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631- 589 -8100
73.20 -1 -14
BOX 28
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ML
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of
M 0 1ro
E
WT -SE
N.ST, I FICO, WAGE.,01SPO-8
-3
Subdivision
���(k,TNAry /,1C
Number of
-of,
'j
Separate t6 System tp�'
Sewerage consist -
conitr6et416y
j Maier Supply � _ Ptjfjrj IZ.,,S Litrolgl_ ;From ,'
�pi6 be drilled _�bk,-
Address
}'Other .Requirements` a
4
�V
K
t- iiblefoft
r4f_e;�ht. that wpolnan ; co!"Ie ply responsible
be submitted to- the Department,' and .-a wittin
-6 4n%,goodj4opdMt1Kg con,
I : . J*, opni), any ,'p orI _
:Af. said
ie"
w-i4e i sp"
ante ao-proVal,:o e tertth te,bf construction, -Compliari
-will be li)c6ted"is ihidikh onjlje�"approved ,plan well
igne
A.`Date
F Address
APPROVED FOR - CONSTRUCTION ,'. This .approval .expir
revocable for , �,cause ,t'o-r,",ma�y-.,,t5e amended - or: m,odOiedwhen .
requires a new A` .l
permit _V.P. yvb d_ foj� disposal o
X
%
TT =OF HEALTH ate
X niV, At,
Town gr' Village .
f AC 9 d69
P
'Job
Address
t
4A
Total Hab�tatile Space SBO 's- S_ c darie Feet,
'236 lineal feet X 3 Width trench
p
-1iroposeclF, systein(s);:, that th6 Isepari.te s6wa6e,•disposal system
sand.regulations'of.'�the-,,Fu nam
uct qp�-jq.on?p.Iipnpq!Y �satiiiactory.to,,th j ;I_ I I bf:Healthwill
_9..C-omm ssioner
�-his �-'iucci)ii6rsi,�heirs:'o-rass's�gns-bli.:'tpre"buildd-r,, that ;;aIq builder will
' i j-' ". ' at the lis
Y"!P6�110. lhg,,th
U_
iri, there _tA t t 2 h��A-Altil well scrib above
rq_ J! 1,egula gulat I utnam''.
Tow .T� V1 1. .11
4
p
'i:e
sunless constructi6n of the a" ..nde e and is
�minissi of Health Any ..I r t QyU 6.ctllo'n`
ary
T It le
j
....... ....
or
_'�' ... ' >� -.;.r E�:i,:, • •._ti. '.c�=.x. 3k44vn: f r� ,»�.= _.re*- d ".-= a- -.�:':'; 4� ._a:'"..w- :•:^o.:,.$�6+. y�.'•o"- r..:•^•' c'? ac•' c` t"'":..:'- wc,... s ?.;:ai"`�i+si�- a•%= .:.:enr <.T,s _
°
INTTIAL SITE IT''SP%CTIOid ° a YC's ho Ccrrments
Proporty lines or corners fo-knd ° 0. ° °• a ° °
Can estimate house location ° ° ° ° o ® ° 0 0 0
JIM driveway need d cut 0 0 0 ° ° a ° • ° C .0
must .trees be rer^oved -note these ° ° ° °
Is deep hole r. presentative of entwr� SDS area
Additional deep roles needed. ° e e ° 0 ° ° °
Sufficient SDS area available considering
driveway cut, house location, .separation
distances, etc. etc ° ° ° ° ° o ° ° ®. o ° ° 0 _ J
DEEP HO=P P.4 TA . • °
Dapth
Water elevetion:
Rock elevation::-
SITE O'.-T.
Date.: 6-43 g::
Insn. .bv 61 z,Y;�, „
House loce:ted where shown on approved plan ° 0
u,r�e:- ..�_y..•,r <•.a0�. Y. • .• i.`\ b'I:.iY., : y r.��. e 0 e e o- _e- o i_ .. �. . • . . .._
Width of .trench average
Slope of file line and trench acct
ptable . ° °
Room al]-t.owea :or e y"ar s _on t P nche s °
- ifn -� �d .,v!;.:= ?1 -.<�.! �`r1�+:." t f, !r l �'� �o.•� a-.-•9 c.��w _ _ w' 4
_?natural soil _not st ni o,�)ed or SDS area
un� ily grades
.necessa.
