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judgment
Kq,
HEALTH fT OF
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ST V. 044 4�
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'Town or Village
.ction;— Block
V
ddress
Width 'trench
--Date Permit, Ilss
rshown on the plans P I
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fim�dpun Y-,epar ment-of,.; e tn.-
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P.E. A I
License No
ion ',al e��ary to:-sec6fe� the ,correction' of any *-unsanitary
k :7null, -vqid- bli
qme 404. ijso.q�,.as-,.a§ipu d'sanitary sewer
j k t .
cl lublic�'watef.',sul bec6ffi-esEI6viHiJbI6., . Such, ap
_Orovals are
; such,revocat , daHication or cha4e is necessary.
;7
4`1
0
;7
nt
Owner or Purchaser Building
C U13 rw_iV'
Building Constructed by
7 rla
Lo�ion - Street
Building Type
Mu icipality
Section
Block
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 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 system, 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-
termi.natiLo.3 ;i ,c.f.. -the Director. of the-Division of ..Env.,ronmenual Health Ser-
v'ic6's ""of�'tKe"-Pu riam' County" Department*'bf''HeaT h as'to whether or "not "the'
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 _ day of Zul - 19_ZSZ. Signatu�
Title
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.
<.. 4'130.
rJ" r
YORKTOWN,M.EDIC'AL LABORATORY -INC.
P.O., Box 99 321 Kear Street
DATE COLLECTED
RESULTS OF, EXAM INATION OF WATER 4/8/75
DWNER DATE RECEIVED
C . CHANG 4/8/?5
CITY, VILLAGE, TOWN. & /OR NAML OF SUPPLY DATE REPORTED
JEANNE DR. PUTNAM VALLEY, N.Y.
SAMPLING POINT
WATER I TANK LOT 28
BACTI RIA' PER ML. (Agar plate count at '35o C).
COLIFORM. GROUP (Most- probable No, /100ml.)
LESS. THAN
HARDNESS; TOTAL - ppm
DETERGENTS - ppm
NITRATES (as N) -, ppm
IRON, TOTAL - ppm.
7LOURIDE (F) - mg./I.
These resulis- indicate that the water was YES of a satisfactory sanitary quality when the a ple,was co lected.
PER: J. TORLISH
A. H. P.ADOVA I, M. T. (ASCP)
WELL COMPLETI'0N 'RER,ORT, PUTNAM COUNTY DF.PARTMENT OP HEALTH
3171 Division of Environmental Health Sorvicos
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This report is to be completed by well driller and subn-.itted to COUnty Health Department together w4h laboratory report of
;;,Ft %^ ar &Iysis• f "�Ai tfrrsar•Tiplsiii i�a in w�l;tet�is<erf :fisf � �;� y Is �ct�l Ul c#u$lit,�� before cer:tificatecof const ruction- cornplianve
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER ADDRESS
(No. 6 Street) aj rJ" (Tartu) (Lot Number)
IOCATiON
OF WELL L E:41,siYe a 5 ule-11 BSI. 2,r
'
PROPOSED DOMESTIC � ESTA6115ESTABLISHMENT ENT D FARM D TEST WELL
USE OF
WELL �
SUPPLY O INDUSTRIAL LJ CONDITIONING El OPQCE y)
DRILLING D � COMPRESSED � CABLE ❑OTHER
EQUIPMENT ROTARY AIR PERCUSSION PERCUSSION (Specify)
CASING LENGTH (fast) DIAMETER (Inrhes)iVrEIGHT PER FOOT, �(D�RIJV�E SHOE WAS CASING ROUTED?
DETAILS I '�I 1'iiR[:.DEO ❑ Y <L'LOEf: I_ Lx; YES ❑ NO 0 YES WO —
YIELD HOURS G.P.M. YIELD (G.P.M.) l•
TEST � FAILED D PUMPED 1^1 COMPRESSED AIR
WATER MEASURE MEASURE FROM LAND SURFACE — STATIC (Specify lecq DGRING YIELD TEST (loaf) Depth of Cempletod Well
LEVEL in feet below fond surfrca: tzl?O A
MAKE LENGTH OPEN TO AQUIFER (loaf)
SCREEN '
DETAILS SLOT SIZE DIAMETER (Inches) GRAVEL SIZE (Inches) FROM (loaf) ITO (�eoi)
IF GRAY[L Diometer of well including
PACkEO: gravel pack (Incho3):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances, to at least
FEET to FORMATION DESCRIPTION two permanent landmarks.
iLC1
� -U
If yield wos tested at different depths during drilling, list below
FEET GALLONS PER MINUTE -
b4
DATE WELL
COMPLETED
DATE F REP RT
WELL DRILt_Ei2 (Sl9natur •�
May 179 1977
Mr. Roger Mayes
Roger Mayes Construction Coqq Inc.
