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631- 589 -8100
61. -1 -16
BOX 23
IN
f
IN
-
,
02669
UTNAM.: COU,
Division: 'of tnitironim
L ocated at
Owner
r.
'W
2
l j
ee
YIil age,
Pi
I Block
da� Sec
4:
Separate Sewerage System built :by -LJ
Consisting of QO Gal Septic Tank 7 lineal - eet ',X,,-' .:Width trench
J
Other r9quirem—ehii
Wa er, lyrom
Supply: u pp T
priv it e 'Supply-
Drilled BYE
Address A
sx
Idirig. Type 0_101 Bedrooms Date Permit Issued�
Has Erosion Control Been. 'Cof -hpleted?
7
I certify that the system(s) as listed serving the abqye',PreT*ei'w-'e-re constructed essentially Ai 1 0 (66'plei-of,'wh1c1i are
42:-. �Pj completed work-
attiched) and -in accorclande with the and regulations plans 0 ea- -1 am, Department of Health. ♦
Date .i ed by
PE
Address
A
WA.
I take i�suctf acts .0 sary to se4;U(G'the, correct
IK
Any person occupying prernises,'s6rved b the 6' 'st' shall promptly Ion of any unsanitary
. .. , a o�e pr., - I Ii., _ ._ '. . � M d11 , _ , pU6rliC
I 'SUC Usage. 01 the e 's III 46 yo k.,q;ijsoj)n�qt! a sShitai�..ieiwei b6comes
conditions re;sultingl-irorr ' h
avaiia:6ie and the approval
apo rovM
6f6:ihelprv,at; water ,,S?I p p �,.s al' l,"becom ul en su $ PT-Ybb6qhjbs available Such ,a",
ppjro.v_ a ,are
subject to' modif iti i6n o r pwhen, in .judgM"n"t 04 th TC s ie ,a, Veation, ange:I s,neqbssary:
%
Tit
Date ie,
is
caner or urcaser o Building a ty h �
building ona ruat6 y
oca on - ree . Block—
u ng ype Lot
GUARANTY OF SEPARATE . SEWAGE .SYSTEM
I represent that I sun 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 sueees
sots, 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 tepairs 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 of Health as to whether.or -not the
fQitur® of the system to operate. wars caused by the willful .or negligent'.
act of the oeQUgaant of the building uti19.si.ng .the system.
-Di t ®d hi aay 61' �.:y i _ I9 signature,fy~ r .
Title
f corporat on, 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 REQUIRE TO FILE N T. C9 2f RATE OF FAST USE OF SYSTEM.
- .- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Health
..; ... 11
PEEKSKILL, MEDICAL ;LA(BORATORY r ,
1879 Cr'ompond Rd.. Barclay Plaza Bldg. A, Apt. 1
_._..__.._. 7 77
�T Vr 's- aY4- ••�i�:b.:: .: iao•n..�vbT'c.nb -.r :i. iti.. w- 't'.' +•+v'
- r•..1r:.rra.,.u4•r•�•cT ..b.. -.r _., t••a•.. an•_Y._�. -. x. r..eex�•eM- vw�rue. +. ....a v�..r ir:War.T': . +�! - ••-•. ^• I•(�
DATE COLLECTED
RESULTS OF EXAM IN ATION OF WATER
.f
OWNER DATE RECEIVED
CITY, VILLAGE, TOWN VOR NAM£ OF SUPPLY n DATE REPORTED,
CO-+n C) ,D(AS %l (:o� �C.
BACTERIA PER ML. (Agar plate count at 350C).
COLIFORM GROUP (Most probable N6. /10.0m1.)
HARDNESS, TOTAL - ppm
`DETERGENTS = ppm "
)NITRATES (as N) - ppm
IRON, TOTAL - ppm,
17- LUUM1UL (t) - mg./ 1.
These results indicate that the water was Yf 5 of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASCP)
r.