10 rte trwintai ned from prop.line and �
20 ft. from house ° ° ° ° ° a o ° ° P C C °
Separation of trench f, on house, well "
etc° follows tilan e 0 o °°° o c o o a° o°
N umDEr of bedrooms checks ° ° ° ° ° ° o ° ° 0 MR
Stones% brush, stumps, rubble, etc. o »eater
than 15 ft . from nearest trencr . e ° ° ° °
15 Ito of peripheral soil horizontally from
trench ° 0 ° • .° 0 0 0 a o ° o O• O •O O O O• _
Junction boxes prope_-1y set.
Gould surface run -of 'f from driveway, roads,
ground sur� "ace, etc channel near. SDS
area ° e ° ° o e O ° 0 ° ° ° e O O ° ° 0 ° ° .
Does lot drainsre annear O.K. in area orb SDS �
MIML GRADING OF SITE ACCEPT.AME
0
. a
• 0
' • 0
t DRA
r
7. r 771 T' TC
0 F E T I
Ds-ti e
Re: 'Pro-pe"" Of zo,/!..$'
Located. a u
0;7
secticm 0 B1. o c
G 8i1'
Tn
7 Z. 11 C
7 ... ....
0
C 0 0
s v
-eal ' Law, a- u t n
o! a7 C .
47 n I.
,
tart' Coda.
Very -:ul 71, yours;
1"4FA!as 7 4,4. /v
TH Id r a c- s
c 0 Lun U r s i
p E. 12- ize
-oh
-cn-
Sic, pa"
ress
.Add
E ra
PT)7TNAM- COUNTY -DEPARTMENT OF HEALTH
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address
07
Located at (Stree't� /-,v, Sec. o'oq Block 0 -;z Lot
indicate.nearest cross street)
Municipality Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
_Number
CLOCK
TIME
PERCOLATION
PERCOLATION
Elapse
-Depth
to Wa er
ater Level
No.
Time
From Ground Surface
in Inches
Soil Rate
Start-Stop
Min.
Start
Stop
Drop in
Min./in drop
Inches
Inches
Inches
2
go _00e
ef , 6
/77)
3
Lo
4..
2 4Vl A/
3 9-w2 1�9
2
Notes: 1) .Tests, to be repeated at same depth until a proximately equal soil
. rates are obtained at each percolation test hole-. AY1 data to be submitted
for review.
. 2) Depth
measurements to be made from top of hole.
':DEPTH
G. L.
611
0
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF _SOILS - ENCOUNTERED IN TEST -HOI
_ , ., .-_ .' -. Ma_�L ... z. `- s.�;_'_ �. •'.' -� J.r ..:. .... i -:. -. ,E-- . .. � .... � �. ��F7's.a., Y _ ,+= r�= -.: .. ; :+'v�r,- T•..a.«.:�
HOLE' ➢ NO. HOLE NO..
HOLE NO . 7 TC-.s r
i
7� 'SaiG
�r
12" Loj,,;,
18"
24"
30
36"
42
48"
5411
60"
66"
7211
I
?41,0 Say c_
40 9� E'' �•�'i� v��
d
TOE° x0" t—
h
J
4414.#n .
N
7811
` ti
INDICATE LEVEL AT. WHICH GROUND WATER IS ENCOUNTERED
_INDICATE. LEVEL TO WHIG WATER.LEVEL RISES AFTER BEING ENCOUNTEREID {
.TESTS MADE BY �/. E/l1,2f1 �,e7ENTE.C° �®, Date ✓�9i✓ /�' 1,,97z
DESIGN
Soil Rate Used /C Min/1 "Drop : S.D. Usable Area Provided .5'600
No. of Bedrooms 4 Septic Tank Capacity /Zoo Gals. Type Co,-/C•
Absorption Area Provided By Efia L.F.x24" X36"— ✓ width trench.
