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BOX 24
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CONSTRUCTION PERMIT FOR
Located at ` g
Subdivision
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512
SEWAGE DISPOSAL SYSTEM �t Gi✓�J L r /.� '
Town or. Villl;ge
Tax Map. . ' ;�, % `. 'Eildck
Aoy Lot Job
Owner LL �'
/LSr+ ✓
Address
s clt. r.�'Ir
l�
Building Type l
�. Lot Area �ls+) / GS;
%� i
L PE-7 4L W
place in good operating condition any part of said se )sp
�-,
Design Flow 4600
Total Habitable
o
Space0y�,_1 Square Feet
Number of Bedrooms
Separate Sewerage System to consist Of ;f Gal. Septic Tank
and &C, <>
County Department of Health. -
To be constructed by y `��
� / S S ���)
Address �°'"
���� '� A?
P.E. R.A.
s^
Water Supply: Public Supply From
Private Supply to be drilled �by . :0fj/J,
Address -[— � L L f , A ,
Other Requirements
I represent that I am wholly and completely responsible for th so
a proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approve ter
ccordance with the standards, rules an regulations o t e u nam
County Department of Health, and that on completion t
ction Compliance" satisfactory to the Commissioner of Health will
be submitted to the Department, and a written guaran u
he is successors, heirs or assigns by the builder, that said builder will
place in good operating condition any part of said se )sp
ring riod of two (2) years immediately following the date of the issu-
ance of the approval of the Certificate of Constructio pli :rte
nal or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that sai w-1 will
() c da a with the standards. rules and regula ion of the Putnam
County Department of Health. -
Date �
P.E. R.A.
s^
s 3Z i2
Address
License No.
APPROVED FOR CONSTRUCTION: This approval expires one issued less construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered nec8
by the Co mi ioner of Health. Any change or alteration of construction
requires a new ApproveclAor disposal of domestic sa wag
and/ r priv to water su ly only. �( �
�`' "r �-
Date By
Title
Im
BACTERIA PER ML. (Agar plate count -at 35 C).
COLIFORM. GROUP (Most probable No. /100m1.)
HARDNESS, TOTAL .ppm
15
0(MFT)
DETERGENTS - 'mg /L
NITRATES (as N) . mg /L
'IRON; TOTAL - `mg /L
AMMONIA, FREE (as N) -mg /L
These results indicate that the water was YES of a satisfactory sanitary quality when the sample was collected.
per: Crossroad Pharmacy r-
A. H. PADOVANI, M. T. (ASCP)
fe
Owner or uurrc aser of Building
Building Constructed by
Municipality
14 LE, J�j1aLt l cr ,q D
Location - Street Block
&ni- ZZAP - �
Building Type Lot
GUARANTY OF SEPARATE SEWAGE SYSTEM
45pl-
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 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 Environmenrcal Health Ser-
V is e-G of he :L uUllal -,. C0 ULL1 Uy J. e-pal Ulrll: nt of ileal Uil as to whc%t11G 1' Vl' 11V U U"G
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system./
v
Dated this da f c 19�� Signatureyy
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
WELL COMPLETION REPORT
3171
f
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of -Environmental Hoalth Sorvices
COUNTY OFFICE BUILDING • CARM)EL. NEW YORK
This report is to be completed by will driller and sll'•'. : ;ited to County Health 04-mrtment together with laboratory report of
analysis of water sample .indicating, water is.of satisfactory bacterial quality, 4efgre _4ertificatc.o .f.tnnstruction cemplia.rt:e E. issgj,
~ ~� �TREPORT MUST FEE SU3rvlll'TED VVITHINr30 DAYS OF WELL COMPLETION
OWNER
NAME
; /I�
f
/
ADDRESS
AT rc E'
CJ. i H /i%
LOCATION
OF WELL
P& _ 1
(o. 6 Street)
>
(Town)
- iN�
(Lot Number)
4 elf
PROPOSED
USE OF
WELL
(
LLy DOMESTIC
SUPPLY
ESS
D E TABI SHMENT
r_1 INDUSTRIAL
j
CI FARM
CONDITIONING
TEST WELL
(SPHER )
DRILLING
EOUIPMENT
ROTARY
Q COMPRESSED
AIR PERCUSSION
1:1 CABLE
PERCUSSION
Q OTHER
(Specify)
CASING
DETAILS
LENGTH (feet)
I DIAMETER(inches)
1
WEIGHT PER FOOT
� '
® THREADED. WELDED
DRIVE SHOE
I DYES [I NO
V-As CASING G %OV t
[2 YES ONO
YIELD
TEST
BARED
PUMPED COMPRESSED AIR HOURS _
1 '6
GlM
YIELD (G.P.M.)
PLATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specifyfeet) DURING YIELD TEST feet)
} � -
_
/
Oee�th of Comple.ud Well
in feet below Land surface:
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER ( feet)
$LOT SIZE
DIAMETER (Inches)
IF GRAVEL
PAC KEO:
Diameter of well including
grovel pock (inches)-
GRAVEL SIZE (inches)
FROM (Peet)
10 (0001)
DEPTH FROM LAND SURFACEI
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
7'
SIX 14 4 R K 0 = -- .<; V9 4
If yield was tested of different depths during drilling, list below
FEET
GALLONS PER MINUTE
C�
r-
RAte WM W.MFLLTED � DATE OF REVORT WELL DRILLER (Signature) J ,/
V]j.g,1) C3I?..,(,jr I, "I: ST
IT1.T.T fAL SI1.7 . TTiSPFCTIU ?: "
yes
: NO
ComnientU
,Property liner or corm r3 found .. .'
Can estim -atc house location
Will driveway need cut . , 0. .
Niu�t trees be removed -note these
Is deep hole representative of entire SDS area
-Additional deep .holes needed. . .
Sufficient SDS area available considering;
driveway cut, house location, separation ,
..
distances, etc. ...'. . .
_
ud
c
DEEP fio=, mZ'A
DsP i;h :
'Water elevation:
Rock elevation: �/
Soils descri,,)tion: 6 — boN�� " &7T
----
Da, Le .
----- -- _. _
l+INA.L SIT , ISPECTIGID Insp. by:
House located where shoim. on approved plan
SEC, located wh --re approved . . . . . .
.Length of t1 onch m --asured
Width of trench average
Slope of the line and trench acceptable ,
r
_.
r• •'a _
Room allowed for expansion trenches ,..
Over 50 ft from swamhp, tr?ItQ !00U, s� _.:
stripped or SDS area
utiriece.ssarily graded . .
_
10 Ft;. maintained from prop. line and
20 ft. from house . : . . . ;
Separation of trench from house, well
etc. follows plan .
•Rtu3)ber of bedroomrs checks
Stone., brush, stwips, rubble, etc . greater
than 15 ft. from nearest trench . . . . . .
15 Ft- of peripheral soil horizontally from
-
trench . . . . . . . . . . . C
Junction boxes properly set
CoiO.d surface run off from driveway, roads,
.ground surface, •etc. channel noar SDS
area . .
Does ] -ot dra.ina fie ai)pe;ir O.K. in area of SDS
FINAL GRADIRG OF SITE ACCLPTI BIB
- r,
iJ
REVIEW CFIECK ST M T
(Meets Std.
Remarks'
lYes No
DOC�JN�hITS
�
. -i.
House plans O.K.
Design data sheet
Peres resoaked?
i
DL1 n., 30" pert test depth
'Const results for 3 runs
D. Hole log O.K.
Corporate Affidavit for othep than individual
Authorization for engineer
Letter from Water Supply if applicable
If variance requested -such noted.on plans & apps.
DETAILS
if change is proposed,)
(if
Existing contours shown new contours)
Slopes for driveway cuts, etc. shown
Xjater service line location
Footing drain, etc. location
f/
Top slope, bottom slope of fill
,�
I
Percolation tests and deep test pit location
Septic tank size and conformance to std.
�f
3 B.R. house minimum
_
House setback shown
I
Distribution box ftg. below frost
All water within 50 ft. of PL shown
Plan and profile SDS
,
T_'- WPl_=�.'- a.nri:- _tr- .cl_o��
•shown or reference made
Property boundaries (metes and bounds- clearly
shown
SEPARATION DISTANCES SPECIFIED ON PLAN
10 1 to P.L.
201* to Foundation walls
i00' to Nearest well
50' to stream, march, lake, etc. incl.expansion
15' to Curtain drain
10' to water line (pits -20
15' to storm drain
!
10' . to large trees
I .c- e
0' from foundation to septic tank
✓
5' to pipe from leader drain &.foo ing drain
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