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BOX 15
01674
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z `�3i, PUTNAM COUNTY DEPARTMENT OF HEALTH s ` '
z i z eN Division of'Enwronmenid/ Heath Services, Canine/ ,N K, '.
17512
t r a_,r i� a
CERTIFICATE OF CONSTRUCTION L (SYSTEMc9
LOCeted 8th a f' Tax Map, Block
e
�, Dwner Tax Map Lot
r' Separate "Sewerage System built by; ' ` ✓t �` address JYl i CW1 �1
Cohsisting of pal. Septic T,-ank and;
Other requirements ' -
-
Water Supply eau Public Supply From
Private SuPDIy Drilledirav - j 'y�i'S
' Building Type I S��'1e -`�tC� /P y No of Bedrooms 31 { yi Date Permit Issued. 7 j
L Has Erosion Control Been .Completed?
a Vr bE 3
L certify':that th'e systems) as`lste3,ser4ing the above.prema es .were constructed essentially -as shown on <the; plans of the oompletedework .('copies
of•which' are attached) and in accordance :with the tandards trules and regulations, in accordance with the filed plan and the permit issued by:the I
k PutnamrCounty DepartmentfOf,Health y ti
i Date P E R A
�
s _Address yLU /t l �a?fG�� �` Licenfe
Ariy person occupying premises served )by the above system( ;) shall promptly take such :action as may be necessary to secure the correction of any 'unsanitary..: ,
. Q,
l cenditions;,resultir►g from' #such usage Approval ,of;�the separate sewerage system shall become null Arid void,as soon: as a, putille sanita►y'awe►, becomes
F f
r <. available and thezapproval of the vate water supply shall•tiecome null and void when a putilicrwater supply becomes syaiiibi " Sueh ipprovak are
,� `subject ,to.modificstion or' changeMwhen:'in t1i ;'j 0 gmnt:of the C issioner of< Health Such odulcation ,& changs,irgeeeuiry ,
�r fix
'' ?i -
Date 8y `�� z7,�•.�• Title i
0490
YORKTOWN MEDICAL LABO,RATO°RY IN�C
P.0 Boz99 321 K`ear Street LocaTloNs
C ❑ 321 KEAR ST., YORKTOWN HEIGHTS N Y 10598. 245 3203
Yorktown ftih$s, N Y. b0598 ❑ 201 13LJTTONW0C10 A�IE PFEI�SK >ILL N :Y, 10566 737$?77
0,5
245 3203 " ❑' 495-'MA IN ST , , '' N Y 1 49 666 -3335
STONELEIGH AVE (NEAR HOSPITAL) CARMEL; N Y 10512 2*0330'
r
DATE.COL:L;ECTED :. ..
RES:W TS.OF EXAMIMATION70F WATER
OWNER WNER DATE
Boze.la Pitra 6./10/8
CITY, VILLAGE, TOWN 6 /OR NAME OF SUPPLY DATE REPORTED
Farm 'o Market Road,, Brewstor,,New Yark:
.6/12/80
.SAMPLING _ POINT „
..
@ ,above.address,kit.chen tap .
BACTERIA PER ML. (Agar plate count `at,35. C): COLIFORM GROUP (Most probable. No. /IOOmI.) RDN TAL. "ppm "
4/ML
0 ; MFT,
DETERGENTS- mg /L NITRATES`(as N)'= mg/L" IRON, TOTAL= rng /L
AMMONIA, FREE (as N) tng /L PH... , 00RIDES
isfaeto sanitary unlit ..when the sam le was collected
These results indicate that the water was _YES of a'sat ry Y 4 Y P .. _Al
n
f, S
.--.. �.r:...._v �:rz• .w -...: .-, ee ... .. ...... :...:aes+._r.1 ._.- ..�+.+ ^.— .. :._ ..,,.<.e. -s. r.�.. -.. ;..._zr•c•.._.._.�.::....... _%"f:;_. _ . -. �. �... ...
0 er o urc as.er Adf Building Municipality
x1 Z
ilding Constructed by Section
Locatio -- Street
2
Block
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-
v .c.L.�,,..o.f._ -the .to, whAther 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 sys m.
Dated this day of Signature
Title 11adam ALmi
f corporation, give name
and address)
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
IXJUN 16 9980
P_UTNAM COUNTY
DEML DE HEALIH
t ;
I
1
M1.1 Pf-,71M Rl*PQRT PPTNAM COWITY DEPAFMAIENT
Division of Environmental Health fiervic9a
COUNTY OFFICE 13UILDINQ - CARMEL, NEW Y(
Thi-vropgri 14 90.b.9 r-omplated by wq!1-c1rillar anq _tq pquaty kjQ-Rixh., Qppi.irtmentsoulothar -with I uator ?p
a ore certificate b constru.ction Wm�p1iyrkqq.j4
f0f
satis actory bactO �I qua ity
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL CQMPLETION
I., A7
Pete Ward & Sons, Inc.
I'ADDRESS
RD #2,,Union Val ley Rd,., Mahopac,, -NY
90CATIOti
vp 1"NeIA
Pitra Hou.se.i. Farmi—to—market Rd. ,.Brewster, NY
rROPOSID
PS3 00
PQ PIPTIq E§T44ISNM4NT FARA §T W94
PUBLIC AIR OTHER
L. 1 ,§UPFLV t,. l INPUSTRIAt C ONDITIO NINO
COMPRESSED
P.QTARY LJ AIR eERCUSS1014
CABLE OTHER
PERCUS51ON L.J Opocify)
CANHO
P'TA10
Tf�i 0of U
�,.2 ft
PIA*Ggft(1nch9qTWj;lQpT
.611
rEm fooT
19-1 TIJ119ADED wED
PELVE �KQ
L."s jqO
I�ASIWQ ff.kq?
