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01572
'I- .Water SupP1Y, _. Publlc'- Supply. From, ..
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F. Prigate _Supply. `Dnlled;,BY _ r--_ .-- �[r ,
_,
Address. ` i ld • � SO .
Building -
- _Ty'e M c�AL Z No of Bedrooms Date ;Permit Issued
y�s
Has 'Erosion. Control Been .Completed? • ,
,I( certif that thesystem(s) as listed serving •the above premiseswe a constructed essentially hown on the plans of the completed work�(copies of'Which are
Y
attached), and in accordance ;with ;the standard ;, rules and.,regulations„ plans•filed,' a permit issued by.: the Putnam County :Department of Health.
Date ert'iffied b P.E. R.A:
F 43 PPP?
'Address License fVo.
f unsanitary
• n erso o ' r ise `r e e a ' stem h II • r m 41 tak � a a.. ne , � sir to sec re the correction o an
A n ccu in em s se v d b th b e s s s a o a such ction as m be ces u
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cohditions;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:pr.ivate water {supply shall become null
-and void ;when a.publ4ic,_,water supply becomes•'avaiiable. tuch approvals are
subjectto modif ic ation 'or change when, in the.•)udgment of the: mi9sloner'of Health; such'i' ca otlificat'ion or change as necessary."
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Date BY ' Title '
ti.
Owner or 1:1urchaser of building
Building Constructed by
J CG o �C>
Location - Street
,e
Municipality
Block
.. � �� LET /- � • ., .... ..
Building .l 'ype Lot
GUARANTY OF SEPARATE SEWAGE SYSTEM
I represent. t1jat 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 Ftealth, and hereby guaranty
to the owner, his. successorstw` 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 occupant of the building utilizing
the. gl,c t -oM..
The undersigned further agrees to accept as conclusive the determination
of the Director of the Division of Environmental Health Services 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 neglig
system. ent act. of the occupant of the building utilizing the
-,. ... .- _. r. _ ._ .. ..
Dated this a day of u'G 19 �3 Signature 4ZI
Title
(if corporation, give name and address
THREE (3) COPIES ARE REQUIRED SMITH 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
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WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 ' 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
Philip StMartin
ADDRESS
Bullet Hole Rd.
Patterson, N.Y.
LOCATION
OF WELL
(No. & Street)
Bullet Hole Rd
(Town)
Patterson.,
(Lot Number)
PROPOSED
USE OF
WELL
® DOMESTIC
❑ SUPPLY
BUSINESS
❑ ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
❑ CONDITIONING
❑ TEST WELL
❑ OTHER
DRILLING
EQUIPMENT
® ROTARY
COMPRESSED
® AIR PERCUSSION
CABLE
E] P PERCUSSION
❑ ((SSpe ify)
CASING
DETAILS
LENGTH (feet) ,
DIAMETER (inches)
6
WEIGHT PER FOOT
19-45
� THREADED ❑ WELDED
S O
YES ❑ NO
YES NO
YIELD
TEST
❑ BAILED
HOURS
91 PUMPED � COMPRESSED AIR 8
G.P.M.
27
YIELD (G.P.M.)
27
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
28
DURING YIELD TEST (feet)
150
Depth of Completed Well
in feet below Land surface:
SCREED
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 (feet) TO (feet)
DEPTH FROM LANDSURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
25
260 lHard
rock granite,
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WEL COMPLETED
��
DATE OF REPORT
0 3
WELL DRILLER (Signature)
,, .
BREWSTER LABORATORIES
WATER ANALYSIS REPORT
SAMPLE NO. ,301.9
SOURCE: Phil I 4p Stiftrtta - ofaucet
Bullet note Road
;)atte - -
443ibins, N*,Yi.
COLLECTED:
By:reahk C '011, W0.11-Detli-ift9t D101i,
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
This result indicates the source of the sample was
Of satisfactory sanitary quality when thi sample was collected.
August 9,,• 19?3
0 per 100 ml.
lkoyAickwit P. E.
