HomeMy WebLinkAbout1622DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34.13 -1 -12
BOX 15
01622
IN
I,y1.
.i
9
No
TIN
IN
IN
No
IN.
Im
I.
! �..
r.
I N
,'
11
oil
i
J+16,
IN
01622
V , '' 1l .. ;.Y� F i ...,. •,l 1,..^1x1 ,, \ - -
` PUTNAM COUNTY DEPARTMENT' OF HEA=LTH i.
.,, 'Division ,of Environmental Health ServicesCaimel .N. Y;.'10512
CERTI,FI�ATE.:9F CONSTRUCTION, - COMPLIANCE. FQR,�SEWAGE ISPOSAL.SYST:,EM1.
1^� G -own or - ViIlage:
Located at LEA, 12CET• Section a Block
9..
Owner E7• Lot Job
C
Separate Sewerage System built_ by Address' Chu �N4c�a�C3 ` !
• { cc�� nntk
Consisting of ®� Gal..-Septic. Tank d-�GX : 3..
{ ,.
Other requirements:
lineal Feet•,X width trench
r:
Water'Supply:' Public Supply From
a.� :SS. �l'C.lC C _ O IIJ " �. C f" 1 ' l l ;7
Private '.Supply Grilled ;BY t b
`'-
. Address
Building Type No: of Bedrooms Date .Permit Issued
Has Erosion Control Been Completed''i
».
f certify that the system(O as listed' serving the above premises were constructed essentially as,shown on -the plans ofthe 'compieted work (copies of which are f
,attached)," and in' accords ce.with' the standards;' -rules ana' regulations, plans filed, a the permit issued'',by t e Putnam' unty Department of Health.
G
Certified by P EY R A.
Address 1;t License N G
Any, person occupying premises served by the above systems) shall.'promptly take such acfion'as maybe necessary to secure the correction of any unsanitary
conditions resulting from such usage: Approval of the: separate;sewerage,systernshall become null and void as soon as a: public sanitary sewer,becomes ..;
available and the.approval.'of the .private water supply, ,shall'beeome� null and void -ve en a public, water supply becomeiavailable. Such approvals ace !
subJectpto odification or change when, in the`'Judgment'of the,�Commissioner of.Health such.reVocation modification,or change'is necessary.
n
r
Date
r' Title
•f
4
M3
•d
M
. 21'. tckerjon, Jfic.
weu Dfilung
•.._ PUIM .e.:WATRI3
Rotin 9W 9W _6,8101 MILTON, N. Y.
WELL DRILLER'S LOG AND REPORT
WELL AT.
Name of place
OWNERl -�iL�J
WELL: Depth''a-C7 Diameter
feet
d
In T' "T .Cr S
city, villages own
1E- Address
his
Yield 14 Disinfected e'S
inches gpme yes or no
CASING: Above Ground Y-- Below Ground °�-� Well Seal
inches feet cement ,grout ,etc.
WELL DIAGRAM IFORMATIONS PENETRATED REMARKS
diameter in inches Depth Ivater Kin'dthickness and if
bearing
Type of well , FQC* -'
Drilling method 117'
Kind of casing < A a—
Was well disinfected , d = S
PUMPING TESTS No.l:No.2 :No.3
Static water
:
level, in ft.
:
below grade
Pumping -level-
i1 feet
:
s
below grade
.Duration of
:
test, in hrs.
Was water at end 'of test
Clear Cloudy Trubid
Recommended depth of pump in,
well, feet below grade
For wells in sand and gravel
Length of screen feet
Diameter of screen inches
Type of screen
Screen openings by
Comments:
Drilling Started :9'61d / "I Completed
Driller
Well
r
rf��d f tl ! t A k t ii i.
6rf""'Fx f
Y
r7 a a t,+ t y i
Y C V -1;
Y
. '.
i
} d r.tt f 5 f 1 �4. , 1
4 S 'x „`': �». -,..n +.a ,. ,... _.,. -.... >..�... .> ors. y,.:. 1 4 �� .4 t �.e. a...x:. t , . I, •
J «Nr ;.
7 - r i' 1 ' r.� +
1: �1 q1. - , y r
is 1 ry }.. + s r , %
.,Ili l�k1�,, r4 '• t.
C
, , , ..Town :of Patterson F
��,+ Owner. or urc aser.,o Bui ding Municipality , 1.
�� 1 5 -
7G1�- Bu _ �, .ruc e -by y; �;, 1. .S'ect10'n _ 3 1 -II 4 .1 i t
U _ .7 5 7 - L
`} Fair s��t Carmel N± Y #1 TAX MAP # 78 V
Location S.tr.eet' Bloek, % y '?' �' - 1.
flF
7 SUNIV.Y. ACRE5'` #,,. 46 ,+
Residence 7
�.,
r- ,`, Building Type t Lot .,
W } s
K,q F. 1. " GUARANTY :OF . SEPARATE,; SEVIAGE SYSTEM .., .. `
',, ' ;.I represent' t. ha t' .I am wholly. and compietely respons.zble for the..:.. .
