartin L. 61 H&atheote Road' Owner Spottl LIU-tv Agdred s s' Yo— kers 9 New York 10710 oa Tax . 1,,,Iap.: Part ofr eX'8 in Located at (Street) (SE side of) See. 77 Block '2 Lot 601 6dicate nearest cross - s reefl Overland to swamp, then'to Municipality Town of Patterson streams /swamps/ S , wamp eventu: Watershed. S/ ally'into Middle Branch ReservoIr SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS HOLES SATURATED & SOAKED BEFORE PERCOLATION TESTS CONDUCTED,: .Hole Number CLOCK TIME PERCOLATION PERCOLATION Run- Elapse Depth to Water- Water Level No. Time' From Ground Surface in Inches Soil Rate •Start-Stop Min. Start Stop Drop,"in'' ­Min./in dr6 p Inches Inches Inches A 5 14 19.. Z_+ Cc t4G 0 S a 2 3 ®_ f 5 19 .4 0 61 16 113 4- 5 13 1 iS Ig- 20 zg,!�21 5 r2 2,72 one 42 1:5 Is SO U"Ey- 3 '50 7E' 4 6. 6i 1 COMCLUSiOW M LT= PA-r a SEEMS A 3>EQV A7t_ — 2 \;IE(,a OF FAc:rj TkAk-T -X>WEL0WG AS — 3 it is 'rd B IF PV,-1ESE'MT� LY TO V3 E CIOV�ST k,UCT e � WILL 4 com s i S�l .–Or- OM 01 -TWO (2) bE--bP_6oMs kc�AekffAs T ff 5 R ES ENl'r ti 2pe F> AR EX>ikQo t_4 �U.) IF L L t tQ G. Awl> F 0 P, Fovk v=ofp_- Notes:. rates 1) T6,�ts to are be repeated at same depth until a �roximatel equal Soil L obtained at each percolation test hole. All data to 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. o P HOLE N0. B ©"�M HOLE N0. G.L. 6" 0 QG AN tC D�GApJ ► G 12" SAt,=y CiaY 18" S A WD-lf �a A vw 2411 y r OA�-1= � Lo AvA 42" SAwv t-�� 60" Op�w�i o�cy�r 66" a��N LC- -D 72" 5 iLTY 78" 5A NP 8411 oao EvSDSOaCE OF Lc�G INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED— INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED- Fiuc- ywA-'ES L4 C O..cu -in tv `CE 7A8& TESTS MADE BY a> EE' -P N0LC - By o'raae" -S Date PP,ok. -ro PltTLCO L A`r t ON7 TC -'5..� °- a► �cHA� O' S3i21 is tJ DESIGN Soil Rate Used Min/l "Dro `' "r �bnat-E �� y p:: S.D. Usable Area Provided ooa► use t. Z. w W 3� � S tc w�a 3 No CCU r ' No.- of Bedrooms z pasri�' eptic Tank Ca F N Gals. Type Av"P OVE-P Gtjc-06°c Absorption Area Prodded By B S11) L. F. J�oaSR MT9G width Erench. Other 5� 01.rA i Ere- 1P P-0 v %S i o n w� L VA —MP r s r Address THIS SPACE FOR USE BY HEALTH DEPARTMENT 0 Soil Rate Approved Sq. Ft /Gal. Checked by Date A D TEST PIT. DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. o P HOLE N0. B ©"�M HOLE N0. G.L. 6" 0 QG AN tC D�GApJ ► G 12" SAt,=y CiaY 18" S A WD-lf �a A vw 2411 y r OA�-1= � Lo AvA 42" SAwv t-�� 60" Op�w�i o�cy�r 66" a��N LC- -D 72" 5 iLTY 78" 5A NP 8411 oao EvSDSOaCE OF Lc�G INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED— INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED- Fiuc- ywA-'ES L4 C O..cu -in tv `CE 7A8& TESTS MADE BY a> EE' -P N0LC - By o'raae" -S Date PP,ok. -ro PltTLCO L A`r t ON7 TC -'5..� °- a► �cHA� O' S3i21 is tJ DESIGN Soil Rate Used Min/l "Dro `' "r �bnat-E �� y p:: S.D. Usable Area Provided ooa► use t. Z. w W 3� � S tc w�a 3 No CCU r ' No.- of Bedrooms z pasri�' eptic Tank Ca F N Gals. Type Av"P OVE-P Gtjc-06°c Absorption Area Prodded By B S11) L. F. J�oaSR MT9G width Erench. 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I - - - -- , , - . �� -,� - - , . , . , 1---4-cA�,"u, - - -- - , �,,j,l �, - , ,.,,,�A�,J- ,,� -, " -, - � - , - - - k,-��-,, , � , , , � A - i�. - ,. -, - 11 ��S:l I '��,,-, � , �� - . -,-,,i a � .. - -, t -:, - �- - . ,�V!�--, - - � ,�;:- ,,.-i � � - . -, - I L -A , , �. , z, � I L�- - -- ', ----,,� --- �, ---!,----,� -:- - - , , . �, - , - - - .., , �� , ,.- I , I , , - , - - . . , , , �.-. --. , ��. - , - I--- . f -,:—, I - - � :Z�-�,:--L, ------.---1 � � a,�, f ,,, .-,., 4 ., � - PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use On ❑ �� ' Repair Permit issued in last 5 years El Not in Watershed ❑ 2( Repair within Boyd's Comers, W. Branch or Croton Falls Res. 5;3 /Delegated ig jwal ap rulecd aren surflr eKpc vvjlow CLV A //. `.Ireoo -t42 aw, ❑ Qair within X200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review J A SITE LOCATION j � h a i t f"kc L C, AP M T�' \ OWNER'S NAME /gdiLT /,) Lo Sip Tli PHONE # MAILING ADDRESS 0,57fMP�L®T'��/// AP 15;A "W.5,60 LO_ A) APPLICANT ftrJ6� 1,, ��O �'?�G CO WAI Name & Relationship (i.e., owner, tenant, contractor) DATE f/v — ), " 0 6 FACILITY TYPE Fg ff ® jPCHD COMPLAINT # PROPOSED INSTALLER lr/ O V "tr PHONE # ADDRESS 30 1,Atg * lywer AP REGISTRATION /LICENSE # 3/6 7—.4 Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. ®/y� ,0�to8j'pe-r .5xjr,1G .0uArxer I, as owner, or reported agent of owner agree to the conditions stated on this form LA-1u1 L,r.sX�F1 s&AVXV SIGNATURE TITLE ®kJpaXvti DATE Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owners name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions. 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