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IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
74. -1 -15
BOX 28
LIM
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9 I
03540
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PPOPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
SITE I=TION
.HCNE
.TO
MAILING ADDRESS
PERSON IWTERVIEWED PC HD
Complaint # 4/,0 1Q
Name & Relationship i.e, owner, tenant, etc.)
DATE TYPE FACILITY « �cJ� • ,,; ., .��/
PROPOSED imm u,EEt �J �� �t� PHONE
REGISTRATION #
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 apprcved;�— Proposal Disapproved
Proposal aouroved 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 components 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 performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree
SIGNATURE
MM: W-dte MV; YeUcw CRM HE); Pink (Applicant)
to the above conditions.
TITLE • /vf DATE '
PUTNAM COUNTY DEPAR TMEIl1 T� OF gIEA�,TH x
> .} f w r 1 i° 1��x s .,-e �, a .1m+�. �i-� y "��s,, �'#*.., rS v, c. •c �
�} �4 x £ U Drvision of Environmental ,�Hea /th Services � Carme% `N r �Y '':10512 +^ � k ' ` � ' ' �" '�
'L
.. GEPT:lF11 TRlIIrtTInWCnfVIP! !An! E EAR SEU�A, p�SPQ_...Al SYST A�y.
y ; a �. - �, -, r'> •:- � . �. . i -.� 4 s 4 ',i ' , =T_ own o V.illag8 .J i..-
'Owner l d ¢ 1(e ) �� Job • �/�
Lot
'Separate Sewerage)SYStem iIt by Ga���. epr'Zl r0., >f , N C Address` '� .tl`v��s e✓ ?j�VC� 9 :12W {T�tlChm�\Q �\
Consisting "of Gal Septic Tank 24n I�neal Feet' X
i th
w d trench
u r Other requirements '
'Water, Supply. " Public' Supply :From>
r u
Private SuPPIy, Drilled ,BY �� @'S t „�/
Addre s
P E :Bwldmg sType h No of Bedrooms ;1__ Date permit `Isiued` `�` �"
1
;Has Erosion Control Been Compteted?
-. � F � S-+i •�1 e :i Y 3";, 1 Y 'f L t a J .'. 1 , 1 { 'i s _` tr {'i_r3 ���. I
I certify' that.the systerrm(s) as IkO serving the above premises were constructed essent�aily as shown. on the plans of the completed work (copes of'which are ,
„' °,attached), and in ac orda ce w)th the standards rules antl regulations :plans filed nd therpermit "issued byr the ':utnam•.COUnty .De artme of= Hea1t6: ,"
(Date F Certified by y ' E R A
a �Y z i4
ddr
License o
;Anygperson occupying ,pram kses served by, the above systems) shall promptly take such action as may be necessary tosecure the correction of 'an vrisa'riitar
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..r i t, Yh_ -. y
contJdions resulting from such usage a;Approvalvof the separate sewerage system shall become null and void as soon as a >;public .sargitary,'sewer becomes,.
°.,available and'tl a approvaltof'the private, water. supply shall become null antl void =`when a public vrater,Fsupply•becomes `ava�labler .Such, approvals.afe % ubiect ao modrf� cation or change when in the judgment of that 'issroner.,of Health such ocatio modification or change -is necessary., _
f
L
-Date s a
Ti tie
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PEEKSKILL MEDICAL LABORATORY
1879 Crompond Rd. Barclay. Plaza Bldg. AV-4t. 1
Peekskill, New. York.. 10566-
.ilti "..v- -F�.,✓Ti �.i�:J� >�.:\ {. -v :AML:... v '1 •:.[ v'G l,i ,Li •M.r!�...
• ►0935
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER 10/19/7.4
�:.
OWNER DATE RECEIVED
Angelo LoPresti, 645 E 228th St., Bronx, N.Y. 10/19/74
CITY, VILLAGE, TOWN &/OR NAMt OF SUPPLY DATE REPORTED
\
wall
BACTERIA PER ML. (Agar plate count at 350C).
5
COLIFORM GROUP (Most probable No. 100ml.)
less thNn, 2.2
L - ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg. /1. I
These results indicate that the water was yes of a satisfactory sanitary quality when the'sample was colle ed.
A. H. PADOVANI, M. T. (ASCP)
A
C-,
V4
r " V
5� �)Ia6' , or buildl.ng Kinicip'lli ty
-juil(ling Constructed by Sec-1-ion
L
0
,ocation Street Block
�;� ��,� .
