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BOX 15
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01721
0
FUrNAM COUZUY DEPARn-i= OF HP-AL Ili
DIVISION OF ENVIRO1,01?l.'A.L HFA.LTH SIIIUXCES
o Y �
dm of Buildding
Building constructdd by
Ut'(10 TN ®1 A-4 H.1 V/ R O0
Location ^ Street
go q 7
Section Block Lot
S Ord W tL A r_,+
R r� �� IOOPIViSIoA)
-Subdi.vision Nane
Municipality Subdivision Lot
Building 'lype
GUARAU= OF SUBSURFACE SMOM DISPOSAL SYSTEM
l represent that Y am wholly and completely responsible for the location,
wor)ananship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has -been constructed as showm on
the approved plan or approved amendment thereto, and in accordance with the
standards, xules and regulations of the Putnam County Department of Realthr and
hereby - guarantee- to_ the owner, his successors,, heirs or - assigns, to. place in good
operating condition any part of said �ystem' coy ru ted by me which fails to
operate for a period of two years imrseriiately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs arcade by site -to such syystem, except where the failure to operate properly is
caused: by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environin?ntal 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 negligent act of the occupant o the building utilizing
the system. T /� A /
Dated is ( day of 19 5-D
U Q
al Co actor (Owner) - gignature
Ploi roe, !��s D lv ga4Leq L ,
Corporation (if Corp.) e F,
cad
i�L dQ %Eo2 �ihELJ�T,r2 1l� iDwS
Address
Signature
Title
rev. 9/85
-t
1)
WELL UL)NrLt 1UV rrrumi
4� a
DEPARTMENT OF HEALTH
- Division Of Environmental Health Services
W Y� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
;
WELL LOCATION
STREET AOURESS. WN /vl 1 Y TAX GRID NUMBER:
Farm-to-Market Rd„ Patterson, NY Lot 10
WELL OWNER
ADDRESS:
MOE HEIGHTS DEVELOPPM. CORPORATION, PO Box 970, Camel, NY
�] p81VATE
o PUBLIC
USE OF WELL
1 - primary
2 - secondary
>Q RESIDENTIAL D PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 to 5/ EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY . ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
W SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 305 ft.
STATIC WATER LEVEL 25 ft.
DATE MEASURED 10/16/89
DRILLING
EQUIPMENT
D ROTARY QCOMPRESSED AIR PERCUSSION ❑ DUG
❑WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING x51 OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH --2.50— ft_
MATERIALS: x2 STEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE .241. ft.
JOINTS: ❑ WELDED )M THREADED O OTHER
DIAMETER in.
SEAL: )QCEMENTGROUT ❑BENTONITE DOTHER
WEIGHT
PER FOOT alb./ft-
DRIVE SHOE) YES D NO
LINER: O YES ONO
SCREEN
DETAILS
DIAMETER.(in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
DIAMETER TOP
OF PACK in. DEPTH ft.
GRAVEL PACK
O YES
0 NO
GRAVEL
SIZE:
BOTTOM
DEPTH It.
WELL YIELD TEST pumping
It detailed
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
0 BAILED O OTHER i YES ONO
1PIELL LOG -It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
8ear-
ing
Well
Oia-
mete
FORMATION DESCRIPTION
CODE
ft..
ft•
fL
WELL DEPTH
ft,
DURATION
hr, min.
DRAWDOWN
It.
YIELD
gpm.
Land
, 12
Ha rd .an &. bou l.d.e.rs .
20
25C.
Sot sandstone
305
24 . -
52g
.
