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02479
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PUTNAM COUNTY DEPARTMENT OF HEALTH.
F
Diwsion,of Environin M61 Health Seryiees, Carme% N Y .10512
ERT4EiCAT- OF X01`4TIt'lJCTlS3?!! ,dCPNiP�
�.1
Town or Village
_ ":Located at: -�S A i!U'AX1141 r
Bloc k
'
_ Lot
' _.Owner
Job
,
j4��7?Lf y-
%��ra'Aay
LLl /%
Separate`Sewerage System built by hl'- Address
'' 3�
Consisting of Gal. Septic Tank :�i fineal Feet X
width trench
Y"
Other .requirements
Water, Supply: P btic Supply From ¢
d
Private Supply. Drilled''BY
Address A, 7.���`� y
d
i L�Rj1 �14t:. x
Building Type 1 No of..Bedroonis Date Permit` Issued
Has Erosion Control Been- Completed? -
-,I certify that the system(s) as listed serving the above premises w o _ a s'shown O n the plans of the completed work (copies of which are
'Department ' !
and in .accordance with the standards ''rules arid,'r n f b
�- .attached) per t issue y the P u tnam-
,County of' Health.
Date trfi -
P.E. R:A.
_
.. _n
. ,.
X �`�
_
Address' License No�/
Any person occupying premises served by the above system sh I: ptlych acts as may, be necessary fo secure the correction of any unsanitary'
conditions resulting from `such .usage, i4pprovaf,of the; ie 'af ra ysterjC§ II' ome null and`yoid as soon as
. -
a.'.putilic samtary,'sewer becomes, i
'
available and t he approval of• the private water supply shall b Id,. `f{n' public water supply omes' available., Such `approvals are
'•'•subJect -:or change o
to: „modification when, rn the,= Judgment of. r" Ith, su ocatton,
age -is- necessary r+`
P^ �a
1
Date' ( 'BY,
Title � I
i
., z.
R.
'V)ELL COMPLETION REPORT
PUTNAFA COUNTY DEPARTIOENT OF HEALTI
D -i��n of Enviranmentai Hpt0th Services ivi,
COUNTY OFFICE BUILDING - CAR,',!,EL, NEW YOfil,
This report is to be Completed by well driller and submitted to County Health Department together with laboratory report of
a;lalysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction complian,,:e is issued.
-rTED WITHIN _30 DAYS OF WELL COMPL -TION
REPORt MUST BE sumoi F_
OWNER
LOCATION
OF WELL
'FROPoSED
USE OF
WELL
-NAME ADD ESS
(No. & Street) (Town) e,'
BUSINESSeZ
21 DOMESTIC ESTABLISHMENT U FARM LJ TEST WELL
PUBLIC AIR OTHER
11 SUPPLY Ej INDUSTRIAL CONDITIONING E] (Specify)
DRILLING
EQUIPMENT
COMPRESSED CABLE OTHER
F1 ROTARY AIR PERCUSS1014 ❑ PERCUSSiON (Specify)
CASING
'A
E I D ILS
YIELD
TEST
LENGTH (toot) DIA WEIGHT PER 1`00� DR,VE SHOE
[51-THREADED 01 WELDED QYES FLJJNO
HOURS G.P.M.
RAILED PUMPED1 COMPRESSED AIR
CASING GP09f[`D_?�
WAS C -
El YES ED NO
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC(SFecilyfeetl
DURING YIELD TEST float)
Depth of Completed Well
in feet below Land surface:
SCREEN
M . AKE
LENGTH OPEN 70 AQUIFER (feet)
DETAILS
SLOT SIZE =D
AM, E
If GRAVEL
PACKED:
Diameter of well including
gravel pack (inches)
L SIZE (inches),
FROM (loot)
TO (1001)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to of least
two permanent landmarks.
FEET to FEET
If yield wos tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATf Lt. C Ai E ED DATE OF RE� TILLE, (Sion cure)
P
Owner or Purchaser of building
Municipality
...... •�� � �� "lam. m,5i.d. p...�_ _..�,.. ,_.w. .. � � ,...;....� ... .. . .
.Building' Cons true ted by ee=tlen 7-,4 /�,410 '
4
CA A
Location - Street
Building Type
Block
�p
Lot
GUARANTY OF SEPARATE SUVAGE 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 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 by me to such system, except where the failure to operate' properly
c-ait.gP8. by J-}ha wi l l fi,il nr novl irrnnt nr,-t _nf...tho_.nnniina,ni- r%-P j-},c. 1k„i 1 rli.nrr
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- -not _..the - -.f ailu.re .of ..the system. to operate was.--,---
by--the•`'wil`L��1'br'ne"gligerit 'act -of" tii'e •bcci1g;i t••-of 't}ie building `U'tilizing' the"
"
system.
Dated this day of 19 7K
Signature
Title e,
(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.
Division of Environmental Health Services, Putnam County Department of Health
HAIL TO
COPY TO
L FE::
l..F,i PLOGY I FG€'J'AT M7•:` Ai n FRESH A- IATEP cv.
i. tY)'SA Al Ybf\i \o 10512e
Laboratory Report. �'' / Pate
SOURCE ✓ Z6, COLECTBD BY tom. DATE).
Tots%. Coliform count per 100 ml., by Fermentation :2ethod
2)2iilliporre Method
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PUTNAM COUNTY . DEP?