-7
3uT1_ —di C
I'T Tape Lot
GUARANTY OP SEPARATE SMIAGE SYSTEM
I represent that I am wholly and completely responsible for the location,
orknianship, material, construction and drainage of the set..,acre disposal system
;ervajig the above described property, and that it has been*constructed as shown on
he approved plan or approved amendment thereto, and in accordance with the standards,
,ales and regulations of the Putnam County Department of Healt-h, and Hereby guaranty
�o the owner, his successors, heirs or assigns, to place in good operating condition
C)
:ny part of said system constructed by me t',ihich fails to operate for a period of t•.,o
ears immediately following the date of initial use of the sewage disposal system, or
C3
ny.repairs made by me to such system, except where the failure to operate properly
ti caubed.liv -che wil`ful uio nef _,!*�4uii ac�*- of '- . ..I.. I . 1 . - .:b
.
_L L L LJ-IE! Ot�L;LlpcaijL. --PA. L.Aa%�!
lie
The undersigned further agrees to accept as conclusive the determination
f the Director of the Division of Environmental Health Services of the Ritnam CoullLy
...epartment of -11calth as to -whether or not-.the -failure -of the system to operate was
au's&l by tH6 0i� iid_Crl`1cent'_a'c't* of thei-o'c6upant of the' bdilding'� utilizing zip-.- tHe
y negligent"
CD:
ystem..
ate*d'this day of 0J 19 Signature �r%�r �`'� 1
Title
(if corporation give name and address
-7
7- XL1 ----------------------- --- ---------- --- - - -------------
HREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES Or FINAL PLANS- BErORE CERTI FI.CATrE1
F COMPLETION (JILL BE ISSUED. . . . .•
LIARANITOR YS RFOUIPTD' TO. FILE NOTICE OF DATE OF •IRST USE OF -SYSTEM.
-------------------------------- -------------------------------------------
ivision of Environmental Health Services, Putnam. County Department, of Health
b
WELL COMPLETION .REPORT
3/71
PUTNAM COUNTY DEPARTMENT OF HEALTH
. Division of Environmental Health Services .
COUNTY OFFICE BUILDING - CARMEL, NEW YORK .
This
report.. . IS to be•crpLeted -by..wc.lI .dr6 il le, r t -a.n.. d suz. _ . ,:.i.tied. to.-County,
o County, H.r e,.Ah ' d, s +e: pa•r..t-mi- 1e,un(t ::. -.1to. ic.i_eO t"•hSIeS-•r.t _-:.ry:. it+h S Yla.b- oratory de port _ oy.
_:... ....T'.• «'yl
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 �t
LOCATION
OF WELL
(o. 6 Street) (Town) �j (Lot Number)
W 0s C
PROPOSED
USE OF
WELL
BUSINESS
® DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
SUPPLY 11 INDUSTRIAL ❑ CONDITIONING ❑ OT
SUPPLY
DRILLING
EQUIPMENT
COMPRESSED CABLE O
❑ ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ OTHER
)
CASING
DETAILS
LENGTH (feet)
L`�T
I DIAMETER(inches)
VdEIGHT PER FOOT '(�
/ L j THREADED . ❑ WELDED
DRIVE SHOE
DYES ❑ NO
%VA SING
XYEs
R U D1
H NO
YIELD
TEST
CJ SAILED ❑PUMPED ✓IJ`
COMPRESSED AIR HOURS G.P.M.
7
YIELD (G.P.M.)
7
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
O17�
DURING.YIELD TEST fleet)
0
Depth 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 pock (Inches):
GRAVEL SIZE (Inches) FROM (loo() TO poet)
DEPTH FROM LAND SURFACEI
FORMATION DESCRIPTION
f ✓ ��p /l�, /3� ,� O C)49C rg- J
Sketch exact location of well with distances, to at least
two permanent landmarks.
.
rccT iv ,�c�
'
33'/
oC_ lC
36U
IJ eo ®
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE . /,// �ETED
rx. lA
DST F RR ORT
J-/ �4j
7
WELL DRILLER (Signature) S
R.
EL
NI
r. _Qiv0qI? of , Enviconmen
-.,-C-" NSTFtUtTtQN-,PtkMIT,"FbR'-'SEWAGE.-.DISF.OSAL-,S
,Locatec.ate
-TWIE , 7� "
wne!
