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' ENGINEER MUST
1, PUTNAM COUNTY DEPARTMENT O., HEALTH p.,ROV I D.E
D�wsion of Environments/ HWth Servroes,t4Cah "i N Y 405t2
MfI ` #v
T
CERTIFICATE W CONSTRUCTION COMPLIAN CE FOR SEWAGE :;DISPOSAL SYSTEM'
`Village:
Located at t!i44.9 .,/ Tax
Owner - !t 1 .���i / Foimeily Tax Map Lot ii.
separate Sewerage System' built' by yj u Address J
Con 0
sisting''of �00Gal. Septic Tank and 7 = L
Other 're-,
cluirements
Water SuPP1Y:`
Public supply From
Private. Supply Drilled 8Y"
.» r ✓S o-=
Address
Building Type No, of Bedrooms Date -parmlt- Issued
Has Erosion Control Been Completed? ` ' Has garbage grinder been installed?
I certify that the system (a) as listed serving the above premises were constructed essential lens of'the completed work ( copies
of which are attached) , and in accordance with;the standards, rules and re latione, in, ac '^ -�f
qu e�ev�i,i)I';t�� plan, and the permit issued by the
Putnam County Departiment of Healtfi..
Date . 47 srtified
! av 2yG
Address Lteenss No.
Any person occupying Premises served by th bove system(s): shall promptly take such actb ieeasar to: the.'
he correction of my uns•nitary
conditions resulting from' such usage:. Approval ot'the separate sewerage system shall pe 4a :v q a. pq " t, , lanitary sewer becomes
available and the approval of the private water supply sha11-become a void wh on, a ub e'YIS1p{>/,° adbtliis avattabla.: Such ,approvals are
subject to' modification or change when, im the 'Judgment or t Com It n4 .of Health such (kation or clianga k necessary.
1 � ., .ybd3tidsP.�C .'.' '
Date y'.. Titre, C.iG�i .�
Rev. 6/85
II.
LV.
W
JI.
;;CATION
APPENDIX C
L' FINAL SITE INSPE ON Date ZO
�_� Ins ed , y
TM # OR SUBDIVISION] LOT #
10
s
NO
CCMMENTS
920DISPOSAL ARFA
a. SDS area located as per approved plans
-�
b. Fill section - Date of placement
2:1 barrier. LGT-E WID`i'H AVG.DPTH
c. Natural soil not stripped
f;
d. Stone, brush, etc., greater than 15' fran SDS area_
!`
e. 100 ft.. from water c se wetlands.
,p
SEWAGE DISPOSAL SYS
a. Septic tank siz - 1,000 1,250
\
b. Septic tar_k instsk1jed 1 vel
c. 10' minimmi fran foundation
d. No 900 bends, clearout within 10 ft. of 45° bend
DS
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested.
��
2. Protected below frost
i -
3. Minimum 2 ft. original soil between box and tre_*iches
--
f. JUNCTION BOX = roperl set
g. 'TRENCHES
1: reqgth uired Length - Len installe& -U 1
_
2. Distance to watercourse measured _ ft.
Ob W a, _
3. Installed according to plan
?
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet free prcoerty line - 20 feet : foundations
7. Depth of trench < 30 inches fran surface
8. Room allowed for expansion, 50%
-61 n
9. Size of gravel 3/4 - 11" diameter
10_ Depth of gravel in trench 12" minimum
c-
11: Pipe ends capped
h. PUMP OR DOSE . SYSTE`^!S
1. -.Sze of mp chamber.. - -
2. Overflow tank
-
3. Alarm, visual /audio
�-
4. Purn-o easily accessible manhole to grade
i
5. First box baffled
--
6. Cycle witnessed by Health Department
est.imated flow per cycle
HOUSE '
a. House :Located per approved plans.
b. Number of bedroans
WELaL
E Well hxated as per approved plans
b. Distance fran SDS area measured p ft.
c. Casing 18" above grade.
d. Surface drainage around well acceptable.
