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HomeMy WebLinkAbout3720DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.17 -1 -77 BOX 29 03720 1.� - -� PUTNAM COUNTY DEPARTMENT OF HEALTH - `\ Division of Environmental Health Services, Cormel, N. Y. 10512 ` Permit B CERTIFICATEt OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM 01 i1ey Town r V it —la# / r ' L OCated at _L. �C.- A U i'�ll• �- ._I1r�i Imo. -- _'f$x -Map ` ..e j?. ... Block •� - - . , Owner��,�Y ®" /Formerly Tax Map Lot_# subd. Lot $ Separate Sewerage System built by •R�.. _ Address ! r 4 h Consisting of �Oai. Septic Tank and �' `J�� � Other requirements water Supply: public Supply From Private Supply Drilled ate// Address +2� 14 ' 1 / G Building Type at-c- ; No. of Bedrooms Date Permit Issued Has Erosion Control Been Completed? 9— I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regal ions, in accordance with the filed plan, and the permit issued by the Putnam county Department Of Health. — /"'y R Date ;i' -- Certified by Address P.E. ZR.A. License No.-,- o as Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private wat sr supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the C mmissioner of Haa th, such revocation, modification or change Is necessary. M1 Title Rev. 9 -81 U;Mmet or Purchaser of Building Section ...,, ne "b Building Costructd" y Location - Street \k de"I Munici ality a Building Type Lot G a>_C' 0 a r Subdivision Name -'I Subdv. 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.tion of..the-Director, of-_the Division_ o..f-- Environmenta .l..Hea.lth...Services. of the Putnam County Department � of Health as to wr et `e`r` or" riot" the ""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 4, 4- L- L Co oration Name if corp 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 Yorktown Medical Laboratory, Inc.. LOCATIONS: ❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245 -3203. 321 Kear Street 9.201 BUTTONWOOD AVE.. PEEK SKILL, N.Y. 10566 737$777 . Yorktown Heights, N. Y. 10598 ❑ 495 MAIN ST., MT. KISCO. N.Y. 10549 666.3335 (914) 245 -3203 ❑ STONELEIGH AVE. fNEAR HOSPITAL) CARMEL N. Y.10512 .238-9330, ..Di> a t,Q -� ]bert -H:: ►?adovat as d9',.I::(�1 SCP) DATE TAKEN: (— DATE RECEIVED: ,'7 DATE REPORTED: SAMPLE SOURCE: Lab, P REFERRED BY: 264- 976 L_ Q��� v��7 J Collector: _ LABORATORY REPORT m9/L ❑ ACIDITY ............................................................. � ❑ ALUMINUM ❑ ALKALINITY i P= ............. A° ........................ ❑ ANTIMONY .,BACTERIA, TOTAL /mL ......( ................... ARSENIC .........:. ............................... ❑ SOD. 5 DAY ........................... ..:.............................. ❑ BARIUM ....................................... ............................... ❑ BROMIDE ............................ ............................... ❑ BERYLLIUM 11 CARBON DIOXIDE, FREE ........ ............................... ❑ BISMUTH .. ............................. ............................... ❑ CHLORIDE ...... .......... ...................... .................... ❑ BORON ........... ............................... ........................ ❑ CHLORINE ........................................................... ❑ CADMIUM .... .............................:. ❑ COD ... ... ... ................ ............................... ❑ CALCIUM ................................................. .................. ❑ COLOR (U n i ... t S ) ................. ............................ ❑ CHROMIUM (tot.) ............................ ............................... ❑ CYANIDE ................... : ............ ............................ ❑ CHROMIUM (hexavalent) ......... ❑ COBALT ❑ DETERGENT, ANIONIC ... ..........,.... : ...:........... ..................... .........................:..... ❑ FLUORIDE ............................. ............................... ❑ COPPER ............... ............................... ❑ HARDNESS ............................ ............................... ❑ COLD . ............:...............•,..:....... ............................... 11 (� MPN COLIFORM COUNT/ 100 ml ..:.J''j .................... ❑ IRON U� ff IFT-COLIFORM COUNT/ 100 ml • I.<•.....••• ............. ❑ LEAD CONFIRMATORY TEST ........................................... ❑ LITHIUM .................................... ............................... ❑'NITROGEN. AMMONIA ............ ............................... O MAGNESIUM ................................ ............................... ❑ NITROGEN, KJELDAHL ............. ❑ MANGANESE .......... ❑ NITROGEN, NITRATE ............................ ❑ MERCURY ❑ NITROGEN, ORGANIC - :............. O NICKEL ....................... :.. ......... ❑ ODOR (units 1 `• .................. ................. ❑ PALLADIUM ❑ OIL & GREASE .................. s..... ............................... ❑ POTASSIUM ................................ ............................... ❑ pH (Utl i t S ) ...................................................... ❑ RHODIUM ❑ PHENOL ................................. .I........................:.... ❑ SELENIUM .................................... ............................... ❑ PHOSPHATE (ortho) ................. ............................... O SILICON .................................... ...........:................... ❑ PHOSPHATE (condensed) ............ ............................... ❑ SILVER ........................................ ............................... .❑ PHOSPHATE (total) .................................. :............ O SODIUM ........................................ ............................... ❑ SOLIDS. SETTLEABLE, ml /L .... ............................... O TIN ............................................ .............................:. ❑ SOLIDS. SUSPENDED ............. ............................... O ZINC ............................................ .............. .................. ❑ SOLIDS. DISSOLVED ............. .......... ...................... O .................................................... ............................... ❑ SOLIDS. TOTAL ...................................................... ❑ .................................................... ............................... ❑ SOLIDS. VOLATILE ...........: ..... ............................... ❑ REMARKS:..................................... ..................... ........... 0 SPECIFIC CONDUCTANCE (uhmos /cm) ............... ❑ ................................................................................... ....... ............... ............. ..... ......... . ............................ ......................................................... . ............................................................. ❑ SULFATE ... ....... ❑ O SULFIDE ........................................................... . ❑ SULFITE ............................. ............................... ❑ .................... ................................ ............................... OSURFACTANTS ...................... ............................... ❑ ................................................... ............................... OTURBIDITY ( NTU) ................ ............................... ❑ ............ ... . .................................. .............................. 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 CHEM- CAL QUALITY THE NEW YORK STATE ADMINISTRATIVE RULES & REGULATIONS, INKING. WA STANDARDS (PART 72) FOR THE PARAMETERS TESTED TH S E AS COLLEC N/A = not applicable WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTF 3/71 pivl ;ion of Environmental Health $ervioet COUNTY OFFICE BUILDING CARMEL,'NEW YORK This :report is to be completed, by wel(Il Iler and submitted to County Health Department together with laboratory report of analysis of Ater sample indicating water.is of, satisfactory bacterial quality before.certificite of Construction compliance is jSsyec1. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION . , ADDRESS OWNER lot Number) IODATION (No. f reel) Town (, Of WELL t, J ►ROPOSED ' ®•DOMESTIC C� ESTABI SHMENT FARM C� TEST WELL USE OF WE PUBLIC LL, . n tJ SUPPLY C� INDUSTRIAL .CONDITIONING Q . (HER DRILLING MPRESSED CABLE OTHER . . (� �,, CO iOWPMFNT l�l.. ROTARY.' C,J AIR oFRCUSSION I� PERCUSSION (_1 (Specify) o' 4 LENGTH (leer) DJAMETER fdhthsP) WEIGHT PER FOOT CASING . .. THREADED ❑:WEIDE6 YES NO YES W. ;. DETA1lS e. HOURS G:P.M YlEltl (t].P M 1 ' YIELD ,. TEST ❑ IAILED C� PUMPEg ®C9h1PRESSED AIR WATER... • MEASURE FROM LAND SURFACE 31A11C(Specllylhef/ OURING`XIEID TEST (feet) pepth pf CanplNed Wrall IEVEI In felt below land surfac MAKE 7 LENGTH OPEN TO. ApU1fER'(lsali SCREEN - , g ROM.