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kHNAM COUNTY DEPARTMENT OF HEALTH- i
Division of ;fmvronmeno Health. Seivices, 0irinei, N . Y ,- 1.0512
CERTIFICATE OF CONSTRUCTION COMPLIANCE. FOR .SEWAGE DISPOSAL
TC :r O VSlhita .. •-
Located -at J � _ Tax Map / 'h Block
Owner G� Cam' /.L,1 '1-- subs q
Separate.5ewerage'SYStem ; bull t by Address Grni,� �j
/ S ,
Consisting' of f —Gal. Septic Tank and /°� ✓��� ✓�� l
Other requirements - ° J �� o `✓ / i�rl ✓ �7 /JiJ
Water Supply: Pubiic Supply F'ro'm' " ..
YPrivate Supply Drille�dLi By e.! ri P 99.• �'�-
p� Addres cT
:Bulldang Type - - No, of Bedrooms Date Permit Issued'.
Has Erosion Control Been Completedt
eyogeaeons s :� '
Z certify that, the system(s) as fisted serving the' above premises were constructed essentially as shown oryeAeazjl} completed work (copies
of which are attached), and in accordance ,with -the standar3s, rules' and regulations,'in accordance with �3ove� gb�neo $tae permif issued by, the
Putnam County Department Of Health. -
INN 0
`o./ aA;
Q
Date `,-
Certiflei! by _ P'. R.A.
Address . - c -I'"�l ail —c—f to ° icensi
An SV o Q',
y person occupying premises served by,the above shall promptly. take such actionis may be ng eft t cure��cah, 't dn..of any unsanitary
conditions resulting from such usage Approval of, the separate sewerage system shall become null anclJ4 Y� a9'*d -QrB nitary ssWer` becomes
available and the approval ;of the private water supply shall, become null and ;void 'when: a . public water• sup . i b o Such approvals are
subject to, modification or change.. when iri the jutlgMent of the C r of Health, such revocation, rAtsr$ii� pFlanow Is necessary.
Date ~ By Title
r J S'
WELL COMPLETION REPORT
3/71
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL. NEW YORK
This report is to be completed by well driller and submitted to County Health Department together with laboratory report of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
C,". T i t v d E pan •r J f w e .r -
_... _- �...�Gg. - �F�.�a -- s'sE� - U�- r.�s�?'�1:� ..:.•i, €Is =�O C. -:,f5 v:'-.�el= �- C;.M�- L�T90;;,. ... ... ,. ...... �. y.
OWNER
N7
ADDRESS
LOCATION `Y
OF WELL
(No. 6 Str et) (Town) (lot Number)
<�
PROPOSED
USE OF
WELL
DOMESTIC
PUBLIC
❑ SUPPLY
❑ ESTABLISHMENT
El INDUSTRIAL
❑ FARM TEST WELL
❑ AIR ❑ OTHER
CONDITIONING (Specify)
DRILLING
EQUIPMENT
ROTARY
COMPRESSED
11 A R PERCUSSION
CABLE
❑ PERCUSSION ❑ (S(Specify)
CASING
DETAILS
LENGTH (ftot)
� 1
DIAMETER (inches)
6 "
WEIGHT PER FOOT
��
[�
THREADED ❑ WELDED
ES HOE
EYES ❑ NO
S �EDTt-
YES In NO
YIELD
TEST
El RAILED
�j� HOURS G.P.M.
F] PUMPED �L'I�COMPRESSED AIR
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specifyfeet)
DURING YIELD TEST l feet)
Depth of Completed Well ® j
in feet below Land surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches)
FROM (feet) TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
PDTNAM COUNTY DEPARTMENT Of HEALTH
CO "LINTY OFFICE BUILDING
CARMEL# NEW YORK 10512.
JUN 3 0 fill
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL OMB
S�
TED
G
DATE OF REPORT
W (Sig
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u e)
Zi
Own 0 c as 0 u in M14ni c ip y
0;
q
Building Cons uctea by Section
Location Street Block
'I A ell
Building Type Lot
GUARANTY OFSEPARATE SEWAGE SYSTEM
I represent that 1 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.th6 approved plain.orapproved amendment the . re t . o,
and in accordance..wlt.h.the standards, s, rules and regulations of the Putnam.
County Department of Health, and hereby guaranty to the owner, hi . s I succes-
sors, cces-
sors, heirs or assigns, to place in. good operat-ing.condit*
ion any part of
said system constructed by me which.failsto 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 iutilizing,the -sy's ten,
The undersigned further agrees to accept as conclusive. the de-
termination of the Director of the Division of En
vironmenral Health Ser
'rt, -r_ -f:- t - C� i1r
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the syste7r.-----,.
