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03406
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PUTNAM COUNTY HEALTH DEPARTMENT V ""y / IY, --
DIVISION OF ENVIRONMENTAL HEALTH SERVICES t.o ;* 17
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PROPnSA, FOR SEWAGE DISPOSAL . SYSTEM REPAIR
OWNER'S NAME � L n,W - d �ST�� V_ i T 1-_ri
PHONE
G 2*- f rr Y&
SITE IACATION �.,`2Q /°�i4k
nnkR -f Now Pj
To
3111
MAILING
PERSON INTERVIEWED
PCHD Complaint #
Name &
Relationship (i.e, owner, tenant,
etc.)
DATE i.- 7
TYPE
FACILITY
PROPOSED TALLER ,.
/'� ('� �- '!
PHONE
S' 2 G d 7 5
REGISTRATION. # jk— ;f
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed ^professional engineer or
registered architect.
Proposal approved Proposal Disapproved
Inspector's Signature & Title Ate
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g.,'1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be'perfornned in accordance with the above proposal and conditions.
L, as owner, r reported agent of owner agree to the above conditions.
SIGNATURE ;fir, TITLE CX t
'IES: Vbite WHO); YeUcw (Tain EI); Pink (k#iamt)
`PUTNAM COUNTY.'DEPARTMENT OF _HEALTH o
DIVISION OF ENVIRONMENTAL_ HEALTH SERVI A
. _:L. �... ---• R"�•.N� .,- ,�s�T' s "'�.. � :..: .. - - .� _. i�"si"„ ., - .� .. .�.. .. ., _ � . � . .-, . „ .._. .. , toz a� ..x „+t _ .; w. .� iT -`i A�we� ..+o : �.r�..,.,.
- .. -. —. e�- mac.- �-.�.. 'Jec.'.t•.: `.:,;',;.,; -
Date pc%- A
Re Property of 'K<- e�- Vac
- Located at
Block 3 Lot 0//
Gentlemen:
This letter is to authorize STANLEY I. LMDER
a duly licensed professional engineer or.registered architect
(Indicate)
to apply for a Construction Permit for a separate sewerage system; to
serve the.above noted property in accordance with'the standards, rules
o-
or regulations as promulgated by the Commissioner of'.the Putnam:County
..Y1 -..... d..,.. LLT.... l J- L, A 4 r. ' 6 .L '11 n e+ --L rep po r my
. LG�.ltzrl�111C:11V .Vl Hea--'Lt l-1- CL1,U U sign al nL/^CES/.7a1 J7' ya.r�%_ 3 vT'1 1JA,y IJ.. L,IC.,11 111
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or £:
M.
1.47, Education La w, the Public Health Law, and the Putnam County Sani-
tary Code.
� A
tersi e
P.Ee, o, #
_ �. a A w1 ee ( Sea],
Address Any OCI ”'
z
Very t
Signed
Bawl V
°
e. ep one,`
Aso,
�relepn
�W
WELL COMPLETION REPORT PUTNAM'COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environm*ental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
dUnty.'Hdjv'tli-D"eoarttnOnt,-,tiDget r-with7'15bciritory'r606rf'.ZrT--;;:,
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
W.
OWNER
NAME
ADDRESS
z
LOCATION
OF WELL
(No. & Street) V (Town) (Lot Number)
m r P po, 9 Iva 11w 4, c-
PROPOSED
„USE OF
WELL
I BUSINESS
DOMESTIC. ❑ E STABLISHMENT ❑ FARM F —1 TEST WELL
UBLIC AIR OTH ER
El SUPPLY El INDU'S'TRIAL ❑ CONDITIONING E] (Specify)
DRILLING
EQUIPMENT'
COMPRESSED CABLE OTHER
❑ ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
I .
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
THREADED [:1 WELDED
E SHOE
YES NO
WAS
CASING Q UTED?
YES NO
YIELD
TEST
BAILED PUMPED
HOURS P.M.
COMPRESSED AIR
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST Ireer)
Dep th of Completed Well
in feet below Land .surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (inches
GRAVEL SIZE (inches), FROM (feet) TO (fee!)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sk etchact location of well with distances, to at least
r
two permanent landmarks.
FEET to FEET
FEE R R Rey- k
D
Al
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
at '7,1—,rf
4• 6'to,s
DATE WELL COMPLETED
DATE OF REPORT
31
WELL DRILLER (Signature) I nature)
Axw�,
Oianer or Purcha':ser of Building Municipality
BUI'Uinig Constructed by
location Street Block
Building Lot
Type
GUAR-ANTY..OF SEPARATE SEWAGE SYSTEM
.1 represent- resent- that I am wholly and completely responsi,ble. for tare
9 workmanship 'ma,ter al- cons trud'-ti on' �And dral-hage of the sewage
itlibii wo :1� 1 9 -
v 'be6h-
'd I s p q @h: �1 system. serving th,O a,bove described ' property, and that it has -
-const'r-'Octed as shown 'on, the approved plan or approved amendment thereto,
and. in. accordar�cv with. the: standards, rules and regulations of the Putnam
County Department, of H661th. and hereb y guaranty to the owner, -his. succes-
s6rs, heirs or.a'.ssigns9 to :place in good op n, eratirig condition any part,. of
.,06id syttetr;-..'66,ristrvcto.d by me wtich fails to operate for ,a period of two
y` ears-ihmediately .fallowing th-e date of initial u-se Of the - sewage. disposal
.system., or any repairs made by me, to. -suc,h, system, except where the fail.ur:e��.
