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BOX 24
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Yorktown Medical Laboratory, Inc.
Director: Albert H. Padovani M. T. (ASCP)
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P.O. Box 99 201 Buttonwood Avcnue
...- ...,......r•.. ..,; .�:.•.i`.`. �. .,.
495 Adn Strcet
- .a�..... m...''- .z, «.... '._. •: :. s.- �.a -... ;-e...:
Stoncicigh Avcnue
321 Kcar Strect
(Corner of 202, across from Hospital)
(Across from Lloyds)
(Corncr of IDrcvwillc Road)
Yorktown Hcights, N.Y. 10598
Pcckskill, N.Y. 10566
Mount Kisco, N.Y. 10549
Gvmcl, N.Y.'10512
(914) 245 -3203
(914) 737 -8777
(914) 666.3335
(914) 278 -9330
U
LABORATORY REPORT
mg /L
DATE TAKEN:
DATE RECEIVED: ' a i';z rS�
DATE REPORTED:'�3 _
SAMPLE SOURCE:. it�17G' /•%L =?i� l/',
REFERRED BY:������
a.
❑ ACIDITY ............ .................... .................. :......... ❑ ALUMINUM ........................,....... ...............................
❑ ALKALINITY .............::.....:... ............................... ❑ ANTIMONY
l ....... '
BACTERIA, TOTAL /mL ...:.... ❑ARSENIC H
❑ BOD, 5 DAY ............................ 2.....................
0 BARIUM ........... ............................... .`..... .......... .... 2
❑ BROMIDE ....................................... ....... . ...... ❑ BERYLLIUM ... ............................... ........ W
❑ CARBON DIOXIDE, FREE ....... ............................... . ❑ BISMUTH ........... .... ......................... ........................ W
❑ CHLORIDE ..... :...................................................... ❑ BORON
❑ CHLORINE ...... * ..................................................... ❑ CADMIUM W
❑ COD .................................... ............................... ❑ CALCIUM' .......................... ...............................
❑ COLOR ................................ ............................... ❑ CHROMIUM (tot.) ............................................................
❑ CYANIDE ............................... :............................ ❑ CHROMIUM (hexavalent) ....... ............................... O
❑ DETERGENT, ANIONIC ❑ COBALT ..:............
.......... ............................... ..................... ...............................
❑ FLUORIDE ............................ ............................... ❑ COPPER . .................................... ...............................
❑ HARDNESS ..... ............................. /. ❑ COLD ...................... ... ...............................
r MPIV COLIFORM COUNT/ 100 ml ...... ....................... ............. 1 IRON ...... ___ __
-
...._.. "� ... "- .. .. ..- .. ... -.. _� -..a �..
r� roiFly rcGAi: S%Rt�"CGi�ivl'i 1Gu mi ................. ...... "u" CtAiJ" ................. �............... ...............................
❑ CONFIRMATORY TEST ............ ............................... ❑ LITHIUM ................. ,................................................. 3
❑ NITROGEN, AMMONIA .......:.... ............................... ❑ MAGNESIUM ............................................................... a
❑ NITROGEN, KJELDAHL ............ ............................... ❑ MANGANESE ................................ ............................:.. W
❑. NITROGEN, NITRATE ............ ............................... ❑ MERCURY ......... j......................................................... 4
❑ NITROGEN, ORGANIC ............ ............................... ❑ NICKEL ........................................ ............................... 3
❑ ODOR ................................ ............................... ❑ PALLADIUM ................................ ........... .....................
r4.
❑ OIL & GREASE ........................ ............................... ❑ POf ASSIUM ................................ ............................... H U
❑ PH .................................... ............................... ❑ RHODIUM . ..............................:
❑ PHENOL ................................ ............................... ❑ SELENIUM ............................................... :................... x a
❑ PHOSPHATE (ortho) ................ ............................... . ❑ SILICON ..................... ................ E-i O
❑ PHOSPHATE (condensed) ............................. 11 SILVER ...:...................... ...........................:...
U
❑ PHOSPHATE (total) ............... .......... ...................... ❑ SODIUM ......................... ............................... ...........
❑ SOLIDS. SETTLEABLE, ml /L .... ............................... ❑ TIN ............................................ ............................... U 'c
❑-SOLIDS, SUSPENDED .... ❑ZINC ......:...............:
H
❑ SOLIDS, DISSOLVED ............. ............................... ❑ .... ............................... :. .. 2 a
❑ SOLIDS, TOTAL ...... ........... ............................... ❑ .... ............................... .... H
❑ SOLIDS, VOLATILE ................. ............................... ❑ REMARKS:............... to
...................... ............................... E-4
❑ SPECIFIC CONDUCTANCE ................. ❑
❑ SULFATE ............................. ............................... ❑ ;
........................ ............................... ............................ E-I
❑ SULFIDE ....................:........ ............................... ❑ .... ............................... TNAM''00UN Y.............. E-4 �
❑ SULFITE ............................. ...............................
.........
z
❑ SURFACTANTS am AgT14 ..
❑ ........................................ .......... ...............................
