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02201
i F� f. F,S«OF t'< C{_•.r� 1 \./ , '' M r
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F PUTNAM COUNTY DEPARTMENT OF HEALTH
;t
x Division .of Environmental Health Ser'v'ices Came% N Y..10512 ,
f .. - ,
T CEF-T,IFICATE OF CONSTRUCTION C011APLIgNCE FOR SEWAGE DISPOSAL SYSTEM �p[rieti OF 84ITA/.59 !/i�lL6�l
r Town or Village
l �/Y/4 � ®Cfll�I 1ye ��.,. a
F Located :at / a Seism
r .Owner ��TE e� c ° Lot. �r5' " Job'
Iy Ida Address �j r
' Separate' Sewerage System built by S N •. - �� '� y
r�' y Consisting of$ f Gal Septic Tarik� ' - *� "• ,lineal Feet ;:X w` �� /! 'width trench
Other (equirements: `��J'�Y �l�vo tle� o L
If f f 1 '%j T 'SLC a, x l ,, ♦ 4
+ Water Supply Public Supply From a ',
'Private: Supply Drilled By*-:
y .l
y' Address s!fia;
i 8wld�n9 Type
4 r NO ofyBedrooms' �O 0 to .Permit Issued
Has Erosion Control Been Completed?
a
t
J L S v .•r� EU 1
- .: •- •:� . '.:
r} 4 certify that the systems) as listed serving the above premises were constructed essentially as, shown•on he plans Ofet�da s `of which are
r ;:f' nd'the" er It a i d nE of. Health:.'
attached) and in accordance with the standards rules and egulations rplans it a p i d y �.
I •Date ✓GOlI<(s sZtS ���� "" ertified b v S `1
,� C •PEA RA'
7L Q
tttt
'3 1
Any 'person occupying ,premises served'byRhe.abovesystem ( s) shall promptly take such action as may be neces t l�►te;t13corre� of y unsa
• a a t
L Hilary,.
{ rr "
conditions: YesuItIng from such "iusage ' Approval, of `the..seppM. a sewerage system shall become null and void 'a l��u l$� r wer becomes
available arid' the approval of the private water, supply shall become null aned void when ,,a' .;water su s '1 'approvals are
i
"subject •to modification" or change when, in the ::Judgment of the; Commissioner Health, such fe`vo n mo oi; necessary.. `. ,
' t r
t. L -'Date r•�i r 3 By Title
PUTNAM Co UNY DEPARTMENT ,OF -HP-ALTH
Division of Environmental Health Services; Carmel, N. Y.: 10512
CONS_ TRUCTION, PERMIT F:OR:_SEWAGE DISPOSAL �SYST! lyl s ily w, yy rT ' ,
r ow II$ger
.:Located at Yz;�I T'°
d1 norVi
Subdivision
_ Section Block
% xis Lot i Job
} . .
Owner Address
Lot
Building Type -
, •Area
Number, of Bedrooms :Total Habitable�Space Square Feet
Separate Sewerage System to consist of Gal Septic Tank' '' lineal feet X width trench
To be. constructed by
Address -
Water Supply : - Public SuPp.ly From
Ply
Private Supply to be drill ed by �•�:' r (atk
:Address t.z' w.
other, Requirements-,
4'X y
I, representahatl am wholly--an dcoinpletelyre for thedesigriand location of °the proposed ',.`system(s)•'LL1) that -.the separate sewage . disposal system
above described will be constructed as sho amendment there to and in accordance with the standards,.rules and regu a ions o e Arnim'
County Department of Healfh; and fa 'Certificate of "Construction Compliance" satisfactory to' the Commissioner of Health will
'be submitted to the, Department a Au a be °,furnished the owner -his'successors heirs'or assighs by the builder, that said builder will 1.
place in good operating condition of said s' oral system .during the. period of two (2);'years immediately following thedate 'of the issu-
ance of the approval_of, the Cdr C n ce of: the origihal system.or any repairs thereto; 2) "that the drilled well described above
will be located as -shown on'the ap a W 8 installed in ,accordance with the staridards,.rules and 'regula i� ons of the Putnam
County Department of Health, v s
Date
~� P.E. R.A.
Ad ss License No.
a �
APPROVED FOR: CONSTRUCTION. oya$�tic Ke ear from -fhe date issued unless construction of the building has been undertaken and is
revocable for cause or maybe amende o®' i� elf ed:nec essaYy by fhe Commissioner. of Health Any; change or alteration of construction
L. requires a new" permit. '• Approved for o tary sewage i4jq;_ prwate water'supply ;only
y ti
Date 4
* �.z; Bye° Title
YO RKT OWN MEDICAL LABORATORY INC. 1845
P.O. Box 99 321 Kear Street
Yorktown`Heights, N.Y. 10598 245 -3203
DATE COLLECTED
RESULTS OF ,EXAMINATION OF WATER
OWNER DATE RECEIVED
-PFIP'F,R DR LTICA, ROARING BROOK LAKE
CITY, VILLAGE, TOWN 6 /OR NAME OF SUPPLY DATE REPORTED
PUTNAM VALLEY, N.Y. 8-23-71
SAMPLING.POINT
TAP
BACTERIA PER ML. (Agar plate count at 350 C).
COLIFORM GROUP (Most probable No. /100in1.)
Less than
. HARDNESS, TOTAL - ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg. /1.
