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CERWF�JC r"ITE OF C
Located.,at
7:
`Consisting -C
�-Other cequi
1%V ply.r
�up
"Building. iv e
Has Erosion Control Bei
System(
I --Icptt q y tw A
attached) ;.;.and -'jn - - accqr,
Any person occupying pi
conditions resulting T
available° and the ap
$ubject:fo modification:;
D"
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Supply From:�,-
Address
Lott
pc
K
Y.
44
M.
A-
6. of,,Bedrooms W
c as shown on; t of Whkfiwe, :1
plans cii, 9:; 3 `(copies
na D e if artmento , eai .'
P. ZtL
li License 'No.
Al�
r such action as maybe necessary to secure the correction PfA ny unsanitary
ary
, ecqTP,991 I
oid2!when a' u H c water supply becomes available Such approvals are jt,
miss!? H" a It h;` such rev 6df i ?e. �ii` necessary
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7M,
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T W� ENT bf. fiALTH
NAC !�j
--t
'j 4, -1. -',
INSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM R,4A'J 4'
......... .....
.
-S
Supply From:�,-
Address
Lott
pc
K
Y.
44
M.
A-
6. of,,Bedrooms W
c as shown on; t of Whkfiwe, :1
plans cii, 9:; 3 `(copies
na D e if artmento , eai .'
P. ZtL
li License 'No.
Al�
r such action as maybe necessary to secure the correction PfA ny unsanitary
ary
, ecqTP,991 I
oid2!when a' u H c water supply becomes available Such approvals are jt,
miss!? H" a It h;` such rev 6df i ?e. �ii` necessary
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7M,
PEEKSKILL MEDICAL LABORATORY
1879 Crompond Rd. Barclay, Plaza Bldg A Apt, 1'; ,.
York l 0565 PE �7�$?77
- - y_
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER
OWNER DATE RECEIVED
CITY, VILLAGE, TOWN &/OR NAME OF SUPPLY DATE REPORTED
SAMPLING POINT
BACTERIA PER ML. (Agar plate count at 35 C).
b
COLIFORM GROUP (Most probable N6. /100ml.)
L• J-,a
HARDNESS, TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL -.ppm.
FLOURIDE (F) - mg. /1.
These results indicate that the water was �[! � of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASCP)
MLL .COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEAMI
1/Tl Division of Enviranm•mtal 11c.Plth ,.:'rv:cus
COUNTY OFFICE UUILDING . CAFIMEL, NEW YORK
Tttt rc�O L is-,to be ccmplete(f.,hv well „driller and cPP! Y +. r! �(! r %! jo7H D •i • / t `
. _ .. !!r. �0.7n , .1 f, a iZ. rT” ^!1, 5-^ ^ ^:. R.' :1:it�:
analysis of water sample indicating water is of satisfaet cry bacterial quality before certificate of construction Compliance Is Issued.
REPORT MUST 13E SULDIM1TTED C ITHIN 30 DAYS OF t:ELL COMPLETION
OWNER
NA
ADDRESS .
LOCATION
OF WELL
(No. tol) (Town) for l:�r,:Gor
( 1
s �2-.
PROPOSED
USE OF
WELL
-- D DUSINESS
O /ESTC ESTAIISH M- ENT FARJA TEST WEII
D _
Alt
SUPPLY OTHER
INDUSTRIAL CONDITIONING � (Specify)
DRILLING
EQUIPMENT
a (� COMPRESSED a CABLE - OTHER
ROTARY L� AIR PERCUSSION PERCUSSION (Specify)
CASING
LENGTH (feet) DIAMETER(tnches) WEIGHT
PER FOOT F.7
jL� THREADED El WELDED
j11111E SHOE
DYES ❑ NO
�'�AS ASING G- OuTrb1
YES El NO
YIELD
TEST
FAILED
11 El PUMPED
'COMPRESSED AIR HOURS G.P.M.
YIELD (G.P.M.)
