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BOX 14
01540
` s PUTNAM COUNTY DEF
' }� �_� �,. �Drws /on of �Environmental;He+alfii
CERTIFICATE OF CONSTRUCTION -COMPLIANCE.. FOR SEWAI
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VV' L�' 9(ONS
D;M�m
i'fi -l�-3S Tb CRTfI'Y THAT THE SEWAGE DISPOSAL, SYSTEM
WAS CO3NSTAUrTtl AS fiYTDICrTLn ON TiIIS FInAN AND THA2
4 ; THE SYST> .I I T,r t, ,.rt � rE ORE IT WAS COVER
2ri 2B.'l2s'o f v
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I'V ACCORDANCE
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PUTNAM COUNTY q
`6.o P `' DES AF HEM+ aK 8C.er
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AA ` Co•uto t�q /L1444 oP•�c n
AI: 1� �!'�pFE5S10ba y�
Owner oV Purser o Bui Building
CA tQtii�Aka
Building Constructed by
Location anon - Street
:&& of
Municipality
Section
Block
`�1 PlG t � 5 a17�IGE 2
Building Type 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 2i 'day of t4V 19D Signature
/Z
Title
f corporationt►i v��m.
and address) fkJ,�,�j''
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Can �L.� 1J•� l�Sf2
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
D
DEC 1 1980
P.UTNAM COUNTY
PVM
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 submitted to County Health Department together with laboratory report of
sa.mp_q nd.ip_tir g water is.of satisfactory_bacteriaPquali,ty'before certificate of construction- complitance is issued
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
Q
ADDRESS
i
,LOCATION
OF WELL
(N . Q Street) If
(Town)
(Lot Number)
PROPOSED
USE OF
WELL
DOMESTIC
❑ SUPPLY
❑ ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
❑ CONDITIONING
❑ TEST WELL
❑ OTHER
(Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED
AIR PERCUSSION
❑ CABLE
PERCUSSION
❑ OTHER
(Specify)
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
� THREADED [:1 WELDED
RIVE S OE
I YES ❑ NO
II G In D
YES LJ NO
YIELD
TEST
❑ BAILED
❑ PUMPED V COMPRESSED
HOURS
AIR
G.P.M.
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST [feet)
lao
Depth of Completed Well
in feet below Land surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL'
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (inches)
FROM (feet)
TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
Q
r !
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL CO�LED
DATE OF REPORT
WELL DRILLER (Signature)
-. —_
t �
r" CONSTRUCTION PERMIT F:013
s
i $ubdnrwdii
i
Awner � l r Ceti.
- epzesent, that I am wholly and comp
dards rules and.requlatione of the
g
Date
.,�` Addrel
APPROVED FOR CONSTRUCTION::'
- ;r.evocable for cause -or' -may tSe amend;
requues a new permd :Approved j
-077
9.
Date _T
N P kTMENT OE lltA Tit
of, Environmental Healih Services Carmel N Y 10512
E _'DISPOSAL SVSTEi1fl `` �/ �_%
T
_
—,L )CL #
x ap
r�
'ia.. �Be� t�• .. s3< Tax ".. Map Lot ,# ,� �.
Address�s�'
ro ;fit N
`Lot Area '�
Totai* Habitable Space
l�dR7£%! Gal Septic Tank and ':;ft 2 trenc
4
-
5_ Y.
drilled b '
s -
gsponsible for the, design and location of the proposed syetem(s).
shown :on the approved attachments,tieretorand is accordance;_with t'
n£g Department Of :Health
SigneA
wal expires o m ne year. fro tlie'
ied when-considered,necessary'
of- domestic `sanit s age,.,
sy m
1> ....
red -un.les construction 26"f
;ommi ner'of Health Any
rivat w ter Supply ,only
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PUTNAM -COu.4I Y
the IflWi�teawY ^P $ al f
ter Supply
'Public !§Uiio
.Private 'Supp
Address' _
her
}Requirements
zt
_
�y
- epzesent, that I am wholly and comp
dards rules and.requlatione of the
g
Date
.,�` Addrel
APPROVED FOR CONSTRUCTION::'
- ;r.evocable for cause -or' -may tSe amend;
requues a new permd :Approved j
-077
9.
Date _T
N P kTMENT OE lltA Tit
of, Environmental Healih Services Carmel N Y 10512
E _'DISPOSAL SVSTEi1fl `` �/ �_%
T
_
—,L )CL #
x ap
r�
'ia.. �Be� t�• .. s3< Tax ".. Map Lot ,# ,� �.