operate pr6p6rly. is *6 au sed . the occu-
by the willful or negligent act of
pant .of- the b u i Id''i n g utilizing t h, b systems
, '
The undersigned f ut-th-et agrees to accept as conclusive : the de-
&A Atid; af.r for of the. D vIsi on- of Environmental health er-
Viceb of the Putnam County Department of Health. as' to wh- ether or not the
failure. of the s*ys'.t*iem to .,Operate was caused by the willful ors negligent
act of the occqpant of the building utiliting the system
Dated this,/4 day-. of 911-7 Signature.
Ti tle /,"*Z-
f Corporation, give name
and address}
s '.*. 7.
0
SACT8RIA"-PER ML (•Agar,p16te count at 35° C)
COLIFORM GROUP (M6st, :) obable No: /1'.00mI) a
:HARDNESS; TOTAL
�..
ETERGENTS' PPm""
( ) PPm.. ,
NITRATES. as,N
IRON,?TO,TAL" PPm:;
.. .z t � ..�.. . -� - .a. a .� � o ... s - .. � ��. .� -�...r ..• - ....'- ... -.... ... r. n c•+r.- �.•� - .�.. c! �.�r. ..... '.- -•..,' r-+.. +.4 ":nr_.:,.m �... ...r ..r...�v.
y
�777_�&77` _7
jj-
00
'd E
,-4 TA ;,.-
0 J 6MO
EM
CER1F4F1 -Att
OF N T Nb LAA I-SE
Town -or,.-,,, Village
-7
4, V
Located'
at
e
L
Owner '
Job
OPT -
MIZ
Separate Sewerage System , ;r bt.ilf lie
Consisting ofGaI Septic Tank lineal %Feet,:X width trench
Other requirements
W at er Supply: P 3lic- Supply.' Fro' m
Private Supply Drilled By
Address
ES1eZZA 'o Bedrooms Date erm"i t '.
lssuedBulidir Ty pe 1 a j i
Has Erosion Control Been Completed?
UP
I certify that the system(s) as listed serving the above ntialh- n on the- :he p?Tpletpd,work, (copies of which are
above 1 s, Plans -ojoil
er , ;
da_
attached), and in- accoirdphc6-w ith'tfici'stbin r a WY Putnam 'County-';LDepartment 9 �Hedlt.h.-
Date P ` R A
Address 6r. N i
Ti
-License No
Any. person occupying premises served:'by,the, Atio, such 'action :aslmay be necessary correction of any unsanitary •
from suF s�ge.,:�, App
c6ndiflons' resulting, h u' rqvja 1. -'9 shall become null .,� d* public rair sewer becomes,,
:water „,sq
avaiIapip;an and the. approval of the private I - 'll when” available .,i6,. Such supply ith
necessary
oner -c
P
subject ko�h or change �.�Ijqn :,,1Wthe"
icat 4ch-revocat
7
D t
BY
"4
_. -T.. p
•
L
T
TUTNAM MUNTY -D EPAr kTMENT
Services, Cjr W., Y; 110512
Division vironmen.. .
S_ M:,
-SENVAGEb!"O �Y$Tl A" &A
C014STRUCTIOW-PERMIT—fOR L, -'e. - C__--Ay
or village
06,
Located ,at Block
Su . bdivisloh Lot A
Owner
Addres,
Lot -Area Building Type p
-
-- Square'Feet
Number of Bedrooms Tota I Habitable Space
nk lineal feet X width trench*
am. 0 consist Gal. Septic Ta
nsbist Of
Address
CIO IS
Separate Sewerage Syst
To be constructed
Water Supply: Public Supply From
.Private ;
tu ply to be drilled by Vt
Address'
Other Requirements
I represent that '1 am wholly and,,completelyjasporisible for th, bi :10c op a ystem(sI; 1) that the jepaLate ewa e disposal . system
�&4,qr, .7 i A g
_T�
an r. .0 r
d. an. RWIAI� -6id it6 the standards, rules a ions or Ane, Putnam
above described will be con ructed-as shown on. the approve
eal will
of 'th. 'y to the, Commissioner of,.H th I
County Department that on completion, e of, a tio liance" satisfactory
s Jc h I he builder, that said builder will
qrs, e rs or assigns by t
be •sbbi-�ittiid to the Department, . and: 6' Wrlitiih,,'46
sewag 0 t 2 1
d1 disp wo ( years iediately following thedati of the issu
place. in good ope'rating condition, any part.. of sas
anee of the appro, val . of 'the Certificate of 'Construction' dom'Ipliance repairs ther , 2)'that the drilled well described above
U it ,the a the 'Puth'am.
