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;Vllater- Suppi Tublm S�4pply,: q pm
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_ Private u ,
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:Building Type a`�
W— ..-'of -bedrooms Date Peimd Issued
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"'Has Erosion rc'.E!een.', Completed?.-,
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thatAhii'ijitbirii(sl) , a l : !l ,as �i,64M Ian -' r I f Pa
"I certify
atiacked and iti ndi� :re Latj rs.filedaWthever County t of e
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Date - , M 't -
--0 Certifi
Any person ` a-
I served-.by, the above -,systems) shallop
::condftions resultingi feoq,such , . . ... Apprivil the 7
ia.,Se
available and the, p shall OW41 ,
iijeictto. juclgmprij�- T,tna;
change
Date By-
icense
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-�S
qtly take such aetioh as mabe ;OrV,tojecuVe, ih'e' coriku W any unsanitary
ge; system shall become -'huil' and :'void a�rpublic;iihitaiy ie war. b
4 PpPmPs
n 19 pply��becomes f",ava-iia, D-le., ;sqch-- approvals, are :
. ..... — ' 1 `6 " nk6siiiry. .1 •:�Of
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Title
. 6&�Ay
Owner or Purchaser of building
Building Constructed by
G
Location-- Street Blee-k
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 sys,fem ,..
serving the above described property, and that it has been constructed as shoran 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..good operating conditio
any,.part of said system constructed by me which fails to.operate for a period of t, =o
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 occupant of the building utilizing
7-FiP CvCtam., •
The undersigned further agrees to accept as conclusive the determination'
of the Director of the Division of Envirdnmental Health Services.of the Putnam County
Department of' Health as to whether_ or not. the Fa.i lure of the system to operate waG
caused -by `'the w lifu or . neg gefft-ac t of the occupant Ui "the budding u iiiizing the
system..
Dated�� day o A r; 19 Signature
Genera Co actor
Signature, Title %/,�Le 01 1
Sept c Contractor (if 'corporation, give name and address
THREE (3) COPIES ARE REQUIRED WITH'-THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICA`L'E
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
ro S?
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTIIfIENT OF 'HEALTH
3/71 Division of Environmental Hoalth Sorvices
COUNTY OFFICE BUILDING • CARMEL-, NEW YORK
r ..This report -is to be completed by well driller-.and suf'r :;i[tc�d to-County. Healt_h...D_epartm_enS together with laboratory repwrt Of, _
���'�""�aiiai'�sYs G`►`�v"aZtY�a��� �'i°il7'I�ili C7oit.�5��' �J�(�rdi:lU`Yy Udt ''",'ieilJdPa�l7�11 "l�fi't�Te I„ rf`( 1iiCd�r' Ufi;' �TiiSl °JGi�v41'C,'UiT�ritail�'i�i� �iEi- i�•�'�'. {'w`��•
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
ADDRESS
LOCATION
OF WELL
(No. a Street) �s (Town) j (Lo► Numt+erJ
rr �d A`l%r ic 1 . ' A. ' i G` 4 tr.�z. C_i. .S~(/ r 9 i
PROPOSED
USE OF
WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
l
❑ SUPPLY ❑ INDUSTRIAL ❑ E] CONDITIONING OTHER )
DRILLING
EQUIPMENT
COMPRESSED CABLE R
❑ ROTARY ®A R PERCUSSION ❑ PERCUSSION ❑ ((Specify)
CASING
DETAILS
LENGTH (feet) DIAMETER•(inches)
/ J
WEIGHT PER FOOT
THREADED . ❑ WELDED
DRIVE SHOE
YES ❑ NO
WA CASING
LJ YES
R U ?•
R NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED iiJ PUMPED ❑ COMPRESSED AIR
YIELD (G.P.M.)1
WATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC (Specify feet)
!