OVERALL WOIRF�.S'riIP
a . Boxes ]pro 1 grouted
b. All pipes partially backfilled
c. All pipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall protected & dir.to exist.watercours
g. Foo intint drains discharge away fran SDS area
h. Surface water protection adequate
i. Erosion control provided on slopes greater than 15 %_
10
s
Yorktown Medical Laboratory, Inc. LAB a ":f. ,
321 Kear Street
Date Taken:'
Yorktown Heights, N. Y. 10598 Date Rc' d
.,•e p o:r.t
Director: Albert H. Padovani M. T. (ASCP) Collected By :
Referred By: L'2i'ss�
rte-��� Sample Location: _
l/2 /Dew QSCV
� 19�1 Phone N
Phone �
L
/ Repeat Test? —
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
Standard Plate Count (CFU /1.OmL) 27—
(Agar Plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)_
/Total Coliform (CFU /100mL)
Feca.l.Coliform (CFU /100mL)
_ Fecal Streptococcus (CFU /100mL)'
MOST PROBABLE NUMBER TECHNIQUE (MPN)
— Total Coliform: MPN.Index (per 10.OmL)
- - Fecal- Coliform: MPIi •Index (per 100mL)- _ -
OTHER ANALYSES
REMARKS (For Laboratory Use)
THESE RESULTS INDICATE THAT THE WATER SAMPLE I
SATISFACTORY SANITARY QUALITY ACCORDING TO THE'
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT
/ x / / /Ft
Albert H. Padovani', M.T.
4
12 /85(Rvsdt7 /8T)RWE
ASCP ), Director
'Time:
Time:
G
Sample Type:
.(check one)
_ ✓Potable .
_ Non - potable
_ STP INF
STP EFF
— Other:,.
Sample Status:
(check each)
Outgoing
._ Na2S203
Incoming
E k °C
GT k °C
— Other:
KEY FOR TERMINOLOGY.
RDS = Recommend Disinfec-
tion of Source
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LT =. Less Than (<)
GT = Greater Than (>)
N/A = Not Applicable
Lit: : Lena than or equal to
(WASN'T) (N /A) OF A
YORK STATE DRINKING
TIME OF COLLECTION.
For Lab Use Only:
_ H/C to
LAB OFFICE HOURS (Main Lab):.
9AM -5PM, Mon. -Fri. -
9AM -NOON, Sat.
Vvj.:IJI.Ll vats
DEPARTMENT OF HEALTH
Division Of Enviro n.mental.Health.,Services.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Use Only
aE COi)
Ar%XAnTr.rrilr^"
D'V nnm
Vvj.:IJI.Ll vats
DEPARTMENT OF HEALTH
Division Of Enviro n.mental.Health.,Services.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Use Only
5i -T AOURESS. TOWN/VILLACI T, GRIO NUMBER
WELL LOCATHN
WELL OWNE1.
HAM ADDRESS:
IXT PBIVATE
r❑ *$UBLIC.
USE OF WELI
1- primary
2 - secondary
gRESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /HEAT PUMP 0 'ABANDONED
❑ BUSINESS INESS 0 FARM ❑ TEST/065ERVATION 0 OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL ❑ 'STAND-BY ❑
AMOUNT OF WE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O. REPLACE EXISTI N G SUPPLY 0 DEEPEN EXISTING,WELL
DEPTH DATA
WELL DEPTH 0200 —ft.
FSTATIC WATER LEVEL
FDATE MEASURED
DRILLING
EQUIPMENT
JE� AOTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER. (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE,IN BEDROCK ❑ OTHER
;CASING
-DETAILS
TOTAL LENGTH �/ it
MATERIALS: 2 STEEL ❑ PLASTIC. 0 OTHER
LENGTH.BELOW GRADE --/I k
JOINTS: Q WELDED .THREADED 0 OTHER.
DIAMETER Af .1 in.