C
'Number
o Bedrooms
Separate Sewerage System to C
- '
o*6e e8rispiuct 6d by
Water p y Public ;Supply A....
v,
Pnvaf t
N- o be,, drilled'-:b
y y ,
i�-Address 't'
Other Requirements L Q1, 4 1:-
-7a, - -
`rl i6p' 4ek
iA6- itj i _ - I
, -
the es i
d6scrihed will'be.constructed is shown
o44116-approved 4meii
County Department of ;'Health,. °and that on com'pletion', tiereo
f
be submitted to'the Department' and „a, dn guarisnii will li
99 c9n , n any,,� ,part
4,pikejn gop -opqrat.i' ;aid sewage dlspi
4 ito,�'itroctT8,ri'-'comp
;,.lance f th
0 , they ` approval -o the
will' be--lo'c"Aiie"d ' as shorVn on the approved plan and that said well will
66tpnty,&dpartm,en,t of Hiialtfi.,"�`I,`:_
.Wv
*- ' r Add 4 re'g*;s
APPROVED F6WCONSTRUCTION
T` '
h
S.aRproya _expires 'one 'y,
(
tirevocable o r-m*y be _amended
modified WhWnIconsidere
requires •a4riew"permit Approved,-- for disposal of dome tic ",.'s—a'61t:
lw� 6v
M
GNU C %
J
PMA V A,
"Town ,Or, Yll IIge
yAddress 7, 'S
ot al. Habictable :Spa ce vc,00
Square Feet
-:width ,trench,
Address
e proposed system_(s) 1) K-
t
eka,
the separate sewage 'disposal system
a -fdar and-regulations of, the Put�narn
cco �O�ithAhiOieridards, rules
- ”, " ��, , t i,i�, _.,, , , ,
ruction „Compliancp .,�,sa actory-to i6'66 mmis'slon'er oUl-16althwill
the builder, that 'said builder will'
,hie successors helri,6i" Jnassijs,bY'i by,
the
4vib&,ofAwo,_(_2)_Veirs Immedlately'foll6win§ -the date,of the issu-
ff',or -any. repairs,;ifiereto ;.2):t"i"the'drilldd well described above I
lance
With `fhe; 'standards 'rules ,and reg�latl�?ps _ �-of the "Putnam
P
R.A.
CV
'Llcei e I A
C, biui
'W”
6d unloiss7`c6k;rijZt on f ldi'6i'ha,.6een",,'u�'ndertikeii,an�-ii
:Oiiliiiiiib�6er', of Health Ahy,.t6a69e-'6i' afterAtIon.of co'nstrui4fo4��
to wa ey,,-sUppiy`
, only
� e _ il- ce.:� -s
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
C' OUIVTY'�OF'FICE`BUILllINU',
DESIGN DATA.SHEET- SEPARATE SEWAGE.DISPOSAL SYSTEM FILE N0. 1`-40 -990
Owne l a f e 4i Address C d,-d, S SEE (2,SW
Located a (Street OSL09M Corkj__ Sec .. 3 Block Lot �ln ica e neares cross -street)
11,00 Watershed � Muns.cira,lity �yl'7Nf� rn � _ t � �I ./u�
PERCOLATION TEST DATA X
TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run 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
1 Inches Inches Inches
1 1119—
2 c ► 5� ► Z - - --
3 1 z t 'L
4 2
1 1 `r4 1 ►4. I Z.- 1 � �-e: I � � �
3
4
5
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
DEPTH
611
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE zNo._ HOLE NO. HOLE NO.
12
1811
2411
3011
36H 2.
4211
4811
5411
60
6611
7211
7811
84"
INDICATE L AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE L TO WHIG JUWATER LEVEL RISfS AFTER BEING ENCOUNTERED
TESTS MADE BY Date i G.
DESIGN
Used d I S Min/1"Dro'p.- S.D. Usable Area Provided– jzuro
No. of Bedrooms Y
Septic Tank Capacity Gal s-
-,T'ype -S-
Absorption Area Provided By _ W L.F.x24" 5b .,W±(: -h.1 trenc h.
`2
Address
bignature
SEAE,
389'
N EN
THIS SPACE FOR *USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved —Sq. Ft/Cal. Checked by
Date
1
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;aL.All ,
12 .
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5r E7014 'W a : JUlVCTIpN BOX
99.67
CAST (4QN
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SECTION '6 F
r 4$ ;
L:OT. 20 \ LOT 21\\\ �oL r2z sewTrc.. ANf�
TYPICAL tt�f>?�. sas •casrlciNa: x+
` 4 B3 3 SEPTIC* TANK + r=tyr a "etc s!w s
?60 \ `�•\� !I c�ersuUO� su¢�flc ✓ i.. =.. _ri
GRa LEVEL
O�% 'E..'Jr�►r4 /! eatrii
o' ;...,i. •. •• - : 9$ �+ ANA 1..�_. ?2.N..'T -5.-��
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