'_� - location, worinn2.nship,, .`material,. cons "tructio.n and - _drainage of• the ":aewage
stir' :.
,
disposal. system 'serving the' abo..ve described property; and that it; has been 1. �sn t `'c;onstritcted''as shown ori; the: approved plan or,: approved amendment 'thereto,
and .iii. accordance `with ,the 'standards regulations of tYie Putnam..
rules and
- County.Department`of Health ",'and hereby gua�anty.,to. the owner., .his 'succes,
w sons -; heirs o "r ass,igns,:_ to: place in; good operating o;ondl. '' any; part of '
��,F xsaid system" constructed by.me .wYiich'.fai1s t`._`1
o: operate.. for 'a period. of. two
,:: years immediately ,following; the':,date of. h t al use ' of the .se.wage.� disposal . 71. �j system, or. any' repalrs:`.made` by:, me to such system; except where .the` failure"
F to operate :properly - i s 'caused :by the willful; or .;negligent. act' of >ahe occu -' ;
,t
" pant' of •the building utilizing, the system
F. S - .. ,
, The.undersigned further agrees to 'accept as conclusive "`the de
.
termination of,: the Director. of,' the :Dlx' ' 'o' .of.: Eriv ronmental- :'Hearth; Ser 11
W
of "the Putnam County,•D:epartme,it of Health :;as to whether or riot the .; 11
failure of :the system 'to' operate was caused +:by the 'willful or, negligent
,> 'act 'of the; occupant' .of the building :;utilizing 'the syste
..
f I.
Dated this 9 day of June l9 72 Signature A
7 W & Q'PER; C 1.
7, 1 Title W.
a, Pou h 'rN, .. x
2. I. f co,rpor:ation g ;ve .name
;_ f:`- . and ,address ). 11
�,'
,; ..
`.THREE (3)�.COPIES
ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE'.:
CERTIFICATE
OF COMPLETION WILL BE ISSUED
{ ...
,
rG
'is GUARANTOR
Y t.
IS REQUIRED TO FILE NOThCE OF 'DATE OF FIRST': USE: OF SYSTEM
E .,
i -
..
.
;
.... t+ 1 '
., .:
K.,
—7
.:' _ '',
-. ,'':.
9
Division of Environmental Health 'S .1, , Putnam of
Health,:;,
}
71 *
;,. _Department 11
f,t -. ',, a. 1 1 1 -,�7 Z
''
-� S y
1
+
r , ,1,
1 '., :F. tn, ,
y
,,; _
r
ID
65
41
ga
A'a
1"I
-11
Sol.
80
14
1I
61
5
44
Zl8 1, o� "a leetjc- i�;
oc� .. C q LI_0►a SCP 1�. at.1
j : . . a
`�lPA 000 ERm gF.3899�I•IC)V ER.'S ..pLAt4NE-�
PUTIVAM ib1N�Tif DEPT $#'LTN
8Y
JC
DWktUR;'D.� 0 OF
ENVIRONMENTAL HEALTH $ERVIG 1
Diwsic
_CONST.RUCTION PER_ MIT FOR SEWA
Located`
ILI
.Subdivision
Owner
ti l
Building Type —�
Number7:of Bedrooms x
Separate, Sewerage System to consist of ±
To be constructetl by C.�142�1f .G
"Water Supply
VAM COiJNTx ,DEPARTMENT -0F f HEAL'T'H = • -°'�,� ,� �`
'of., Envionmen'tal Health Ser ✓ices Carmel =.N Y 10512 - r
L D(SPOSA0SYSTEM"
_ ? Town or yillage
` > °Section ` ' +Block
Job
Lot' Ej
Address �
Total Habitable "Square •'.Feet
a
c Gal Septic Tank �`�- lineal feet' X `� `A width trench'
/. `
Address
f Pewate .Supply to be drilletl by„
u -
A
Address
Other'- Requirements
f
.
y
1
s :,I represent that 1`am wholly and; completely ire
above descri6iiia will be' constructed as sfiown' of
J, County;: Department of ;Health, :and that• -on c
:ebe isub mitted to-- the Department., and a' *'writ
-place in goo, , 9peraUng' cond _ lop any ,part, .