250
'30E
H.ard' & soft. bedrock
WATER] CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED ?, AYES ONO
ANALYSIS ATTACHED? WES O NO
STORAGE TANK: TYPE D 1 ap�l.ra9m
CAPACITY 86 GAir. 23
WELL DRILLER NAME
MILL DRILL.I I °��% /89
ADDRESS stet
Putnam Avenue #
Brewster, NY R OP. M 1 ,
PUMP INFORMATION
TYPE sUbme.rs.i b 1 eCAPACITY O
MAKER G ai DEPTH. 160
LM ODEL1nEUn7LL12_VOLTAGE2MHP�
/tty
f
BREWSTER LABORATORIES
Soft 224 - BREWSTER, N.Y.
(914) 279 -4945
SAMPLE NO. 7549
SOURCE: Steinbeck Estates
Indian Hill Rd.
Patterson, N.Y. 12563
COLLECTED: 10 -19 - 8 9
BY: Mill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
ij ti4.. f
NEW WELL LOT# `0 ��
i
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
10 -20 -89
0 per 100 ml.
Date j
lnsrt
3 IYO
.bv - W 1i _
FINAL SITE INSPECTION
P-TMM-IT 51 62— c? 9 SUBDIVISICN' LOT -1 /0
I YES
I. SEWAGE DISPOSAL ARE
A
a. SDS area located as per approved plans
b. Fill section Date of placment
2:1 barrier. WTH W= JANG DPM
C. Natural soil not strivoed
d. Stone, brush, etc. , eater than 15" frart SDS ar=c =.
e. 100 ft. fran water course/we—ands.
M SEN71 =-E DISPCSAL SYSTEM
a. Sceptic tank size - 1,000 �la,255
b. Septic tank installed level
c. 10' minimimn fran foundation
d. No 90' herds, c-le=--ricut within 10 ft. of 450 b---d
e. DISTRIBUTICN.' MX
1. All - outlets at Same el-evr--t,:cn -'Water tested
14,
2. Protec,:-,ed be-lcw frost-
3. Minim= 2 f = crialrial soil- box and trenches
f. JTj=!C.N BOX - rrope--lv set
9-
r==. -mired - Q I,,=—nct-h instal-led 15'0)
2. Distance t6 water-course measu-•ea." ft.
3. Inst--1 led accord? ng to Dl.-=n
4. Distance center- to ce-ritev-K
5.- Sloce of t--enc-h acceptable 1/16 - 1/32 /=cot.
v >r I
6. 10 feet frcm prctx---t:-.l line - 20 feet - fcundations
nt�
7. De a cf trench < 30 inches frart surface
8. Ram all cw ad for excansion, AM
9. Size of �avel 3/4 1 diameter -
10 . 'r-e'Vdf'cf'qnaVeE 1-irt trphc'1 '12:2 in ninmxft
111. - Pipe ends =-aced
h. Pm-MP OR DOSE sysTEms
1. Size of utnip chanbe---
2. Ove-•flow tank
3. Alarm, visua-11/audio
7F
4. P= e--,si-lv accessible manhole to grade
L-
5. First bcx baffled
6. --
cle witnessed by Health Department
estimated flow pe-- cycle
IV. HOUSE. I
a. Flou a 1pcated peer approved PL-ms.
b. Number of bedromis
V.. WELL
a. well located as per amraved ;Aam
b. Distance frcm SDS area measured 4 ft.
c. Casing 18" above grade.
d. Surface drainace around well acceptable.
VI. OVERALL WORM90- 3, p
a- Boxes prcperly grouted
• b. All pipes partially bac)dilled
c. All pi-pes flush with inside of bcx
d. Backfill material contains wanes < 4" in diameter
e. Curtain drain installed according to plan I
A -fla I
f. Cbrtain drain cutfall protecteff & dir. to exist.watercoursd
g. Footing drains dischar ge away fray SDS area
h. Surface water vrotection adeamte I.
1
Date j
lnsrt
3 IYO
.bv - W 1i _
D a
4
�® j
"n r'ii_cted4i' shown on
cdkintli Department of',mee tn.
jo,
Dais
ddrGSS
Rev.
1/47 Date 13.4 . .....
