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Home My WebLink About3584DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.09 -1 -5 BOX 28 03584 INNS I I m ., 1 r ; 1 1, T II,, ! J 4 ,� , , IN y I N ' i 1'L , ` 03584 t PUTNAM Tot of Enviconm o tY DEPARTMENT ;OF kI[FAi.TH W HeaLil► Seivilaea, 'Came% N,`' Y .fOlrrl2 Permit r o eE1NAGE DISPOSAL' SYSTEM ' �uTll}/�Y\ �$�1,� ��i ' ' i 'Located' / Formerly U �fJrk Separate, Sewerage System built Consisting of � 'al. Septic .Tank and t , r,•- r .Other requirements � ` Water,'Supplys 'v- Publ{c: <Supply °,aFrom` y[ Private .Supply :Drilled 4Building• Type t i j t L �� , No of Bed Pe rooms _: Data, mit Isiued <Erosion'Control Been. Completed? 1 R- I certify that th6'dystem(s) ae listed serving the above: premises weie:conatructed ea 1 '_s shown ,on the Tana of .the completed work (oopiee of:which, are attached)..'and in.aocordance with ,the atand_arda ru and_zegula ,_in' acs ` e'with the,fil d plan, and the'peximi,t issued by the Putnam County Department Of}Health f t y Date r Address w License No'�!`r A ; Any person occupying 'premise; served by above system(s) shall promptly take -such action`as may be necessary to astute the torrectlon- of,•any unsanitary condifions'resuliing from weir': usage Approval; of t he.. 'separate'seweiage "system`ihall become null and`vold as aooii as a `public unitary .seiwer becomes available and'tha appioval of-'the.,p`rlvate ' waW46pply shall Decom" d void :when &,.' public "wat . wp y becomes :avallabN. Such':appiovals are subject to modlfleation,'or change when, in tnerJudgmeht; of th `Commis er of: Health, sueh'r tion modlfleation'-or change is necessary. ate Tltb Rev 9 -Sl . Towri or yplage 'ji8$'t1a L,i (j • f SO 'Loot ,# } 1 Address�/��}�,�iv CC.'ryry/rl,, Water,'Supplys 'v- Publ{c: <Supply °,aFrom` y[ Private .Supply :Drilled 4Building• Type t i j t L �� , No of Bed Pe rooms _: Data, mit Isiued <Erosion'Control Been. Completed? 1 R- I certify that th6'dystem(s) ae listed serving the above: premises weie:conatructed ea 1 '_s shown ,on the Tana of .the completed work (oopiee of:which, are attached)..'and in.aocordance with ,the atand_arda ru and_zegula ,_in' acs ` e'with the,fil d plan, and the'peximi,t issued by the Putnam County Department Of}Health f t y Date r Address w License No'�!`r A ; Any person occupying 'premise; served by above system(s) shall promptly take -such action`as may be necessary to astute the torrectlon- of,•any unsanitary condifions'resuliing from weir': usage Approval; of t he.. 'separate'seweiage "system`ihall become null and`vold as aooii as a `public unitary .seiwer becomes available and'tha appioval of-'the.,p`rlvate ' waW46pply shall Decom" d void :when &,.' public "wat . wp y becomes :avallabN. Such':appiovals are subject to modlfleation,'or change when, in tnerJudgmeht; of th `Commis er of: Health, sueh'r tion modlfleation'-or change is necessary. ate Tltb Rev 9 -Sl . Owner or urc aser o Buil ding Section / Building Cons t cted b.. -zv Block- y v. Location - Street Lot (/77✓� lrt-U, Municipality Building Type Subdivision Name Subdvo Lot # GUARANTEE 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 guarantee to the owner, his success- ors', 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 determin- "' ; a "tiara: of, the.,., Director- of--- the Division of- Environmental Health- Zervices _ ... of the'Putnam County Department of Health as to whether or not ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. 7 ,r f� Dated this /`) day of / / 1 19 Signature Title (`'lc Corporation Name if cor7_ 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. i' Division of Environmental Health Services, Putnam County Department of Health REPORT WELL, 'MPLETIb,N kEPO PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environtrishtal Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK report is to be completed by well driller and submitted to County Health Department together with laboratory report of ysis of water sample indicating water is of Satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST RE SUBMITTED WITHIN 30 DAYS OF WELL COMPLEW6W'j'- Ow NAME ADDRESS L .. C F (N .6 Street) (Town) (Lot Number) PRO use W TI BUSINESS FJ FARM L!2�f DOMESTIC ESTABLISHMENT TEST WELL PUBLIC AIR OR SUPP LY INDUSTRIAL ❑ CONDITIONING '(SpeTHEcify) DRI SQUI T COMPRESSED CABLE R.6THER ROTARY AIR PERCUSSION PERCUSSION (Specify) U A IT DIT )JA LENGTH (feet) JDIAMETER (inches) WEIGHT PER FOOT THREADED ❑WELDED 2BLVE SHOE ES ❑ NO MW CASING YES GROUTED? NO Y yi 1 T T 1401.111$ G.P ;M. [:1 BAILED El 'PUMPED IS d6wkESS6 AIR 7 YIELD (G.P.M.) . W. ---�We ify MEASURE FROM . LAND SURFACE-S.TA DURING -ViELD TEST fleet) Depth of Completed Well in feet below Land surface: SC MAKE —(In LENGTH OPEN TO AQUIFER (lost) DST SLOT SIZE DIAMETER E T E- C' h- )F G IF GRAVEL` PACKED: P Et PACKED: Diamitir of well including gravel pack (inches): GRAV EL SIZE (inches) FROM (1001) TO (isiiif) DEPTH F FE I AND SU2FAC[ FEET FORMATION DESCRIPTION Sketch exact location of well with distances, to at loss( two landmarks. 