Y0 NQ
TIEV.)
Tan
11 SAIJLgO
0
14CURS G.P.AA'
fumpen El COMPRESSED AID '6 10
(Q-P#�
10 GPM
WATC-1
1M411
14 ;�/y f0001
�WZ9
.27 ft
DURIN9 VJ�LP T45T jfQQIJ
.60 ft
'th " Com a
pop of plated W 11
In feet imlow Land sur(gpe 160 ft.
04 Lk?.J9TH OF&H TO A9
CCREE-4
I F GRAVEL PI; Xmitor of wall includl
PACKEDs uravol pack (inch&$):
pt SOFACE
rmi F;;,i LP74 � Skatch exact location of wall WIM cristances, to of 1914?
FEET to F.'T I I PRMATIPH DESCRIPTION two pvim4nqnt landm4rko,
0
21
Clay and Boulders
i
PUTNAM CoUrNTY
DERV VOE HEALT
Hit rock at 15 ft
.-Dril-ling, in rock set
32
160
Drilling.'in, granite. Broke
X Q4WL61;_f."1=
we flow of water.
if y1old was toated at difler4nt depths during drilling, list below
FEET.
GALLONS,PER MINUTE
71§ TM, 7"qlfg
j 2.:IL7
_27— 4 80
."�.„
PUTNAM C UNT 6! DIEPA�RT MEN'II
DNlsion of Envrroninental Health�Services�C6` % IV Y 10512
t
COI�STRUCTBORI P,t' i l FOR SE!lVAGE ®OSPOSAL SYSTEfN , AM%,T�i
t r
Town or Village }
� Located at � � �`� � �.�» ,. � ''� �^ `°'t`ax"Nlap ,i� P f3 {OCK •kw-W wrhr: `
Subdwision x Lot Job
Zf'
Budding �TYpeC
Number of Bedrooms Design Flow Total Habitable Space Square Feet
Separate Sewerage System to consist
To be constructed by S Address
{
,,Water Supply A Public Supply From
il '' "r k}f Y T'¢. • kw 'S�6i+ a�f V/ fV' /r I _� �' : r` : { U '
Private Supply to be drilled by j
Address,
5
I represent chat I am wholly and complete) nd Iota i n of the proposed system(s); that the separate sewage disposal system
;above described will be constr4ucted.as shoal ndritent there�torand` m accordance with the
-'standa'rd an regu ations o _e u nam
. ,..
oronf ! a ... - e -
�'. •== 'Cm.nfv '-- '`rinn�rf "men* . of .: •uual *1. i`nA Yh�f n - r .. a.- Gnrf.f,�'ta nf; ^'rnnetnxM�nn (`nm nlxa nra4;.cat icfa rfn ?v- to "tkP .C�emmiSSxoner..�f•.He81t h'w l v{
PE �j "RA i
License
.. y. J No
riless coristrucUOn of the' bwldmg has been undertaken and is
r'issioner'of'Health Any:`change'or alteration of 'construct ion
`water supply only, zs k
Tdle
K
PUTNAM COUNTY DEPARTMENT ` =0F HMLTH
DIVISION. OF ENVIRONMtsI`ITAT, I ? LTII SERVICES
COON'l'Y OFP'I(.P.., YU:C1aIPJG, GAR* 1,2, -N. Y. 1051
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM. FILE NO.'
Owner,OVS Address �'A,e,� TD /f1/VX& -% F6.4b
Located at ( Street See . I %/ Block Lot �Jr
6dicate neares - cross street)
Municipality g2dr7, -- SbA Watershed 0,0V
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
5
1
j oe
Number CLOCK TIME
PERCOLATION
PERCOLATION'
Run Elapse
No. Time
Start -Stop Min.
Depth. to Vater
From Ground
Start
Inches
Surface
Stop
Inchos
Water revel
in Inches'
Drop in
Inches.
Soil Rate
Min. /in drop.
1 `i:• sue- i1'ss
.�
as
a6
� `'
�' .
3W
4 /,? rr- i'�.�
6
ar
5
1
3
T
5
1
2
4
5
Notes: 1) Tests to be repeated at same depth'u.ntil a roximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth moasurements to be made from top of hole.-
t
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION. OF S07LS .T�InCOU'I\1'.I'.I�PFiD IN L'I',` T
HODS
DEPTH HOLE. NO. HOLD NO.
HOLE N0.
12"
1811
24:"
7 ; .
3011
'
42" diyt
48"
.,
54"
6o"
7
84"
;
INDICATE •LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE •LEVEL TO WIIICH WATER LEVEL RISES AFTER BEING ENCOUNTERED '
TESTS MADE BY
Date
DESIGN
Soil (late UsedMir�/1'lDrop: S.D.-Usable-Area Provided p0�
No. of Bedrooms Septic Tank Capacity �d Gals. Type .'"
Absorption Area Pro ded Sao
By L> F. x24
l%%%V Nd1;P trench-,
r
o
,�
ame Eo /�. r� gna u._ a
Address.. oCllE Sa �Z �t/ t EAL°
-
m. W -
�,-
o
THIS SPACE- DEPARTrflENT ONLY: °�s�FfSS10`+1����`��"
' FOR USE BY HEALTH
�rrreee►eu��
Soil Rai;e Approved Sq. Ft /Cal. Chocked by
Date
4
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