WELL COMPLETION REPORT"
Sib 9
PUTNAM (COUNTY DEFIARTFiENT OF HEALTHi
a OvWan of -Environmental Health Services
COUNTY OFFICE BUILDING •'CAAMEL, NEW YORK
7hi% report is to be completed by w0l driller and sul,% :4ted to County Health Dgvirtment together with laboratory report of
°'^' ~arrai}rsi f vKatEtrsarrrtpls iiidica3irl 3 =iatcr is�€�f sat > aesary sact -6 . t iialitybefore•certificate* of cc�listructior9 corr�plia ce is' iss�edr
REPORT MUST BE SUBIMITTED VIITHIN 30 DAYS OF IVIELL COMPLETION
NAME
ADDRESS
OWNER
it/
�N r"
aOCAT101d
(No. a Street)
(roan)
j (Lot Number)
OF WELL
C
es fldlaul Rau>
R '0 1 P _r
_ 1
I
11
R
®
PROPOSED
DOMESTIC
ESTABLISHMENT
FARM
TEST WELL
939 OF
WELL
L7
INDUSTRIAL
O CONDITIONING
® OT HER
SUPPLY
)
DRILLING
(C'X
N
D COMPRESSED
AIR PERCUSSION
El CABLE
PERCUSSION
® OTHER
(EQUIPMENT
ROTARY
(Specify)
CASING
LENGTH (feet)
'
DIAMETEP(inches) WEIGHT
PER FOOT
L C�
DRIVE SHOE
[:]NO
WAS CASING %O t
ERYES
DETAILS
�j
I
THREADED. WELDED
YES
NO
YIELD
Q BAILED
El PUMPED
HOURS
COMPRESSED AIR
GPI&-
7
YIELD (G.P.M.-)
"' :. '
7EST
pi
_,,•.,
WATER
MEASURE FROM LAND SURFACE— feet)
Y
DURING
YIELD TEST feet)
D p& of Completad W -11
LEVEL
]
Ere goat below land surface: Isd
MAKE
LENGTH OPEN TO AQUIFER ( leer)
SeREEPd
'
DETAILS
SLOT SIZE
DIAMETER (inches)
IF GRAVEL
Diameter of well including
SIZE (inches) FkOM (lest) TO (feet)
PACKED:
JAlf"
gravel pock (inches):
DEPTH PCOM LAID SURFACEI
FORMATION DESCRIPTION
Sketch exact location of well with allsOnces, to of least
two permanent landmarks.
+�
S
---
-,-
S�
_
If yield was tested of different depths during drilling, list below
FEET
GALLONS PER'MINUTE
Pa ;/c'1 1
is
DAT& WELL COMPLETED
DATE OF RLPORT
WELL ORILLErl (Signaturo) V /,
f
lot
�*) _ `i
As
'-
4`Ji. }'r „•r-] %on Y �i✓ f0 � Y'F`• 1` � d r r/'. _ �V
-
-
_ i.,..v� - ,.s ?�a3<. f� .,+ •'' -`�' -, .`i. - 1. •�"l' ®}'a s •�>
Y 'll
7
{
- .<� }•k °'�£"�"� ..I�' - Via'+ ^. f� 4a of � r•l -� •�A ^�Je - - �.L ”.
a�
- a _
� •. - ] !, tz. r:V•- .t .. 6vn r`, ..... -.� :.a..� "er,..T. '. y � � i 5_ - F Y.
wlj
fig
Way-
At Ow
a
_
y
s
- .- �.:.. - :.T _- .� .-v. .. .<. -•- , :aa,. .. sin,
g> - - a 3', r �a y� 5� _ F '�} iTtJti' �'l�`�) � .l.•vJ
-.: n,> .1. G.i;� '� :. •S �1ii1rE ��Z -
qfv •i �=3'� 'x.�. • ...Yf .r..4• - ::.�
f
Q:
1-
• G!
• i-
�! 5
' y'
by
S7r J'� _ - lc;;..� ,_I?_;,
Prop::rty limes or corner.,) found
Can c.stj.mr.j-t;: ho"L;:;e location
IUD. drivct,•ay need cu.t . . : . . . .