Director
aPUTNAA
j h �� � '`� Drprsronf of E
r CONSTRUCTION PERp3 FOR SEWAGE dl
Located:
�, Subdivision max, � _ ; � a
+Owner
Building, T j _ )/ IZEI - oeoc = k Lot`
i
:Number of Bedrooms
Separate ` sewerage System�to consist ofk ?
76- be constructed by � � �� '
ter y: Public Supply'From `
Private :Supply` to !b6 drille,
dress ct
Other, Requirements G'GiQTfI�/1/
I represent that I iam wholly and'; Completely respon'0 ,
?' above described will be constrfucted as shown on , _q,,ap;
_'County 'bepartrent of >Healt.h, sand that -on completi,
subinftted to. the Department; antl a.:written`.guai
place An' good operatimg condition any p'_art of-'sa'id'
i ance.of. the approval �of"the"Cer "otificate f Construct
'.Date 1,3 -
Address.'
f
ate.
Q!
)UNTY DEPARTMENT. OF ; - HEALTH
mmenta/ Health Services, Carmel -N Y, '10512
>AL SYSTEM %T,Ei��Sa�,...
Town- or Village ,
Section
BWck •�w-
� r
..
d
F,< Lot
Job
,Address
� ^S
-
i Total Habitable Space
Square :Feet
Septick�Ta
1
Gal k feet X
Width Trench
�Fidtlress =
_
c L
4
q Y MY gr�s .L^ �, t y
� A � � Vii- f Y.v
•� .
y
f C$ �. '�• K f
3v . -r i S Rr S •M. ks. . _
i
4 S
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of'"Construct'ion Compliance satisfactory to'the Coinri�issioner of Healthwilf
,the owner :his successors h' Ii assigns by, he builder; that said builder will
during the.- period ofAwo (2) years_:irrimediaieiyfbllowiti- the date,of.the issu -` .
origme( system or any repairs thereto 2) that the dulled; well described above
i cordance with the stantlards rules and ,regMUM of 'the Putnam
Signe - ` P
License No `��•��
royal expires one ,year from'the date `issue ' less construction of the building has been .undertaken.and is
3difrad +wh nstruction
>sal of'domest'ic sanitary sewage d /or rwate water_ supply -only 4 v
•,�
V • s
Ohl
t�
P/`I TTE�So.�
31 � Towns /y'7� L
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION, OF_tNVIRONMENTAL HEALT i
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner %Iy /G /P ST. 6%1�?Tii✓ Address
Located at (Street )CE poAvv .<,L> Sec. Block
�Indicate nearest cross street)
Lot
Municipality /°fITTEi?SoA/ i WatershedyG, _
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
s�1T�/R�1TEO C�
3'0¢
Hole
2 J� , V 0
Number CLOCK TIME
PERCOLATION
PERCOLATION
Elapse
p
o a er
Water Level
No. Time
From Ground Surface
in Inches Soil RatE;
Start -Stop Min.
Start
Stop
Drop in Min. /in drop
Inches
Inches
Inches
3-/S/ S.,/0 s j iq
�+
5
l
2
3
4
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rat.es:Are obtained at each percolation test hole. All data to be submitted
for :review.
2) Depth measurements to be made from top of hole.
2 J� , V 0
3-/S/ S.,/0 s j iq
�+
5
l
2
3
4
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rat.es:Are obtained at each percolation test hole. All data to be submitted
for :review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION, ..OF:7 SOILS- ENCOUFTERED. -1N;,TBST;.HONES__ -
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
611
1211
1811
2411
3011
3611
4211
4 8" 8 17 GofpalvO ,t1jre,\
5411
6011
6611
7211
7811
8411
,INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER -BEING "ENCOUNTERED
.TESTS MADE Date
DESIGN
Soil Rate Used/ 0 Min/l "Drop : S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity 170 0 Gals. Type I,7A,5o . A.1
Absorption Area Provided Byttc-lo L.F.x24'f 3b" �widt4 ,rench.
e
7 7-12 / j,-- 7 Signa
Address /Z,/ 4L>- SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft/Cal. Checked by
............
Date
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