Dated this day of � J-;7-Je. lq� Signature
Title
If dobporatioh'
give name
and address)
- - - - - - - - - - - - - - - - - - - i - - - - - - - - - - - -- - - - - ---
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 Or DATE Or FIRST USE OF SYSTEM.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health.Servic-es,
P m County Department of Health
"N COUNTV DEPAITNENT
CCOUN7 OF HEALVE.
"RIWE - OFFICE FFICE BUILDING
/L, Y if
NEW YORK 10512
'j Uly 30 89 81
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C1� °'ns
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/•.S 00 GALLON SEPTIC TANK
.S6D LF X 24 ABS. TRENCH
n
0,
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Putnam County Department of R'Balth
Division of Environmental Health.Servioes
it Approved ea noted for conformanoe.with
nlicabl0 rules and Regulationstr,f the
f
Fign,atur Countyh Department. e u& it a Dais
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P L A N . -_
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A
COGESTY DEPARTMENT OF H EA L T!1/dL /9 Al
COUNTY OFFICE BUILDING
CARMEL, NEW YORK 10512
'JUN 3 0 190 AS CONSTRUCTED
_ E•
, t
SEPARATE SEWAGE DISPOSAL SYSTEM
- /%r e /Y
- t ` �' �_ °_'"'�--- �- •- t.1�- ►3--- tr_ -t7-^ � /L o Yv c✓ ,S/ /i /a �-c �?pd' >
G
-�, ! �+ rG
Z `''�GS�•'� i'r✓ r.^ TOWN OF
COUNTY. NEW. YORK
DATE G -3 U -o / SCALE i}3 SiSwr JO E.NO. i 9-ZG
f�/OfII� .S6.CZg e- ..F.i.:'6- .SULLIVAN -
I +;, CONSULTING ENGINEERS.'
t Ace Vo r K o w 4a4x wod%�?RC. HE* YORK .
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PUTNAM 'COUNTY : DEPARTMENT OF HEALTH
Division of -w/ Health Services, Carme/ N. Y.,, 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL. SYSTEMWJ'!
Subdivision
Owner_2// T
Building, Type
Number of Bedrooms
Town -or*
Tax Map Block ...
Lot - Job
Address
Lot Area. G' 7� /°/ - G f e-
Defl> Flow ® ®� Or Total Habitable Space. , Square '` eat
Separate Sewerage System to :consist of U Gal. Septic Tank and
To be constructed by ' Address u pvt
Water Supply: Public Supply From
v Private Supply to be drilled by
Address /.
Other Requirements €! . ! V C:� •rQ O��i- 1 -i1 �e..S fi'J77d ✓f° �'PVN �i3�S
i I represent that I am wholly and completely: responsible torthe design:and: location of the proposed syste 1� .;that thi
•• %'•above described will'be constructed as shown on the approved amendment thereto and in accordance with th ards li ryl
•
County Department of Health, and that on completion thereof a "Certificate of Construction Compliancy., Sate ,yQ
be submitted to the- Department; and a- written guarantee will be.furnisheC the owner, his successors, h r lb
place in good operating. condition :any part of said sewage disposal system during the period of two (2J'•y s
ance of the,approval of the Certificate of- Construction' Compliance of the original system or any repairs ere �� ha
will be located as shown on the approved plan and that said well will tie installed in accordan with . st-a les;
County, Department cjj Health.
Date 5igned
Address
.APPROVED FOR CONSTRUCTION This ,approval expires, one year m fro rn the date, issued unless .constr ctlon�+ tii9,p�d
revocable for cause or may be' amended or modified when considered necessary by the Commissioner of Healt ,,,ppp...���
requires it new permit. Approved for disposal of domestic sanitary sewage, and /or private water supply only.
Date ��ygy�i �� BY
Al issioner of Healthwill'
he,t�w34 ghat saitl builder will
ado, o V tdia date of, the issu=
the' f$p A described' above
egul s . f , the Putnam
�
6
R.A.
cert{� Na.'
irtg�:aa! : undertaken and .iv
talt tion of construction
aCrt
PUTNAM COUNTY DEPART M.. OF HEALTH
T n ' .n '. f 5 �' ,�i i]' � r r y'
T r c . s-
i
Date
Re: Property ofi�
Located at..— yy�/-
Section 41 Block Lot
74 1�le
Gentlemen:
This letter is to authorize
a duly licensed professional engineer or registered architect
(Indicate) -
to'apply fo.r a Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated by the Commissioner of the Putnam County.
Department of Health, and to sign all necessary papers on my behalf in
connection with .this:mattex�. and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health 'Law, and the Putnam County Sani-
tary Code.
eb E OF NE* o{,
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Countersigned,�fl; a �p
® +" °pen•° e°
Address
lz�'�
T3 ephone
Very U.J. -our; -
Sign
Own of Pro erty
Address
lzv 7 ca. / -
4'4 -- .� 6 e-D
Telephorie.�
�•�,._� •�•
� psi,
.�� �
; � .