•ance of'the approval of the Certificate.-of C
will be•iocate ' shown' on the approved'o)an'a
n
;Courity� =pe" men ofyHealth
Date 7-
eF Ad'd
•APPROVED FOR CONSTRUCT101
'z revocable for cause or may be affier
T r� regwres :a new m t Approved
ihsible forl"the design and location of the peoposed.-system(s); 1) that the separate - sewage disposal system
e,approyed amendment�th'ere to and in accordance wdh the standards; rules an regu a ions'o e., Putnam i
ipleUon thereof a :Certrficate of Construction Compliance ;satisfactory to, the Commissioner;of'Healthwill
wl _ ....,
i:.guarantee will be, furnisFied the owner his "successors he�rs_or assigns by the: builder;;, -that said builder'will'r'
'said sewage disposal system dunrg the per`wd ofitwo ( 2); years��mrtiediately `.followiny_thedate of tlie,issu-
struct.on _Com `liatice of ffie o "r,i "naGsystem or any } - repairs thereto';,2) `that,the drilleci'iwell descr - -ibed ;above,
that said -well will?tie9nstalle :accordance with:atie. standards✓rules' end =:regu a ions f :;the ^Putnam ,
w;.I
PUTNAM COUNTY DEPARTMENT OF HEALTH
_..... DIVISION.- OF- �ENV.IR-0N- NMNT-AL- BEAI;TH °- SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE
Owner _Z.,_ tea Address
Located at (Street,��, st Sec. J Block
6d:Lc__d;'_te neares cross street
MunicipalitYl , �.�� ;,��— Watershed�,,4,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number
CLOCK TIME _
PERCOLATION
PERCOLATION
-'E_ aPse
p o Water
a er ve
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop in
Min. /in drop
__...
Inches Inches.
Inches
124
7
5
4
5
1
2
5
Notes:
1) Tests to be repeated
at same'depth until.
approximatelyy 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.
TEST PIT DATA REQjJIRED TO BE SUBMITTED WITH APPLICATION
w:DESCRIPTION7J OFD: SOILS.. ENC; OUNTERED ;...IN:_TESTti.HQLES..:- ;:..s:.s_ -
-DEPTH HOLE NO. HOLE NO. HOLE NO.
:INDICATE 'INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
_INDICATE LEVEL TO WHICH WATER I.ML RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date
DESIGN
Soil Rate Used 2,� - Min/l "Drop: S.D. Usable Area Provided
No. of Bedrooms -_y Septic Tank Capacity Gals. Type /1fj4j,,,,g
Absorption Area Provided By,2�.,,�,, L.F.x2411 36 width trench.'
Other
Address
THIS SPACE FOR>USE BY HEALTH.DEPARTMENT ONLY:
SEAL
Soil Rate Approved Sq. Ft Gal. Checked by Dste
-------------
S 1°- 20,_00 E 100-00'
NO WELLS 0K SEPTIC'
SYSTEMS WITOW'100'
PROP
WEL-L
O
Res.
10'
0 1 SEPTIC
TAmK
*Lj
0
>
00
EXPANStotl
40 -W 100.05'
FA I R STREET
i PLOT PLAN
SCALF_
LS
0.
0
71
T10 ,
--zoc,
:z ,
-70o
7-
7
WANHO' U IDA) V E I?
7=�J •
---- MC;.![ 6 MANHO! F VER
..........
7'-
71
t_41l:0LlKJE> SURr--ACC- RES. ti
11:0L "13
SEpTIC TANK
SECTtoff
�4- A
NOT To SC-AIE,
APPROVED!.
4ujvo.�t.�j "'N t OF.
Sfl.l
SEP7;:,1971 z
.m OF HEALTH
UT!
swAcla NI R. lEo._oN_,.oF
UVIRMUENTAL HEALTH SERVICU
"Jam
t
4
13—
CAST 1A 0 N T`_
I S A I A FAY rE'E -I
T1lplc/A:_ PR E Sj CO N,-,
5 Ul rIC TA Pi K CC. a/
H!, LEVEL
I- F?
L
F-i
F 4,Aw L 0 A
.21
ARSCoRPTION, TRENCH
SYSTEM To BE CONSTRuCTEL) IN ACCORF-Ar-a-r. WITH; I HE RULES AND
REGULATIONS or THE _P.9_1_?,AAM —_ COUNT* DEPARTMENT
OF HEALTH.
SYSILM SHALL NOf BE 9ACKFILLED UNTIL WSPF.01ED BY DESIGN
ENGINEER AND THE. LOCAL HEALTH OF%'-'-�;AENT 'IF
Cc A 900 1 N S "4 P:
;MO, OF 3 F. T INEN-*H Wll.,i
Cr pER
S.S.D. SYSTEM
Fop--, P CERR� TA
r —s, 67-� i T WnR A. KE L L Y -, J R.
A S c, C! A I e. S
CARMEL. I, 'r, !0612
TA- MAP T8 BLK i._vr,4 46
L=A 12. ST. $um"V ACRES
Town o;z , ?U114AM Co, VAY.
3
G.A.T..
2B Au c, 71