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BOX 26
03206
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03206
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5 P(jNAM COUNTY DEPARTMENT - OF- HEALTH a
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bmii6n of Enwronmenta/ Health Services Carm% N: Y 10512
f`ERTl�ECA_TJ cl14 TR�lf`) ��� +� � s`1.. .r'?t� r lx � �i��^�F.L ":l.�.i F�,trN^ E3�' °�►�ir►� -'� N�--t :
lNAF' p.J� �� ,GF CEO Sa 1'1l�rchS ��►rL ` +VIL1_.�,`Cy� s Town or V�ilage `,
i Located ets�' °� O uT '�R d� ;.k 'S Block �-
ir
f ti t ®v'
separate 'sewerage system built by�� LTV E S�� Address
Consisting of OO Gal 'Septic Tank B lineal Feet ,X 6 width trench
`� other requirements ' +G u�'t^Q� ItJ DIZ At
Water�Supply v Public Supply From z a
`z Prrvate $uPPly Drilled1BY �VCEy \/.nrc�.� 1 P1 ja _
1 AddressPRt�uT' 'BOO 1iC tzo�A`O PEE1G SILL
O S %ECi:� Yb2tc ,i
Bu�lding.`Type `0�3E 1= "A/yteL LESiOE1JG�' No of Bedrooms 3 Date Permit Issued �a' �'(
y ^d
Has Erosion Control Been Completed �� Tia¢�rres� °�
�.s QE; IIEFgi °mss :'
..F s Q +° Qty °`.. �� app •.�
I certify. that the systems) as i�sted'servmg'fhe above premises were constructed essl,�ltt4elly ' Xta�t ans of the ,completed work (copies of^ which are ,r
attached);. and ui .accordance with `.the standartls rules and regulations plans;f�la$ -arid permit,Y h/e�, P'` na CounDe trrieantlof. FI'pq[�.It ;�
L;. 3.X 1 4 _ k tf h 5'1 . >i' •: V t • V }�.+r1 -� MF `�I b
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Certd b • _yRA �Y
r P, E
' Address
Any person occupying premises served by the above systems) shall;prormptly talc ��'(Rn4+4 r ssary to secure the correctI of an y unsanitary 1
conditions resulting from` such usage Approval 'of the, _separate sewerage sYSte a 4e�Qr�,pOA." Wold..as soon -as .a ,public sanitary sewer becomes; ,
a`vailabWand the,approval,of the private ,water supply shall,become,nulParid' void @F supply becomes ava table such •.approvals are
sub)ect`°to motlification or change` when :in the judgment :of the Commissi ner of _ �rb�iocaUOn modrFication or change as necessary
�1~ gy y a Trtl@ T
ry F. f
A
'A
K 0`61; 7
KILU�."MEDICAI-- �ABO AkAY
W
PEEKS 21870 '
T�r'
Mi0' Terrace
Bldg;
orid--'Rd` e �
PeeksklFl, New York
PE 7-8777.
3
-T7 7,EXAM I NATI,ON,OF:WAT= R
COLLECTED
ES
� -
77
o
7,
OWNER ,�-
DATS.'RE(
CITY VILLAGE TOWN & /OR NAME OF SUPPLY a
-S
DATE
"d
SAMPLING POINT','�,
.
' tk
`BACTERIA , 6i;?c ikf�6t35 °C) '
-Pbi
M WT bp
fl Rd POINT por
S�" 11
A
CHLORIDES' {CI) mg /1
NIT
FLOURIDE .(F) mg /1
y
7:
JThese result's �nd�caie thct the water was of a satisfactory sanitary quality when
h QS collected t r{ 2
A
VAN1,3.
-it -\ %
,�,.,i .:. .:'Nl� T��A� •itl ;/'t d..L���..
® 1, \ c. \-. v V EGG \Fc�0., ®
Owner or Purchaser of Building Municipality
_�,-)C:P-%w \c-k-,- �GL1GC `e 0
Building Constructed by
-T do�F- o AD
Location - Street
Building Type
Block
-rA%C q
Lot
GUARANTY OF SEPARATE SEVIAGE- 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 made by me to such sIrstem, 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-
._:..Vl.l: t nt' JPJ a : �c, prT-;e Cam• rCt �y14
r_ _
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system.
Dated this 1.3 day of ����. 19 --T l Signature
Title .LEJP-
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 PUTNAM COUNTY DEPARTMENT OF HEALTH
3j71 Division of Environmenttal Hoalth Services
COUNTY OFFICE BUILDING CARMEL, NEW Y' ORK
Is--
s to 1 complet6WC �weii driPie'r and s "ubn��tted fo'Gounty Healtn°D'epartrni: of togetner wlin rauGrat6ry* igp'ort of�
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
I REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
!-A Ik P N O • \ 4- e- en I.N •T\ I.Z E LO-'C Ill- V 1 %- L. A. %• c- . L- d T 7.n O . 3
i
NAME
ADDRESS SPG".OV'T �(� ®tea. me> AD
OWNER
-t+ OIba�>J \plc S0GG.IE.�b
�t•T Nat AM VA, 1 4-F-1 qe
LOCATION
(No. 6 Street) (Town) (Lot Number)
-r A --I.
