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11664.
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02382
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1 PUTNAM COUNTY DEPARTMENT <OF HEALTH
3 Division of Environmental 'Health Services Carmel N„ Y 1Q512
_CERTIFICATE >.;OF �CONSTRgGTIAN CONlPL LANCE FOR:; SEWAGE DISPOSAL SYSTEMUTlS(�� _v!q`G_��
ow �r _
- L'ocated ^at N ,Ab A -/ o, 5 tom. 4 -.• r Section �f' ' Block: lag
e
K�B�i4� Sd ���A� E'%>ri IQ cib�r lot Job -
Owner -
[iK �' / �5 Address
Separate Sewerage System! built by /x J
1 Consistm of- Gal` Se tic :Tank Ifnetrli•X width trench
i
Other requirements
1 Water .Supply "Public ,Supply From _
G a
^Private Supply- Drilled By
i Address.•
x
:` N•�'L Er N o. of Bedrooms Permit ssu Date 1 BWlding Type ed �%
} ' Has Er n osio Control B&h COMPleted� , _' r- = $ i � K lrLf�
I- certify that the- system(sj as listen- serving the aboye•premisi'slwere constructed�essent ally as shown cn.tOe plans of the completed work (copies of which are
,
attachedj,'_and in` accordance witFi'lthe standardi,.z_ les and'regulatigns plans filed arad the permit - issued by., the Putnam County D'epartmenL of Health.
Date y�.d. y Certified by '��.v�.� P:E RA.
Address
} d a' License No.�TQ
( Any person occupying premises served by the above system(s) shall .promptly "take such actLOn as may` ie necessary to_sacure the _i orreetioh 'of any unsanitary
Z _ : conditions resulting. from such usage,- Approval ;of the .separate eweiage system shall become nu11'and vo.id'as sooh as a public sanitary sewer becorrmes- .�
t available and the approval: of the'prrvate;.water supply shall;become, null andtvo�tl when a publii .w ter supply beciimes .available Such approvals are
subject to modrfication or change: when ': in the judgment. of'the G mm er of 'Health suc rev tion `modrfication or change .is necessary '
l�_�J-17
% w
Owner or Purc aaser of Building Municipality
-
Buildirfg Constructed by Section
Location - Street Block
Building 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.servir_g 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 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-
vices .of the..Putnam, County Department Hof Health as. Ito-, w- Nether or not• the- -
faiure or the 'system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the sys m.
Dated this 0? 2 day of 19 %% Signature
Title
If, corporation, 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
t.
ev COUNTY OF WESTCHESIER
DEPARTMENLO} LABORATORIES AND RESEARCH
►�F_W Yba— k
"BACTERIAL :EXAMINATION- DRINKING AND. TFLEATED WA fERS
Lab `No W Bottle No z
p
Lab-; No ENT. Date Col;l`d r Time v. -�
Time $et x TmeSu[imitted .�
Tests Requested z Refrigerated
f
Coll'd .by_ Agency Coll d .or
K�
Coll'd=from� NameF
(St Rd.) (City, Town Villoge) (Zip Code), (County)
-F
Identification
Sampling Point `
Supply Chlo inated when sampled "Yes No ®' Free `� Comb n P
RE Sl1LTS OF EXAMINATION: OF :WATER Standard "Plate Count, .3
k `' � �' Bacteria er <ml
VON /i00.m1. P
Coliform ,Group'
y �� Membrane Method /100 •ml
` Total: Conform
.
Fecal Col'iform i s „ t
Fecal Conform
These results aindicate sample (was, 'was not) l,.. ENRY SIEGEI M D r';Diredor
of rsatisfactory' . - sanitary qualityheh the x c
.sample "was ;cotllected:4 ROSEMARIE DI LALlO M S Chief of latioratones
m
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 by well driller and submitted to County Health Department together with, laboratory report of .
N °ar�al�rsls�t=vvarier= sat>7�;3 i�rdicatrrt�w�a'c r i�'ofi'saPtisfectbrTWa_dtdiFW 4uality`506Wcertificate ofi construction compliance`isissued'
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
AME ADDRESS
OWNER
LOCATION
No. &Street)
(Town)
(Lot Number)
OF WELL
BUSINESS
❑ESTABLISHMENT
Ej
PROPOSED
DOMESTF
FARM
❑ TEST WELL
USE OF
WELL
❑ SUPPLY
F1 INDUSTRIAL
El
ER
❑ (S(Specify)
CONDITIONING
DRILLING
EQUIPMENT
❑ ROTARY
ACOMPRESSED
IR PERCUSSION
CABLE
❑
❑ ' (Specify)
PERCUSSION
CASING
LENGTH (leaf)
DIAMETER(Inches)
WEIGHT PER FOOT
[
❑
I O
hAYES
CASING T
DETAILS
,
4
THREADED WELDED
❑ NO
YES NO
YIELD
TEST
❑ BAILED
HOURS
❑
G.P.M.
