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PUTNAM COUNTY DEPART1GhENT OF HEALTH
Division of:Environinental Health'_Ser." "vices; EarmeJ,.:N Y.:10512
C RTIFIC, EcQ�� CQNST•.Ft1�CT1.QAI CQ�I�IRUANC FQR.. SEUU�R►GE;- DtSP,O*SAL.SVSTM ;_.; 1� �t�c � = :-',: •,
Town or:'Village' .
D /j
Located at��. Q.i 92
V i (� Sectio n Block �•
Owner •v AA 6c)Y-NS \.. Lot 1011
6S 1 A Y �Ai��E 1 C�?Y
Separate Sewerage System ebuilltt 'by A '� Address G
Consisting of LLB -Gal; Septic Tank ?At lineal Feet X width trench
Other requirements
Water Supply: Public Supply From
Private.Supply Drilled By
Address �L�d
Building Type '�1 = C..+1'
Has - Erosion, ControI Been Completed?
ar' \is
No, of Bedrooms Date Permit Issued_
1 certify that the systems) as listed serving the above premises were constructed-essentially as shown on the plan of the; completed ,Work (copies of which are
attached) and in accordance with the standards rules and regulations plans filledu, d the permit issue b' the Putnam County Department of Health.
Date G� `r �� t.� ertlfietl hv ,. 47
E R.A.
_
Address��� ' �-4\ License No
Any person occupyipg. premises served by, the apoye system(s) hall promptly take such action as may be necessary to secure the correcti9n: of any unsanitary
conditions resulting from such lusage.. Approval' of the separate sewerage` system shall become null and void as soon as a'public sanitary.sewer becomes
available and the: approval of the private water supply ;hall become null end void when 'a public water supply becomes available. Such approvals are
subjecti to.,modification or ;change when, in the judgment of the mi oner of Health, s ch- revocation, modification or change is .necessary.
Date g Title
. a
lu
1:tner or 110rcha::cr of twilculig
R
11124 C-4XP
/3".
l'unicipal.iCy
Suildi>>g Con-structed by Section
•�� JrsN -�
N
,ocation - Street
O ..
milding Type
Block
.= ..
Lot
GUARANTY OF SEPARATE KMAGE SYSTEM ,
°
I represent that I am wholly and completely responsible for the location,
iorkmanship, material, construction and .drainage of the sewage disposal sysfiem
-erving the above described property, and that it has been 'constructed as sho-:;n on
`h'e 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
o the owner, his successors, heirs or assigns, to place in good operating condition
my part of said system constructed by me which fails, to operate for a period of tv:o
rears immediately following the date of initial use of the sea:age disposal system, or
lny.repairs made by me_ to, such system, except where the failure to operate properly
LS C cLt:�eU _LV -che willful ui' 11C' l 1�t11 L c1i: L O 111e ola:Upaii f- u1 �„i:
:he
The undersigned further agrees to 'accept as conclusive the determination
)f the Director of the Division of Environmental Health Services of the Patnam County
)epartfierit. oT -Health --as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the becupant of the building utilizii:o the`
,ystem.
)ate'd this 5� day of �,�y'i 19,E 5 Signature
I1 Title ' Y,4 Lo '
•- f ��� f con poration, give name and addres
r�
PHREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS' BE17ORE CERTIFI.CA'1'i
R C0MPLETION WILL BE ISSUED.
'UAMN'TOR TS REQUIItTD TO. FILE NOTICE OF DATE OF TIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam. County Department of Health
PEEKSKILL MEDICAL LABORATORY
1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1
Peehk111, New, York 10566
K".L.` _, "r.` �' *- `•5;..a�'�t,•iri' �d , b' �'. 3'" ��`. �. c, �anti• �•: + �. +v,:..;:t^.'- �e�"�- .+C..r-:.! -. w- .:.'-r.�: v .....h'a' -..•^� ♦.nom•: �rs. .w.ra:i xk°."..e.wv:mr��.i. .,rro
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER
OWN QI /� / /1 DATE RECEIVED
_le, C S r(AJ10 1. o 6randuilc HI`s c� -off 0' %5
CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY DATE REPORTED
b - Lo C Su 3 -fir
SAMPLING POINT
BACTERIA : PER ML. (Agar plate count at 350C).
COLIFORM GROUP (Most probable N6. /100ml.)
HARDNESS, TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg./i.