DURING YIELD TEST `fleet)
Depth of Completed Well
in feet below Land wrfoce:
SCREEN
MAKE
IENGTH OPEN TO AQU11FERt (feet)
•
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF.GRAYEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches) FROM (last)
TO (tee d)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FLCT tJ ILL'1
w
•
se
/o` •.r
L �
� /�! � � � /lie.
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL rOMPLETED „
DAT F OF •R�EryPOIRT
WELL DRILLER (Signature) --��
43296
PEEKSKILL MEDICAL LABORATORY
1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER _1
OWNER DATE RECEIVED
Val Pete Construction 3-17-75
CITY, VILLAGE, TOWN VOR NAMt OF SUPPLY DATE REPORTED
10 Grandview Avenue, Ardsley 3 -19 -75
SAMPLING POINT
T_4. Un Boswell Subdivision
BACTERIA PER ML. (Agar plate count at 350C).
COLIFORM GROUP (Most probable N6. /100m1.)
Less than 2.2
HARDNESS, TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg. /1.
These results indicate that the water was yes of a satisfactory sanitary quality when the sample waspcollect
A. H. PADOVANI, M. T. (ASCP)
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PUTNAM COUNTY DEPARTMENT OF HEALTH
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.- catYxr.-- .;ca�.,r�r. �- r:- ..a.... -.m. - rx...,:Jc�.�:. �.:��es,. c.�y�j,;� =.<'. •.. ,�qF= ,':e�.',Di�.e,+:- ncc�:�`v. `ar -.vo.a �F.'.r: titir r..: �S; a�TF,: cn= v+ . �i..+ �r`. w,:: �':= va `�m:�:c.".,.:....i.�<Saaee:e:vW '•,�.C'�.:s.. �A..n....
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. .11 - t oa4-
Owner 1��� - P¢a ��s-tr, Address
Located at (Street Sec. Block — Lot.
6dicate neared cross street)
Municipality PLAnaam UJI Watershed PQ�kS I auy
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 tot° 1�� t9 ���. I��Z °/►
3 �o`u tom
4 12
5 11 11 *3 0 a� Q'l Q6'14 1 /�. is t
1
3
4
5
1
2
3
4
5
Notes: 1) Tests to be repeated at same depth until aroximatelyy equal soil
rates are obtained at each percolation test hole. All pppp 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
HOL '0 H LE NO. HOLE NO.
>s<v- .:'sa+.r:.0 e�J..'�. ca:.. ak•v n`w, -:. ��`'..�`��"��u, rim -«..<. u,:. sw... n«. e7, .a�rc.�'�r`a�.z.:i.�ywcwo_�v t�+G+.�- ...�-y :x+�.i. :i wr:.r.:,ex'c� .. wit% �.++ �M1. w�.. '�r,.u.;vrv.o- i.�&.,..= �..w�._.
6"
12"
18"
2411
0. �
3011
361
42"
4 i
5411
60"
66"
Sck v�
7211
G
1 i;5
78 I,
`
t X
8411
INDICATE
=A AT.WHICH GROUND WATER IS ENCOUNTERED
INDICATE
LEVEL TO WHICH WATER -LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY 95 Date 10 3 1 -'1 Q
Soil Rate
Used S Min/l "Drop: S.D. Usable Area Provided S
No. of Bedrooms
Septic Tank Capacity qd-,o Gals. Type tcts
'3 .- -.width
Absorption
Area Provided By_,24o L.F.x241' 36"— trench.
Other
Name
�: q igna ure
Address
pr
. �� Lc �_ .SEAL "
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate
Approved Sq. Ft /Gal. Checked by Date
DE-PnM ,,.T_-
0 F HE A.
DIVISION OF ENVIRCIN, tTAL HEALTH SERVICES
Date —
vaRe: Pro pert . y of (_ Sit •
Located at 7c A M kt,& v -
SecSection Lot Block Q)_
Gentlemen:
This letter is 'Ll o a u tn o r'i ze
,
a duly licensed professional en' ineer or register-=4" aron-itest.
