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Owner-.;--- - K • � LJG. '�.
Separate Sewerage` System `built by
Consisting of` Gal
Otherr requirements
Water Supply ` iP biic SupFply Fr
}t
V 'Private Supply Di
t �
4 �
ddresst*
B�wlding._TYpe '�`�10��
HasErosion Control Been Completed?_'-
t k ti. F
I "certdfy that the�system(s) as listedserving tr
`:attached)�Lentl.� :e„,::Lba.staf
f
Date " SavT .,s
£ Addre
Any person occupying premises served by fir
conditions resulting from,zsuch usage ^Apt
available and fthe ,approval of 6h i'private w
subject A01,1 or change when; u
ry
Date
In
F
TN.AM COUNTYi DEPART +MENT O'}F HEALTH7k
•{�'J� x}�i il:e_'4,(�x%. q. �f } C. "... E }"M
of Environmental Health Se woes, Carmel N. Y 105121 ';
riy7PLit`�iVC���OR` 3E'diJ��E DlStaoSc�l.� �Y�'�Elllt�s � �l���� fJ� -
Town or V�Itage
'q
Se66rAgy � Block `
_ Lot dl�' Job
Address a
do Tankh , lineal Feet X width trench
J�
tr No` of Bedrooms Date Permit Issued'
love pre s iel s shown on the plans oft ,completed work copies of which are
� r s
d�tt}r+Y P E R A
Er ;i,! , T /� License No Z7 z `
7
>oJe s am ppta "su acUori'as maybe necessary to secure the correction of any unsanitary
al of a sewera- em all become nuII';6nd .void as soon'.as a pubIic'sanitary• sewer comes `
su,pply�s 1 OjuB`�' hen a public water supply becomes •available Such approvals ake"
ie judgme tl� is II of, Health ;such rev tion : mod�icat�on p'r;- change,•is necessary
- %, •� rat' V r
A.
v Bye tia.
� � Title
K.
Ith t,14
to SODUC System. In. alled. on
r e
op
L t 24, 9 Ck 2i, ax 1. ap.
To :tdJOM'-1T ��IAY Cons'a's;
Withoat IWWIAdge. Of the
Vh1i `14 svitsj�U for soptlAd` r,11
Arti6r` the ASU110 iov, Vag:
Ovlall,�',Vaq baied 00,
some.., Tho di's 4P 6h
of a tiro ch4a 'we" 6 fint' 1 be Z
06011d I t V*as difficult tA tial. -]ft. ext#&
90
kIffid thor6foro , idhe,,�
t t
thitall, &:"0
'-It �v4s_not pogd;bU16 Oki I I ,
! W add"
inal ground.- t 'way "d4tilded P
t, t
n nal .0
t 01
3161, Vide, rena
:00� OUS:- r9ro,
ea. It t, old:, find,
ow g r: wad
gad l
401Y di p vV.Od
.
t
th4t the, bq, t6t, bf 'SOMO
0 1 "
o0ve t -h 0A
61 a.a. grdund
Mev t m u the
11"neal
for tho
No W the ftginoft.. doe* ftt Wli,6,00'that the comp
ever i ansatlon I a
6 3o .1 netj. foot t, 360 trench
Garriotint" , to 0401-v6,66to this , eye am t o
insUl-lid. In the '6ri"
9
r bo ha
Thereforo the Owner- X.r++ -Fleig 'hel, eby 'maids ., Mless the
tanleY-Ji: la" P-. S. f. r * m an'y 114bill-ty..-.4ut to
failure. of said at-e%-Y labl.ltq -AROU"Os to so� mortgogorso
WDOra'; Ote. wbo may seek, action*
The ieptla syst,60 In stall a 4hosv, . nee to listed beiQW. ogre#is to
OorreeV an ± verflows by Instal _dAttlohal f1:61.
ds# bringing In"
bahk , run. ravel orl arly other dorr6etAV6 rioasure for the suarazte'41'
'gi
porlod,,,' The�-Xnstaller:hereby vai,ves any liability thit flh her
has with respect to this system*
L7r.
