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HomeMy WebLinkAbout2479DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -45 BOX 21 02479 I,y'L r r E ,I +. ;rl6'm LR J. . I r, 1 r 1' 0001 mi WE 02479 R. 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 -- •.i+�MY y+.-w•�..: ,r. -n r•p ,'t".'"ir .!w(�'�wµ•»a�iJ,,,,.- ,ww w� [,y f t � � i � l.,. kit :, � �.n � �, 4 t a mss.....- ,...., .«a t5"'"� �+ h �, rw• vro� .*s.... -b "' w+�.o-.l -w•:w 4»M .r4y� 'iw- '"M�aw"k w, 3;.•H'_�L.i ..l- �4. .�.,rj -,j F_.;. `�'.p ,i': .� t �q''.. t �,•, x ,��:::,. •r� .;,,F �i. .,:I ..,':...,....z: ..�. „..�..i.:...:. . :CL St ne 11 �i i .,4r • � 1. 4V! 4r� t ) i w .i t 1 (1 ny1 73 ... � ..� L J l •�d 'r4 i 1 d ” i t �✓� R' ! r tl - "`' ;t'. `• ,a�j t4 vl'a 'r av a i a^�. v n �FY"'.W� T ' ., ;5 $ s t! h\ i'r�_ , ens y�. ,max l p ( �u:" r,� J ai• + .'1kw' _ tf � 7 7 "11 k v A ,. i.. ., :.\ ?l.�r � ', r,.x• -:�• 'fit � ..ac �•x'^�Lt fi" y n H"+,,.bl�'t w o r f rr av , t• w 9r ,ty a1 'ti w�� t � k:MS r '.. 1 �.,•, �'- cF yro � � � �' n lr" �, ,� y i i 3 �+ �, � � c , � 4 , �t a' 'c+6 ,,gy}f•:'1�, ��' "! X Y �;4 )�b x r i .. ., � ,,..w- ".•G+.�eY•�M, i* y p y r ^gyp r 1 y �` s t.. kF ' it , s r A ! � :•� 1 1 �! `{tl..! � 4s�, .k'.p • t�. e a t L�, a � 1c x Q ., � ,.. >n k,� t f r� i^t � yr • 3 � t � d 1 i � t . ,, �� r � � s•, Yri• '4xh ` u , 1 �'t t ' a ' P t'1` r6Y* '' , f -Y > � Q •fin• &����,% ` r r i a n ,� c.,� i ��1 eA ri � ! J � : t• 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 ) -e at Re v Property of Located at- i.c AA TLj . ot -t /Xl, "This letter, ia td a. Ody I,, QaA of ea's ioriall qa�,giiloioi: jc',O. dontitrubtidn ---pe '-�lt t 06-PA 0" 'h A, r t b r- v e �t a-, voted Pr- 6r.',. - .. -Veg . p: a t pr. PU Oki . t 6 ....,-Dep -ttmei tbo -d: .:a: 1. '066" !P�6 dn-wy� it on P K 7. IS r 8 y M -P* ' N"'A% the - Pub b, EdUt a it ton--'law -Pq� G0 t 10- d, tru B .fit 'r of OV C. ads no 2720 Tb Ophoze*. S .5779- 3, Y-t' V -TAx TUP08b A., Bak 2' o ans 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