7 yield was.tested of different depths during drilling, list below FEET GALLONS PER MINUTE J", DATE WMCOMP ETEO DATE OF REPORT, WELL IL (Si gnature) ,__�,�: I RKTOWN MEDICAL LABORATORY INU P.O: Box 99 321 Kear Street LOCATIONS: ❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245.3203 Yorktown Flei htS, N.Y. 10598 201 BUTTONWOOD AVE.,•PEEKSKILL, N.Y. 10566 737.8777 ❑ 495 MAIN ST., MT. KIS CO, N.Y. 10549 666.3335 � ❑" S7�'�E"isE1YiFi'A v c: �W1�'ii�i° H06AtF�e1_► :a:,J:0'i1.2:.�7E� °330.,;.. LAB # DATE TAKEN: E° 4 _U77 DATE RECEIVED: DATE REPORTED: LAM y 'SAMP,LE SOURCE: ---� -- / REFERRED BY: L ✓ L 7—,"-V /17—) b',171 [. C' J COLLECTED BY y �Jd `j LABORATORY REPORT / mg /L ❑ "ACIDITY ..........r.�........ .. ............. ❑ ALUMINUM ................................ ............................... ❑ ALKALINITY .............. ............................... ❑ ANTIMONY ...............................: ............................... F-- BACTER :A, TOTAL /mL .. ......�� ....................... [D ARSENIC .................................... ............................... /❑ -BOD,-5 DAY ................... ............................... ❑ BARIUM ....................................... ............................... ❑ BROMIDE ................... ............................... ❑ BERYLLIUM i ❑ CARBON DIOXIDE, FREE ................................ ❑ BISMUTH .................................... ............................... 1 .❑ CHLORIDE ................... ............................... ❑ BORON ........................................ ............................... ! ❑ CHLORINE ................... ............................... i ❑ CADMIUM .................................... ............................... i l ❑ COD ........... ❑ CALCIUM ❑ COLOR ....................... ............................... ❑ CHROMIUM ( tot.) ............................ ............................... ❑ CYANIDE ................... ............................... ❑ CHROMIUM (hexavalent) .................... ............................... t ❑ DETERGENT, ANIONIC ... ............................... ❑ COBALT i ❑ FLUORIDE ...... ❑ COPPER ❑ HARDNESS ................... ............................... ❑ GOLD ........................................ ............................... ❑ MPN COLIFORM COUNT/ 100 ml ...................... ❑ IRON ........................................ :.............................. ,RMFT COLIFORM COUNT/ 100 ml ............... ..❑ CONFIRMATORY TEST :.. ............................... ❑ LEAD ................... ... ...................:. �I ❑ LITHIUM ................. I.................................................. I i ❑ NITROGEN, AMMONIA' .:...:..:........ t] MAGNESIUM .......................... .. ........ ❑ NITROGEN, KJELDAHL ... ............................... ❑ MANGANESE ................. ..... ........................�...... ❑ NITROGEN, NITRATE .................................... ❑ MERCURY .. ............................... ............................... ❑ NITROGEN, ORGANIC .................................. ❑ NICKEL ............................................. I......................... ❑ ODOR ....................... ............................... . ❑ PALLADIUM ................................ ............................... ❑ OIL & GREASE ............... ............................... ❑ POTASSIUM ................................ ............................... ❑ PH ........................... ............................... ❑ RHODIUM .................................... ............................... ❑ PHENOL ....................... ............................... ❑ SELENIUM .................................... ............................... ❑ PHOSPHATE (ortho) ....... ............................... ❑ SILICON ..................................... ............................... ❑ PHOSPHATE (condensed) ... ............................... ❑ SILVER ........................................ ............................... ❑ PHOSPHATE (total) ........ ................ ............ ❑ SODIUM ........................................ ............................... ❑ SOLIDS, SETTLEABLE, ml /L .......................... ❑ TIN ............................................ ............................... ❑ SOLIDS, SUSPENDED ... ............................... ❑ ZINC ............................................ ............................... ❑ SOLIDS. DISSOLVED ... ............................... ❑ .................................................... ............................... .❑ SOLIDS. TOTAL ........... ............................... ❑ .................................................... ............................... ❑ SOLIDS, VOLATILE ....... ............................... ❑ REMARKS:..................................... ............................... ❑ SPECIFIC CONDUCTANCE ............................ :. ❑ .................................................... ............................... ❑ SULFATE ................... ............................... ❑ .................................................... ............................... ❑ SULFIDE .................... ............................... ❑ ................ ................................. ............................... ❑ SULFITE .................... ............................... ❑ ......................... . .................................................. I...... ❑ SURFACTANTS ............ ............................... ❑ .................................................... ............................... ❑ TURBIDITY ..... ....... ............................... ❑ .............. .......... ............................... _. _._ ._....... THESE RESULTS INDICATE THAT THE WATER WAS OF A SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED. THESE RESULTS INDICATE THAT THE WATER DID MEET THE SATISFACTORY CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE RULES & REGULA'TI S, DRI>KING WATER STANDARDS (PART.3.2) RA F OR THE PAMETERS .TESTED o . � u• � /i.... -� -- • — – ...._ rw / e rno\ TTV rTf)R _ � � F i f. .iTi M11 93a, ric oQ QQ Lira 41 �; Q It t7 cw NN. 17 Oi O Zi m m N ty) tci \S N a) 0) I:j Oi O Zi PUTNAM COUNT 'Id Division .'of, In et :,CONSTRUCTION- PERMIT F R'S WAGE DISPOSAL located at Subdivision - .o"er /Address Building Type Lot Area Number_ of 'Bedrooms'_ Design ;Si, Flow G /P/ ; Separate _Sewerage Syste H to co is of To be :constructed by T Water Supply Public Supply Fr E Y- 4 A Private Supply to be tlrilled by 7;lgdress q Other Reuirements (,represent that I- am wholly and' completely responsible for -,the def 8D'ove described wilt -be constr =Cfed as shown on the;app►oved, amen "County''Department' 'Ot Health, and that on completion *thereof a be submitted to�the Oepartment,._and awritten guarantee':will:I '!place ;ln'- good': operating .condition any ;part of said sewage 'disp an • of. the `approval tot -,the;Certiticate of: Construction; Compli ,',will be located as own on the appfoved.plan and that said well wiI County Deparim Pt, of, ealth � ��Oate � Sign . 3 '.� ;s Address APPROVED FOR.CONSTRUCTION: This'app oval.explies ' y -revocable for cause or may be amended or'riiodified when cdnsider + requires a new permit Appr ved for disposal of domestic'sanN it Date � � 'gy r r Rav 9 81 ^1 2 t DEPARTMENT OF HEALTH' pe=wit a U r Heahh Sery <ces, Carmel N:: Y 10512 k" w5 2 �,..� c. i •7_ own O S aviz µ : Tax •, Nlap� '+ V.Block' Lot of q Renewal ° � Revision � • / � Date;, Of, Previous Approval `� ' �- ' F311 Section Only ❑ r P C N' D Notification. Requir" 'a• al Septic Tank - and , . 1 ' Address 7 It 1 a ' I k and location lot the proposed system(s); 1) that the'separate sewage disposal i stem enf there to and 'In 6ccorCance with the standards, rules an regu a ons o a u nam ertlficate; of Constr =coon Compliance ";satisfactory . to -the Commissioner of Health will urnished -the owner, his successors, heirs or assigns'by the buil. a'. that said builder:will. 1.4 ystem during the period of. wo.(2)'ye4rs immediatelYfollowirq thedafe of the issu- e of flie.original'system or any iepairsther o,' jahhe drilled well:deseribed above,' ansta11 I c da a with e, stand , ru s end; rep= *113n; - of the •Putnam ' A. License No. - from the date isiued unless construction of tha -buhl ing `has been undertaken.and' is iecessary`by the•Commissi r,ot. Health Any;,change; or•alteration of construction ge d /or rivate supply only i1 `j PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Wd J f -5 Re: Property of Located at dlllb Section Subdivision of Subdve Lot # Block Lot Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineer ✓ or r gistered 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 connection with this matter and to supervise the construction of said system or systems in conformity with tYie provisions of Article "f45 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned P*E., R >A., h Very truly yours, Signed Owner of Property Address Address Town d' OCR rr_iep Telephone ,SUN 61S %3 PUTNAM cout4 PUTNAM 'COUNTY DEPARTMENT -OF HEALTH: DIVISION OF'ENVtRONMENTAL HEALTH SERVICES ------- . ..... -.--COUNTY OFFICE BUILDING; -CARMEL, N. Y. -10512 .......... . ... ...... DESIGN DATA SHEET -SEP T SEWAGE DISPOSAL SYS EM FILE NO.' Owner UK-1 ,Address Located at (Street) e)j 0 1 Sec. Block Lot ... .. ........ ..... .......... . -- -------- (Indicwte neares t 'cross'-street Muni cipality-R-:b.-A� T '7 SOIL'' PERC OIATION TEST A- -REQUIRED -TO BE SUBMITTED WITH APPLICATIONS I T0767 '--,'Number'.:-'! CLOCK TIME PERCOLATION ............ . ............. �iapse. Depth,.to,Wdter Water Level o'. 1m Time Ground d'-Surfad'6i n 'Inches "'I h Rate' Min. Start Stop Drop in Min./in drbp Inches......._____.__Inche.s -. Inches -77 2 Z2, J-1i -!i KV1 T '7 .......... T 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) Depthmeasurements to be made from top,of hole. 71 J � .f