These results "indicate that the water was Yes of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASGP)
• I
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Bu; _di n.7 Cor_s -uc d by
Location S.u•re,z t. Block .
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Men v 64V776(, • . ...
:Building Tl -pa Lo
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location, ,:� nJ_� - J _.0 -�J :_'_^� J �.�N� �: ��..v_'.J :_ •�~� d_'!__ -r v- J� � J°. S. �s.°
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Division o En r e n t l L °?1 'a Se" "'iC83 u Inam i3Ou ✓°jar -4 ent J1' 3a�
I
WELL DRILLER, f S LOG-° AND REPORT:
01.1e
Welu.at . . . . . . . vie ty-,
-, oun
Name o;KP14qe 7 1 t
.001w,
P'- 0
-�.A.Diameter"It
asi=,
YUId n lv
-.ectdd?�
Um.
1,T
•
Amt. of 9 above' Below'
in, p*dck6jr; 7emen=grout
i Draw a well diagram in the:space provided below and show.the depth of
casing, the well seal, kind.- =and thickness',,of formations pen6trated,-water
bearin formations, di ameter.df drill holes with dotte d lines and
,
casings)
i1th.--sbi-id.-I.I.n
'tttt DIAGRAM
FORMATIONS PENET RATED., REMARKS.
,
�;6 vt P
IDiameter. in... DD&.t1i__
in ft. if wat'e'r beat-ing! Drilling method.
W as well dynamited'?
. j
25 TESTS
Detdils #2
static water
50 below grade.
in rate
�.. ; f' " °•75 k .,�� in - g4i P m#
Pumping level in
M,
'Dilrationbf
10 Y
,te s it hts-jr,-
0
_4_ WA-TER --A-T.- .TEST.:
ole'dt Cloud9 Turbid f
l5Q :Recommended depth of um p in
we.1,11 j, feet 6 elow. ,grade
WE, LL,S... IN SAND, & GRAVEt:.
200
7' 7
-Siiiia'Eff j . size nm
Uni 1i -Caef..,
am, .
Jr. 1"; .... ......
..Dian __of.- -screen
250
Type' of screen
Screpn. open x„ .
:COMMENTS
Draw a sketch of.the property
on the back ---of 'this 'sheet Drilling started Completed '7/''
p e
locating the welland'-sewage
disposal,
ri
.'bignature
_.�. .. _ ':4v .ti. � t:.i i - ' ,F } uT!'t'•ti i3 ? ]1 Y..Y 4 -: ti+5 -R fL i 'r , .y. _ ...
;4i1ELL :LOCATIONSNETCH''
Draw a sketch shoring out ire ,of pfbperty9 general slope. of k
ground,y locationtiof structu9res� roads, ditches, watercourses, wooded.
areas, swamps, porads, rack ;out6r6ps sewer 9_lseptic tanks leaching
systems for secrag�e2, test holes 9 we11s and springs o .Give dare.ctions .
and f distance t:o nearest cgmmuni'ty
..� 4
t t i4
� _? `• -` _ . � 1
,n a ._ .,
t( -r
• r
� 1 1
t 4 + p`
"
a. .
4
�i7
OU1
71
Consider. space between .lines equal to 25, 50' or 100 feeto N
,, of,, page , North...and draw sketch.,,acc•ordinglyo '��
VUTNAM LUUINTY ULVAXTMENT Ut' MhAliTh
DIVISION OF *ENVIRONMENTAL HEALTH; SERVICES.,
.:..' DESIGN ..:DATA -SHEET' LSEPARATE: SEWAGE DISPOSAL;' SYSTEM FILE N0.
L G.s 7.
�
R . .... u.
Owner C; c- i p - 6 Addre's's t
_L0. 1�
Located at: -6 Blo'*ck I LotS 7- C
(Streetl im� C= e, -V:� "4
(•ndicate nearest cross street).. •
N#_ LIE Y
Municipality Q r- v. -T %Z bo-A Watershed
PERCOLATION- TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
�tV= MJNP (!>IF V-2 c) A 6 t o G L, A. r c=
F IES k'a t Ct.4 Ct %..G P
Hole
Number'. CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth.to. Water Water Level
No.- :From Ground Surface.'in "Inches Soil Rate
Start - - Stop. Min.. Start.. Stop Drop in MirVin. drop
Inches. ..Inches Inches,
P ko S <F:)x S s A L_ Ta k IE7 .2.3,
2
V,, A\) e L_ T, kz C__ I is 6.Y .3 L_
S e T L e 1P
-.4 .
5
2
4
2
3
4
5
Notes
1) Tests -to be repeated at same depth 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.
72'?
78"
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED �` Io �✓ �':r ,s � = G�
INDICATE LEVEL T0. WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED fz),.
TESTS MADE BY � j) ', v T- c Date C7 " 7 v
DESIGN
Soil- Rate Used �� Min/l" Drop: S.D. Usable Area Provided S�000 t T7
No. of Bedrooms 3 Septic Tank Capacity 4 0 o Gals. Type &-k NS C,
Absorption Area Provided By �4 a L. F.x24" 361'__-Z width trench. Other
- ;-z H. s. � d �Name @'.6Si nature
Address UI�l1'�,H TN!EDE ° s s� IF
y 1tLlRA PLACE
f1f e
PUTNAM COUNTY DEPARTMENT OF HEALTH
2489 °e°
0
Soil Rate Approved Sq.. Ft. /Gal . Checkec���Fs+ loc��;;�. Date
I