I':uv,t trees be r.- move -d -note those . _ ✓_ � _ " r
ls. deep hole rcprc;sentative o!' entire STNS area
Pidd i tiona.l decn holcs lnccdod. '! - - - - -.
Sctj'.fJ.cicnt SDS area available c:onsiderii)g
driveway ay cut, house location. separation . . .
distances, etc.
DE►1 I ours Dy11'1
Mu pth . -9
I -later elevation: UOPJ `e-
hock elevation: ww Z.-
SO:lls descri rtion:S* - lov�G - •G �e i'�a /
Date: ;
FINAL SITE RISPECTIOD1, Insn. by
House, located t-:here shown. on approved plan
STS, loc:atr-ci"where a,pproved . ... ..•. -,
Slope "of: tile lire 'and' trench Olcceptable
Room allowed for. exp.nsion trenches
Over. /go,f from�s-�;ai��u;llatercourse . . . _ -
I�aturA_3 soil not str ed or SDS area
unn^-.cessar:�la_..gr�.ded
l0 �a� J_ tai, fr'cm Prop. line and
20 ft. from 'Llouse . . . . . . . . . . .
Separation of trench from house, well
etc. follovis plan . ----
Nwnber of bedroc'ms checks .
StcnGs, brush, stumps, rubble, etc. greater -
t:han 15 ft. from . nea.rest trench
15 YL. of peripheral soil hori/z ontally from
.trench . . . . . '• . . . . ..
Junction boxes properly set 1
Could surface run off from driveway, roads,
ground surface; etc. chamel near SDS ,
area. . . . . ....
Uoes lot dr. aina r-;e aurear O. K. in area of SDS
FINU GRADING OF: SITE; ACCEPTABLE '
0C)
1
%7 PIJ'R 1�1A1VR C ®�JN'R Y DE'PARZTMENT OF HEAL'H y
-
rl s'
Dr' ision of EnwrohAWiill Health Services Carmel N Y '1,0512 '
CONSTRUCTION PERMIT .FOR, SEWAGE DISPOSAL, SYSTEM.' y 09
Town or Village
l..
Located _at y X Section Block
_.s . _ _ ...3._ + �M1t 'GV fy.s,_ Y•.U' n.Ji•HY�v.r.,. Y� 'vR.r• d. ar �,.� .Y _ ..1_ b �.£ t-v... `c.�F-+�!'�T. f
Subdivision Lot` ' w J,ob -•p�
Owner - - Address
f .:.
µti `4't7 ��!i:. �1� : `'e r� 4✓J / G� /<C,.& . /�/
G �j .
Building Type � � � Lot Area..
Number 'of- Bedrooms Total Habitable Space j -� ` T. Square -Feet
- -
Separate :Sewerage System to consist of ��� °U Gal Septic Tank c' lineal feet' X width trench
To be constructed by Address
;f
Water Supply! Public.Supply:From =-
r t
y Private - Supply -to be. drilled by
"�
(;Address
�, _,.r
other Requirements -
i.. N
{.. 2 1
I represent .that I am wholly and completely responsible -for the design and- .IOCaUon of the. proposed Syst m(s); ljttr the, "separate sewage, disposal system
above described will be constructed as shown on':the approved amendment there to and in accordance with: e_btlA�, d`�-(��yp,I n regulations o t e Putnam
i. 'County Department of Health, and that on completion thereof a 'Certificate of Construction Complian. ,.9tctiSty!to�, Commissioner, of Healthwill
be submitted to the Department,. and a 'written- •;guarantee, will be. furnished the owner his,successois n,b qO' Diyo �Ider,- that _said builder will ,
place. ;in good'.operating,`condRion any ,part of said sewage disposal system during the perwd of tw�'�2 y @a�§�� o w.in9 the date of.the-Issul
ante :of the 'approval, of ',the= Certificate ,of Condtruct�on Compliance of theryoriginal system or any,�epaorrs ereto 2) th a d led`we1C'described'•above'
will be located as shown the approved plan and that said well will tie installed �m actor ante' dh 'td�+stpe! r les an�rl ions of the ^Putnam
County .Depart n4 of FI alth.
a°
Date ` ,� Signed ap ° P E �6 c R.A.
