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BOX 29
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03717
< x."
4M 'COUNTY DEPARTMENT OF HEALTH.
EnJironmenta /> Health : Servtoes, Carmel, N -.Y 10512 eermlt
4
LIANCE .FOR `SEiNACIE DISPOSAL�SYSTEM
i
own Viile We
Block
r / 1
r
SUbd
ly ! Tax Map ,LOt' N v Lot k
,j...,E47- -
!��N:
,
Addr�eiJS�i
ank and,
,`.� � ° €� ,i °.L 1 i�'fti: i°Y /!. •.f . .CaiP,�- :.1i�';�,.L ����iD. �.�6aa:.' I��,a
Private Supply Drillletl By,
Addr S, ,
Building. Type
Nas Erosion Control Been Completed?
I certify that the syste(s) ae.l'isted sere
of which are attached) and ia- accordance ^r
Putnam County Department of Health
Date
Address
Any peKion occupying premises se►ved,by the
":conditions resulting from': such usage AP,
available and the `approv6Fof the $hvite *ate!
subject to modification or change when' t
�� C-*.'�
H. N
Certif)edDy- PEy t R.A.
f
.''
Licenso No '
+4sy m(3) shall piomptly+tske such action as may be neceasa►y t. o secure the correction of any unssnitary
t the separate sewerage system shall become null end void q "s soon as a publie sanitary ssvver;;beeomes
ply sha(I become null and ,void "whey a public+ water •supply, becornw 'aviigble. Such .approvals ,are
idgment of the,Commi Warier, ;of M it such revocation; mod0l"tion or change is'necesniy.
Date .' �.:O�C� 7 Y Title
�
par
2.
y
Rev 9-Si' s• �.�' ".
.i 7q x ,[ t
�ivi�rc►n
t.
'.CERTIFICATE' °OF CONSTRUCTION 1;3
T ', •`
Located at
Owner' .�F,+
'Separate Sewerage System^ built by�
Consisting of,0a1 =Sep
Other j
requirements
1Nater Supply � Publfc� Supply From'
< x."
4M 'COUNTY DEPARTMENT OF HEALTH.
EnJironmenta /> Health : Servtoes, Carmel, N -.Y 10512 eermlt
4
LIANCE .FOR `SEiNACIE DISPOSAL�SYSTEM
i
own Viile We
Block
r / 1
r
SUbd
ly ! Tax Map ,LOt' N v Lot k
,j...,E47- -
!��N:
,
Addr�eiJS�i
ank and,
,`.� � ° €� ,i °.L 1 i�'fti: i°Y /!. •.f . .CaiP,�- :.1i�';�,.L ����iD. �.�6aa:.' I��,a
Private Supply Drillletl By,
Addr S, ,
Building. Type
Nas Erosion Control Been Completed?
I certify that the syste(s) ae.l'isted sere
of which are attached) and ia- accordance ^r
Putnam County Department of Health
Date
Address
Any peKion occupying premises se►ved,by the
":conditions resulting from': such usage AP,
available and the `approv6Fof the $hvite *ate!
subject to modification or change when' t
�� C-*.'�
H. N
Certif)edDy- PEy t R.A.
f
.''
Licenso No '
+4sy m(3) shall piomptly+tske such action as may be neceasa►y t. o secure the correction of any unssnitary
t the separate sewerage system shall become null end void q "s soon as a publie sanitary ssvver;;beeomes
ply sha(I become null and ,void "whey a public+ water •supply, becornw 'aviigble. Such .approvals ,are
idgment of the,Commi Warier, ;of M it such revocation; mod0l"tion or change is'necesniy.
Date .' �.:O�C� 7 Y Title
�
par
2.
y
Rev 9-Si' s• �.�' ".
� � �� _, � • 4 � �• .. gt�'I ��Y��itr Sllypt'Fi; t� ;l'. , -. �...,., _..; -.. - ...
Il:I h, ,l(ryXilf
WELL COt P,LETION. 5
REPORT' PUTNAM .COUNTY DEPARTMENT OF HEALTH
( -
Division of Erivironrnentel Health Sarvresr,
1. COUNTY. OFFICE BUILDING - CARMEL, NEW YORK .'
}
This report is to be completed by welrl 'Iier and submitted to County Health Department together With laboratory report of
analy iis:�f �vaCer sam lP,indlcepng water �s ofaatisfaotdry hactenal-quality;_b fare certif i rate of construction campliance is issued.,
.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION.
NAM
ADDRESS .; t
OWNER
LOCATION
(N is 'Strssl) % (Town)' (lot NumDef) '!