Other
Name
Address
�iQ.YTd br//1/ &Z /Y
gnature
SEAL
v
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved /,,_Sq. Ft /Gal. Checked by
�� 'r 014 ?'��
co
!/ � , . e t ,.t". f i � " t t -, t45 a } � y ,y'*' k R t,., �i?°g4 t „ + � •"x r&,.�'f M`''p( `��°' -ash �' a
(j +
`, i
p 211
r PUTNAM COUNTY =DEPARTMENT OF HEALTH
Division of Environmental Health Services, Cam% N Y 10512
Y w..L� tt--` '�". �. +.. a. !� �V �, t _ •
.T. •v ( V� 'VY �J1u1 VJI�L Jii�1 �;y r—F. "'�"t��✓ �i�%j%L�'%' C
' :�zr Town or villa 8
AQT.e /OBE 3L�if%' '
„Located;
O
k
x'a ,_ •".. r r 3J -•�oi� � .. - "' ,! L � ,__ q _:_� t Y .J.l� b t rtin �.•� C � l ., .
� � t
r ., .`Owner.. ,; S. t.•• /'AG ...•'. . -' ... �/%%�, . �
a
Blo
Q
xt .},� -i �4 -.. �' nr .tl� S°.I.'S>`•1',s � �a l� L/�r T
=5e grata Sewera e 5 stem built b /QL 1 O _ C.O.{iclT � .SN4•�o,Q, -:r. �i4 py ss Gfp�y�5r Aof v
P 9 Y Y Address
Consisting of + % Gal Septic' Tank gg �Iineal Feet X �6 ivldth trench
''� iG" 1 l J y` Spt �,�y°"`y a4 �� 7 •c :w S4 SatL4 -� t `° �',t xH t .y aV �i m ;n i hid y.. .� 5 - l w
rOther requirements '3 # 5 +
6.
} .Water Supply Pubic Supply 'From
ut r + tidy.. •` r ' S x s cJ r z ay ^r 5;.,,1V c
iPrlvatfe..Supply Drilled By
t •,�. S„"t 1 t� 4 t tr.y t I7 ��/P� PSG (/S St •F f _ ..
�V
.Address d'S � V � � , � •
t.v t J ., 4 q :, "•y t r tjz s x t r t "" '�' Vlt i t to t,. ,.-,
QAtcO ;Qi�+C/y
Building Type , }' *No \of Bedrooms bate Permit Issued dGtit�
Has rEioslon Control Been Completetl ?���� x f N
i *4'' f s' ' ;.' rt` t �y _+ ty i L •.* t Fh '. hi ..
!•QR
µ I�certify' that the,system(s)�as I sled serFvfng•tha;above premises were constructed essentially as shown on the plansyof'Lhe'co h re''
Llattached), and-liri accordance with the ,standards rules an3;%r— egulations 'plans filed and the permit +ssued byw the r Putn a ea h`.
ge
Date i9v19 ..
it a t, Certified by y �cw ��, + w
J'
I` n
x rr ••y�y•..
r t3 xs � u . - e+. •zv y C,.� b �; 1 �: L {. � ?t e i - '° t4 s; Y � ��. "' ft `.i; I'�•' r ►.' -�� �.. .�., ,.
Any person occupying .premises served Dy trohe above system(s):shall promptly take,such action as may be necessary to secure:, rs� ary
conditions resulting from such_ usage ,GApproval -•of the se parate.�sewera a system'shallati me r►,u11 and void as soon as a ! 1 6D rqe omen
t - availabfie• and'the approval tofahe private water +supply shall become n ` an vold..whe a . bllc water supply becomes avail i� als,are.
sutilec -to rmo kkation'br change when; in fthe, Judgment of�the, fnm sloner.of t' tis ch dMication'or chap
at
Oat +'V $�t 4 r v �U' s� r s n •
A• J ; ," `.t t � a -! � "fan � °e � 9 s1 O
ic
I 1
ra; (?wager or Purchaser ildinp Munieipality
Q L
1.
Buildin nstructed By Section — Ward
'.; Location Street i Block
}
ALE 12 ply �F'�'``e
Building 'type Lot
OF SEPARATE SEVIGE SYSTEM .
represent ;that I am wholly and completely responsible for the location,
worknanship, materials construction and drainage of the sewage disposal system
serving the above described propertyo and that it has been constructed as shown
on the approved plan or approved amendment thereto o and in accordance with the
standards' rules and regulations of the County Department of Healthy
°..and hereby guaranty to the owners his suc snirs or assignst 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 completion of
the sewage disposal system or any repairs made by me to,such system' except where
,t
the failure to operate properly is caused by the willful or negligent.act of the
rrPcL,r�v_Z syst
v•- .d-
"` The undersigned further agreesto accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Weic�'��glfl
County Department of Health 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 I
utilising the system.