Address ��� c����G� ,�j ,.orc °, ° S y���NO �✓ ss f' j
APPROVED'FOR CONSTRUCTION: This approval expires one year from the date issue .:unless conste �i ��mfi °f�j�ab9 °Id�H��o9ias been tundertaken and is
revocable for cause or maybe amended 'o[:modified ^when'considered necessary by` -A'e Commissioner;of �{j�QF a ®nor alteration:of "construction
requires ar, new erm t ;Ap ov -d for disposal of. dome i n' ary ewa a /or priyM e- p 'oiitii�r.,i� ad
Date BY °Y'wV . �i1't!� Title
r Y
PUTNAM COUNTY DEPARTMENT OF HEALTH
_DI.VISION..OF. ENVIRONMENTAL ._HEAL.TH_.SERVICES_ .
Date 4,0/&12 1Z
Re:' Property of /PAN j�jj��� /� e45 SA R1_
Located at ( ,eq&h ou
Section 1qP P 5 % Block �_ Lot 13
Gentlemen:
This letter is to authorize V
w
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
L)VIIJRL-C L.'V11 w.L In Lilis ma L LLv aiiL*i to. supervise the construc tun of said
system or systems in conformity with the provisions of Article 14S or
_ _... :..: 147.,. •-Eduoation--Law, the Public Health. Law, and -the- Putnam County Sani -.
tary Code.
Very truly ours
/1' }
Signed
Owner of Property
Countersigned �, �� s� ;r. - i 21XIA !/,4��� ivy
z * � :,w '- , % a: Address
P. E., R. A.,
;,t� .,,;� �, ,-moo �`, .
Z" ��r ��''�', Telephone
Address^dp�,—
Telephone
COUNTL OF �� j DEPARTMENT OF HEALTH � Division of EMviro ntal.Health' Service®.: .
e
. DESIGN DATA SHEET m SEPARATE SEWEEACE. SYSTEH
�ddY�L "I. / � .r: / / - � �W �[ Y, ..ey 1•
)Located At �Street� `` .�:, , �.; so g ®c& Lot .
(Indic a nearest roes street)
mmici aliit si ht✓�y c' ' Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMTTED IIYTH APPLICATION '
Hole
ffN mber° CLACK TIM& �EYtCOLATIOAT 'PERCOLATION
'Run' ° Elapse . °Depth to Water Water Level
'No., ° Time 'From Grou d Surface in Inches • 'Soil bate
° °Start' Stop ° Min. 'Start I Stop Drop in, OMin /in, drop.
o v °
'Inches Inches inches °
v . 1 . v ; � � o' ' —lei o X— C,, o
o
o e o o °.
a c v o o v o 0 0
Notess
IlD Teets to be repeated at,same depth until approximately equal soil rates are
obtained at each percolation test mole. All date to be submitted for review.
2) Depth measurements to be made from top of holed
o
o
0
0
o
o 0
0
0
0
o
e
°.
o
o
h
0
0
B
o
o
o
0
o.
o o
B
o
B.
o
B
o5
Notess
IlD Teets to be repeated at,same depth until approximately equal soil rates are
obtained at each percolation test mole. All date to be submitted for review.
2) Depth measurements to be made from top of holed
� c
77 T
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APPROVEIC
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-7. .
197
fuT
)VISION OF
cp�
61
PARATUSEWAGE
NT RMTW MY=
p" POOP'O!�Eu
SE owosAL
zri
YSTEM,
j: 2-- . "t,
I(A
TOWN
kgw YORk
DATE
SOIL PERCOLATtON,RATE
Ao ....... MIN/IN GALLON' SEPTIC TANK
DEEP TEST� -I- W SULLIVAN. -1339EM
LF 4L LABS. TRENCH CONSULTING ENGINEERS
ATION 0
AND
SEPTIC r- A EA It
Ell-,'Tlo MAN U140 CONSTRU
R L 00A ANDA00s *Ns
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