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r iPUTNAM `COUNTY DEPARTMENT OF ` HEALTH
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`{ a Diwslon of Environmental Health - i..nkes, Ca m% N `Y 10512 - E
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CERTIELCATE OF C011tSTRUCTIONL "COMPLIAN;CE FOR SEWAGE�DISPASAL SYSTEM o4 _
t r t i a ikk a xis A-_Village " - own 'or
Located at }/"�� v Sectionse Block
_, ..
L
owner' _ �$L� �0�/! / �N,Sohs/i�T�� lam' /` Lot Joli,f7�le�j /%1�7.cyad�- 993
r_ y 1a,�y d�c�Ut't ��I '7
Separate'. Sewerage System built by y�yPa^ '' z' Yea Adtlress F/
Coris�fstmg of �0flr�Gal. rSepUc'Tank *t � t lineal Fe6t',X �b a width trench
Other• requirements MO tom
Water Supply Pubha Supply From _ }
Private; Supply. aDnlled "BY / • , ty17s
•. i
t
ddress
F � I
Building T,y,pe;r_E�y� No�of Bedrooms Date Permit Issuer!'
< c
Has Erosion Control Been Completed t''
certify that the.system(s) as listed serving theSabove prem "lees were constructed es s nt�ally,as tshown on the plans of the completed work (capres of which, are
attachedj and in accordance with the "standards rules and regulations plans filed "and�the :permit issued " ' the ,Putnam County„ Department of Health.'
Date Cectif b P.E. R,A.
Address r "P �-� 'License No
Any-person occupying premises served by ithe above systems) shall promptly take such action as maybe necessary toy secure th_ a correction of any.uhsanitary
conddions resulting from such -usage Approval of the separate sewerage system shall become nul( and void :as •soon as a public, sanitary sewer. becomes
available' and the, approval of "they private water supply -ahall become null and void when a "?public ,water` supply`s becomes a5ailable Such ``approvals are;'
sub Ject'to modrficetwn,or change wlien'tn the`judgment of thexCommissio er`of Health such revocation, o ifiication'o "r change is necessary:
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Date !j -~ 2 i
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- 9Y " T¢1e
CARL P A U L S 0 N
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
repurt is.---to- be;-.compWted.by-.wel,L-,-driller.,anda submitted...to County- Health- Department .tpgether.. 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
NAME
CARL PAULSON
ADDRESS
HILL & DALE RD, IM YORK
OWNER
LOCATION
OF WELL
(No. & Street) (Town) (Lot Number)
LOT #19 FIELD CORNERS ACRES FAIR STREET CARMELs Ned YORK
PROPOSED
USE OF
WELL
BUSINESS
® DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
PUBLIC
❑ SUPPLY ❑ INDUSTRIAL AIR OTHER
CONDITIONING (Specify)
DRILLING
PMENT
® ROTARY ❑ AIR PERCUSSION F] CABLE P PERCUSSION ❑ OTHER
(Specify)
)
CASING
DETAILS
LENGTH (feet)
20
DIAMETER (inches)
$ �[
WEIGHT PER FOOT
® THREADED ❑ WELDED
1 " lb o
DRIVE SHOE
®YES ❑ NO
WAS CASING GRROUTED --
® YES LJ NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED E' PUMPED ❑ COMPRESSED AIR six
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
369
DURING YIELD TEST (feet)
Depth of Completed Well
in feet below Land surface:
SCREEN
MAKE
LENGTH 07PM 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
0
10
Drilling in overburden -
clay
Hit rock at ten feet
:...
10
,_ . _.......
Drilling.-In--rock..- setting.
casing - grouting
20.
Drilling in rock granite
and g uartz
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
Dec 19, 20
DATE OF REPORT
Aug 13 70
WELL DRILLER (Signature)
BRGWSTER LABORATORIES
69-224- = BREV✓�i , ^1'.4 :'tt.
WATER . ANALYSIS REPORT
SAMPLE NO. 2514
SOURCE: Carl Paulson - faucet - well supply
Lot #3 Fields Corner Acres
Fair Street
Patterson, N.Y.
COLLECTED: Carl Paulson
BY::_.Oc,t, .28, 1971
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml.
This result
indicates the
source of
the sample was
Of satisfactory .sanitary
quality when
the sample
was collected.
Oct. 30, 1971
oy Bickwit P. E.
Director
pai'tersm
_ -
Fields Corners Acres Subdivision
_rL L?a�l inn
n^v .
:,ion
--
_ ^�
c�a3 r Street
B! o '_
Fram
----
--
- - --
L o
10 C
`••.',i-
ice._. -. rJ �.:, =..; -. .._.�`_' .��'_. ^J -.. �_•_
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,.._ -✓,' .__,J 'v .�� `���~_.-
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Julyf�
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. _ .....a
_ PUTNAM CO�U_ NY,.DEPARTMENT OF, HEALTH
_. . _..__ ._...
_ ... �_ ....,._
Separate Sewerage System y A'ySo•�
Municipality
CONSTRUCTION PERMIT
Located at �-�r ,$' 7--� �f �� V-37 Block
Subdivision y Lot Job
_
Owner Address ,- �,p/�T Lot Area Z/ >&W
Building Type /50,
No. of Bedrooms Total Habitable Space /0807 sq . ft .
Separate Sewerage System to consist of ODU Gal. Septic Tank� lineal feet
width trenchG'
To be constructed by % a Address
Water-Supply Public Supply from
t,,,"'Private Supply to be drilled by ?