These results indicate that the water was yGS of a satisfactory sanitary quality when the sample was collsO.
-
a qL
A. H. PADOVANI, M. T. (ASCP)
.y
c, ! q
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING CARMEL, NEW YORK
_ - •7his. rE.poct.:iz, to: bEaxmolete¢, by .v4!ell.deillec.and,sut r,:i.tted to County, {health De��artment together H ith .laboratory repor* of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
---"
ADDRESS
LOCATION
OF WELL
(No. & Street) p (Town) (Lot Number)"
4 .' %s�I• • Z)l i' i �er�k�
PROPOSED
USE OF
WELL
+ BUSINESS
U DOMESTIC ESTABLISHMENT L FARM TEST Will
SUPPLY INDUSTRIAL D CONDITIONING � Ope (Specify)
DRILLING EQUIPMENT
ROTARY ®A R PERCUSSION a PERCUSSION (specify) OTHER
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
THREADED ❑WELDED
(( (� DRRI�IV''E SHOE
.,I�..JYES LINO
WAS CASING
❑YESNO
ROUTE .
YIELD
TEST
HOURS G.P.M.
E BAILED IpJ PUMPED 1:1 COMPRESSED AIR 151
YIELD (G.P.M.)
WATER
LEVEL .
MEASURE FROM LAND SURFACE— STATIC(Specify feet)
-1?
DURING YIELD TEST (feet)
Depth of Completed Well
in feet below Land surface:
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (feet)
SLOT SIZE =METER
(Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches)
FROM (feet)
TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
y
fCLI 1J IlC\
..,)...._
o
_ 7
'! I
1-,70 it /pr Cc .�
/)
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPL TIED
(�Z -I31 —f
DATEpF� R POORTj
�/ -J 7/ i�
WELL DRILLER (Signature) //►
J G
.,above des6ibed will be const , ruc , ted. , �as show6 on tWapproviid amen
- County - -, - - � , - -, - y, ' .and — - `�
'Department,, of,, Health, -.an that-,on. completion.', hereof zf
be submitted io Ahe Depart'mQni,-and,,'a,,wrj en',guaran ee will jl
place in ';good operating ;coinclition any part- of 'said - sewage. clis�.
of s i
-.anee of•-the app.r-o-v-al,,o'f the Construction -CQmp i
that saNdWe Wi
vykl!, b,q,lqcatqgd,a s-.sh own. on the ai:;,pibved-ia` a
nty.�Depa mewt, Health
Cdii t
:n ,o .
Date
Address
-,,-,-,APPROVED FOR - CONSTRUCTION " T h.Zisapproval -pires.!o_p%e.,—
y
`.revoca ca USe'or may be ame& ed.or.modmied w h en onst der
,requires a new 0
permit. '-,A Id for disposal - '-of -d : ome - sa Ff
'A
0
MI
_dU the . -
g,, fieriod of_two (2) year
sfactory to. the, ,com rnissi6ner alkealthwill
3ssigns,by th ' ' ui Id r that said build - ' will
,immediate ly following the - date of the issu-
' e diWell.clescribed above
to ha h drilld
`the' rU 1, nd - ulations of
1. ine ri_sp
I from iuedU6iess.-.cc?,nstr6ciion oft building hae.beeh'�undertaken. and Js
om - misss q o W. 'f Heal ."'n cfiahge or :alterat i6ii of'co-ristruct ion
rivate supply- only
to
Sir
O_ ' .. ..
.4'Z, C.0.U_,TY D7?aRTi 'T 0N- •H�'A.L•.TH,..
..r.e�� - • ..!e^- �.��'�,- .:�^?F�- .,'�:�p:, .yam f�...:.�y".�.•n....tl"5.te wa°i'a..M1amCJl.r,.�t Ya �w:vtw.t ri*u.vos0.4ri
•DIVISIO`? On atVIRO_,r',=',. -,TAL HOALTH SERVICES
Date
Re: Property of
Located at
Section Block r Lot
Gentlemen:
nor ut -
This. letter is �o a�� �orl ., a duly licensed enVineer or registered architect
(Indicate)
�' In a ,,, t� n T> ..-- = ., r e?,7 _r y 1.e • '..