O F WELL
BUSINESS >< ®
T <
❑ El ❑
PROPOSED
#--3 DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF
WELL
1:1 El ❑ CONDITIONING ❑ OPH` fy) -
SUPP Y INDUSTRIAL
DRILLING
� COMPRESSED El PERCUSSION ❑ OTHER
PERCUSSION
EQUIPMENT
ROTARY AIR PERCUSSION (Specify) e
CASING
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
[:1 WELDED
DRIVE SHOE
❑YES LINO
WAS CASING G�OU ED?
®YES LJNO
DETAILS
j
THREADED
YIELD
HOURS G.P.M.
1:1 E] 10
YIELID (G.P.M.)
TEST
BAILED PUMPED COMPRESSED AIR /
WATER
MEASURE FROM LAND SURFACE —ST TTIC(Specify feet)
DURING YIELD TEST fleet)
Depth of Completed Well +
LEVEL
J%I
in feet below Land surface:
MAKE
LENGTH OPEN TO AQUIFER (feet)
SCREEN
DETAILS
SLOT SIZE
DIAMETER (InchesHIF
GRAVEL
Diameter of well including
GRAVEL SIZE (inches) FRDPA (feet) TO (feet)
ACKED
- g rgvQl packr(lnches):
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
., n
2
.41" 1,,- I �t p� � p k
l Sketch a t odat! rriaf -we l , Ith d aor qis� aml sF
tw �manbi� amerk�
�c
FEET to FEET
a
E
3`iJ��1T iS x .
-
al..d
1
G
0 0 11 1-7, ji vf-
i�
�L C11
04.
------ - - - - -- — — -- — �!1 a
3
t
.-
4 --
`
1�1 *V� i s-
'
If was tested at different depths during drilling, list below :a
yield
FEET
GALLONS PER MINUTE,
3 "�. -��
I
r
i �8 K
T
L a%iT21
L)
�`
4 � y� 1 ''? �•
°nl-
.fi > bl_.a
f.— :ae.f.re.,wn*-
.+le+"*s S�'x.,..R,n+s.'1i9^>: .ft. of ^`•et*f^Z�!'.'•ti- !rrv,°^r..' . _
DATE WELL COMPLETED
L . Q�
DATfE/E OF/ R�EPORTg
�1 IAN/ {.!
WELL DRILL EytUrej"'a x
,,. #9�,gz(Fxcn r( 1,,k�°.,_.i'>"=
i
I
I
BE .DOOMS
jig
4.
1.
4
xl
jig
4.
1.
4
N 0 971
-o1 —1 OF HEALTH
DF
T
--.P 'A"
MVIROMMENTAL 14M
-c4
AS CONSTRUCTED
SEPARATE SEWAGE DISPOSAL, ';YSTEM
W6.
4
s
TOWN OF
COUNTY', NEW.YORK
DATE SCALE =2L-1 101) NO. 7/
�qoo
SULLIVAN - THIEDE',
GALLON SEPTIC T ANK
CONSULTING ENGINEEM
F X-36 ABS. TRENCH
CLARK PLACE Mk?IPAC Ml- I...
m
f.
*_p if HEALT
Add
Lot
Separate S� if 1:6i GM,.� septic Tank h
st
r,ucted by.
Nate S.upply,to be _41r.
'Other .0y.4
prar -s
f�Wi6n6ar.di,-iCilg� and regul�atignA.bf.':the -;Putnam
r en
.9 la ons
pa
AL
i the
si-
new di
Daie
'
Countersigned
�q�[.rr ►it►
0 f
P. R.A., F �
Aadress9
FJ Cam'
Z'elep:
I b�
S
Lo
no
z�
A
O
o C'
` PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH; SERVICES
Z.
DESIGN '...,DATA. SHEET - SEPARATE; SEWAGE DISPOSAL SYSTEM FILE ' NO .
Owner _;p,9
� �Y S cZl(G b .
E
Located
at (Stre:et)jZ2az/r Sec . Block
Lot
..(Indicate nearest' cross street) . .
Munic ali
P .
tY "C1'e/7-.yW•ti_ y/�C�Fy Watershed
SOIL PERCOLATION TEST DATA REQUIRED -TO BE SUBMITTED WITH APPLICATION
Hole
Number
CLOCK. TIME PERCOLATION
'PERCOLATION
Run
Elapse : Depth to Water lWater Level
No.
Time.:: From Ground Surface. in Inches
Soil Rate
...Start
.,Stop Min. -Start Stop Drop in
Min/in. drop
Inches Inches -Inches
2
/Z: /o ... /Z: 2 S" /S' ZI Z_¢- .3
J-
3
.
4
5
3
5
1
•.
2
4
5
Notes.
1) Tests
to be repeated at same depth until approximately equal soil
rates are ob-
tained
at each percolation test hole. All data to be submitted for
review.`
:2) Depth
measurements to be made from top of hole.
1 a
r
e A.
SYSTEM TO
AND. LOCAL
24
APP OVED
MAR 181971
Illy. 6iVi'i'IWW
ENVIRONMENTAL HEALTH SERVICES
sbtL PERCOLATION RATE ....... :7 ... .... MIN /IN GALLON SEPTIC TANK
DEEP TESi nor-
LF X —
lig "APS. TF ENCH
ISTUhBED.ALL CONST RUCTION TO IONFORMrCO STATE
AND REGULATIONS
5
- --- -/- --- --
PROPOSED
SEPARATE SEWAGE DISPOSAL SYSTEM
WN, OF
COUNTY. NEW. YORK
SCALE ,9s 410;1�--9 FC-0-NO.
SULLIVAN THIEDE,
CONSULTING ENGINEERS
P, Arr 41400PAC NEW YCHIM