E-4 3
❑ TURBIDITY .......................... .............. .................. ❑ ..........................................
Is W40 / '�
11:iZLul,L-w «; -LCG X'D.'Poli'I'_
iv e 1 at
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ovJ;ier P:,o adress
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ft. arras we dzsln ecte
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mi, . of 'cFsing above ground Z.t{....B.elow :.;round /,� �'io11 seal C L AN 4'/v� _
in cenen ti
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l.ra�v �. ; ::'LL di.ugr_auI iri the space provided { Y�e7_o�J; and sh.uT - -� ;� e depth of
c, sing, the tiv. sickness of � � n
�, J l s., a L', kind and.'. thickness ; f �.rma;�ions e :,rued ,, Ovate
bear n.� forrilac-Ious 5. -..dia aeter of drill holes. _-with'd�Jtt.ed lines und
casz.ag s j w=t" : solid ;lined i
`'T JJ a" L a.;
. �. J .Ii
no t;e r , din.. Depth .ind �� thickness 'and ype of well 1/, 1, C-'
ALL. f if wat r bearing r. il.l�ngi t` t�'d
Cr_ _,de... lw�
a .s 'well dyiraini=t;�ed? s
PUT 1YIi..! G T -� ;Z T
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iG.. _ '66" ride
3 ;7l:l ping rcite
ra
i5 1ump ing 1e \re1 in
Dt' below XEL 'd� i
h
ad-d FrCT
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i V
).. 'w a S"Iec k'l- . Of the proj:erty ;
t11e- .ci� of „�. i^ s�l�eet ^i� start : :cl, ��,C,.' ?let de,
`"8 D.J. C; RAM VA I Well .-Driller
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id._
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.i�eCU?i;i:i:?nde( Clepth Cd: uum - ) III
w: ll, feet:.b : :lo T T-rade
Sand .offs ' sj.z . ,
Mum.
U JI dtu eW6e, f size
i
Length of. scrc en-
f"t ;
Diam�. of screen v____________.�
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2'ype of screen
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0
Owner or Purchaser of Building
_ / Nn t'o 6Z4 ' i ul- 0
Building Constructed by
Location - Street
e6 114Z-
Building Type
,�-
Municip ality
Block
Lot
GUARANTY OF SEPARATE SEWAGE 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 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 -rade 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-
vi ^as of the Putnam County Department of Heall-ti as to whether or. no_t th.e
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the systq*.
Dated this %�� day of 2 19.E Signature
/�
� X
'fir - CaJA/_-_7
THREE (3) COPIES ARE REQU
CERTIFICATE OF COMP±,ETION
Title /,hf4
If corporation, give name
e and address)
A7 ----- A �'
IRED WITH THREE.( COPIES OF FINAL PLANS BEFORE
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
048Y 1 0 1993
10"I IAA M
N.,-..- _ COUNTY
. PUTNAM `COUNTY DEPARTMENT OF HEALTH r
Division of ;Environmental Health Services, Carme% N Y :10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM . ts*.a /, r�,c :`%w,:vA /!,41L,Z/-
Town' or::Village"
Located at 6ee0+ea eiock.
V iSivri
n`C''riia':S �f= Ci'oPCSJfi %c'J Jr /IJ _LoY �AKT- ,OG.�f Job r
Owner i4A/oL� c7iA2cS /IJLc� l rAddress �� `oLoAlij�w?L /7/Y/'"�
Building Type, �f.S /D!/gL Lot Area ,r���� ��'Y Jam►�8�
.:: ry
Number `of Bedrooms le Total Habitab S'�2 1.>7 —:Square
� pace r 6 y Fe et
Separate Sewerage- System to consist of ,Or� Gal. Septic Tank ` 4' lineal feet X width trench
`� ,
To be constructed by �PSc,NM�NAi Address >� ✓���% �.�L�Ec/. " y
Water Supply: p lic '.SuPPIy From -''
—� Private SuPPIY to be drilled by
.z
AdiJress . oaJ" o
Other Requirements
I represent that I am wholly'and completely`r.
above . described will be constructed as shown i
County Department of Health, and that p�
be submitted to the Department, and a �l
place in good operating.condition any
ance of the approval of the Certificate
will be located as shown on the approved p
County Department of Health.
Date m' =� 7°
ry
Address
APPROVED FOR CONSTRUCTION:, This approve
revocable for cause or may be amended or modified when
requires' ew p rmit. Approved for disposal of dome'
Date s'By/t
�n location'of the proposed system(s); 1) that the separate sewage disposal system
ere to and in accordance with the standards, rules -and regulations o t e u nam
Re of Construction Compliance" satisfactory to the Commissioner of Healthwill
d the owner, his successors, -heirs or assigns by the builder, that said,builder will
real during °the period of two (2) years immediately following, the date of the issu=
pce 6 rigin system ,or any repairs thereto: 2) that the drilled' well .described above
be ssttal d o rdance_,with the' sit ds,'rules and regulations of the Putnam
ins .ider' ' es
ecsary':by th
)c : ary sewa" a an�Lo
P.E.-±f::— �7 R.A.