Address
Other Requirements /Va„e
I. represent that I:-am-wholly and :completely. responsible for the-design
and location of the proposed system(s): 1) that the separate sewage dis-
posal:s.stem above described will be 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 that
on completion thereof a "Certificate of Construction Compliance" satis-
factory to the Commissioner of Health will be submitted to the Department,
and a written guarantee will be furnished the owner, his successors, heirs
or assigns by the builder, that said builder will place in good operating
condition any part of said sewage disposal system during the period of two
(2) years immediately following the date of the assurance of the approval
of the Certificate of Construction Compliance of the original system or
any repairs thereto; 2) that the drilled well described above will be
located as shown on the approved plan and that said well will be installed
in accordance with the standards, rules and regulations of the Putnam County
Department of Health.
Date j�d' `�o Signed
APPROVED.FOR CONSTRUCTION: This appr va expires one ear from the date
issued unless construction of the building has been undertaken and is re-
vocable for caus.e.:or..may be amended..ar modified.when considered necessary
by the Commissioner of Health. Any change or alteration of construction
requires a new permit. Approved for disposal domestic san' ry sewage.
Date �/°29`o By
M b PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISLON OF. .ENVIRONMENTAL HEALTHiSERVICES_
DESIGN ,6ATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner . Address
Located at (Street) ��3 A
) Lot
(Indicate nearest cross street) 7'--
Municipality. &eaah Watershed`,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
5
Notes
1) Tests to be repeated at same ddpth until approximately equal soil rates are ob-
tained at each percolation test hole. All data to be submitted for review.
2) Depth measurements to be made from top of hole.
•A_--
Hole
Number
CLOCK TIME
PERCOLATION
PERCOLATION
.Run
No.
Start Stop
Elapse
Time : --.
Min.
Depth to Water ..Water
From Ground Surface
Start Stop
Inches Inches
Level
in Inches
Drop in
Inches
Soil Rate
Min/in.dr.op
3
3
/
G
5
Notes
1) Tests to be repeated at same ddpth until approximately equal soil rates are ob-
tained at each percolation test hole. All data to be submitted for review.
2) Depth measurements to be made from top of hole.
•A_--
• 1
TEST PIT DATA REQUIRED . TO BE' SUBMITTED WITH APPLICATION
..� .. __F, �..... -. , ...DESCRI,PPP�ION -OF - SODS. E•NGOUNTE I-N -EST'RULES - _.___....._ 4_...�_....._ .
�.
DEPTH HOLE N0. :' ` ,HOLE NO. H LE NO.
G. L.
611 I
I
1211 �� Cia9iCS
1811 o .. .
24"
3011 a74x
3611
4'21t
48 T1
5411.-
6 OT1
66"
72"
78f?
(o ef ar ;
1041
8 41i
INDICATE LEVEL AT WHICH GRO D WATER IS ENCOUNTERED Me4e
INDICATE LEVEL TO WHICH: WATER LEVEL RISES AFTER BEING ENCOUNTERED /(/c -•e
TESTS MADE BY Date
DESIGN
Soil Rafe .Used .
MirVI" ..Drop:. S. D. Usable. Area Provided.. yo '0
No. of Bedrooms 3 Septic Tank Capacity /Ooo Gals. Type Q9cysod,iv
Absorption Area Provided By�L.F.xe�o F11 ✓ _width trench. Other,
Name 1_4" &. A/es _41
Address ®21 z-1, ?e-3
PUTNAM COUNTY DEPARTMENT OF HEALTH oFrHF
Soil Rate Approved. Sq. Ft.. /Gal. Checked by Date f
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF.ENVIRONMENTAL HEALTH SERVICES
PROPOSAL -FOR SEWAGE TREATMENT SYSTEM REPAIR
_biter. -no! Use Or!�y ..�41lT
Repatr Pe=tt Issued to test 5 years ❑ of In Watershed 1
❑ Repatr wMM Boyd's Comers. W. Branch or Croton Fals Res. For Delegated
❑ Repair aftib 200 R of a waWcrose or DEG 'nt Review ii ^
IG4 Ay -4
SITE LOCATION / TOWN TM # ?�l
OWNER'S NAME Q PHONE #
MAILING ADDRESS r6 C 4"A ti
APPLICANT _ �/� _....:...:
e t owner enant, contractor DATE FACILITY TYPE contractor,
DATE PCHD COMPLAINT #
PROPOSED INSTALLER PHONE # A I�/Iyywf
ADDRESS %EGISTRATION /LICENSE #
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair. , ^ _ N
I; as.owner,agree.tafll .conditions, stated -on this form
SIGNATUR TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this. permit for the septic system repair
--SIGNATURE ....... .: . ... r TITLE ....DATE
Proposal approved with the following conditions:
1. Procurement of any Town Permit, If applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b: Location of installed components fled to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair Is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
f 1 i ' 1� wo'Ic is to tie bac�ctil until author zagon to do so has been obtained from the Department
MITERNAL USE ONLY
Proposal Approved Proposal Denied ❑
?L1
Data
is in compliance with applicable codes Yes X No ❑
COPIES: PCHD; Owner; Installer
PC-RP 99ML Rev. 2/07
414 7
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REVISIONS
SPECIAL DISTRICT INFORNIATION
I.In 1114
Sheet l of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
D—WISION O$ ENV1-RONiNIENI'AL -IIP,ATLIX' SEiRVa ES
FIELD ACTIVITY REPORT
N ANM: 15 + r `S 1, Tel:
AT)T)RF44s Vi
Street Town State Zip
PERSON IN CHARGE
OR TNTFR VTFWFT): �� Oi O � 5+� � � ® °� T)atp. 9 ll 9' /® �
Name and Title
TYPE OF FACILITY: .
FINDINGS: 5Q Z`a;Z _ !s4eS c i5 n
dPs
Signature and Title
RFPnRT RRCFTVFTI RY1
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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