Dated =this ay of �� �- 19 Signat re
; at � "� a �. Q4 T _ . c Title
Place & State. (Ir corporation9 give name and
f address)
® ®m ® ® ® ® ® ®m_ ®v
FIVE' ( 5) COPIES ARE REQUIRED WITH 'FIVE ( 5) COPIES OF FINAL PLAINS BEFORE CERTIFICATE
OF COMPLETION WILL BE ISSUED.
. I
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM
e — o ® ® ® ® m ® ® ® ® ® ® m m
u'..-Division of Environmental Health Services County Department of Health
-- �""`'. --- ,y_; ,a:- - =fi "' r:r1 t�s. --+»•-- n� *• --.-•. ^^ 'yea MTk'a: 'r" 'F`w '•... -. . S'" �, 'Wr'tn 7 .. •m•s+-•",; Sr•r --•"a -- f.'-r^"-t. Y -'^1`1
r s»e wp \
YORKTOWN MEDICALl- LABORATORY INC.
` P 0 Box 9 321 Kear `Street
° .i:, O..i»'C.'
i1�i+`; r, :��-`,+�'i's."ut.�L'.,a- �..b.l: 1.r• "�. y�,. - ..L•.,,," •V''�,p. r� 4�� >.
DATE COLLECTED
RESULTS OF.EXAMINATION OF WATER
NNER' DATE"RECEIVED
• :-
LOUIS rU zo
.'Ty, VILLAGE, TOWN & /OR NAME
;OF',SUPPLY. DATE REPORTED .
SOMERSET'. L9NE. PUTNAM VALLEY NAT YORE 8'18
WPLING POINT
-
TAP (�VEW' +TELL') '
ACTT RIA P.ER ML. •(Agar.plate.couint at 350C).
3
COLIFORM.GROUP (Most' probable N6; /100ml.)
LESS THAN 2.2
.-. HARDNESSI TOTAL - ppm
7'TERGENTS.- ppm
NITRATES (as N) ppm
ARON, TOTAL'- ppm ,,.
Y i
914 - 245°-3203 A.. H. PADOVLNI, M.T.o,(ASCP)
YORKTOZrTF PSDICAL .LABORATORY
P o 0, 1V)X 99,321 KRAR ST.
The Means n of` the Water alvsis Report :
This statement has been prepared:to help you interpret the Water.Analysis
Report you have = received. Tke,purpose of this examination is 'twofold; the
determination of :the total . number of' bacteria present and. the specific . -
determination of'the preserice.of members of the coliform group.
The item bacteria per ML (Milliliter) is a measure of total bacteria present.
.One quart of1water contains 940 milliliters. . One ML of.water,is added.to a
nuts_itive mec 'ium:. which acts as a,' source of food for the bacteria... This 'port-
ion of water sample plus medium is then.incubated .for 24 hours'at -37° centi-
grade. At tie ei?d of that time, the organisms which have grown and multi-
plied are counted.,. There is.no.limiting value for this determination but it
is of interest in judging the sanitary.quality ` of the sample.
The second determination; the.M.P.No.:(Most Probable Number) is...of more
importance since' it i6,a specific. test for one, group: of organisms, the Coli°-
form:' Group o ' The `Coliform:Group includes: several species of. bacteria which
are, more or less, normal:nhabitants of the intestinal tract. of man.and
many other animals. Consequently, 'they ; are four_d` in. tremendous'numbers in
fecal.- matter and sewage.. The organisms "of this group are usually not danger -
ous in� themselves, but, when found; they do indicate.potentially dangerous
contamination since sewage at any time might carry,pathoge'nic or disease-
producing organisms.. The source of this contamination might be a sewage .
system which is located too close to the-well'.
or spring. It might also.re-
sult from failure .to ' protest the water supply rom . 6urface ...drairnage ` or cOn-
tamination or the ',entrance of small animals.. Any time a water system is
repaired`or opened up, it should be sterilized .by. the, addition.of chlorine
:7 Yt rM _9A_
iriation which might have been introduced. MPN�is a statistcal.term which
is used to estimate the concentration of those Coliform organismso',A.stat-
istical.evaluation is used since. several portions of varied size are . sepa =
rately'cultured. A negative test is indicated by a..value of less than 2.2.
