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J a F '" _,COUNTY
Division of Envvonmenta/ h
X1,1 a
EPARTMENT OF
Ith Services Carmel,
3EALTH
F . ' Town or y�l la? e ,
Located a4 Sectio - t Block`
Owner Y Lo Job
CA
Separate Sewerage System, built by 4 Address
Consisting of GaIL Septic Tank q lineal et width trench f . G.
'Other requirements ' �� • vim. a'
jr Water Supply Public Supply For - _
Prrvate..SuPpIY D,rilled.:By ,
ddress r
} -
f Building :Type No: of Bedrooms - Date Permit Issued
" Has, Erosion control ;Been. Completed' -
I certify that the system(s), as listed s yr ing'the above,premises wereyonstructed essen_ti shown oq the plans of he_ completed work (copies of which are
i attached), nd in accordance with _the standards rules and regulations plans filed, he permit issu by Putnam County DepartmeHealth.
i
Date C - tified b P;E. RA
# Address Y , r ° s License
F1ny person oc ying .premises served by the abo4 systems) shall; promptly. take such actwn`as may be necessary to secure the - ,corre ny unsanitary
! conditions resulting from. such. usage., Approval of the" separate ;sewera §e system.stial4become null and void,as soon 'as .a public sanitary sewer becomes
-. pp P Ply becomes available -;,-..Such-,, Approvals are
available and the a rovaf.of the nvate water supply shall .become. null nd, oid 'when a public sup
subject''to modification' or change when' iin the judgment -.of the :Co fission o HealtFi; -such evocati modification of ~change is necessary
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( Pates° gy Title
Co
;PARA►SIT4LOGY VIROLOGY 4, � `''
LL �B�►�TERIOLOGY
�
ANTlBlQTlC aUSm = <-n
#
SOURCE OF';MATERIdL p ;REQUEST
_ ,
❑, Blood 3 ❑ SMEAR > CULTURE
❑Sputum � ❑Routine -� `. � �U m "�F ,� �� ; �V
i
❑Nose � �:�` ., _ , _,� ❑ T B °
� - ; � ��i y`.�,� > � � 3
p Throat :" ❑Diphtheria '..>
—
❑ - Spina - F uid !- ❑ Fungus
n
v
❑ Feces � ' ❑
3
_
❑ Pus From _ - r ❑ F I;
Other ..
PUTNAM DIAGNOSTIC LABORATORtE5
[],,Ova and .Parasi #es
.
_ . Q VIraLStudies = ,,
- "- 1U STONELEIGH A1/ENUE, "= CAFtMEL N Y -;
7.7 SENS
RESIST:!
'
❑ SENSIThVITY , _
STAPHLOCOCCUS
❑- Aerobaeter-
h- hlorart►Phenico_F„ =:• - : :-
; ,
`Non- Hemo.- COag...To,.Follow „
13-,Corynebacteriuln
°olistin Sulphate.
p_ H @molytie Coag aTo.Eollow , . °=
❑.;Eseh6rik is _, •
= Declomycin . 'a=
=-u Coag _ Positive;'
❑ ICt'ebs eR
Dihydrostreptom'
O " ' �Negafive" x ` -'❑
ParacblO;_ Bact _
s`E- throtriycm _ f `
;� .
STREPT ,COCCUS; HEMOLYTIC �_;.:..
p:Proteus x
;.
-- eomycm _ i `'
`,_"
C] ".Alpha . ;(� Beta -' ;0" Gamrila`..:
❑ °Aseudomonas ='' ..
—'N itrof ura htoi n ,;`
❑ °Enterococcus -, _ .Enteric <Path6g" "ens
&Oxaeklr
❑,.Pneumococ6ke .' +- ' _ _ Q'_Found` ,
analba `
[�;Neisseria i [(..Not Found -€ '
F„ enicillin �� -r °• ;
-
Q,Hemophilis' - _ _
7etracy re - . -;.- t_: r.' >.
, ;
;TUFlERCULOSIS;SJVIEAR = :. T.UBERCULOS„ 'CULTURE ,
7riacefyJoleandomynn ` `" .
_ ":,`;
❑' cid :Fast - 'Mot -Found,- ' ' p Neg' ar Acid Fasts '
=-
° =Ampicil Fn_
° cid'Tast - Found .0 Pos. ,
( ;Smears Routine Nag : E O & P_ Not Found = ,
(]•,Cu tures, ❑ - ACV P qx�
os;t- — For
_�A-om
fi.