CPO
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Spectlyfee
DURING YIELD TEST.(lcer)
Dep }(,.of Complelad Well �
Fn feet below Land surface:
SCREEN
-
IENGTH OPEN TO / QUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches) FROM (foot) 10 (tact)
I I
'TN FROM LAND SURFACE
1 FORMATION DESCRIPTION
I
:koteh exact Iocat on Of we// wl'h distances, to at least
two permanent landms /k3.
FELT i.+ ;Lc,
If yield was tested at different depths during drillin *j, list below
FEET
GALLONS PER MINUTE
W�t JCOM E►ED
/
UA1'E OF itENPRT
WELL UftILLErt (Signature)
I
.l J
Owner.'or Purchaser of building
�.�C.6 4/
Building. Constructed by
Location - Street
Building Type
Municipality
Block
Lot
GUARANTY OF SEPARATE SEMAGE 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
to the owner, his successors, heirs or assigns, to place.'in good operating c, Jtibi
any part of said system constructed by me which fails to operate for a pA14,• ii—two
years immediately following the date of initial use of the sewage disposh.' "-9` stem, or
any repairs made by me to such system, except where the failure to operate properly
i.c: nniiSprl by thn roil _1 fiil_ nr rn_acrl_irrnnl- ant of i+- nnr inpni- n_F +-}hra hi.ii.l_rli_nrr ii- Fil.i -jnrr
-The undersigned further agrees to accept as conclusive the determination
of the Director of the Division of Environmental Health Services of the Putnam County
Department of Health as to whether.or not the failure of the system to operate was
cau5od uy -'the w i fu - or* negligent act or the occupant of the buil ing util g the
system_
Dated this day of ��� 19 �igna
Title
:."r,Fg_ b
L11-Xorporation, give name ana aaaress.
----------------------=------------------------------------------------------ - - - - --
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
rye" f
am
ee this gwar�at'e -
`` uY (fisted BY mfft k was caaere
1 sywi,, was GBASGmw i
s. 29 the r" doi ld rep
" -w d tr L.
f
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T
f APPROVED
i �n 4Y
, e
CCT2 197
N7N U HEALT - we t.
1 D 0 ,DIVISION O
I Pr EN f {
. t�VTAI -NEUT SERYIfA �'.7 - 0 5:•_ }`�`tl .fA. '�„ b
fK
i �..�•t xx6` .. _ T�raYSn hEreaT r r'1.,•awn as
J
,. _ .. _.,:...__ _, «� _. ,_ _ _ _ ..: ,.�.s"��f' :.I... 2p .. :. B1 oc.�E 3, ��c �/'xp:72 an Try Lis."•racm �,e.-�
11 i.%,'.
A.
_.G fP�eonT p �1� o a� F ro
{ �. e(-� 5(0'.•3 ,- t �J"�: Gf' /�.l . .rem.
All
Y �.
PUTN��I n
s t'
;DIvlSIO(J of EnvIto� men
Y.'.
CONSTRUCTION PERMIT FOR SEWAGE -DISPOSAL .'
# Subdroision
„
3 s Owner At r
ESlL7�.i%
Building Type Are
Number of Bedrooms `
s
t .e a CitJ 4
o Separate Sewerage System Ito consists of i
I n _y � •yam 1
Water Supply _`Public Supply From
1 -
I _
';Private Supply ;to be drNiled IS
yZ
� _ Address :VY �c
_.
L
Other Requirements a
EU
C .Arepreserit that 1 am who lyantl eo nl
i aboVe,desoribed' will beFconstructed'
:County�`Department of�,Heatth, _ n'�fe
_ }be _tubmitted_to the Departmeht�
r
;place in',good gperatmg :jconditio a par d
( ance of the ap,prgvai of�the CeR. i of om lip
} wUl be located is shown on the ap lan Ij said'wxell tll
�� ;County Department of Health -� , ,
'40PR6VE6 FOR CONSTRUCTION This approval expir` s
e-= 'amended o► mod�fred when d sides
Eevocab'le for .cause or may b .
i regwres :aj ne p(er�mit — A- 7p�pr?oved for disposal of dom w sa
` 't
PARTMENT �OF� ,,HEALTH �.