Any value other than this indicates the. of Coliform organisms and
gives reasons for stating the source of the sample.is not satisfactory. This
test .requires a minimum of 48.hour8 and, very often, 72 -96 hours.
It must be understood that the results of this test apply to the water source
only at the.time of sampling. Unusual conditions, such as heavy rainfall or
drought, flooding,, changes or additions to the water system, installation
of septic tanks or cesspools to the nearby area might all have effect on the
sanitary quality of the water. Consequently; analyses should be made as
often as circumstances warrant..
There is,q Government pamphlet, availabe, from the Supt. of Documents, U. S.
Government Printing Office, Washington 25, D. C. which give more information
on this ana related subjects. It is.
Individual Water Supply Systems
Public Health Service Publication No. 24 -256
Individual Sewage Disposal System
TELL COMPLETION REPORT PUTNAM COUNTY DEl'AnTP4ENT OE 1fE/1LTff
011 Division cif Environrnontal Ilc.ilth' ;.e,rvicus
COUNTY OFFICE UUILDING CARMEL, NEW,YORK
' -" •�� t:•,r l.� 4 Te 1� �t• r0 r.tnsn I lief. .:)i .e �':. • ...r ..fir r ♦may `$ r•' 1 •- 1' rr Tf- (T.n �' f:'.t �., r - -' �... __
e�iv:s.,s`�5.7w'r..r'c.. ��V.':- �:..r. +it►�. '�i' .' +,_G.,m..xy� + "irei+l�sr ii++'i�;��{�if•�'cjt:.':�S'�Ti 4�ibrdr�.,:i rim ".a:!;a,ryr��..•C..+e,�%.. .. �yw.u: ! y+ ia: ie�., i. S�-, �,.: i {F�ybs'.!���:,T".$'ko,Yyi•i�S ti
analysis-of water sample indicating water is of satisfr,cicry bacterial quality before certificate of construction compliance is issued.
REPORT MUST 13E SUS 1.111'TED WITH IN 30 DAYS OF COMPLETION
OWNER
NAA�E `
.,T..
ADDRESS
LOCATION
OF WELL
plo. t 1) (Town) (Lot l:un :L81)
PROPOSED-
USE' OF
YIEII
DOMESTIC ❑ ES,TAELISHMENT ❑ FAR)A ❑TEST WELL
SUPPLY' ❑ INDUSTRIAL ❑CONDITIONING OTTHER (Specify)
DRILLING
EOUIPMENT
11 ROTARY
COMPRESSED CABLE OTHER
AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING
--DETAIL "
- -hG -H eet) Di - fjh --
� AMETcr(inthes)
WEIGHT PER'FOOi
-- /
® THREADED ❑ WELDED
DRIVE SHOE
YES NO
❑
�'�'k
® YES LJ NO
YIELD
TEST ''
1:1 EARED ❑ PUMPED 5�
HOURS G.P.A.
COMPRESSED AIR . /�
YIELD (G,P.Af.)
/d •
WATER
MEL '.
FROM LAND SURFACE -STATIC (Specifyfeet) DURING YIELD TEST float)
Depth
Depth of Complefod Well
in feet below land surface:
_ _ - --
SCREEN .
MAKE_ — - — _ — - - `
-
IENGTti OPEN TO t,QUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches) FkOM float) 10 (loot)
I I
'TH FLOM IAND SU2FACE�
-
FORMATION DESCRIPTION
Sketch exact focal :on of Kell with olStsnCSS• to at 188$1
two permanent landmarks.
iEE7 f� „`i
r
Q
•
If yield was tested of different depths during drilling, list below
FEET (
GALLONS PER MINUTE
i WLLI�90/FLLIED
DATE OF RLPORT -
WELL OnILLEn (Signature). , �`�14� �, j -•�..� ,
I
L. —4
I Z,
I.. ,
N,
37" -
fop T I 'All
N 11.1
-,gov Y; 1
1� ARPO '4,
Uj
I lAlf _t I
t
.44
45 ii Z5
IWIM-
_U 0
Ol
{'LOT
V.
L07 41
A"
cd
4
1-4
4 0
Al
A.0
7
i4l Xv
J;HENRY CARI
CIVIL ENGINEERS
"YORKTOWN
H. E. RR 0 M M HC L