YIELD (G.P.M.)
PUMPED COMPRESSED
AIR
/O
0
WATER
MEASURE FROM LAND
SURFACE— STATIC(Specltyfeet)
DURING YIELD TEST fleet)
Depth of Completed Well
LEVEL
/
in feet below land surface: a b
MAKE
LENGTH OPEN TO AQUIFI
SCREEN
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
Diameter of well including
GRAVEL SIZE (Inches) FROM (feet) TO (feet)
PACKED:
gravel pack (Inches):
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location at well with distances, to at least
FEET to FEET
two permanent landmarks.
�1
If yield was tested at different depths during drilling, list below
FEET I GALLONS PER MINUTE
""" ^ "` "'/^'.� W I DATE OF REPORT I WELL LER ISi re)
M
r0
PLJ'i'1VAM .,COUNTY: DEPARTMENT OF.. HEALTH � -
!�i >Pivision of Environmental Health Services," Carme% N:' .Y..f0512
p
.
CONSTRUCTIONV, PE6 11AIT FOR .SEWAGE DISPOSAL. SYSTEM & fg41 7¢
/J Town or. Village
air-fdlai'
Subdivision ,ey,/rrr .�s'�-ooQX /t��C Lot / Job.
Address ec" ./B
Owner U y/+f/
/' (��3
/
Cl�lCt/ � fr C! ,Cf /��'C /ter �� •� /r �V,
Building Type.. Lot Area°—
Q f
Number of Bedrooms Design Flow —j 7 �c Total Habitable Space ) u Square, Feet
�e
of Gal. Septic ""/s Lea C n e4f r' �� – (O i`G�
Separate Sewerage System to consist �( Tank and rS
To be constrycted by ale, /1-441 Address /
Water Supply: Public Supply From
of
Private Supply to be drilled by :—Q e,-- `° ��
Address
Other' Requirements
1
I represent that 1 am wholly and completely responsible for the design and location of the proposed s em(s), 1) th separate sewage disposal system
above described will be Constructed as shown on the approved, amendment there to and in accordance w' the standards, ru san regu a ions .O 8 ,• U -am
County Department of Health, and that on completion thereo "a "Certificate of Construction Complia ce' satisfactory to the Commissioner of HealthwilI
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that *said builder wiif
place in good operating condition any part of said sewage -disposal, systeirl. during the period, of two (2) years _irnmediately following the.date of the issu.
ante of the approval of the Certificate- of. Construction Compliance of the original system or any repairs thereto ; ,2) that the drilled well described. above
will be located as shown on the approved plan and that said well will be'installed in accordance with the standards, rules and regula�'ons ' of the Putnam
'
County Department of H Ith.
Date c-? Signed P.E. R.A.
//
Address ��° PG/e P/h rr "9fA License No. 49 fly/
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction of the building has been undertaken and is
revocable' for cause or may be amended or modified when considered necessary by the Comrhissi.o of Health. Any change or alteration of construction
requires a new permit. Approved for disposal of domestic sa se :, /o private er supply onl
�d
Date By Title °
f
M
COUNTY DEPARTMENT OF HEAL- TH
.�, Division :of Environmental Health Services Carmel,.:-N. Y, " 10512
CONSTRUCTION PERMIT -FOR SEWAGE bISPOSAL SYSTEM v�?lZ�c, l/�i. %e
f r v I
5ubdivisipn Ot1P `YI /3 lee Jtob -4
,Owner:- - �!�,C1�//'' ., _�.,.1 r i�i� /d'G� /n - Atldrlcc %,y;•�G�`rJ,7 .
1 . 13uil ding, TYPe. ` C/ lA Ile � Area
� Lot
Number 'of. Bedrooms Total Habitabje Spacy quake Feet
i�ParcLih -f J -0
:Separate Sewerage System to consist of.,-.-- �LZ ::Gal Septic Tank hriealt• Xj -width trerh'
s
( 'fo beconstructeil by ,M �, si Address
l ,� i < i s
Water Supply Public .Supply 'From w
~Private Supply to be drilled by'
F>ddress e
K
Other Requirements
krepresent that,l,am wholly and completely responsible for the design and location of, the ,proposed .systern(s)j 1) xthat� the separat@ .sewage. disposal system,
i
aboveidescribed will be constructed`as shown lon t p approved amendment there to and in accordance with the standards `rules an , regulations o the u nam
County Department of 'Health; and -that on completyon thereof a "Cert'fIc of. Construction Compliance" satisfactory to the COTmIS510ner .of'Health will
e
be. 'submitted to the. Department;' and a .written `guarantee; will be- furnished the ownerr his °s successors heir; or zrssignssby the bwlder,:that said builder will,.