Division of `Environmental Health
- :CONSTRUCTION ,PERMIT FOR SEWAGE. DISPOSAL SYSTEM ,
_.. _Located at
T. .,OF, HEALTH
Sery ices Carmel;'. N Y_ 10512
lout v a P4171114 2 _liA�c y
Town 'or Village
-Job
Lot
owner /'010
` Address
Building Type '. e F�%iQL%t/Tp /.�G Lot,•Area ,.�i�� :NYC. Q�-0/L.b� All
Number of :Bedrooms �oU/2' Total Habitable Space Square Feet
Du, .3boo
Separate Sewerage System .to consist of b Gal. Septic Tank l3(0 lineal feet X `�L' width trench
P/,fiJG . fi,45i1� Address Ail-i d.4., s� LE Al- Y.'
>TO be constructed by �/ � ,
0
;Water—Supply: Public..Supply From
Private Supply to be drilled by. y Tai --T—f-
' •. CAF o��c •
Address
Other Requirements'
I- represent that I am wholly and completely responsible fort aAS 'n aX to @at�o�ih'gf the sed system(s), 1) that the separate sewage disposal system
above described will be constructed as ehown'on the, approved �ei,' nen-C' are to- rtd tin a or hce With Ahe standards, rules an regulations o e u nam
County Department of Health, and that on completion,ther f a, 'Cer Aitate of CcJnstr' 6io Compliance' satisfactory'to the Commissioner of Healthwill
e .'be =.'submitted to the Department, and a written,guarantee 1141 furvj lted the owner,A. ccessors heirs'_or. assigns by.the builder, ,that said builder will
place' in good, operating'condition.any part -of, sewage spo IC eig,f. pe d of,two'(2) years immediately following thedate of the issu-
ance" of the approval of the Certificate of Con'strucUOn Coin 'a 6Q: a or 'rAa 5t or jny repays',thereto; 2) that the drilled well described above
'will be located as shown on the - approved plan antl that said well w �7 0¢ th the standar s, rule nd regula ions of the Putnam
County Department of Health:
Date • J14, z ����� Signed P,E, R.A.
.Address ' -%�: ' Z� ii5�t.� - ,.di/r License No. .Y Z %Z 6
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 whenconsid ed- necessary by.'t'he ,Commissioner of Health: Any change or alteration of r&MILruction
requires .a new mit.'.`.Approved. for dis osal'of domestic sa itary. sewage, d / or :priv to water'supply, only.,.
P - P _ �4 r.
Date By Title " 7
m
'1?17 BIOIT Op
MPO SERVICES
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at
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Located at- i.c AA
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PUTN.AiI COU��TY DE?z?T; •NT 'OF ''-'7 LTH
DIVISION OF..ENVIRON�rNTAL HEALTH�Sv_ VICES
DESIGN Da TA SHEET - SEPARZATE SE.,.aGE DISP0SAL SYSTE: FILE N0.
Owner Address SC p�dv�c�rrc�
fS�? .ve. ly•�/
Located
at (Street). Czse,g�i�,q �E����� �O ._ 34 Block d7/
Lot- �. Z
(Indicate nearest cross street)
Municipality
. %i1i viG ��7ti U�lc� t'Taterstied
'SOIL. PERCOLATION, TEST DATA REOUIREL D TO BE SUE:fITTED I';ITH APPLICATION
Hole
Number
CLOCK TINE PE' RCOf ATIO \'
PERCOLATION
Run,
Elapse . . Dept to ( +;Ater L Gter Level
No.
Time From Ground Sur :=_c ='in Inches'
Soil Rate
Start Stop Min. Star : Stop Drop in
..'Min/in . drop
Inches Inches Inches
2
9 ' 2� X1.`32 � � /� `3/¢• /9 3
Z. / , _
-_ -
2
- - -
1
4
Notes:
1) Tests
to b•e repeated at sa ^e de0th until approxi -=tely equal soil
rates are ob-
tained a.t each percolation test hole. all data o be sub7itted for review.
{
:.o.:.....� ,;.a,�<: ;.—z f�;:a;r� �an�.; =: �_•.. . �. -nom -i= rte.: :rte r
TEST PIT DATA REQUIRE _O E SL'B�fITTED .:ITH APPLICATION
a
DESCRIPTION OF SOILS E_ "�Ci:`TERED I':..:EST HOLES
DEPTH HALE `NO . H_OL 9 NO HOLE \O
G.L. So/ G
36"
42'
43"
j 4r
.1
Name - - BOX --257 Sio
Addres- gR%MAW- ARM 'kl V 1001 _.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Soil Rate Approved
Sq. Ft. /Gal.
Checked by
Date
66"
-72**
781
4TT
INDICATE LEVEL
AT I HICH
GROUND
WATER IS ENCOUNTERED
INDICATE LEVEL 'TO
WHICH
teT4TER
LEVEL RISES AFTER BEI_':G
ENCOUNTERED
TESTS ^LADE BY._ ..
,S %.j�
J
G.Qi1/r�c�
Date: %- /- -. 7✓
Soil Rate Used
�d
Min /1''
D 6_ c
Drop: S. D.. U,sa�1e Area Pro-.-iced -ram
No. of Bedroo "s
4
Septic
Tank Cap= city_ /Zoa
Gals. 'djg�9sv�i�y
Absorption Area
Provided
By �3l� L. F.Y2':`
�'dth t c�j Other
^-r A ra e e r-et .A A ARMED
e Q�® —�
�lA
Name - - BOX --257 Sio
Addres- gR%MAW- ARM 'kl V 1001 _.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Soil Rate Approved
Sq. Ft. /Gal.
Checked by
Date