36 Lakeview Road
Carmelo N, Y. 10512
Re.: Separate Sewage Disposal System of
Colbert,. Chan
Dear Mr. Mayes:
I have been advised by Mr. and Mrs. Chang that a separate
sewage disposal system installed /by you in early 1975 is in a
failing tonditioni, Mr. Chang advises me that You performed cer-
f-1,976j.- but-th-is
in-,.apprQximately -Sep-t -0 _did.
ot rectify t-h e s f-i ua _ tion* . I"t would appear that the
warranty'
for this system is still in effect.
Would-you,please advise this office -of your plans to
rectify this situation and the approximate dates that you in-
tend-to. be on the site.
Thank, you for your cOnsiderationci
. Very truly yours
o Robert Folchettiq P. E.
Director
Environmental health. Services
JRF/ps
cc: Mr. George Haughneyq. P.E.9 Route 529 Carmelo N. Y. 10512
Mr. Colbert Chang, R,D. 19 Geanne Dr.9 Putnam Valleyq NoYb 10579
;_�^«'7°^-c-�•? 'M^.-'^--.
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PUTNA_M COUNTY `DEPARTMEN'f:`OF HEALTH s}
w
D/vis�on 'of Environmen H alth Services, rCarme/ N Y{ -10512
, L, CONSTRUCT E SYST EMS -0
x Y -r.� >r e� �x t 1 r✓ .r A Sbwn or -_ V�Ilage.
LOC3tetl' .
k e. ��,�_, -r—• -r _ �` Section ` /,j�,/p H oak -
s �•.wr�f- . a � s, . .s -#r=�� ir's ; ni 3n- .a u- C-L �''"_. ,a>_�'T'� 11 a^•• ;-3 w, .a,e 'is
Subdivision �� L�.s;T�� �$ Lot ob
4
k� 0 Wner
^'lac l"'p.�� •y t. { ,� e� �"kj h r3'k' �" •s •y7 S"� b
inc�,��'S, # e ;... � .�[ �. `i 1' i j i � {y � ,� a 4`Y t R �.} T.� � � ',` b } '" t. as " •' F c x , ' y
y
.Number of ,Bedroom; ` V o� ' Total Habitable -Sppce 5 Square Feet Y
s Separate Sewerage System to onsist o ` } Gal+ Sept Tank �' hheal feetX / width ;trench.
Address 1
„
a`k�`'..`'a '.. � �c ,� t rr*, ' �. _, z 2m � ,vxF ,k. a -.nr.. �"q"ka5 r° `".e%.11 ?End ay''�,��4� �:c�r N' r _f �a y rah* �• �. -. � y i 3 x x,:
s~���;WaterSSUpply �,�„w'° � �PUbIiC'SuPpIY.+FrOm '� "c s mrr
y" k1:^ w+, y ,��7
Private- Supply t0 'be druie {
1 �> •�< r y.. b : t. { }.; •r- F x� y
Address r
�*
-�c..• ra-' x 6 s¢ _�„r K- rim .a -.�a -k k 2 a a "'' � ,€ .-`3R '' `6 3� ���fi, �"�4 x � '� ..
Frhrepresent that loam wholly and completely responsible for the design and location,of the pro i,islyfgtp s) ,1), that the separate .sewage .disposal. ystem.
" a, w, apt ds rules =an ,regu a ons o e " ..0 nam
R;3 :will befonstructeand' that on tom 8l�ton thereof atlCertif sate tofaConstac o i,a 'sfactory ; to- -the Commoner of?Healthwill
�., Couhty Department o , Health, p �0 .Ii7Rl . J
.4 be `submitted •to the =Department and, a. written guarantee will, be furnished the own�,;'t1y s}�Ee lf$, i.. �a signs by the builder; tha.:said builder will.'
piace'.lin. good; operatirig condition any ;part of ?;said sewage disposal system during t�epenf of•;;two_(;ys lr►mediately, following thedafe'oi the issu -:
,• a
i a ;ance of" the approval ,`of the Certificate of Constructwn "Compliance of the ina�s nor a 'air_ egeit 2) that the drilled well °described above..
