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PUTN- M COUNTY DEPARTMENT, OF HEALTH k
D /V %S /On of` Env�ronmenta/ Health Services Carme% .7V; Y 10512 , '- ` _ ; }
CAF CONSTRUCTION,_
e,
s
Ow er or Purchaser of building Municipality
_.arum y.......,. �e.>_+-a .pe. "..— .ysy.�. -�. �.� .�. �.... -.r -..y -, r.. .. =�v. �s..•.W- �.a�:«•y =oa��r ._w. -� awv. .AT.. -� .. .. r.r � _. ..n .. r. :�..�rW'�a��e
vc _3b
Bullhing Constructed by Section
Location - eet
Building Type
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',)s.hown on
the approved plan or approved amendment thereto, and in accordance with tlgNstandards,
rules and regulations of the Putnam County Department of Health, and hereby"guaranty
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 initial use of the sewage disposal system, or
any - repairs made.kby me to such system, except.where the failure to operate properly
is caused by the willful or negligent act of the occupant of the building utilizing
The undersigned further agrees to accept.as conclusive the determination
of the Director of the Division of Environmental Health Services of the Putnam County
Department of health as to whether.or rot the _failure of the system to operate was
caused }�y the willful yr neg3igent act of the occupant - ofd :t--he- baitdirtg�Zrtil�,z rjg aloe
r
Dated this day of ��;r 19 Signature
,, Title (S��'let7�:,1
mar e�- .: ----
EA -P.IL c0� ,tea , jeovc' oTo (if 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..
—..-- ----- -------------------- rM ------.----..------------------ ..---- --- .-- -- - - -. - -- ----
Division of Environmental Health Services, Putnam County Department of Health
PEEKSKILL MEDICAL LABORATORY
1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1
Peekskill, New,York 10566 ---PE -7-8777 .....
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER
. . p-1- ?q
OWNER a k 1I,,
DATE RECEIVED
Afw
CITY, VILLAGE, TOWN VOR N OF SUPPLY DATE REPORTED
I-11 I& ev-7 14
SAMPLING POINT I I
BACTERIA PER M . (Agar plate count at 350 Q.
COLIFORM GROUP (Most probable N6./100m1.)
HARDNESS, TOTAL -ppm
DETERGENTS-ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm,
11 L.UUMIL)t; (k, ) - mg./i.
These results indicate that the water was Vrz of a satisfactory sanitary quality when the sample was c : ollected.
#ULff'1V0&vJNr, FA.T. (ASCP)
WELL "COMPLETION -9EPORT PUTNAM COUNTY DEPARTMENT Or HEAM,/
3171 Division of Environmental Hualth.Sorvices
• COUNTY OFFICE [BUILDING - CARMEL, NEW YORK
This report is to be completed by well driller and Sut'rrutted to County Health Department together with laboratory report of
"''""" °"a�sa9�sisdF"�' titer' san' ffsic" ri�t�rr; �atlYtg °watCr-ssrofsatis'Fac2Ury" bacterial' qt ;aiey °l�ei,�re-ee�- tifiicate -of coristru�ti"oi=corr,pliar+ea i�•issued :� �
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
J`rr:P EN L. MAKKAY
ADDRESS o
144 ARBUTUS ROAD, PUTNAM"VALLFFY N.Y. 121
LOCATION
OFWELL
(No. A Street) (Town) (Lot Number)
PUDDIM S'rREET,.ROARING BROOK LAKE, PUTNAM VALLEY 10579
BUSINESS
C� DOMESTIC ❑ ESTABLISHMENT El FARM ❑ TEST WELL
PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
PROPOSED
USE OF
WELL
DRILLING
EOUIPtAENT
COMPRESSED j ] CABLE (� OTHER
❑ ROTARY AIR PERCUSSION 1 J PERCUSSION ' I (Sne:ify)
CASING
DETAILS
LENGTH (lee!)
201
DIAMETER(inches)
6 If
WEIGHT PER FOOT
15 C THREADED ❑ WELDED
DRIVE SHOE
C�O YES ❑ NO
WAS CASING �ROjU1 f
C#7 YES LJ NO _
YIELD
TEST
HOURS G.P.M.
l
❑FAILED ❑ PUMPED COMPRESSED AIR 7•a 15
YIELD (G.P.M.)
r
15 .