place in good operatingi, condition. any part of_said'sewage disposal systern.during the perioC of two (2j years immediately` #ollow.ing: the date of-the issu-
ance of; the approval of: the -Certificate- "of Const-ructbon?complianc- of, the original system! -or any repairsIhereto;2) -tha4 the drilled welt described above
will be.located'as shown on the approved plan and that said well will b_e installed in accordance with. the standards rules and `regulations of '.the. Putnam
County D_ apartment of Health `
Date P E -M A.
i {�
Address
- L1c_nse No.
` °
APPROVED FOR CONSTRUCTION This approval expire; one ye r from the date issued, unless onstruction of the budding has been undertaken and is
revocable for cause or -may be ,amended or_modified: when considered necessary by' the Commis tuner of Health Anyrchange.or alteration.of construction'
t `requires �a new permit Approved for disposal of domestic y ewage a d r nva ter pl only
_Date agy it 5� --
- r ,
�
Ki
^
�
10
°
ip
V
------------'-----------------------------------------'
^
�---------~~-~-«----^'~---'----~----~-'----'--'~`-]��� ~----~
PUTNAM COUNTY DEPARTMENT OF HEALTH
.u<RDTVISTON'-Ol - ENVIRONM1V AI;7- HEALTH"SERVICES:..., <.:....�, .., .:._.. _.........._-
Date c sari/ /l "I
Re: Property of PO4eri'S
Located at Gv�sl c�f' i�.r <r %�c�.� �rrrr. �✓f. ll� °,
Section /e Block Lot 9e
Gentlemen:
This letter is to authorize Or✓,7 4 1l4e •-e
a duly licensed professional engineer Z✓ 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 nece$sary papers on \my behalf in
LU1111CL L.LU11 w-L Sri Oils ma c i.ev anti to. supervise ine construc ciun of said
system or systems in conformity with the provisions of Article 14S or
147, - Education -Law; -the • Publcic -He-alth� Law; and the - f'atnam County. 5ani= _ -- _ --
Lary Code.
Very truly yours`,
Signed T( Z
Z4 �_
Owner of Property
Countersigned: "'� ice°/ _ -�ro5 6
Address
R.A #
7 1-'7� 1
/t 6A10Cr 6[rcJ% Telephone
Address
114_L *1_,Lg3 1 0
Telephone
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 NO.
OwnersS; ��eE6Prsa /c', Address ���a,l� -rc�e �esr
Located at ( Street Sec. / Block
�Lots
s 4dicate nearest cross s ree
Municipality Jo&?� A, 4 11eti �7'f Watershed_
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number
CLOCK
TIME
PERCOLATION
PERCOLATION
Run
apse
Depth to a er
a er ve
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop
Min.
Start Stop
Drop in
Min. /in drop
Inches Inches
Inches
4
5 Cli e Soil i'h
1
4
2 hrk .l. U I�j1`i
3 PU'3 ,11A i u,,j Ui\i I'Y
Notes: 1) Tests 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
4:
DEPTH HOLE NO. HOLE NO. HOLE NO.
G::Z:
6"
12"
18"
2`F"
30"
36"
'
`F2f'
48"
54'1
60"
66"
7211
,...— _ .�.:� . ., .,x <. ,.. - .r. o ..a. .....� „�_Y.. - .r�+ -i.,.. ter. ..•...m... .v...u..n.. �,..,. - ,.}.s .., r..a -,- ...: o-:.r_+n -W. _. ro .,
f
7811 he rook or vyyyd4.Y1fP�
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED VO/V '-'
INDICATE LEVEL TO WHICH W�TER LEVEE RISES AFTER BEING ENCOUNTERED
TESTS MADE BY 1�lr`rr "e/ OG/tG /� 4" Date ��%
DESIGN.. ,...
Soil Rate Used %j Min/1 " Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity Gals. Type��_
Absorption Area Prov ded By L.F.x24" 3&"— width trench.
,46s�.pf:+� Rk fie. -, ��w� /n�v� 90o 97�/� aPr y am; re d _ sa c7� u
Name y4pmi.eI 9J,MOAdr rsaw- aignaLure
Address ;)/ 0•p4& re /e_ SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by, �►� y��.' ��``