SEAL: ❑ . CEMENT GROUT. 0 BENTONITE IRDTHER
WEIGHT
PER FOOT I lb./ft.
DRIVE SHOEA&YE
LINER: 0YES)QN0
SCREE
DETAILS
.,SECOND.-
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH To SCREEN (it)
DEVELOPED?
FIRST
0 YES_ Ja#0
HOURS
GRAVEL PACK
, ❑ YES
040
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH —ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumpi'
ng
METHOD: ❑ PUMPED tests were done is fig-
formation attached? ❑ COMPRESSED AIR tac ed?
'0 YES
❑ BAILED ❑ OTHER [3 NO
Ti more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACV�i
watel
Bear'
'ng
well
Dia-
meter
In
FORMATION DESCRIPTION
ft.
T_1L
ft.
WELL DEPTH
It. -
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
1.2nd
surface
goo
I
gQ0
,
4q:2k
Z99
'0
V
IWATE9 0 CLEAR TEMP..
QUALITY UTY LO
UALITY 0 CLOUDY RkADNESS'
0 OLD
COLORED,.: ANALYZED?'- ❑ YES ONO
IS H
ANALYSIS ATTACHE -YES ONd
T?. 0
STORAGE TANK: TYPE
CAPACITY GAL.
.
PUMP TION
PUMP INFOHMATION
P IN OR M
TYPE
MAKER
MODEL
::.CAPACITY
DEPTH
L VOLT .,GE HP
WELLLORILL NAME
ADO,
if z
PUTNAM COUT91 Y DEPARTMENT OF HEALTH
:D SI iii.. _ OF. OAT #�AT� --
- ,ER -
Owner or Purchaser of Building
it
Building Constructed by
Location - Street
Municipality
Building Type
3s- Z 7
Section Block Lot
S vision Name
17
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 guarantee 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 fora period of two years imnediately following the date of approval of the
- "'Certificate of Construction--Compliance" for- the -sewage disposa , 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 occupant of the building utilizing
the system. I
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system.
Dated i:his day of 19 Signature
General Contras or ( er) - Signature
rev. 9,85
mk
Title
Corporation Name (if Corp.)
Address
ti
riu
7� IJF igP riOwl k�lel H. -O. Notific
i .to ;consist of ✓!i ®o Gal septic Tank. and,
Address
P bloc SuPPIy Erom
y
Private. Supply to be drilled by
Date
Rev. 6y 5
a
• 0' zaoj ADZ ktj •' •; ' I N ; IY I Fl W.0,1413!10 013;.
DESIGN DATA SHEET- SUBSUFACE SS AGE DISPOSAL SYSTEM FILE N0.
..:Owner i� G.a� � / ✓PiY. - Address :X-V ,-I-
Located at (Street). Sec. J Block 2 Lot T
(indicate nearest cross street) ,.
Municipality' / �, /�!�'r� ,c Watershed
SOIL PERCOLATION TEST DATA REQunm TO BE SUBMIT= WITH APPLICATIONS
Date of Pre- Soaking �Z ,F- Date of Percolation Test-
.. .
HOLE
NL14BER (1= TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water From Water Level
No. Time Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop In Min /In Drop
Inches Inches Inches
.2 7 7-V 3 %
2-° 2 3 a -zv
3��rf >.. Z32 3° Zv 1-3 3 '1a
5
4
5
,. 1 ..
2
Oi 5 yc„ 11r.
NOTES: 1. Tests to be repeated'at same depth until'apprcximately equal soil rates
are obtained at each percolation test hole. All data to'be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
7'
8'
9'
10'
11'
12'
13'
14' >.
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING. ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY T �o9J/ / yeow DATE: 2 TOf' S�
DESICGi
Soil Rate Used A7 Min /1" Drop: S.D. Usable Area Provided'
No. of Bedrooms —3 Septic Tank Capacity /Ori C/ gals. Type
Absorption Area Provided By L.F. x 24" width trench
Other` EW
Nanie 14
Address 7i/7%>-
ve, v 4".