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TOWN OF PUTNAM VALLEY
WLLL DRILLERS LOG AND REPORT
WELL LOCATION/ 4"
�1.foe ,��. /� r. c . C mss.•
street section block lot °±
WELL OWNER,�FA/ais .f. �.41A.1 /Yaf urlcyvlE� .611w6ES,
name address city or town }
WELL DRILLER C) 2 Avoy . ^���vrEw Vt. j(tEuvST -�.
name address city or town
MING DETAI
EL TE
TER VE
DETAILS
Lerigh:
feet
.Tailed
or
Pumped H
easure from
kc
. Static 0 ft
d surface
Make: 0 o 0 r--
Diameter:
Inches
Yield: (b GPM
e-r a1 led--
r Pum ed ft
of
Length Ft Fi ze
Kind: 101
1„g
Tes-T
Diameter In
TOTAL DEPTH
OF
WELL
Feet
Depth From Give description of formation penetrated, such as: peat,
Ground Surface 'silt, sand, gravel, clay, hardpan, shale, sandstone,
ranite, etc. Include size of gravel(diameter and sand
_ finey._medium, course), color of material, structure
(Loose, packed, cemented, soft, hard):(Ek. Oft.to"27 "ft.
fine packed, ellow - sand 27 ft to 1 4 ft gray granite)_,
Feet to Feet ormation Description Sketch exact loca ion of well to
,. ('L_ at least two ermenant Landmarks
,
;1
Date Well Completed Date of Report
'Well Driller��
signature
F "
k
f p\
Tn
Y ' .. l ;�� i k ACS � • t f _
!moo' �.� ���k� C�O/�!.•STi'��C?~i����,� i�
A $'�,
ROV'E"
p
A
f t p ✓ fir' �
nnn
r
is$!,A' ` 2 7
r { - ` 5 - 4L,
t
,,rf iu HEAI o
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9'
D; R, DIVISION OF
f.
Yh-✓ -) �+
ENV Eroral HEA114 SE1R1NtR
k�p 15#0 lee
�*
r,
9
r.or Purchaser of Building 1juni clp41ity
ovvr .e r
Building Constructs by
�ak O
Location Street
(�'� 4("? M PQ
Building Ttrpe
Section
Block
!:_ _C5
Lot
GUARANTY OF SEPARATE SEWAGE-SYSTEM
I represent that I am ' and 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, 4V Z
and in accordance with the standards, rules and regulations of the Putnam
County Department of Health, and hereby guaranty to the owner, his succes -f,�,'a
sots, heirs or assigns, to place in good operating condition any part of Q
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. o'f the'Putnam. County Department.- o•f•Health as to whether or -not -the =
failure of the system to operate was caused by the willful or negligent
act of the occup //aunnt of the building utilizing the system.
Dated this /_• 'day of 19 -) (�rSignature, A .
Tit!
If co oratio give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP,ETION 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
44 s'Y�
. /f /nom,
REVIEW CHECK SB r,T
DOCUDENTS
House plans O.K.
Design data. sheet_______
.a
�d -s -3
Meets Std. Remarks
es No r
Peres presoaked?
i
10in.t 3011 perc test depth --
Const. results for 3 runs
(�-
D. Hole log 0. K. M
`� ✓
i
Corporate Affidavit for other than individual i yg,
i
Authorization for engineer
I ✓
Letter from Water Supply if applicable
I 44 ®.
{
If variance requested -such noted on plans '& apps.' AW
_
DETAILS
if charge is proposed,)
Existing contours shown show new contours)
.Slopes for driveway cuts., etc. shown ^
�
Water service line location
Footing drain, etc. location
Top slope, bottom slope of fill
Percolation tests and deep test pit location
; f
Septic tank size and conformance to std.
3 B.R. house minirmLim
✓
I
House setback shown
1,•- ,�',i•i 17111,l�)�! 41i'j1. 1.!_ tyw _41J'iJ:ii
Wes, l,t',J.' WL t,i AA1 )l/ J_ 1, < VJ. •1:.1.,1 z5 V W 11
Plan, and profile SD.S... _ ........:.. ................... _....._........
_.. ✓ .
All othez, wells and ADS closer 200'
shown- o -reference rrade
Property boundaries (metes and bounds - clearly
- - - - --
shown]
! ✓ i
_
- -----
SEPARATION DIS`1`ANCES SPECIFIED ON PIAN'
10' to P. L. ! !
20' to Foundation walls
100' to Nearest well i 1
50' to stream, march, lake, etc. incl.expansion)i ;
15' to Curtain drain I _!
10' to water line (pits -20' ) I �1
15' to storm drain
10' to large trees r ! I
10' from foundation to septic tank I i I
5' t o .pipe from leader drain & footing
f�urnIn d
FIELD CME LIST
Date.:
,8e,"
Insp
by _.