Address�s�'
ro ;fit N
`Lot Area '�
Totai* Habitable Space
l�dR7£%! Gal Septic Tank and ':;ft 2 trenc
4
-
5_ Y.
drilled b '
s -
gsponsible for the, design and location of the proposed syetem(s).
shown :on the approved attachments,tieretorand is accordance;_with t'
n£g Department Of :Health
SigneA
wal expires o m ne year. fro tlie'
ied when-considered,necessary'
of- domestic `sanit s age,.,
sy m
1> ....
red -un.les construction 26"f
;ommi ner'of Health Any
rivat w ter Supply ,only
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PUTNAM -COu.4I Y
the IflWi�teawY ^P $ al f
YORKTOWN MEDICAL LABORATORY INC.
P.O. Box 99 321 Kear Street
Yorktown Heights, N.Y. 10598
245 -3203
#C1051
LOCATIONS:
❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245 -3203
❑ 201 BUTTONWOOD AVE., PEEKSKILL, N.Y. 10566 737 -8777
❑ 495 MAIN ST., MT. KISCO, N.Y. 10549 666 -3335
❑ STONELEIGH AVE. (NEAR HOSPITAL), CARMEL, N. Y. 10512 278 -933
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER 11/19/80
OWNER DATE RECEIVED
Robert Chipley 11/19/80
CITY, VILLAGE, TOWN VOR NAME OF SUPPLY DATE REPORTED
Bullett Hole Road, Carmel. New York 11/21/80
SAMPLING POINT
Lnt 4F2
BACTERIA PER ML. (Agar plate count at 35 C).
4/111L
COLIFORM GROUP (Most probable No. /100ml.)
0 MFT
HARDNESS, TOTAL -ppm
DETERGENTS - mg /L
NITRATES (as N) - mg /L
IRON, TOTAL - mg /L
AMMONIA, FREE (as N) -mg/L
pH=
CHORIDES - (mg /L)
These results indicate that the water was YES of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASCP)
i
PUTPAM COUTITY DPPARTPTNT .OIL' HEALTH
DIVISION OF E1,; TROT ?PTJ7,JTAL 11EAI,TI-I SERVICES
�.._. ..COUNW'OFFICE. P,UILDI=I'IG; .Cl2M:L; --N.-Y; 1.0 1.2
DE, SIGIT DATA SIIEET- SEPARATE SL':dAGE • DISPOSAL SYSTEM FILL N0:
Owner C# P t Addrzss b��u'� f��: L ��.
Located at (Street B &i_L r Ocv' �, Sec. 7 Block Lot
�Indicate:nearest cross s reet
Muiucipality Watershed
SOIL PERCOIu1TI0N TEST DATA REr?UIRLD TO BE S0i1ITTI✓D WITII APPI,ICATlOiS'
Role
N b CI O("lr TIME PERCOLATIOIkT YERCOI,A TTON
Rote,: 1) Tests to be repeated at same
- r,itos nil. obt,11ined at (-:ac•h porcolat.:ion
for . review.
2.) 1A.,pth measurements to be ii'adt
. Cli3 �"it i 1
to "A
from
MAY 6 ly(y
Lentil CIAYRTY.
iole . All data, to TEEM WiRMUTH
I -lop of hole.
F
Run
apse
Dep
o a er
:;aver eve
No.
Time
From Ground Surface
in Inches Soil Rate =
-Start-Stop
Min.
Start
Stop
Drop in Min. /in drop
Inches
Inches
Inches
l •L "!0 Z._�ry
is
-
21
Jr.5 h '
2
T--
3 O.S 3; �
j;
z 1
l
;
7,
2 ,
--
_
l•
-
2
>P .= '
Rote,: 1) Tests to be repeated at same
- r,itos nil. obt,11ined at (-:ac•h porcolat.:ion
for . review.
2.) 1A.,pth measurements to be ii'adt
. Cli3 �"it i 1
to "A
from
MAY 6 ly(y
Lentil CIAYRTY.
iole . All data, to TEEM WiRMUTH
I -lop of hole.
F
3011
36"
421t
4
8
-Y4
6011
6611
7811
84
IRMICATE LMTL- AT VMCH GROU-11',D WATER 'IS ENCOM,TTERJEM
-INDICATE =EL TO 14 CH WATER- LEVEL RISES AFTER- BEING ENCOUNTERED
TESTS MADE BY- 7 1-e Date-
DESIGN
5oil.,Rate Used MirVl"Drop:.., S.D.*Usable Area Provided s 00t
No'; of Bedrooms -cit Type C-O�Vo
.9 * Septic Tank Capa ,*,7o Gals.
Absorption Area Provided �L.F.x24-11- ��7�T- width trench.
other- AIO*V
ldame /V. 4;4f Signa ure
44
gt4U-6 A6,
_
/,NT ,,- M F- - -'-,
_ >-
Address
S SPACE FOR USE'
BY
1. EAD.V11 DEPART.-MIE-MT
ONLY:
1, Fate. AI)proved'
Sq. Tit/Gal..
Checked by
4
te.
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