Cioiirnip'lis'nice"' satiifidoiy td.the 'CoMinissiOnii"Of H"IthWill ► ;Ahe said bu Id r will
id'th* owner hi s' Suc Opork"fie $or,&=
-date
iM,,d4rin9'-the'p*r 'of two jeari fin" , iatii ' 'Jol I the if the lau-
A,, 1, io ' Z'Z -, 1111777. 7 " . 1-1
corig nal system o,.any re t ;I) that, the " drilled wail �Iaseribed'ibowq
,t -
with "J
ar ru nd u a lo, ns, of the Putnam
P.E_J�A.A.
k iJ 'M4;
if Icense No
ha,da issusA unless eonstr Lion of. the buildiny,has,been , q,nd'p!tak.en and is
qmm i sio AY Oaf* o►leftwatidn of cd6vi►'u'dion
.7:'o of
'Af ' 71q / % � PyMM cMM MAFaMT. OF HFALTS .
DIVISICN OF HEALTH SrRV M
DESIGN DATA S=T-- cUESUFACF •__,v ....;.w:,ILE
Sr�idAC="' DISPOSAL SYSTEM FILE PA.
.owner ,$° %E //��� C K Address C P—M To ed
Located at (Street) 69 (c P-S 0 !� Sec_ Block Lot C�
(indicate nearest oss treet)
riu-Zicipality �LL�S � � Watershed
AIL PE:-=A=CN TEST DATA REQUIRED TO BE AMU'= 'W= APPI I=CNS
i
Date of Pre- Sca:ki.ng 1700
Date of Percolation Test
Z �g /�O .
EOL•E .
Nam C=
PHZ TION
P—P RaXAT CN
Run
Elacse Deoth to Water Frcm
Kate_, Level
No.
Time Ground Surface
In Inches
Soil Rate
Start Stop
Min. Start
Snap
Drop In
Min/In Drcu
el
Inches
Inr-yies
Inches
.D
toCE #J 1 �P,S� /Q : ,2 7? 3U
2 30
3 10 .5830 /1��
30
5
2
3
5
ItE#3 1
2
3
5
R=, : 1. Tests to be re_oeated
are obtained at each
fcr review_
2- Dept -h meassrenents tc
at sane depth until aporeximatel y egual soil rates
percolation test hole. All data to' be sub-mitt 3
be made from tap of hole.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
r .. ...y -v- v.- . . anti c_ .. n .-,__ .. _ _ ._w .v.av . +r.r.. v. .. �_ _ .• cWa...n .av_-v. - ....m<' �h cr.. a .K .e-...w._V ...,.... . -... ... iM � ....r ' ?.
APPLICATION TO CONSTRUCT A WATER WELL o
P.CHD PERMIT #04
WELL LOCATION
Street Address Zo�yjnV444eSQ444&y Tax Grid Number
A2�� vAQr�T �i� ,9PZS �ti AIK z — Z 4.e;.7
WELL OWNER
Name
Mailing Address P of 77Q
,5 l/�!- Si'�9�id/J C,�.o . LT,� C ,G
Ofirivate
O Public
USE OF WELL
l - primary
2 - secondary
M ESIDENTIAL
C1 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM ❑ TEST /OBSERVATION
[]INSTITUTIONAL O STAND -BY
D ABANDONED
O OTHER (specify
p
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVEDL/ -G /EST. OF DAILY USAGE /CAD gal
..REASON FOR
DRILLING
EW SUPPLY OPROVIDE ADDITIONAL SUPPLY ❑TEST /OBSERVATION.
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
,6" 401 ,,Vc
WELL TYPE
DRILLED
DRIVEN
E]DUG
GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L-,'-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: S 7251W X-C& /i /u
Lot No. lC�
WATER WELL CONTRACTOR: Name ,J Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO'
NAME OF PUBLIC WATER SUPPLY TOWN /VIL /CITY A114
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:��
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
ON REAR OF THIS APPLICATION SEj'ARAT SHE
- i(_1A- F>6 (,�
(date) signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this pe
3. Submit a Well Completion Report on a form pro i ed t Putn m C n
Health De/�artmentt.