=wUl beaoWied4i i"a on�the approved plan and that said well wil�lie instal `ac ld3li w a ,g r Iles and cegula —i ons of; the 'PUtriam
COUnty= Department Of- Ffealth {', °` y'
'Al
�i?<JK. , r J �s G Si9ne a t :ti a P ES R A.
i_^ � � �`'� rt r �' �ikldtlre5s " , -� o- t �. s . � ".. Q r ..+ !•, �..iCense NO:
'_APPROVED FO;R CONSTRUCTION This approval expires one year from theidate', issuedily `t+d�3tr�Q �b� -of bwldirig has .been undertaken 'and is
revocable for cause or may beA ended or modified when consldered necessary byFS a Commi �dl klkl�tHealth A y than r. Iter Uon , f�con'struction.
=regwres ewpermitS "�Appr ved for :dreposaFrof +dome' wageYan o private water supplyonly y'
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Gentlemen:
PUTNAM COUNTY DEPARTMENT OF HEALTH
.DIV3SION� = -OF °- ENVIRONMENTAL ---fHEAI TH= rSE-RVICES�:= - °.,�-. w ;,
Date��;
T
Re: Property of Mr. Colbert Chang
Located at�.', :� !��S ' %;y. i TG� l/yf,�� %/�� y�
Section Block Lot ,,2f
This letter is to authorize George A. Haughney
a duly licensed professional engineer X 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
vwnit!v L1.u11 w-L Sri iiti s ma c LL-r anti to. supervise the construc ciur! of said
system or systems in conformity with the provisions of Article 145 or
143,.LEducatidn. :Unv, :the-Public -Health ''Law-, = arid''the 'Pufinam'.Couiity San.i
tary Code.
Very truly yours,
Signed
Owner of Property
oCounters igr��� ` - ..... ii�lF1',.'
Address 'T
P.E., R.A.,` #C5
Route' Telephone
Address �0,p
�I.�. �resS 10\A
Carmel, New Yo'r'k ") 0512
(914) 225 -9393
Telephone
1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
0, q', r. .1 4i *:it1 v. :1-tio ;w ii"i•.n,. p��•, .MS, ,•v,.�rw iii`: aE,::: i.•+e- � .'din• Py :,y`iv�no ..r •j+n is .::�:..ii+%tily_ �.ia :i7.i. .rii iii..:.•, x.•.v+;, vn,4: >._
COUNTY OFFICE BUILDING, �CARMEL,�N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSALS TEM FILE N0.
Owner Address
9
Located at (Street �Sec. Block of�
lca e nearest cross s ree
Municipality Watershed - _
SOIL PERCOLATION TEST DATA QUIRED TO BE SUBMITTED W H APPLICATIONS
Hole
Number CLOCK TIME
PERCOLATION
1
PERCOLATION
Run Elapse
No. Time
Depth to Water
From Ground
Surface
Wa er Level
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Inches
Min. /in.drop
Inches
Inches
`
1
for
2 ..:_,.•. , . ._ ,._......._ _. ,. - _.__ .. _ _ . _ jam/ / .d.r.. y�� W.
3
4
5
1
2
1
3 ,
4
5
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. A11 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
DEPTH HOLE NO. HOLE NO. HOLE NO.
.✓ ..�- ie'.,'•. }.lf�Sll:J •.'rv. -�tf ¢a� �. :A1 ir%tir' :1 �� •.r :. :: r. i.^.1•';.._......Ky .,N`� -,c +i•-a-m- +r.` -.-u a_. .- �� \visr.� .P-`c• wiri :�:..Y..:. h'. �'nr.: « \r.:.in
611
12"
10"
24'1
3011
36
4211
4811
54 �� All' I
60"
66"
72
7811
INDICATE LEVEL AT WHICH GROUND WATER S ENCOUNTERED
INDICATE LEVEL TO WICI �R LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY / V Date
., DESI.GN:-
Rate _...�.: _.:.:_Usabl...... o:. r•
Soil ~ U e
sd` Drop: S.`D. e Area Provided
No. of Bedrooms C Septic Tank
. Capacity Ga s.
Absorption Area Prov ded B (r L.F.x24" �
USE BY BI,ALTH DEPARTMEI T
Soil Rate Approved Sq. Ft /Cal. Checked by_
Type L!%mo _
width trenc .
wjia o@�, ,er
i
00 pE 0438° :'
igFFSS I
�''I'i i ► ►1►►►►Date
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