Zf r-
RL'VIF;W CFIi :CK SIMP"T
/del y7 rte %C��wfe , ,
r)nOTR �sNTS - -
.House plans O.K.
Design data sheet
Peres presoaked?
I-Lin. 30" perc test depth
Const. results for 3 runs
D. Hole log 0. K.
Corporate Affidavit for other than indivil
Authorization for engineer
Letter from Water Supply if applicable
If variance requested -such noted on plans
cots Std.1 Remarks'
es No.
b
i
I�TAILS
if change,is proposed,)
Existing contours shown show new-contours)
Slopes for driveway cuts, etc. shown
Mater service line location
Footing drain, etc. location
, 1
Top slope, bottom slope of fill
l
Percolation tests and deep test pit location
i
Septic tank size and conformance to std.
3 B. R. house. minimum
y 1
House setback shown
! I
Distribution box ftg. below frost
411 water within 50 ft. of PL shown
Plan and profile SDS
All other wells and SDS cTc_ser _2001
1
'. shorn cr tai erlence- made
! }
Property boundaries (metes and bounds- clearly
shown ;
:PARATION DISTANCES SPECIFIED ON PL-W
_I
to P.L.
' to Foundation walls
' to Nearest well
' to stream, march, lake, etc. incl. expansion)
�
' to Curtain drain
' to water line (pits -20
' to storm drain
''to large trees
frol"I 1.'01111dation to septic tank
I
' to pipe from leador drain &- . foo Lille; drain
I
fl2l�irl s� 1 �e FxEMD CJrl,,'rK LIST
Date:- i��L v�ety
Insp. by-:,..
INITTAL SITE INSPECTION
Yes.
No
Comments
Property lines or corners found . .
Can estimate house location
Will drive ivay need cut
Must trees be removed -note these .
Is deep hole representative of entire..SDS area
Additional deep holes needed. . _ o -
,f
l/GLs^t A&< Isw1w
•�
_
Sufficient SDS area available considering
drive ,v,ra.y cut, houc° location, separation , .
distances, etc.
DEEP HOL?; DATA
Depth: .7�
Water elevation:
Rock elevation.: S�
Soils description: oa,4 e-
-
Date:
FINAL SITE INSPECTION Insp. b r :
House located where shown on approved plan
SDS located where.approved . . .
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable . .
Room allowed for expansion trenches.
Over 50 ft. from si:Tamp,watercourse
_ _y -
.Natural Coil not strl_ n= - or.= SDS arca ....
unnecessarily graded . . . . .
10 Ft. maintained from prop.line and..
20 ft. from house . .
Separation of trench, from house, well
etc. follows plan'. .
Number of bedrooms checks . .
-Stones, brush., stumps, rubble;. etc: greater
than 15 ft. from nearest trench . . . . . .
15 Ft . of peripheral soil horizontally from
trench . . . .
Junction boles properly set
Could surface run off from driveway, roads,
ground surface, etc. channel near SDS . ,
area. . . . .
Does lot drama *,e appear O.K. in area of SDS
FINAL GRADING OF SITE ACCEPTABLE
PUTHAM COUPITY- DRPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. .,.. _ .. = uuUNl'� OrF'lCE tsulLi�ilVG, `CAttt�IEL; 'iv `Y 1051
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM ,F�ILEf NO. /
Owner /6� �,�' CA/ :�C_4ee � Address 7 �� // �cAc
Located at (S treet `�i• s����� Afl Sec. Block Lot % 2,) 2-
Indicate nearest cross s re
Municipality / An,, c' Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
RLM Elapse Depth to a er Water Level
No. Time From Ground Surface.in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches.
2 3 /11 3 7
V 3c % 37- % 2_e
e
!i/
3
Notes: 1) TpAts to be repeated at same depth until aroximatelyy equal soil
rates are obtained at each percolation test hole. All pp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
G.L.
611
1211
1811
2411
3011
36511
4211
4811
5411
6011
6611
7211
78
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER ,IJJ�VEL R.ISE.S-AFTER'BEING ENCOUNTERED
17-7
j
-1:FSTS--MA-DTR k- -Dat C--
-4-7 7 501
DESIGN
'Soil Rate Used--2�Min/l"Drop: S.D. Usable Ared -Pro v ided
No. of Bedrooms Septic Tank Capacity Gals. Type
Absorption Area Provided ByL.F.x24" 3b" trench.
r ,
J vt 19 d�2
. kz � 9- 4
Name SignatTl
e
SEAL
Address r—�r S
':�11 A
THIS SPACE FOR USE BY HEALTH
ONLY:
t1q. 2499�' -o
s : - 6*
,_ o 00ba.6
Soil Rate Approved Sq. Ft/Gal. Checked by - "*�;4=""'Date