Date of Issue: ( J � 2,—_19 (�
Date of Expiration:(_��9 ermit suing Official
White copy: H.D. File
Permit is Non - Transferrable Yellow copy: Building Inspector
2/87 Pink Copy,..,. Owner Y
A.I�
.500
cJ �_ =`tC r
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vaziancz 7Rs—_':S_=
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Ecuce ITC. C_
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(Tz ch
F.=Se Szi7- 1 C
4110; Z.i:-= -,a
Fie LES
T-
-a C
_Z c -4
201 to C=r
loaf noo j:,_ D_L_C.:Dr
tc st---sarnt
101 3
50'
wall t=
CF cf- EL
013-
C4
44
71
j_;TV
of C,,;r ar)
No
ca.-C. TTS"
plan-5
r - = (7
'=� C:*I---
c"
psr::
cz.
A.I�
.500
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(Tz ch
F.=Se Szi7- 1 C
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Fie LES
T-
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201 to C=r
loaf noo j:,_ D_L_C.:Dr
tc st---sarnt
101 3
50'
wall t=
- DESIGN DAT -A•, SUBSUF=E.;SEK= p - SPQSAL SYSTEM,- R FILE No. ,
NO/
�/l9a =
Owner i- T,O _ Address /" y �s c;X 97 o C A1Z AjE6 /VL/ / O sy
ro NiA�LF,cT �j
Located at (Street) /Zo Seca Bo Block .Z, Lot Z6,1
( indicate nearest cross . street)' cLo n
Municipality : % /Al, or 'P 477,,,5;e l Watershed
SOIL'PERCOLATION -TEST DATA REQUn ID TO BE-SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking 9&/97 Date of Percolation Test /��J
HOLE
NLMM C= TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water Vrcm Water Level
No. Time Ground Surface In Inches Soil. Rate
Start-Stop Min. Start Stop Drop In Min/In Drop.
Inches Inches Inches
�et,f 1 2'x33 - 3. L . 3 Z W �L Z� /z , �Z
3 Z6,
4 ..
5
'3v
2 2
L �
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained .at each percolation test hole. All data to' be submitted
for review.
2. Depth measurements to be made--fram top of hole.
rev. 9/85
TEST PIT'DATA • D• t• Et TO SUBMITTED WITH APPLICATION
msmipmm OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. / HOLE NO. HOLE NO.
1°
2 5,4A401/
31
5°
6°
7°
8°
9°
10°
11°
12
13°
14°
INDICT LEVEL AT WHICH- GRanmam IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENMUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:
- DESIGN
Soil Rate Used / / -/ S Min/121 Drop: 0, go S.D. Usable Area Provided
No. of Bedroans 61 Septic Tank Capacity /Z So gam, Type
Absorption Area Provided By Soo L.F. x 24" width trench
Other
Name C/al�/C / / ✓�,r�,iZ�� ✓�, /�SSAG. ,O,G. Signature
SEAL ,
Address. �3 �/� /rzFi,EGO. /]JZ . y
No. 56124 �C
/vz �'OROFESS1o�P�
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq o f t,% o Checked by Date
fr
Putnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE OWNER APPLICATION -
FOR PERMIT. APPLICATION SUBMITTED TO -
PUTNAM ACOUNTY HEALTH DEPARTMENT
Tb: Commissioner of Health - In the matter of application for
L jc {�OL�N T,� — -- — — — — — — • represent
that I am an officer or employee of the corporation and am authorized:,
to act for ,l'LDA��OC_�1 ��"� ��v�GI�,�1'�i✓ %�,_� L_7`� _
(name of corporation) _
having offices at ,.�C'QU7�"� _ J"2 3 �byq,
Whose. officers -are
President C,j,000o�!4-,,u?7 61-0.5 7-6 -- jj _
Name and Address)
Vice- President IDAV )� C (o G&,9e-j "7 j — G�jQn_/I � -
(Name and Address)
Secretary � } 1� _ GL4 GGO L- %rvt7/ G _-'I � _ /J
(Name and Address) .
