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01578
JL-
01578
PUTNAM COUNTY DEPARTMENT OF H_ EALTH
W. Y 10612 Pe
oes,' Caren%
Division of Environments/ Hat /th Sewi "� retie a
k
•.CERTIF.,ICATE OF" CONSTR:UCTLON COMPLIANCE FORSEWAE_'DISPOSAL SYSTEM, / �.
To _ r
. f
wn .o Vlllbge
LOGated at Tax'Map Block ~
/Formerly 4'[1L4LUi�N��'f/7iGQ L9_I .
;. ;OWner• - - _; - .._ .Taz'Map Lot.N Subd'., Lot q
-
.Separafe' Sewerage System built by +�Y -" — Addressr
- -C r r g -
iC _ f
F - .
v ,I Consisting `ot e.o pal: Septic, Tank andW� �V IVDLC D �9Ae.0 S!x T �Y_ T4i o. _1iivFAR" FEET
Other requirements-
._ .._ ..
;� Water , §uPPIY � "Public Supply :,From - • - - " _ _ r
1 ;Prlvate,SuPDIY, Drilletl ,ey As7 519 $x: Ywc
�.
;Building; Type __ o � of Bedrooms Date Permit IssuW
r
Nas Eroilon Control C
een ComDletsd7
�I certify that the syatem(s) as Aisted- serving the ibove"premisae were conatructed�esaentially ae shown on the plane of -the completed work (copies'
x °•.;voftrwhich areratt" ached),,. and: 'in accordance wiith the standards;, rules and cregulat'ona Sn'aocordanep`ivith,` -the fife, plan,,,, and''the permit'issued hy. the
:Putnam Lounty' parffienE Of Health.
3 r Address - • U1, License No:, - Z
:Any :person oeeupylny,'premises servetl,by the,above systems) shalPjp►omptlytake such aeti6n,as +maybe neeesaery,to�secure the correction of any unsanitary' "
.
condit'loos ,resulting, ,from' wch usage:' ,`Approval.,oi ,the separatejseweraye'isystemrshall become,quil,and`void,as.'sodn es` •a pub'lle .sanitary Nwer, becolnes'r
.44ailable_ and the appfoval +of ,the ,private water supply shalb,become'Ynull and vokt,?when a public wa DIY baeomds aveilebl�. - Such approvals are
ssubject';to• (Modification or change' when; in 'the,[udgment oi`.therC `I ner of.'Heilthvsuch f ocatlo .`modlffcition'`or cyan" *$airy
it
e ti
S k z r X
: e. r
Rev 9-81""
t, r � � i' it � � � � � 3..«�.�''�_'` a` KJ �.�..d4 �•a X. "D'k..�r, � i� . _7�4 -t3 . Xc .''• 4.. r_ °,�� ., .'. .. �. -� .... n .. ._
so
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` ApUF,I�AM 'COU�ITY'i�DEPAR�i,11E1�ITyOF HEA'LT'H Per��_t.
. .
YQIYI to of` rEnvironme Aw Health; Services, Carmel 111. +
K '" a Y 105'12
CONSTRUCTION PERM {T `FO SEWAGE _D{SPOSAL, SYSTEM
r , y r "n -or ymaige �®
Loeaietl at " ��'►� STax hlillap �� dock Lot.
t;. t
Lot # Renewa_1 ❑, a. - Revision f ❑.
sr ,Subdivision •. - r - �
� �, 'Owner /,Addiess'�� 0 j �, -R ��i' ��n � o•� \is �-� at� Df - Previous 'Approval _ _ _
n Fill~Sectio ❑
i � Building Type ^-- D lot Area+ Ohl
�tl���^ G Lis- D Notification RequiredT
Number of Bedrooms : Design E1ow Gx /P /D i •P, tl 41 -
r s.
r Separates Sewerage >System to consist zof > Ga! Septic Tank oiid
r
-- �7 �NJC /YZ� l� �} Address d��J/1i���- /max
To De conFtructed by - s *
I u V1later, Supply.Publ�C �SURDIy From _� a�q j_' 1pJ n
' kPrjvate SUPPIY to De drUled�by4
Address `
w Other u irements - $ - a� 4 ' ` eak x ±• ac v�.