License No.
issued, unless con44ruction,' of .the building has -been undertaken and is 1
e `Commissioner pf, Health, ...Any change or alteration of construction J
rivat ater supply only.
I
-, Title --
500, -
Gentle ^en : /
Thus 1 ttar'is to authorize
a duly licens ed profess on al en?ir.eeT j,"/or ren- stered 'architect
( Indi c? t�
to apply for a Construct- on Pars:. t fo''� a separate sa:•rera.e s sterm to
serve the nol,ed ! acc0 4 e with L�a standard's, rules
e prO��r�`" n r•�anC iit �
or ra--ai a t;o_1s as '•to ld c- aued b`J trite rCO_"`"'; Ssloner of tha Fuunstn county
��,.t, _.n= °fin i ?r_ t0 51� ? 3�� ?7?CCSS�2' D?"e`'S On M-- be� =.� ?r
De �� _ o_: ul t_ ,
co_iri eclion :r_th this Matte -^ =rd to sue_Jise the construct.on o. sa_d
r L - orov sionJ _ . Ulc� . 1� o^ .
STISteri or, systems S in COn! Orni t� i%R �'•r On
1
7.. Fillii•' -ti0 =1 Lz;:•+, thaePil^l1C Lal t�? +L.i, and the PUvn= _ Co',.ir�f Sai1.___... ...__...._
tart' Code.
Countersigned:
P ., '., rr S212--o
a�7 (seal)...
Adaress -f-
9�r� o2- r
Telephone
.Very trul',r yOUrS,
SignedY
weer of Pr per:uy
Address
jr
PUTNTA`,I COUNTY DEPA'0UTNT OF HEALTH -
DIVISION OF E\VIRON,Et4TAL HEALTH SERVICES .
r
~ DESIGN DATA SHEET�- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
.Owner �f2NoL �i9�'G ✓.yt.a... Address
- . Tex 1�✓�
Located at (Street)ZAKe J/�ay /� „sue a=. �� Block / Lot �i a �
(Ind.icate nearest cross street)
Municipa1ity�h%: 45 ;; �y z- -i_e Watershed 1��F �sc�w�+.,�,✓� .
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMI TTED WITH APPLICATION
Hole
Number CLOCK TIME PERCOLATIO\' PERCOLATION _
Run Elapse Depth to �-iater Water Level
No. Tir,;e From Ground Surface in Inches Soil Rate
Start . Stop illin. Start Stop . Drop in Min/in.drop
Inches Inches Inches
9.,� z 6,
2 = � = ��, . IS
/ 6 v
%9 a ��
7-,7
3 04Z 1026
a ..
3 fo; D� /� "3� ,3r' %9¢ Z Xr -Z)
4
5'
2.
4
a ..
Notes
1) Tecti to be repeated at same depth until approximately equal soil rates are o') -'
to j-n:d at each percolation test hole . All data to be. SUbriitted for review.
2) Dcp-ti measurements to be made from top of hole.
667- y
72.'
78•` _
S Orr _
INDICATE LEVEL AT tvt[ICEI GRO'lUND t'? ':'R IS ENCOUNTERED
INDICATE LEkTL TO P iTHICH MATL,R LEVEL RISES AFTER BEING ENCOUtiTERr D
TESTS �LLADE ?Y ,.. :�% ��.✓aE,�: Date 7P
VE 5
Soil Rate Used Ro Min/1 ". Drop- S.D. Usable Area Provided S,,:rvv
.No. of Bedroo-s 3 Septic Tank Capacity 'v Gals. Type
Absorption Area Provided By a8S' L.F.x2«rr . 36" ✓�v;-ath trench. Other____,_
Name
6 r
Address X �� % �$ �° EAL
PUTNAM' COUNTY DEPARTMENT OF HEM T o
Soil Rate Approved Sq. ed by _Date
TEST PIT
DATA REQUIRED
2-0 BE SUBMITTED WITH
APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES =.
DEPTH
HOLE h'0. P� �' �:-
.HOLE IN0.
THOLE NO F '
G.L.
611
A/
12'r
sl mS
.T %•P - ee
18' r.
24" f
y
.
667- y
72.'
78•` _
S Orr _
INDICATE LEVEL AT tvt[ICEI GRO'lUND t'? ':'R IS ENCOUNTERED
INDICATE LEkTL TO P iTHICH MATL,R LEVEL RISES AFTER BEING ENCOUtiTERr D
TESTS �LLADE ?Y ,.. :�% ��.✓aE,�: Date 7P
VE 5
Soil Rate Used Ro Min/1 ". Drop- S.D. Usable Area Provided S,,:rvv
.No. of Bedroo-s 3 Septic Tank Capacity 'v Gals. Type
Absorption Area Provided By a8S' L.F.x2«rr . 36" ✓�v;-ath trench. Other____,_
Name
6 r
Address X �� % �$ �° EAL
PUTNAM' COUNTY DEPARTMENT OF HEM T o
Soil Rate Approved Sq. ed by _Date
40
All
Futn
Division
eq
Approved
a P iicab
C(
Of
14
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