— — _ (Name. and Address) .
and that I am and will be individually responsible for any or all: :acts
ok the corporation with •res•pect to the approval r quested and all sub-
' sequeiit ac.tg relating - thereto. -
sworn to before me tYiis L// day Signed _
�_ ...
of 198,' Title
otary Public
ANNE B, COMI AN
Ofty 1-mmul a MW Y**
My C w �"„ "h' ' �
wrote 23 u
RE!1 0 Qja7/
:.887 -' 3
Lj
Corporate Seal
Rev. 3/ 6
YJ�
Located at a/ W
Owner /applicant Name
Mailing Address —L510
PUTNAM COUNTY? DEPARTMENT OF hEALTD `
Divisloa of Environmental Health Services, Ctirmei, N.-t. 10512
Engineer ust Provide
Permit 11 - -�-
ONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM � ��[ `rte
/�L�.., Tax Map �l{ l lock . �- Lot
E'l N lr %N S`f . Formerly 1' m A �C Subdivision Name Subdv: Lot o
Z10 Date Permit ]leaned �y /�S
Separate Sewerage System built by -. Con+57 Address SNUE AS NPA) 7°�
Consisting of % Gallon Septic Tank and
-3 3 l `wa
Water Supply: Public Supply From
Address
or; Private Supply- Drilled by
r
It
Address
Building T 'pe; e7 Baas Erosion Control Been Completed?
NO
Number of Bedrooms lies Garbage Grinder Been Installed?
.
Other—Requiremen't's
I certify that the systems) as listed serving the above premises were conatruc scent
"which the standards, rules and regulaG
1 a ah on the plans of the completed work (co ies
c the filed plan, and. the permit issue y the
of are attached), and in accordance with
Putnam•.cqunty Department Of H 1 /
Date �/ 0- y Certified by
Yy✓t> 1� b
6 No.
Address
L:iconee
Any person occupying premises served b,y" the" above system(s) shall promptly take such action oa,may be neeossory to e6cure the corroction of any unsanitary
conditions resulting from such Usage. Approval of the separate t�Bwe/ g®'fystem shell b" o null and void ba won as a pub,'.: wnitary s?awor becomes
available and the'-approval of the private water supply shall become nu a d'vo when a'
4®r supply l�ec0 avalklbb. Such approvaid are,
subject to :m ificeti n or. Change when, . in the judgment of" the C Is$lo 04 Pt ;sue evocotto modif Ion or change necesaary.
DI Lltg�
Date �QrL' t 7. ey T141e
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 tiv.well_ driller end..submitt to,_Gotirty lea
'analysis ot'watei sampla 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
ADDRESS
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
7- (J .&
PROPOSED
USE OF
WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
El SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING OPHER)
DRILLING
EQUIPMENT
COMPRESSED CABLE
)
❑ ROTARY A R PERCUSSION 1:1 P PERCUSSION E] (specify)
CASING
DETAILS
LENGTH ( feet)
DIAMETER (inches) 177
7
T PER FOOT
�{
z THREADED ❑ WELDED
O
YES NO
2YES
CASING
n
UTIED?
NO
YIELD
TEST
HOUR
❑ BAILED ❑ PUMPED Jr COMPRESSED AIR S G.P.M.
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YI L TEST lest)
Depth of Completed Well
in feet below land surface:
SCREEN
DETAILS
iy
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 LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
DAT F REPORT
WELL DRILLER (Signature)
a,
UNITY STREET AT ROUTE 376 P
HOPEWEL-'!LJU.NCTIoN,N EWYO
22172485
NAME, `i 7-
flA
v 7
SAMPLING-POINT
TREATMENT: t'H'66RIN AT
SOURCE: D'R I NIK-1 N6'WAT_"E
-OU
,NT M.P.N., PER'100 M.L.
