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F I PAT-9-_7;.QF',,CQM RUCTION
jd(�M 1A, CE QK xv _$Y
T 0,
-.06. oi Village
e�
Located..
't�d at S c
'Separate: SeWerage System.:built —by., Ad&eSs :`
Consisting of 00 I Gal. SePtic-,Tarik (I'neal Feet- '..width tr
Other rdil-6ir*
0o ;,W
Water Supply:: Publfr Supply From
S u PPI D
will
ri`st
Building, A dI!flAV
Type 141 f
R Y.
Has Erosion Control Been Compliiteil?,
TNAM',COUNTY.
F
HEALTH
ceqify, that .,th I e.systern( . s)'", . li,itedl'sbr4kig the. b_ constructed eiss6ntidll ..as" own 11 AT-6IetdWWork,( 14 of which are
189VP - hq
.�".p!,e,pr�T.ises�were con
-witfilf6'it'inclards, rules,and"JeS14"
atta'ched) "And In act`ordande�' requ n,w PU 4 eIii im6nt of Health.
7ZA,,
57
Date' P. E. R.A.
Address,
ses:served'by the above -system(s),, e r to je Zorre'c_tiq`!_1�:qif-, -any unsanitary
Any person occupying prerpi
babe "
:c6nd1148ni�-'risLiftilng' t rom, such usage A p of SvS ff 2AUQF "P6blic,sariltaiv sewer becomes ,
available and the
ap, p rVV. aCof'ihi,-Jrivate TO
106
UbJ6 0 oa if i ca t ion )r I 'fjldgmenV`of suc
0
oats , 7*: By
approvals are
mv cqan 'o'r,chahge Is*nece'ssary.
'T It le
el
weer or Purchaser o l* Budlding Mun ci p al ity
-,u r ng ` • Construo,t6d by Rection -'---
Location - 3tr—ea ' o Block
u n-g 'Type 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 eonst'r4eted 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 repai rs made. by me to 8ucki 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 dp,
termination of the Director of the Division of Environmental Health Ser-
vices 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 oaoupant of the building utillaing.the system.
'this�'�_'day o1' - -19 wSigna.ture .. _..._..._..._
Title
corporation, give name
and address),
THREE (3) COPIES ARE REQUIRED WITH THR.JaE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETIGN WILL BE ISSUED.
GUARANT9R S R4qUjRgP TO EILE NOTTC9 2f W9 QF FIRST USE OF SY�.
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Health.
TOWN OF PUTNAM VALLEY
WELL DRILLERS MG ANb. REPORT _
.. _ ... .. ...... ... . xT.s •.. - . -tee-. x. __ .ate ..¢bw ..i! -. a < ♦ r,o•P -Vry � - WELL COMPLETION ' REPORT
This report is to be completed by well driller and submitted to
Bldg° department, together with 'laboratory report of analysis of
water sample 'indicating water is of satisfactory bacterial quality.
Well Location ��� �%%� /D�r,� /3/�/�//� ��� 7 c"Y
Tax Map Street Sec. B1. Lot
Vle.;.1 Owner.8/r,8292, q� Alovr ��/9 N. I'*
Name Mailing Address I City-..6r ToWn
Tel. #A2 V` = V)a�
Well Driller�LS��
Name MailizZf Address. City orTown
CASING, DETAILS
YIELD TEST
WATER LEVEL
SCREEN DETAILS
Length Ft.
Bailed Measure from
or
and surface)
Pumped Hrs.�Statics
Ft.