577;
Address .3
'Sys
or
U.LLL DRILLERS LOG 12ND REPORT
J`l L; J•J i..7o Vi11'.1_V1V_ y"'�f/i/ �`l � O ..�� %i /C�i= _ ��. .._.�.���..._ .. �
't tree t section block lot
a, U,
ElL.L �17E P
1i a- M e address city or
DR ILL-i2.(_,7
address ^ city or --U X-
YIELD ML178,17T-71177T TEVEL SC:R.T,,T-,, IYETAIL,.3
. Lengi-i -Ba-JL16d 0 asure j.rom lind surface)
feet or
PumpedZAHrs. Statj.i, —ft 1"lake:
When Bailed 0 t
Yield -Cr S.; -e
ameter: In�,hes, -eld. Gpill r PILM2E
e ft. Len h
Diamet-
�9EITITH OF IJELL- 0 F e e
De Ji)th F-olm ' Give description of
forma "ion p-e--n�e t r a t e d , such as peat,
r o nd -urfac- 'silt,
sand, gravel., clay,.hardpan, shale, sandstone;
rani-te, et-c. Include siz ,-:,. of gravel (diameter and sand
fine, medium, course) , c")lor of material, structure
(Loose, packed, cemented, soft, hard) .(Ex. Of -'-. -o ft.
f v-11-ow sa-;.J,,, -:27, -ft - to 1: 4 f
,_ -Ter, t 0 e ft'rl-Latio-T). Des0.1?J.pt.-;-o11 t Ski tch exact location of we1.1 to
F at
_. 1-.. L �_. �.,. _ w._ ._.._.�,_ H ...__ S Least two 221 - m_ 30
Date Date of Report
Well. Drill er2-1.,4-1214
signatu--e
low
Owner or Purchaser of building Mdnicipality
„•,Z{;r . s,�` .:....- ..,.-- :::.•F.•.,.. _.. c .,-. :�.`.. r ,. e ...- ....w..�.. •. _.. s .y.c, - :-+. a '.:mac a . .,.. .a. <,.. ,- ". ....... - .- _ ... ,v,. + .. ....«. .. .. ,vim ,
.Building Constructed by
� . e
ffL Ct�- /LL A
Location - Street Block
Building Type 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 successors, heirs or assigns, to place in crood 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
i.� nancnd by tha t.ii 11 fill nr nocil_irrc.nt pnt of tl-in noniinp -n-F of •Fl,n }k„ ;1 rl ;r,rr „-F-; 1-; o ;rr.-
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
-= caus "es -b}r t-he= fug r-- -:ieb1 btu -c -act of- the- occupant- of the .building utilizing the-
system. r
Dated this ---�f- day of 19--L1 Signature
Title
co poration, give name and addresF
-------------------------------------- - - - --- ------------------------------- - - - - --
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
1
t PEEKSKILL MEDICAL LABORATORY:: _
1879 "Crompond Rd. Barclay Plaza Bldg "A;; Apt. 1%.-
eekskall;- rl�1�w,�Ndik X10466.
DATE "COL LECTED
RESULTS OF EXAMINATION OF (MATER
Z18/77
OWNER DATE RECEIVED
Mary F ei 5/1,8/77
CITY, VILLAGE, TOWN 6 /OR NAME OF SUPPLY DATE REPORTED
Peekskill Hollow Rd., .:Peekskill, Noyo. 5/20/77
SAMPLING POINT
Mal l
BACTERIA PER':ML. (Agar plate count at 35 C).
1 /ail
COLIFORM GROUP (Most probable N6. /100ml.).
less.: -. than 2,.2
HARDNESS, TOTAL: -ppm
DETERGENTS pPtn ' "
NITRATES (6s. N) - ppcn,.
IRON, TOTAL - Ppm
FLOURIDE (F) - mg. /i.
These results indicate that the water was yes of a satisfactory sanitary quality when the sample was collected.
A. H. PADOVANI, M. T. (ASCP)
._ �.:. .. .. a— ,a -{ ...... .. _ y. ...r.. �-.. _ _ _ .z . r .... . .... . - .: ♦ -r, - -_ -.a .� ..♦. a_.. _ter$. .. � _. .a "4 ...� . .�-. _ .... � ..s - _._ .Y �. ♦ � : ._ . . . - i.� a ... s
so
r
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. /
Owner / eil- Address ioj,/ v G� Apr/
Located at ( Street �S`dexw - _Block Lot kin ica e nearest cross ss ree T L¢.Z
Municipality y�✓ ay e-� �,g -��� ��� Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS.