WATER
LEVEL
MEASURE FROM LAND SURFACE — STATIC(Specily feel)
DURING YIELD TEST fleet)
Depth of Completed Well
in feet below Land surface: 1701
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches)
FROM (foal)
TO (toes)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
1'
.101
hardpan
!,i✓'�/� —�'"�
101
170'
bedrock- granite
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED PATE OF REPORT WELL DRILLER (Signature)
3/20/74
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REVIEW CHECK SHALT
Tf HOWARD, �4. KELLY, JR .
!Meets S td.
-os
Remarks
AS50CIATES
o
i
:-DOCUMETdTSnhI.GINEERS. PLgfJNERs
House plans O.K.
✓ +
Design data sheet
! i
Peres presoaked?
'
Alin. 30" perc 'test depth
Cor_st . results for 3 runs
D. Hole log O.K.
,7 i
Corporate Affidavit for other than individual
Authorization for engineer
Letter from Water Supply °if applicable
NA_ !
If variance requested -such rioted on plans & apps.: n( AC i !
DETAILS
I
-
if change is proposed,)
Existing contours shown show new contours)
✓
Slopes for driveway cuts, etc. shown
Water service line location
ir.Ik
Footing drain, etc. location
,/ f
Top slope, bottom slope of fill
NA ! i
Percolation tests and deep test pit location
Septic tank size and conformance to std.
; ,!
3 B.R. house minimum
House setback shown
!
_
L1D u1 "_L u LVl.l {JV1L. 1 1� ._...1J Ci1VW. frost
.. .° _. .. .
All water within 50 ft. of PL shown
I
Plan and profile SDS
All other wells and SDS closer 2001
I
:Or, re-ference-made ,.... ......_ . ,. .. _- .__...�:......_'
_� I
`.
Property boundaries.(metes and bounds- clearly
shown ~!
..._
SEPARATION DISTAIvCES SPECIFIED ON PLATv'
+-
10' to P.L.
20' to Foundation walls � =✓" .: i
100' to Nearest well
_
50' to stream, march, lake, etc. incl.expansion
I !
15' to Curtain drain
VA
10' to water line (pits -20' )
tlA
15' to storm drain
10' to large trees
. 0' from foundation to septic tank
!
5' to pipe from leader, drain & foc ing rain
-- ± ----
--
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re:.., Property of., ..�TEQ��3 AE�(CAt�.
Located at Ca h. fZ l t-lcl _cot , ?ODD f Qa t �� P- F-�
Section V34 Block Lot
Gentlemen:
This letter is .to authorize W,41Z %� . l� E LL �J i
a duly licensed professional.engineer_� 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
De.partment.of Health, and to sign all.nece$sary papers-on my.behalf.in
connection with this matter and to. supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
,....- , . • 14J;- - Educatioh�Law; ' -At e' - •Public � Health- Law; and, -the -Putnam - Cbiihty `-- S -4n7±-;
tary.Code-
Very truly yours,
Signed
04ner of Property
- . ^ - - - A - /
Countersigne
P.E., .F--<,
Telephone
015-
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE N0. x'1301 -'18'Z
Owner SWIACt4 A A� _Address QLr114xM /ALLEY—, ooh ow,4 -
Located at (Street 11poyIG rj &I"ze- T Sec. Block - Lot -1 30$(6
Yd ca e nea.rest dross street)
Municipality 9010AM VALL E _ Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS*,
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
apse Depth-to Water Water . ve
No. Time From Ground.Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches .Inches
1 ?:IQ
3
5
Notes: 1) Te'ts to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted.
for review.
2) Depth measurements to be made from top of hole.
3
2:40
4
-L 3: 0 o
s
1
TO
1
g'. 0 0 3'- 0 4
9
zb
l
3
3 : � a 3 :2-�
�
ZZ-
Z-3 1
��►
5
1
2
3
5
Notes: 1) Te'ts to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted.
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. I HOLE NO. HOLE NO.
G.L. O�
78n v
lIINDICATE - L AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE L TO WHIC WATER LEVEL RI ES AFTER BEING ENCOUNTERED
TESTS MADE BY , C.L Date
Soil Rate Used 10 Min/1 "Drop: S. D. Usable_ rea Provided 263o o $
0F�si`;�
No . of Bedrooms- :3 Septic Tank Capacity A Type & ,
Absorption Area Prov ded By 210 L.F.x24" &- 7,�dth trench.
1VcLil1C — �C7WcA.6'Cx �. w- Gal.�1 va � �.L i ' u 4 js.
Address b4 GkAkAQ4C-
359/
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Galt. Checked by Date
�CIA tr K �J��e.c dp 10 Allwv��
Perc ir�� e se I re 1 S L F 1 gP- _ ��11 �-� - �m= 69LF
U Qi9 lax PA a1.S i oN
r%iJ id's Con.