9f WELL
BUSINESS -
❑ ❑
❑'
PROPOSED,
DOMESTIC .. ESTABLISHMENT FARM TEST WELL
USE OF
WEII
Q ❑ INDUSTRIAL ❑ CONDITIONING El. i
SUPPLY (SPA
y).
DRILLINq
COMPRESSED CABLE OTHER
❑
SPe i y)
®BOTANY ❑ ❑
..CASINO..,.,,,_
LENGTH.(Jaet)
DIAMETER(/ hes)
/ �l
WEIGHT PER FOOT
® ❑WELDED
NO
CASING
YES
NO
DETAILS
THREADED .
YES
-
YIELD
�. j HOU
❑ ❑PUMPED I
YIELD (O:P:Y
TEST . `
aAtLED COMPRESSED AIR L
WATER
MEASURE FROM LAND SURFACE— STATIC(Spocfty.fsel)
DURING :TIEW TEST fleet)
" '
Depth of. Completed Well t
yy
in feet below. Lend surfoa: l7LQQ .
MAKE . '
LENGTH OPEN TO AQUIFER (leer)
SCRREN ...,.
DETAILS
SLOT SIZE
DIAMETER (inches)
IF GRAVEL
Diameter of well including.
RAVEL SIZE Q na _ )
BOA► (NarJ "TO
(roetj
'PACKED:
pidvel pock( (inches):' `
DEPTH FROM LAND SURFAC[
rORMATION'DESCRIPTION
Sketch.axact location of well with dafances,'to at least
two permanent landmarks..;
FEET" to FEET -
i
i
• If yidd' was tested at different depths during drilling, list below
FEET CATIONS PER MINUTE
DATE. IVEllLO TED.
PALE OF REPORT WELL GRILLER 9 a s)'
�.
;
Owner or Purchase r of Building Section
. Building Construe ed by - -•'r.. ,.... : --' Bloc`k._. .. .... : � .... . .
1 p Ord
Location V - StIreet Sd Lot
Municiballity ^{ ' Subdivision Name
L3
Building Type` °' Subdv. Lot #
GIiARANTEE 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.tion of the.Director.of.the Division.of Environmental, Health Services
of ttie Putriam"C'6unty Dispart"merit of Health as to' °wlietrier "o "r "'not "tfie' °fail - ""
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated this day of �.. 19 Signatur - �✓
Title I /? Q4
U_ .i LL l v
Co poration Name TIT cor .
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.
- - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Health
J
Yorktown Medical .Laboratory, Inc. LOCATIONS:
❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245.3203
321 KCar Street W-201 BUTTONWOOD AVE.. PEEKSKILL, N.Y. 10566 737.8777
Yorktown Heights, N. Y. 10598 ❑ 495 MAIN ST., MT. KISCO. N.Y. 10549 666 -3335
(914) 245 -3203 ❑ STONELEIGH AVE. (NEARI HOSPITAL). CARMEL N Y 10512 278.9330
ni .Alhert -H Padovaha r e (Arectn. DATE TAKE_ : y 2
,
(- DATE RECEIVED:
SAMPLE SOURCE Lab /1
REFERRED BY: j
J Collector: 264- 9 75
ZABORATORY REPORT
mg /L
❑ ACIDITY ........ ...... _ ............... .......... :. ❑ALUMINUM .......... ............................... ................
.... .... ....
❑ ALKALINITY i P= ........... .. .A= ....................... ❑ ANTIMONY .............
ACTERIA, TOTAL /mL �. ........................... Q ARSENIC ...........................:... ........:......................
UeOD, 5 DAY ............................................................ ❑ BARIUM ..:.............. ............................... ..... .
❑ BROMIDE
............................ ..........................,. :.. ❑BERYLLIUM .....:.......................... .....:.........................
❑ CARBON DIOXIDE, FREE ........ ............................... ❑ BISMUTH ............................:....... .....:.........:...............
❑ CHLORIDE ........................................................... Q BORON
.................................... ...............................
❑ CHLORINE ................................................... ... ❑ CADMIUM .................. _ ............. ...............................
❑ COD ................................ ............................... . ❑ CALCIUM
......... ........................... ................................................
❑ COLOR (units)..*
.... ..... ❑CHROMIUM (tot.) ............................ ........ ................. ......
❑ CYANIDE ............................ ............................... ❑ CHROMIUM (hexavalent) ...... ...............................................
❑ DETERGENT, ANIONIC ............ ............................... ❑ COBALT .....:. ...:...........................
❑ FLUORIDE ............................. ............................... ❑ COPPER .............................:...... ...............................
❑ HARDNESS ............................ ............................... ❑ COLD ........................................ ...............................
��❑��MPN COLI FORM COUNT/ 100 ml ...0 ........................ ❑ IRON ........................................ ......................... .......