Role
Number
CLOCK
TIME
PERCOLATION
PERCOLATION
RIM
Elapse
Depth to Water
WaEer ve
No.
Time
From.Ground
Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
le t
2 9,r:S
% /C,,=
'3
39;" °43 9 °s/
T—
/A/
Notes: 1) Tots to be repeated at same depth until aroximately equal soil
rates are obtained at each percolation test hole. A11 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 I�
-- PPLLCATI.ON
NCOL�lt?Eb`IW- TEST_')R67RS .,
DEPTH
HOLE NO. /��
HOLE NO. Pam
HOLE NO. A e,"
PJf:
/c���t�'S
TEST. _.PIT DATA REQUIRED TO BE SUBMITTED -- WITH I�
-- PPLLCATI.ON
NCOL�lt?Eb`IW- TEST_')R67RS .,
DEPTH
HOLE NO. /��
HOLE NO. Pam
HOLE NO. A e,"
G.L.
/c���t�'S
/�-
/t�✓°'� vic.
12,11
11-11 APA6 -..
fiyt� �/Z g�. (L A =
, Hr' ��,cr-✓. �
118, +'
�/
h
2`h'+
h
3011
36"
42++
48"
h
5411
6o++
66++
7211
78++
84"
°WATER-IS -ENC0T) Ttq
INDICATE LEVEL TO WHICH WAT R LEVEL RISES AFTER BEING ENCOUNTERED
:'TESTS MADE BY Date
DESIGN
Soil Rate Used r Min/l "Drop: S.D. Usable Area Provided L,11'
No. of Bedrooms_ Septic Tank Capacity r Galsy Type A4.-
Absorption Area Provided By 2.5� L.F.x24+ b"— width trench.
71 — Other
Address
THIS SPACE FOR USE BY HEALTH DI
Soil Rate Approved Sq.
by . Date
1 J
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property c
Located at
Date ynj .
Block Lot
Gentlemen: Lys
This letter is to authorize STANLEY J. LANDE
a duly licensed professional engineer or registered architect
(Indicat—
to apply for 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
uepa r tiiieilt Gf tleU -L U115 alld to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
".T. i47; ° Edu'cation Law;—the Public Health T;aw, ': ricl ° "tfie Putfiam bounty Maria ="" "" ' "°` ` -<
tary Code.
Court. rsigned:�
P. E. -9 _
STANLEY I 2151 A resB � Z
Very truX�(/' urs,
Signed � Pro _ ty
1
Ad ess
�• a�j��
y •
-"N
ep one
a
0. 3.
-- ';�,�?
FIELD CHECK LIST
3r • ° 4 7
INITU_L SITE INSPECTION
Yes
No
Comments
Date:
Can estimate house location
INITU_L SITE INSPECTION
Yes
No
Comments
Property lines or corners found
Can estimate house location
- - "`
Will driveway need cut . . . . . . .
Must 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.
DEEP HOLE DATA
Depth:
Water elevation:
Rock elevation:
Soils description:
Date.
FINAL SITE INSPECTION- Ins p. by:
House located where shown on approved plan
ST)S 7_C?�' .t A(. T.T)lere a.- nnrovPri
JX'lJ�lll ll1 • LY'Clll:ll L1Cd�U:.I'CU. . ___ ... .- _. __... ..
Width of trench average
.... .
Slope of tile line and trencFi acceptable
Room allowed for expansion trenches
Over 50 ft . • from swamp, watercourse.
Nat ural — "soil -no —t str ppda cr 8DS area"~ '9 `
unnecessarily graded
_
0 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
- -"
e trench . . . . . . . . . . . . . . .
�-
Junction boxes properly set '
-
gould surface run off from driveway, roads,
ground surface, etc. channel near SDS <
earea . . . . . . . . .
P `es lot drainage a ear O.K. in area of SDS
FINAL GRADING OF SITE ACCEPTABLE
Any
rti
eft
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