'th Services, tame% N Y 10512
r6� F�ae� Town oTa a '�
... ,rc
AddressDzX
Total Habitable Spaces ���aC Square Feet
ptic Tank lineal feet.X N width trench
{y S3
,,, 1• s
W.
.So
s
'7. r
cation of••Fthe proposed system(s). lj that separate sewage di stem
ire to and in accordance with the standards yule regu a, ions o '' u nam
rte of Construction Compiiance % tisfactory.to th, mmissioger"` Heaith,will.
ed the owner his successors heirs'or assigns by .the bull a said bwlderwtll
in dur ..'g^ the period of two (2) years immetliately following the date of the issu
Fie o nal system' of any'repai {thereto'2) that-.the drilled'twell described. above
ed accordance h'tfie Bards, rules and • }egu a ions oi- the Putnam ,
- "Tfl ysc F •,, 1 a* t i E
A'r
,,'License No -5Z�2A
he date issued unl ss construction of the' bwlding hasibeenundertaken and is
rj 'stoner ;of Health tAny, change or alteration of.coristruction,'
1r p ateT ater supply:,10
Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
-- - -- - - - - -
..:...._..,,,, iit' ElvvikUltiftivT%'itr.AipEiiCLS
Gentlemen:
Date
Re: Property of Jv yc 'e
Located at %4GGal.J A104 a yOr JV Or- lv; ,a� L
lox HAP ox
n 72 Block Lot V ��r 2
T' M�9 E�9 � :M ;� R
This letter is to authorize .�,� " .��u�`�� =�' � ��'��' '
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
Lwilit_t.: L.Lui, wl Lr1 gilds ma a Lev ailii to. Supervise the cunstruc ciur! of said
system or systems in conformity with the provisions of Article 145 or
_. ,..-- ...... >�.....'i "tr-7 ..._ T�.7.: °.r_;_ -'r ':R.: ' : ?.1.1 r^: +ry
.r_-7, i;uuuutyJ.. Tiaw �..a Lu&I i'i "-L = r- ;a �:n,a c• .I�,icirri E �u:'it=y"" �U: �"
Lary Code.
Very truly yours,
Signed
Owner of Property
Address /
P.E., Imo, # t f 2 l
elep
STA ���
BOX 267
Telephone
3
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner 'JO YC 6 ,P- eA Address ox'. /6 /ycaTNaiy t�i}oT /j/ -
Located at (St reet '4-w og0 2_ Block 3 Lot
n ica e neares cross s Fee
Municipality �,; �4tj 54 .G . Watershed aGd le-
SOIL PERCOLATION TEST DATA REQUIRED TO'BE SUBMITTED WITH APPLICATIONS
Hole
Number.
CLOCK TIME
PERCOLATION
PERCOLATION
Elapse
Depth.to Water
.
a er ve
No.
Time
From Ground
Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches.
2 z I/; 3 111�4
174
4/2/.
2
13
go
--=,
5
1
7 r
Tsrs - /d4- ke-A.� /V A 6 kI,— 1744.&T' ..
5 ..
Notes: 1) Tegts to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All 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
DEPTH
HOLE NO. /f/
G.L.
6
1211
1811
2411
3011
3611
4211
4811
5411
6011
6611
7211
HOLE NO.
lei
HOLE NO.
C,4
Z=
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE'LEVEL TO WHICH WAT R LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY ----Date -Y -,5 7.r
m Soil Rate Used J,9_Min/l. "Drop: DESIGN S.D. Usable Area Provided —5/
No. of Bedrooms Septic Tank Capacity,/00,a> Gals Type/reczv/
2 1 - ;�;�
Absorption Area Provided ByZg L.F.x 4' 3b width trench.
STANLEY I WDER
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved Sq.
t We Tog and' water, analysis must .be submittet
Health Dept befor- Certificate of'Construction`
-•:�. mp a wi.1
ano. issued: _
�....., _
t
o e
1T; ..After ?completion Of septio s+etem, top.drieas
-� oCPAi15lbA/. T�2 an eed e
area with 4" topsoil d s � un�<ll good stant�
grass 44 apparent
ot
Of
C .ul� ioE P/14f�eQr�a ( .'.�*lw�i b :iR
xy
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