.. r
INITIAL SITE INSPECTION
Yes
No
Comments
Property lines or• . corners found
Can estimate house location e . , ,
_ ✓
Will driveway need cut . . . . . . . . , , . .
-
Must trees be removed -note these
Is deep hole representative of entire SDS area
Additional deep holes needed. . . . . . .
�
' ~�
erne 9e,
Sufficient SDS area available considering
driveway cut,, house location, separation ...
distances, etc. . . . . . . . . . . . .
DEEP HOLE DATA
Depth:3�.
Water elevation: NvN6-
Rock elevation: 3'
Soils ,descri tion:,�-
,
Date:
- -..
FINAL SITE INSPECTION Ins p. b
House located where shown on approved plan.
SnS loc..a,ted t.There a -nproveA ,
Width of trench averagev�
Slope of the line and trench acceptable . . .
Room al1_owed for expansion trenches
Over 50 ft. from swamp,watercoUSSe
Natural =; s.oiT :J"' " - 'stripped or SDS ;area:
unnecessarily graded . . ,
10 Ft. maintained from prop.line and
20 ft. from house . ,
Separation of trench from house, well
etc —follows .follows plan . . . , , , . , ,
.Number of bedrooms checks . .
Stones, brush, stumps, rubble, etc. greater
than 15 ft. from nearest trench . . . ... .
15 Ft'. of peripheral soil horizontally from
trench . . . . . . o
Junction boxes prope_�ly set
Could surface run off from driveway, roads,
ground surface, etc. channel near SDS ,
area
Does lot drainage annear O.K. in area of SDS
FINAL.GRADING OF SITE ACCEPTABLE
PU`1'NAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENT -AL- HEALTH SERVICES
Date (v /�� 73 . .
Re: . Property of -
' Located at
Section _Block Lot J
Gentlemen:
This letter is to authorize George A. H ujjftey
a duly .licensed professional engineer_ y: or•registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with tnis matter anct to.supervise the construction of said
system or systems in conformity with the provisions of Article 14S or
14.7,.. Educ_ati,on..Law,,.: the Public Health. Lana, and the .Putnam County Sani --
tary Code.
r ivy °.j,,` Very t
.c. ,• Signed
Telephone
IV.
Countersigned:
Cv'•. ?• o H�
P.E., Rr, #
may•. o, , .��
f
�4eve�a►i?t�'`'
Dykeman Rd.; 27 Rohn' Drive
Address
Carmel, New York
CA5 -9353
Telephone
Telephone
IV.
PUTNAM CO.UNT7f DEPARUM, TF OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CA_RMEL,�iN.'Y. : �~1�12r.
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM . FILE NO.
Owner 0 EN N IS M el oil /°ff Z Address s /eYV /Ew e*77, ors
Located at ( Street t.f.Ys�s'wo.re .eo.a'o Sec. Block _Lot
(Indicate neares cross s roe
Municipality, 84172Vs� Watershed /I/.
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
4 ..
5
1
2 -
3
5
Notes: 1) . Tests to be repeated at same depth cii:approximately equal soil
rates are obtained at each percolation tee_- hole. All data to be submitted
for review.
2),. Depth measurements to be ::de from top of hole.
o e
Number CLOCK TIFF
PERCOLATION
PERCOLATION
Run Eiapse
No. Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
a er ve
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
1' 9:
2 y�9 : s y
s
�y l
,� i
—,Z<
q 5y.
9 59 /0..
S,
29
5 ly"*ay /o: 04
2
4 ..
5
1
2 -
3
5
Notes: 1) . Tests to be repeated at same depth cii:approximately equal soil
rates are obtained at each percolation tee_- hole. All data to be submitted
for review.
2),. Depth measurements to be ::de from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTrED WITH APPLICATION,
DESCRIPTION OIL' SOIL" E NCCUNTERED . .TEST HODS
DEPTH H07:.,.NO:
G.L.
12"
18" Fu� eA /T
2411 GOBI
30«
3611
42" a
4811
54 C,I QG�
11
.60" '.
66"
72,E
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
.MICATE: -,LE L. TO. WHICH �rdATER
LEVEL ISE� - =A TER°..BEING...ENC_OUNTERED walV� _
TESTS MADE BY /= /� .� T k �� /(o��.� Date
DESIGN zt
Soil Rate Used Min/1 "Drop: S. D. Usable Area Provided �doo
No. of Bedroorns 3 Septic Tank Capacity �900 Gals. oo � ..,
Absorption Ares, Provided By u -�?��I " - � ����� Nic�t.K''�tre�c h. '
Name Signature - -` 4 541 ', m. - I
i
Address SEAL
dell
THIS SPACE FOR USE BY PEALTH DEPARTP ; T ONLY:
------ ......
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