•. ., _ 3
: rep[esent that I?amaMrholl.y and +coin let�ly respon ibleforithe designanGtlocafion of "the proposedr'systeOr S) ; %1) ,that the separate sewage di3po861 +ty3tem ;
above, described will De constructetl- as.dhoiun on The�approve i - amendment ±Lhefe,,to and, "in accdrdanee with the standards,•rules an _regu a ionso e' , u mm
s ,
De' _ will °.'
County: ,,- partment of,NOatt:h; rand that 0'n cgmplet�on thereof a Gert�f� hater of C'onstructign +Compliance satisfactory, to the. Commissioner of- Health~
be`Ysubmitted ,to,the. Department,, ,and. a :written 4guarantee�;will :De,aiurn� shed, the owner, ,h is;successou; heirs. o► ass�gn_r,by the butlder; that said budder will _
! 3 lace in, ood operating ,CCOndition any- (part ,o`f, �sa`tl lsewage <d sposal asy_stem during,Ahe period of` two (2),years immediately' fo- Ilowiry the date tof the ,iss-w ti
rr tp 9
r
,;ante, df ,the approval of 'the Certificate df COnst►ucticn !Gomplwnce of `the orqinp! system;.or any.r,epairs thereto 2j that ttie dialled well dosc►ibed above a
Will, bellocated s3shorvn on theaRProYed, - +plafi and,that said well WUItbe7installed, fin accdid th .the standards, rules ,and regu a�Tfloni of the" Putnam
z f
County [Qepaftment o�Health N _ -__.�_ Y �
�Oate • _.1 gSignedi - - - `_ P E R A
{
4 {
,},a n -�. i aAdAress -
;,A'PPROwED FOR Cg_NSTRUCTCQfV This,approyal; exp�red`,one yeatirom'the date al, ;sued ±unless construction ±ot the, budding (has Deen +undertaken and'.is
'-4 '" s Y' " r `+ s - ror ' odi$i jwheri considered "necessa `? b the Corn - ass : f IHeaiM;` 'Any}rChange ;` "" IteratiOniot ;const ►uction
grevocab�e,,lorteause or {may be amended m ed Y a
'requve3'a new ipermd App]/royw f r disposal of _domestic; se a -. d r;; a e, stippl only r
a- "•Dates .L �itey � +x;'4 �. , :.,aSi�tle 1 ..
n.
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3171 T04m Of Patterson Building dept.¢ Division of Environmental Health Services
r C8ep COUNTY OFFICE BUILDING - CARMEL, NEW YORK
Building Inspector John N.
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.
I REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION I
OWNER
NAME
Jack Wade
ADDRESS
93 Old Wagon Rd. Mt: Kisco, NY
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
Ice Pond Road Patterson, NY
PROPOSED
USE OF
WELL
BUSINESS
DOMESTIC [] ESTABLISHMENT ❑ FARM ❑ TEST WELL
❑ SUPPLY El INDUSTRIAL El CONDITIONING ❑ O�Efy)
DRILLING
EQUIPMENT
ROTARY ❑ ACOMPRESSED CABLE IR PERCUSSION ❑ PERCUSSION ❑ Specify) '
CASING
DETAILS
LENGTH (feet)
0
DIAMETER (inches)
6
WEIGHT PER FOOT
19 lb S .
,
' Vic' THREADED ❑ WELDED
YES ❑ NO
�R
YES
TEDT
NO
YIELD
TEST
X HOURS G.P.M.
❑ BAILED ❑ PUMPED ❑ COMPRESSED AIR 6. 5
YIELD (G.P.M.)