OF 220 L-F e 4
'I• MANHOLE COYER
-PLAN i - -- .1
- . f'
�IIAtliS yi1V3N JV1N7WN0MI11N) I o
i
f0.N01S_UIO 'y01D3N10., 4O ]2- ... •L___J•i
•d"" "_. .'nog wv � � � I �- - - -
220 -� CRU. LEVEL '.-
N3 JUNCTION 80X -- 1,l N. l?" Id' MAN `
jO
- S6` _ 10 - _ MIN.
_r64 - �l �Od '_''^`'�,. .. LI UI LEVEL
„'.-� {_ MIN .�' I
TL' T 001 4a CAST IRON x i
11 -ANTI A.RY jF.E I
Okve:ec �' r SECTION
t�h,.• � ii — _ __ 4 ZED , :�, _____. -_�_ � ae "� � -- .;.
TYPICAL C 11 1.
I �I$ ri � ' - -- _ "• p AL ONC. , I ARE - CAST ;GONG. ,1
_ 3 y SEPTIC TANK n NFINF 82'C C. B: W 1-
eq
Lol 12L C,RD LEVEL
t~ \ -� to N1 \I 4'iN ��•' - - �/ l✓"EARTH -
.�. - f 1 Q BACIS FILL. +..► JUINT is,
\ f zzZ� w 0 (,. fJ VER
"00, ( 1' - y�. j` ---'t' �.•� IH'. xtJ BLDG. PAPE R.
OR HA', a•
�rSl �til 1. F' � Q� _ 1
i
-L k`XlS tA.I Ck 24'MIN �.SSL CLEAN CRAV t:I. OR
216•;, ! p�'i - boa flAii 1 hl4 Clam, - ctuJ ;HPU iTUNF:
gE✓�1C �AttIZ �oxeS " A85nRPT10N TRENC:1- 1
0 F, S.
S' . M TO' BE CONSTRtlC1ED IN ACCORDANCE WITH :THE RI!LE'C AND
` N
'^•- 1 .j01lc. 101-t OOK� O lk c, , F -
..,) , j r -j y SE,1 �E,4oW Fr;uS� LINE,. RF:f�ULATIi1NS VF THE �''u7NAM COUNTY DF'PARTME;NT
A4I_ L_A.V_r ri2EES: wI�IIrNI Io' or plsRosAt, OF HEALTH. ..
A4 CA To 6L 4LMOVE'D SYSTEM SHALL. NOT 9E BACKFILf ED UNTIL- INSPECTCD 8Y' DE.SICN
�/. FeoaoyEp - EPIrINECR ANLt FHE LOCAL - HEALTH DEPARTMLNT IF REQUIkEf).
SCIiCLAjtoy DiSjAmCc. S.o I0 L. &AOEP DeAW
t(' 11liMUM. SYSTEM TO CCYISIST OF A._ "?pU CALLON SEPTIC TANK
tA
( AND 220 FT. QF __,.t5 _FT TRENCH WITH A fdAX1MUM
4� Ougf' ' v CE SE. A- 2 °z'l.o EI-, MtM%"AU&I, _
p¢ -.. � �} � 1 PITT, Fi nF I / Ir.' 1-l=R FOOT
o O cv 0 faLLOW S£P' FG- F'LUV4 '(o FII?S 'Uo% 16 [JRA' {1- +I SF'QS •.
1, y TY• LM F�Ii/aOC r +;:FtRFhWrn 10 FNISHED Fti;Sl'
�} •'� �., FLOOR LI F%;AF ON 1NLFSS 0FHVPwISE N �!t -'0.
S.S.D. SYSTEM I.OR 5.TLPULA AUXKKf
S i �o I3, ,. •.:� E
LO" --- rzrnvlsluNS HOWARD A. KELLY, JO, ,
I,b w ASSOCIATES ;
50' NI �..O.o 1 I �OfESSIpA4 Nu DATE BY CARMFL. NEW YORK
.S.lrit [A A P N1. 12.1 BLK,ryO.. LOT FJ0.30FiP.-, i
A �� J� TOWN OF P0'( NAM yAL.L &„'�
tr��� 3L� 1` m Dra xi r -�TAT in 41�A 5 �0�� Mnu:ihl�
_
13 U+ewinq No
SCAL L. 1 "= 39 ' 38998 �r 5 w_ _ _ _ _ -- -_
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