t., app_y 10�. Cons ;,r �c �_o:: : e_ _,.� :, for a se-pa-rate s , e: �v s fs � .:, .,o
serve the above no led p ert7T _ _ accordance w! th '[le s �andards, rules
1, 4- , ' y
Or re �1l c'1tiOnS .a..S 7`'O.':t;1 ra �ed v�J' „�'?: i3Or">1SS� C_"?Or Ol � i0 Plltnp1r. v0�::'„'
De,jartrilnt of Heal'n, and to s i ?'Ii all necessary papers on my Je lalr' in
C- Kj - (,
connec., �_ ._ n "t r �., : -to� •s -� p•�� ._5• - v��-- �__• ����i�.,- �:' o:~ ;�o:f-::s,- ��.d�...._.._.`..__.�
systerm or systems in conforn-n-i ty ,Ti th the provisions of Article .lL5 or
L!7, Education Lavr, the Public Health La:•r, and the Putnam County Sani -•
tary Code..
�f
ro�
X
Counters
P.E., Rte!;
(Seal)
Addres
Te epnone
Very truly yours,
Signea- -
0t,mer of Property
Address
DL
r
Telephone
a
qq
(Seal)
Addres
Te epnone
Very truly yours,
Signea- -
0t,mer of Property
Address
DL
r
Telephone
a
t:.
t
�`e�_
���
i t
-s.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
...�,..t..'„ ....._ r r;. ,�,s, .r.. _ ..-.._ .�:..- +..y�.Y.,. :,i- �..+-- '-x'r.-"�. fit,,. -�. ::.e•.a..�C�. ..,. >..�e*.n....:ati�...;.R,t y..
COUNTY OFFICE BUILDING,* CARMEL, N. Y. Y10512"
DESIGN , D/ATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. S-14 1 1 10-LS
Owner VAL -PATE CouSj, Address A9_p5LF-j� �.�.
Located at (Street JEAN11,L 7i 6�• Sec. (0-A- -Block — - Lot ')�
Indicate cross street)
Municipality `•QuT K)gM Y iLLr_V Watershed PE�4E74S V-1LL u.OV.)
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run apse 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
i t0'�f
2 100 11 i g a- I �(
3 i 1'
5114 12 °� 1( 42 a43Iq- 3r4 �Z>
l
3
4
l
2
3
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.
DEPTH
6"
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION 7
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. HOLE NO. HOLE NO.
12"
181►
24"
.&AIX
3011 ..
36 If \
42"
48"
54ff SCL
60"
66
7211
7811
84"
INDICATE L AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE' L TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY `� , �. Date 10-3O--?d
_ - DESIGN � - -- -: .
Soil Rate Used t$ Min/1 "Drop: S.D. Usable Area Provided S dam
Septic Tank Ca - � T --,
p Pacity- !Gals, 4j =Type'
No. of Bedrooms Se ,
Absorption Area Provided By�2go L. F. x24 dtfi�rench.
c
ivame - F -4oWar t-4 vs, . 0 4.1.1 J g-, bignature
Address Gene `��, /` SEAL
\ \� 38998 F
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Date
' ,Y F{ F } .r st J-�" 1•. - t - t I t. - is MANNpLE C Y�
' i; •" is LAN. �: =i. 4� f i
JUNCTION BOX MIN 12 ,-til V
ir-
`. $MIN r' - CA 9T IfiDN ;
�'; - •` -'`,y •,�.�q' �f• \ �•S. /` SECTION- SANITARYTE i t
TYPICAL CONC.
' - % � 1 �•'.' '' -s'r :�G.<'` i � '\ . �•! .t vRE CASTI
SEPTIC TANK ,, REtNF a rC C B/w _ I
> ° i91 =:p1 '.��•• �7 �:�. � + 'GRU 'LEVEL -i
EARTH
%�. i.' .''\4. •;. y f : O u% BACKFILL. " JOINT 8'.19••
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'Y -r .• ', _.� -: ��Z-Si � ., ,. -,. .i �` J A ?•o OR MAY.
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% ` PERFORATED gt�,
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STONE
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AB ORF'T1 N TRENGII'
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.'� , .f _ 1 14.�»A :I BACKFI HR .UNT14 .INSREC F� 9Y F E51GN .^
YSYSTEM `SNALi NOT: BE.. sf�.. (�
?.i..,.•A :A H CA _ T DE T' T riP:..;R IREO
Rf L'Q - L': HEA MEN Qtl
EltidiNE� ..7E H PAR F ; t
OF,,.A.�_ _ GALLON S, PTIC TANK
W'ITH'•A MAXf UM ,
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/� ASSOCIATES
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