32',(I `''COLI FORM COUNT/ 100ml ............. ❑ LEAD ....... ............................... ............:..................
❑ CONFIRMATORY TEST ......... ... ............................... ❑ LITHIUM ...... .. ............................... ..
....
❑ NITROGEN, AMMONIA ........... ............................... 11 MAGNESIUM ................................ ..............:....:...........
[],.NITROGEN, KJELDAHL .................................... ..... ❑ MANGANESE ...............................................................
❑ NITROGEN, NITRATE .........:.. ............................... ❑ MERCURY
❑ NITROGEN, ORGANIC ........................:...... ❑ NICKEL _
................
......:...
❑ ODOR u n i t s ) ................ ............................... ❑ PALLA191UM .................................... ....................:.:..:..... .
❑ OIL &GREASE ........................ ..................:............ ❑ POTASSIUM ................................ ...............................
❑ pH ( 1121 i t S) ...................... ............................... ❑ 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 (U11IDo S / cm) ............... ❑ .................................................... ...............................
❑ SULFATE ....... ............................... ............ El
OSULFIDE ......... ............................... ............. ❑ ......:....................:
❑ SULFITE ............................................................ ❑ .................................................... ...............................
❑ SURFACTANTS ............................................... ❑ ...... ...............................
❑ TURBIDITY (NTU ). ............... ............................... O ........... ............................... ...............................
THESE RESULTS INDICATE THAT THE WATER WAS J OF A SATISFACTORY SANITARY
QUALITY WHEN THE SAMPLE WAS COLLECTED.
THESE RESULTS INDICATE THAT THE WATER DID MEET THE SATISFACTORY CHEM-
ICA QUALITY OF THE NEW YORK STATE ADMINISTRATIVE RULES & REGULATIONS,
D ING. WATER ANDARDS (PART 72) FOR THE PARAMETERS TESTED
W H S PL W S C ELECTED.
�. N/A = not applicable
111
oate
APPROVED, I
P111"M CJTEC'KK Ij,5T.
P &&01 rDA)f1 1000,
fm Pjamw
Zn�p.b.Y...
INI.TTAL SITE, Ii �Y1?CTIO?' _
Ycs
NO
Comments
,Propert.y lines or corn:•r3 found
Can cstiinatc hour; location . . .. .
Ifill drivcway need cut • . • • - .
Yiust trees be removed -note these . . ... . .
Is deep hole representative of entire SDS area
__
P
-
Additional deep holes needed. . . . . .
Sufficient SDS area available considering
driveway cut, house location, separation
_.
�
distances, etc.
DEEP HOLE, DATA
k.
Da h:
ldater elevation: � . Vf VN
Rock elevation: ivy;
Soils descr.i,,)tion: cr. -Y1,s� L�
—
Date .
: by:
F NAL S-TTE I',, P,1 -CTTr 1iSp•
- -
House located vhera shot.n on approved plan '• .
SDS Located whei'3 approved
Irrgth of i;rcnch mcasur-OCA,
Z•Lid to of trench aver! c e
Slope of tile, line and trench. acceptable
✓
.
Room - allow-dd for.. exransion trenches
Over. 50 ..fi;. from swamp wa .ercourse "_ . .e ,..:.... .o: _.....
•�..
;.._ .
�...... _.. ,- _.
Vatural soil not . stripped or SDS. area
inuiecessarily graded ... . . .
__
10 It. maintained from prop.line and
20 ft. from house
Sep*-- ration of trench fro ;i house, well
_
etc. - follows' plan . - ..- - -; - - -- - . � --e- . -� � � -- : -:
- _�-.
_-Per
- - -
v
Number. of bedroo-.r,s checks . . . . .z .
Stones, brush.,' stumps, rabble, etc. greater
than 15 ft. from nearest trench . . . . . .
,✓'
15 Ft. of peripheral soil horizontally fron
trench . .. . . . . . . . . . . . .
f
Junction boxes properly set
Could surf. acc run off from driveway, roads,
• ground surface, etc. chamael near SDS
✓
area . . . .
--
Does l.ot dr. airnEte armor), 0. K. in area of SDS
FINAL GRADING OF SITE ACCEPTABLE f
�� 1,41
l
� -- 75 ---- ---ate'
2.
L.
� 5 X
�1lrC C r
�FfZ.EDRtKS�rJ - CNGfz :_.._ REVIEW CIT:CK SIQ;T j
(Moots Std . f Remarks •
nAtIT TT,mnrme I
House plans 0. K.
Drrasign data sheet
Peres presoaked?