THIS S FOR USE BY HEALTH DEPT
Soil Rate Approved
SEAL
0
app't
+oeo0o°
N.
.00
ONLY-.
sq.ft /gal. Checked by _
Date
t
$UTNAH COUNTY DEPARTMENP OF HEALTH - DIVISION OF ENVIRaMMM HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEV,GE DISPOSAL SYSTEMS
$FRTTFW SpF m -
(Name of Owner)
COMMENTS
...__. .._..........__. _: .. ____ ...._ __71 - _
Eel
PERMIT
BY:
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Ed Design Data Sheet (DDS)
Deep Hole Log
ya d rwq_
VW 3 y
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
If PWS - Letter
-Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile - Gravity Flow
.Fill Profile & Dimensions.- Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
Expansion Area; shown.;_gravity flow, suf f . size
If =-PLC °Pit-&-D Box-Shown & - Detailed .
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees
20' to Foundat' s
100' to Well 200' i D.L.O.D, 150' pits
100' to Str a ercourse, Lake (inc. expan)
15' to Drains- irtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
'Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
PUT NADI COUNTY D.EpAR TjjZNT
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY;
ignatureaTitue mate
p IV clrt
(6.,erjo jc)
3
-- I- JF�447 4/
e- tl
20 l-I /1/v /7 -Y*�5
A/
, Z,4..
z
1986
JOSEPH F. SULLIVAN, P.E.
cond-utting,F).91A.t
2972 FERNCREST DRIVE
YORKTOWN HEIGHTS, N. Y. 10598
(914) 962-4248
2
/ f
-,
14V
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
AFFIDAVIT — CORPORATE,.OWNER•�APPLICATION
FOR.PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
rA
i
I� 'FO Rs7, E (D, K. ✓�
represent that I am an officer or employee -of the corporation and am authorized
to act for t* ? Veoel0pcA& 3GvC
(Name of Corporation)
having offices at ,p S �io� ) 91 1 0,)4V„Pi(j' 4 0,6
J
Whose officers are:
President: �3ie'OiiCt� (�.7. �2-`i NpR.� �(Z,9i5 a01L �cl°1 !a cKVXLQ6�$ fZe� �A1N8-*I i ,V r-¢f N.�
(Name and Address)
n
/0579
Vice — President: l_.lor�la "Dz- \fAj,bAA Go,,' 19y✓� yu iq �R.d `�. ">va,� llort�i�,� � �,
(Name and Address)
Secretary: `$t)2YS 7b7_`fyuAftt1 (ZbS Y3 oz[ 15°� ur9 -vr
- -
.(Name and Address) t
Treasurer: GI��� �ZitiwDu� 1(ZDb` (you 15�� C✓tau' 8 R1 `1�'�4�"�r�xi �1�r�teY A? J05 7e1
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts relating
thereto.
Sworn to before me thisC:;;&77-/ day
192C
tary Pull is
PATRICIA ANN UNGER
Notary Public, State of New York
No. 4806887
Qualified n westchester county
Peres March 30, 1986
Signed:
J--- -U 0
Title:
�� +�,�� L ✓d-.a� ICJ .
ate Seal
j
1
Yk f
r
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of
Located at 0-5 COT ryGl1po67
(T)% d Section 5 Block Lot 7
Subdivision of
Subdv. Lot # % fled Map # Date
Gentlemen:
,This letter is to authorize
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
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system - -.Qr :sys - c
tems - -.im onformity •-wi-th-the" provisioris� o� °A`rt cle 145' or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
r
Gr „ Signed 1rJ`
Ownee of Prop y
Countersi
4 c*k t9-
P . E . 1R 06 C�,u c (�
'' Address
-r�
Address "
y S
Telephone
Rai-z" �*411�d Lc)(577
Town
Telephone
4
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(� f f
'44-1
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99
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