(Indicat_--)
to apply 'Lor a* Const.-Inu-iction Pe-rr-lit a sepa-rate sewer-= systemi; to
Serve the abo ve no ted nro-o er t
Y 4- accordance v.rith UL-le s;_.anda_-,.ds, rules
or r a E u 1 a o n s as 0- e a ,y the C o rrLm i s s i o .-. e r o 'L t P u n ztl Coun y
D_--)ar"1-1ent of 11--ealtn, and to s-*L,-:,-n all necessary pa-pers o-n- r--,'T behalf in
cm tl O.'r, .3 1
4- Or
system or . S7st-en_s in con,f"o--ml ty with the plrovisiozns of e 1L,
147, Educa"Ition.Law, the Public Health Law, and the Putnam County Sani-
tary Code.
V
Countersig-ril.
yj
(Seal)
Addrest
Telephone
Very truly yours.,
S i gn e d
Ovi-ner of
Y_Q n n
Address
a-
Telephone
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M N - OLE 60Y .f t
7 , PLAN,. I - 1 ,1
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JUNCTION BOX Mlw.la =lrtt
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4" 1 —
S JVNG.'j10 }3ox Fan�inCC�S 'Co ti3B. /�^ 1 E
f LIQUID l VELS
CA'gT IRO f �:
1.a. �^•. ",. - � � ..� - `"*+ie.:�..,���� -!' - - - "�O� �tI t -r ZJ "IALI.. LAC 6iE.�. -�R ES .14 IVA CN, }O.: ..SECTION ', ...SANIWARY T
+� v�,~ik R \, E. % �`• f2�MCYKET}J TYPICAL COkC 'PRE OA9a;' Nc . 1
XPANS OA!
y ` SEPTIC TANK �' EINF 8 CCB /W f
TZO. WE�LL.s )mITµltl. 2Qg lr_ 50%
�:?�'.`�'•�.'. \t`i+J. ..0 . _ �,T;...�, /. .�, of Yr.t : t Q i - EARTH. l
J ,. ' _ 1.r o •'., y� BACKPILI J 0 1 T" -
{ COVER-
r $LOS. - `PAPER.: :•�
�I p PERFORATED 5. ,
SSE' oot o 4' PI PE
8.:54 «,t c�eaw cRA •i OR
�.. _ _ 24:'MIN i ,•,• _ - CRUSHED TONE
i
i
, �►.,;,;;� ice• �., � � � �GAt i'° t3RPTi0N? TRENCH'
NOTES. I Y
SYSTEM TO BE CONSTRUCTE61N ACCORDANCE WITH T E RULES AND
RFGULATIONS OF'THE "�� ?Z V,,C - COUNTY SPARTMENT
/NOV 974 OF HEALTH. . i ..
E1fGTS ALD THE BOECBACK EAUL7H D PARTNENTCTi R Y DESIGN
x
umSlori OF CONSIST 0 L 'A `� an GALLON. S P ESC TANK
ifuT N 1 R AN
Y C
ort, S ;ST'EM 'TO ONS
\�- +' tlEBLINSFBYt ANf7_`FT QF 3 FT TREN'_CH WtrfiA 4XIMUM
9� .*' t 1 .-. . • PITCH.' OF If16 PER FOOT.
�Qof�}►p .N _ t
y j FIRST
�..•Q �� A � QISP09flL SVST.EM,f3RADES REFERENCED TO F1�'�SHEO RST '
Z �1 FLOOR E:L•EVAT -ION UNLESS OfiMEAWISI NO {E I:
� � �SUR:�At.E.±. •� 9% � �r� 1, � SCAiE', j � Sur R°
S. D.
SY TER FOR _VA = P ET"F_
i.N1,C�IO�i iXES,.'. o I
i ,' QRO., - -- '� $HY }SIGHS HOWARD 'Q:' KELLY, JR.
ASSOCIATES !}
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