5
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (SpecUyleef)
26,
DURING YIELD TEST fleet)
Depth of Completed Well
in feet below Land surface:
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (feet)
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKEDs•
Diameter of well including 77VEL
gravel pack (Inches):
SIZE (Inches)
FROM (feet) fO(feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION .
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
0
6
Drilling in-- overburden-
dirt clay and cobble.
6
30
Drilling-in -rock -.. -set
casing and grouted
O
205
Drilling in granite
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
9 - a.. f 9f
DATE OF REPORT
q-,l
WELL DRILL Slgna )
�5
Owner or Purchaser of Building Section
Bu l d ing- C dust rucae:d--by
l� PUY)
Location - Street Lot
Municipality Subdivision Name
Building Type Subdv. Lot #
GUARANTEE 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 guarantee to the owner, his success-
ors, 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..failur-e
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 determin-
ation of the Director of the Division of Environmental Health Services
of'the Putnam - County - Depa-rtment of Health --as to whether or not the fail
ure of the system to operate was caused by the willful or negligent act
of.the occupant of the building utilizing the 2sy' Dated this / � day of 60WIC. 19�� Si a
Tit
Corporation Name if core.
Address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
1.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONI'4ENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARPEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner -T6hn ?. WAM, Address es 01 . 0 WA&6r\ PO(AD, PAT- K� Q,Y1
Located at (Street Zc,§-: fbno D Sec. -79 Block 3 Lot 10
Indicate nearest cross street)
Municipality ?A-W60n M\ov Y,09-K Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIPS PERCOLATION PERCOLATION
Ra— Elapse Depth to Water Water Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min./in drop
Inc, Inches jInches
L
2 1 ic. V"'Alfil I ?_
'
3 11,'! 5— - RL , S 0
2
f
1Sir"tn;.
0
1,0% %,0,% NY'
?_5 4A
7
V.
RM
I Ja
I ji
1"011
Va
� Vj " 1 3:'
Notes: 1) Tests to be repeated at same depth ur 0 a(�l� equal soil
rates are obtained at each percolation test hole. All data to e submitted•
for review.
2) Depth measurements to be made from top-
hi
-7
2l:lc
�'1Z° �:,Z��41
M, Ayv
Min
`4
�q
?_5 4A
7
V.
RM
I Ja
I ji
1"011
Va
� Vj " 1 3:'
Notes: 1) Tests to be repeated at same depth ur 0 a(�l� equal soil
rates are obtained at each percolation test hole. All data to e submitted•
for review.
2) Depth measurements to be made from top-
hi
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
. - .:'..., .. _.._._ C ".. n ... ._ 4... ....__
TQ_.��►...
v .� ♦ 1.
12"
T ®P
18"
as A AgL9 AOn rtl` y LO
24"
C ",MQ tY1 .60knoy LC)ai+v\
30"
3611
10AM
42"
W6 Lead
48
54"
( � Lai
60"
SA
66"
��cae.Li�rn �o�e
7211
P
78��
84
Vr,
INDICATE IEVEL AT WHICH GROUND WATER IS'ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY P. 1E.
Date '112510
Soil
Rate UsedMin/l "Drop: S.D. Usable
Area Provided
No.
of Bedrooms _Septic Tank Capacity goo
Gals. Type y%v
Absorption
Area Provided E&_ L- F.x24"
width trench.
-Other
- s
- �;z- • ue,;,
THIS..SPACE FOR USE BY HEALTH DEPART14ENT ONLY:.
5 2 8°� i
Soil Rate Approved Sq. Ft /Gal.. Checked by
1. - . .... _ i ..
■
su r�N�
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CALVIN f� �- t�i�F Ft443'CytJ_0 __:
- sFx.'(lc�tJ �•NDJ.•� i� �'v.r�- S',A►.3, �cvt:, . .. . � ; _ • - . :a .,
tnam County Departaent of Eealtri
Di aion of Environmental Health 8erbiceO
P- \(- sys LnyO,)-T* FOB.
Approved as noted for oonformacioe, with
1pplicable ^Rules and Hogulitione of the
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