Kin., 30" perc test depth
Cont.-results for.3 runs
D. Hole log 0. K.
Corporate Affidavit for oth o than indivs
Authorization for engineer
Letter from Water Supply .if applicable
If variance requested -such noted on plans
DETA I IPS ,
if change is proposed,)
Existing contours shown show new - contours)
Slopes for driveway cuts:, etc. shown
Rater service line location
Footing drain, etc*. loca lion
Top slope, bottom slope of fill
Percolation tests and deep test pit location
Setitic tank size and conformance to std.
3 B.R. house minimum
House setback shown
Distribution box ftg. below frost
All water within ft. of PL shown -r
Plan and profile -SDS -, :
All other wells and SDS closer 200'
'shown or reference made
Property boundaries (metes and bounds- clearly s
SEPARATION DISTANCES SPECIFIED ON PLAN
10' to P. L.
?0" t o Foundation walls _
)0' to Nearest well
50' to stream, march, lake, etc.
L5' to Curtain drain
!0' to water lira; (pits -201)
.5' to storm drain
(?' ' to lar,o trccs
10' Vrolil i'011ndation to septic tan:
.1)' to pipe from leader d. rain &. 1'd
L.0 ADZ_ h`► I �"
ScoPp-
.expansion
i
.ne, aralrl !
C) CA-Y_4_ I< P_ .
I
I
IA A
7.
j
. aD;
00
10�
_/O/
/J ,
PUTNAM COUNTY DEPARTMENT OF HEALtH
Located at
(T)
Section
�
P Block W Lot
`
N
Subdivision of 11 NO. UIL� V-OOK._-
;;Z�7 o IZ
Subdve Lot # O Filed Map # 160 Date G( 46:
Gentlemen:
This letter is to author ize17�Z1
a duly licensed professional engineer �or registered architect
(Indicate
to apply fora 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' n' conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
P.E. , R.A. , #
Ve,, Ly,n
Address
A, G 1-1. o -4 I
Telephone
Very truly yours,
Signed O2 ,t.t:bA u-&99 10'4
a tit Gin22
Owner of-Property
Address d
Town
C Y2 -- 7,4/1
Telephone
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
°- -- ° _- -- COUNTY = OFFICE- BUILDING; CARNiEL, .
N. "Y'. -1-0512--"-"
DESIGN DATA SHEET- SEPARjkTE SEWAGE DISPOSAL SYSTEM FILE N0.
Owner ZA y'l ja til wl 4 Address Ao ( . y 1.
F7 . Located at (Street Sec. Block to Lot -Z---
n icate ne est cross street
Municipality OLD S Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
5
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Run
apse
Depth to Wa er Water Level
No.
Time
From Ground Surface in Inches
Soil Rate
Start -Stop
Min.
Start Stop Drop in
Min. /in drop
5
Inches Inches Inches
Z
2
3a
17 %- l % %z
1
2
3
4
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.
5
1
3
i
5
1
2
3
4
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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE N0. HOLE NO.
G.L. D
611
12"
1$"
24" -
36..
i
42"
48"
54
60'►
66"
72..
78'►
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
:...:. ..INDICATE. LEVEL :_TO YJgCH ATE :LEVEL: RISES AFTER BEING ,ENCOUNTERED
TESTS t�1ADE 'BY _ _ D .. 5� Date-
Soil Rate Used 0— / -s kn/l "Drop: S.D. Usable Area Provided 6 E c gn5ie-
No. of Bedrooms _Septic Tank Capacity 0 Gals. Type Gr��
Absorption Area Provided By3;L. F. x24 rent .
�..
Name L lgna ure s
Address KS L �)e a LvD SEAL z
nzal
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: �J�Q s 0 5 00":
Soil Rate Approved Sq. Ft /Gal. Checked b SS10
��, � ion 9 L - L,�1,► =0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUN`T'Y` OFFICE BU7Lb G, CARMEL 1f...T. - ". -.105120.
DESIGN /DATA SHEET- SEPAR4TE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner LAM 4 tJ Q Ar Address
Located at (Street iZl�, Sec. (otp Block (o Lot 2.-
Indicate-nearest cross street)
Municipality IC Ot4 f} .� i4A Y LLE-Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
5 -
1
2
3
5
Notes: .1) Tests to be repeated at same depth until approximatelyy 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.
Hole
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Run
No'.
Start -Stop
apse
Time,
Min.
Depth to Water
From Ground
Start
Inches
Surface
Stop
Inches
water ve
in Inches
Drop in
Inches
'Soil Rate
Min. /in drop
' � 1
3c)
2o
2 y
!�-
2��
3
3c)
4
.17
5 -
1
2
3
5
Notes: .1) Tests to be repeated at same depth until approximatelyy 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.
BAR!iER
° SEE INStT• I f I R
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