Will be 16' ied a'si'shbWn on-1he i0proved plan "'&t'hai said wall will be li� hdar rules and resFulaVions �Of
ins
County Departriient-of Health.
P.E.
Date
Address AIX —License No.- A? .. Mo - •
APPROVED FOR CONSTRUCTION: This his approval expires. one year from the date issu unless ristruction of the building has been undertaken and is
revocable for.cause or may be amended or modified whe'n'consideVed,necessary by Ahe' orninission of Health. Any change or alteration of *construction
1
requires a new permit. Approved for disposal of domZffM-V"aR ser&% 6 Le, a n ior Private, Wat supply only.
Date .1cl— By Title
u
PUTNAM COUNTY DLL?, =.?i ANT OF LTH
C
�.;.' D-I:VISION OF EN.VI,R N T. aL 14 EALTF v= ?ViCES .
DESIGN DaTa SHE;z ;I -. - SE-PA:A%E
RATE SE..
DIS= OSAL SYSTE: FILE \0
Owner /�r> �:� LE y� cr,4°c'°
Add r s s 92; !�/l�A �CfCc�rzdaa�A.
Located at (Scree t).1�i�f% /Es
�oi��o :��,/,' ;_ /"t Block 3 _
Lot Z/. /
.(Indicate neap e t cross strut)
Municipality �ic/riKt ' ;latersYed. ,5 . �a /�.
SOIL PERCOLATION: TEST DATA
.REQUIRED TO BE SL'F':I 'TT ED N TH. APPLICATION-.
Hole
P��mber CLOCK TIM
PERCOLATION
PERCOL•1TI0`
13.in Elapse.
Deo t to ['rater G ater Level
No. Time
From Ground Surf-ace in Inches
Soil Rate
Start Stop `lin.
Start Stoo Drop in..
Min/in.drop
Inches Inches Inc:nes .
16 4
:2''��
3 /a .'!3 /o., 21
% 6 f�1
4
5
1'.
3
Notes:
1) Tests to be .repeated at same
death until aoprox_te ecual soil
rates are ob-
tained at -2ach percolation'test
hole. all data to 'be submitted for
review.
2) Depth measv.remnents to be -made
from top of hole.
0,
3 &1"
42': -
48'!
5 Wr
60".
667
-7
2:. - -
78"t
8 4'
'C OL
INDICATE. LEVEL. AT. VNIICH GROUND UATTER I S-E N. INTERED
INDICATE 'LEVEL TO WHICH j'JA T E R LEVEL RISES AFTER B E 1 -11" G ENCOUNTERED
TESTS ,KA DE 'B Y Date
Rate U s ed Min/1 Drop:,. S.D. Usnnie Area F r o d -5-w
7
No. of Bedrob.rns Sept-ic. Tan'.-, CapEcity IS 00: Galls. , Type
Absorption orprion Area Provide'd By.,gMS L.F.,,,2L?- v, i d Lh trench. Other
7
Name SMILE, Si 3 9
A ddress BX i 22
O
Mal
PUTNALM COUNTY DEPARTL%[ENT OF HEALTH
So i 1. Rate Approved -Sq. Ft./Gal.
Checked by
Date
•
TEST PIT DATA REQUIRED'
-0 uE o-UBLI-ITTTED I I T --f
A-PPLICATION
DESCRIPTION Or
SOILS E-.-C'-)`.NTERED I `l �-ST
SO
HOLES
DEPTH-
HOLE NO.
10 '
HOLE TO /-/v. -
G.L.
"Ve>e -50/c
5v
4
lee.
61f
1211
/eWq.
6)ow -z�'-44-c
.18
24,
0,
3 &1"
42': -
48'!
5 Wr
60".
667
-7
2:. - -
78"t
8 4'
'C OL
INDICATE. LEVEL. AT. VNIICH GROUND UATTER I S-E N. INTERED
INDICATE 'LEVEL TO WHICH j'JA T E R LEVEL RISES AFTER B E 1 -11" G ENCOUNTERED
TESTS ,KA DE 'B Y Date
Rate U s ed Min/1 Drop:,. S.D. Usnnie Area F r o d -5-w
7
No. of Bedrob.rns Sept-ic. Tan'.-, CapEcity IS 00: Galls. , Type
Absorption orprion Area Provide'd By.,gMS L.F.,,,2L?- v, i d Lh trench. Other
7
Name SMILE, Si 3 9
A ddress BX i 22
O
Mal
PUTNALM COUNTY DEPARTL%[ENT OF HEALTH
So i 1. Rate Approved -Sq. Ft./Gal.
Checked by
Date
tv i.
W
0
De sawsze
diaper e omkmd as i -
as r" W ft tr system
as twfcted by me te""Gre it as.,overej
C9• The systpm ra ezo*o,tu :'q
cmtzj vib an tie ujsa aw, rel;
mm d th Fftr. 9caty fiept 6:
Uft
N
M61 140
APPROVEb
1972
-I T: Cf HEALTH
p r E
ll:.DIVISIO OF
--ENVIRONMENTAL HEALTH SMVICES
r;