PER 10-0 M.L.
IJOUNT M
IT.
PER 1 M.L.
-7
-OU
,NT M.P.N., PER'100 M.L.
PER 10-0 M.L.
IJOUNT M
IT.
PER 1 M.L.
A",
ALT UP 4
_71
-OU
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PUTNAM COUNTY HEALTH DEPARTMENT
Q DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M..S.immons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT -
NAME �.. � N Civ S 1900 G�
ADDRESS �• L� t'�L"� �`-�
-No.. Street
l
Municipality (T)(V),(C,
,MAILING ADDRESS
P.O. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE 'nC J
OR. INTERVIEWED �U t�
Name and Title
DATE 60 .S� I U�2 TYPE FACrILITY
Sheet ..� of
INSPECTION
Orig. Routine
Orig. Complain
_ Orig. Request
Compliance
Complaint_ Comp
Final
_ Group Illness
Construction
Reinspection
FX Sampling Only
ield Conference
Other
INSPECTOR:
Signature and Title
PERSON IN- CHARGE OR INTERVIEWED:
I acknowledge receipt of a copy of this SIGNATURE:
Field Activity Report ..................
TITLE:
TELEPHONE:
7
e
0
PUTNAM COUYN DEPARTMENT OF HEALTH
_ ... _. _. _ _ , ... _ us v ia� viv vi �,►v v u�v ►vrirav trw UrdWJ.Ln ArAL%V 1l.C.a7
der or Purchaser ofc Building Section Block Lot
Building Constructed by
Building Type
S V4��hel #C-C(7, e �.
Subdivision Name
Subdivision Lot #
GUARANI'EE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
wor]amnship, 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 successors, 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 approval of the
"Cert f�cat of...COri. t ri jon= Compliance" for the sewage, disposal system, .or- any_ -.
repairs made by me to such system, except where the' fa lure "to° operate proper y is ~- --
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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 negligent act of the occupant of the building utilizing
the system.
Dat this y of �' 19� Signature
Title
General Contractor (Owned - Signature
/-f' F-! (I col k t��/- �C /6 Corporation Name (if Corp.)
Corporation Naw (if rp-I) '
ess
Address
re �.9/85
mk
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LD
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
f4 A T,
Owner
Located at (Street �lj��' Sec'. 7�q Block c- Lot' ZZ
L $tz
indicate nearest cross stree
Municipality Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
-
Run Elapse Depth to Va ter Water ve7
No. Time From Ground Surface in Inches Soil Rate
Start-Stop Mina Start Stop Drop in Min./in drop
Inches Inches Inches
5001100*/ffo , -7 hAy
2
4
5
2
Notes: 1) Tots to be repeated at same depth until approximately 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 of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
- y ,_�:�.: wm.DE_S_,CRIPT•ION, OF SOILS -ENCOUNTERED, -IN-, E T HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
6"
12"
18"
24"
30
361
42"
48"
54„
60"
66"
7211
78"
84"
0
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
_...., INt7It;A'1'E liEtiE1 ''T'0"-WBICH WA °TER 0�TEL RIBES -AFTER BET
-LNG
TESTS MADE BY Date
DESIGN
Soil Rate Used Pftq/l "Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity 10406 Gals. Type
Absorption Area Provided By L.F.x24" width trench.
Other
gna
THIS SPACE FOR USE BY HEALTH DEPART14ENT ONLY:
�sT2�5Sg O��
Date
Soil Rate Approved Sq. Ft /Cal . Checked b ATE OF N
A9- ErUILt
DI MEN'�oN GkA2T
N"
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WITH ALL �✓'CANt?r°�RO KULES'q KB(�ULA- 1'IONh OF
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