Makes
�J
(
When Bailed
_ Slot
Diameter: Inches
Yield: GPM
or Pum ed Ft
(Len: th ' ;':'" Ft e- Size
shale, sandstone, granite, etc. Include size of
gravel (diameter) and sand (fine, medium'
�
°
Kind ° �
{
� �
D eter
Date Well Completed %���•�� Date of Report
Well Driller
Signature
BZS 1 -77
Qt Ij
TOTAL. DEPTH OF
v r;
WELL Feet'',j��� . �, 3 I
WELL LOG
t'UiNA'sV; COUNTY
Depth from
Give description of formations penet ,r s` '
Ground Surface
asi peat, sil:t9 sand, gravel, clay, hardpan,
shale, sandstone, granite, etc. Include size of
gravel (diameter) and sand (fine, medium'
color of material, structure, (L^ose, packed,
cemented, soft, hard,).. For example: 0 ft. to
27 ft. fine, packed, yellow sand; 27 ft. to
Date Well Completed %���•�� Date of Report
Well Driller
Signature
BZS 1 -77
Er
3. -00
Zoo
c)
GALLON SEPTIC TANK
LF X-ABS. TRENCH
Ci -
17
13
2
3
/0009 a r7 J1
.,4
7
-3: Z
R
12 91,
1/0
!3 0 731
4 wy
7j 2,
4
I
170 23
-511717,9
1-3,10 2
AS CONSTRUCTED
SEPARATE SEWAGE DISPOSAL SYSTEM
TOWN OF o 4
COUNTY. hEW.YORK
DATE I SCALEq5
_.:CWW.,j JOB NO.7 /r
.5V P_ F4- FE-SULLIVAIN - VMOIIIIE�
CONSULTING ENGINEERS
NEW YOR
A I
3(5'
7L ithA
APPR..............
, �l I
OF 4
..JUN
.17
OF
sp
4
I
170 23
-511717,9
1-3,10 2
AS CONSTRUCTED
SEPARATE SEWAGE DISPOSAL SYSTEM
TOWN OF o 4
COUNTY. hEW.YORK
DATE I SCALEq5
_.:CWW.,j JOB NO.7 /r
.5V P_ F4- FE-SULLIVAIN - VMOIIIIE�
CONSULTING ENGINEERS
NEW YOR
A I
le
PUTNAM COUNTY DEPARTMIEI�1'I OF ;r�LTH ,
Dwis!on, bf En-*6o rno f, Hea %th- Services, r ol, : r 'Y ,1iQ -P2,
CONSTRUCTION B,EiRMIT 'FOR_S_f;WAGE_'DISPOSAL SYSTEM:
_ Town or village
s
S4bdivision
�i✓ >
owner
/1 7
3
Bu�Itling Type Lot
Number ,of "Bedrooms
Separate `'Sewerage System toy consists of r R a
To be, constructed by -
'Water 5ply 'up Publlc, Supply From t- .
y F S �.
,,
IR !Cat., pply to be idr.illed'by
Other ';Requirements
I represent that I;:am wtf6lly and completely responsibietfor the design and
above described ^wall1be constructed as showh on the approved amendment'
Gounty, geparYment of 'Health;`,and it•hat on completron tiliereof1a 'Certil
tie submitted to the Department and a tten {guarantee well beAfurn
place yin, ;good o,peratmg conddio'i any part ,of' ,sad sewage disposal sy
anee of ;the approval of „=the 1Cert ficate -of �Constructlon iComplianie zo;
County Depart eht xo_f, iHeaith
APPROVED FOR''- CONSTRUCTION Thls.approgal� expires o
revocable for -cause or ,may be arriende. or iinodlfiedm0en c_o "_n-
requires a new, permit . i Approved for 'disposal _of- ,domesY'ic
Date. -�� BY
z
Sect,ior �� Brock 2--
t, Sys
Lot L - Job _
—�. !Address °_ _
J% lam. 1Lz
t -,Y
A, lx Total Habitable Space �-�- O - 7square Feet
Sep �c Tiank� -� lineal feet?X� — ,kwidth trench
. , 3 Y
J Address
F a
� n
ion It the :proposed systerji (s); 1) that; the separate. sewage disposal system
te�,of Co.nstrucfonYC�Qn1�A�dYy tisfactgry,to the,Commi ;sionerof Healt`hwill
eC the towner his:. cefor3�4idliC signs by the'bulld'er,, itliat said builder will,
'% rb� media'teVV ,fo.11ow:in g, thCclate of dhe :issu-
;inaduring h_,pif@ �:$,-,� r- �_Y 9
hec ,p !npj sys�6�ry .. _ i r abo.Ve
�,��jr� reto. )that the drilled. well descriibed.
ed to accordce d r a, , l , r and regulations of t;he Putnarn
B:E RA.'
o.
he date issue8i,lEis st e. building, has been ,undertaken and is
fyyby t _ ; , i�Qw�ybr y, change; `or ,alteration of nstruction
je a or 'pri' t atQ� L
y R -
ltle