(Har) TO (reel) DETAILS SLCT'SIZE RAVEL :LIE (inches) GRAVEL piams is rof wall ind udi n ACKED: gravel pock:(Inchpsj. ,otrty reOn+ LAND 342.0AC -- ` . &tetcA'�sie�ct�lo��n of 11 srlui 01slaneai. to a Meat .. FORItiATION DESCRIPTION FEEL to: 1EEjt .. „ fwo ptrlman�nl a ma .. T� Of If yield; -wet Hued, at different depths during drilling, list below FEET GALLONS PER MINUTE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at (T) Section Block Lot_ Subdivision of Subdv. Lot # F5 Filed Map # G0 8 c-) Date U114 S Gentlemen: This letter is to authorize a duly licensed professional engineer -- L'Or registered 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 the provisions of Article 145�or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary.Code. Very truly yours, Signed Countersigned: �,Pi�' Owner of Property i a r P.E. , R.A. , # ..v l Address tile5r 4A kle, 13�v� '? Addr ss Town kk,f L t e o Telephone 14-6200-439Z-- Telephone Date ca 4-- Re: Property of Located at (T) Section Block Lot_ Subdivision of Subdv. Lot # F5 Filed Map # G0 8 c-) Date U114 S Gentlemen: This letter is to authorize a duly licensed professional engineer -- L'Or registered 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 the provisions of Article 145�or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary.Code. Very truly yours, Signed Countersigned: �,Pi�' Owner of Property i a r P.E. , R.A. , # ..v l Address tile5r 4A kle, 13�v� '? Addr ss Town kk,f L t e o Telephone 14-6200-439Z-- Telephone REVD CITI:CK S1O ,T R b2eSCSF N s Ci�C��.. (Moot ►iYe s DOOMITITS House plans O.K. D - -sign data sheet Peres presoaked? I,� n. 30 perc test depth I Const. results for 3 runs D. Hole log O.K. Corporate Affidavirt for other^ than individual Authorization for engineer Letter from Water Supply if applicable If variance requested -such noted on plans & apps._ u . t Std. Romark,) NO M DETAILS if change -is proposed,) Existing contours shown show new -contours) Slopes for driveway cuts, etc. shown 1ater service line location Footing drain, eta. location I ►ODr 10D►Cl�' D Top slope, bottom slope of fill _!2C Percolation tests and deep test pit location I i Seutic tank size and conformance to std._ _►___ 3 B.R. house minimum 1 House setback shown I 1 Distribution box ftg. below frost All water. within 50 ft. of PL. shown , ...Plan -and ..profile SDS , All other wells and UDS closer 200' shown or reference made Property boundaries (metes and bounds- clearly s =SEPARATION DISTANCES SPECIFIED ON PLAN 10' to P.L. ?0" to Foiuzdation walls )0' to Nearest well j0' to stream m, march, . lake, etc. incl . expansion i L5' to Curtain drain '.0' to water lire (pits =20'— � .5' to storm drain O' to large trcl.s ! O' fr0Ii1 foundation to sopLic tank i to pipo from leador drain & .1'0o ing drain (Z �iI�C ot2 ,Sf_t)P,&: 00 'FILL SF—C -T(C) j C'N lLteas TO septic llyeE9 'd=t� f p—. , , a ao,. 1D� 1 Dry /J � s 1 a ao,. 1D� 1 Dry /J � � S � N. Q 'Ai ,"l sMf '9o- j. c� v PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING,'' CARMEL, - N . Y.­­105!'2`_`­" DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE =NO. Owner Address' -Z �Y. ?0b4,qM FiF- GaSTo�� �� Located at (Street L -oticyV Sec. �� Block Lot Z_ n ica e nearest cross street Municipality p�r•1 ��" LL-6 SOIL PERCOLATION T]�ST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS oe. Number CLOCK TIME PERCOLATION PERCOLATION El—apse Depth o a er a er ve No._ Time, From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches c3 17 / 2- 2�z /2 2 3 0 Z 5-- 1 — /S 1 . 3 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. All data to be submitted for review. 2) Depth measurements to be made from top of hole. e - - r TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF.SOILS ENCOUNTERED IN TEST HOLES .. .,. .- ._• m1 -•.:, o. . :.:..r•c.:.. ._..;. ..r ... -:c. .. •.. -.. .. -. ,_ — .e _. 01._..e... .w.:.v�.4 snv,...a .....vrr .. -,. a,. . •. —. DEPTH HOLE NO.�_ HOLE. NO. HOLE NO G.L. 1 6" 12" 1811 I 24" t,jZ 30„ ` 36" i 42„ 4811. F-- 54„ t ir — I 60 i 66" I 72„ 78„ � 84 i INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE:.LEVEL.:TO W CH WATER LEVEL RISES AFTER BEING: - ENCOUNTERED..' TES'.CS � MIM BY Da e i DESIGN j Soil Rate Used/ -/ Min/1 "Drop: S.D. Usable Area Provided �Oj QcR, • y No. of Bedro oms�Septic T L k Capacity O fk� Gals. e- Absorption Area Provided By,3 .F.x24 er- vr Name -D E igna ure Address _ 11e �� SEAL iA r. Ulii :r_ =n?! ,rte THIS SPACE FOR USE BY HEALTH DEPAMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by d' 1 T/ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF.;ENVIRONMENTAL HEALTH SERVICES COU1 OFFICE `BUILDIX(G,: CARMEL, DESIGN DATA SHEET- SEPAW.TE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 4.5.50M E'— Address Located at (Street) RtDS' 0b E_2:, Sec. 64P -Block Lot (i dica e neares cross street) Municipalit t'4 \/4LLf_ Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole 5 Number CLOCK TIME PERCOLATION PERCOLATION apse Deptti to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in. Min. /in drop Inches Inches Inches Z. 1 �► 1� Zofz 21z- / Z 2 3> /lp / 'z Z/� 12, 3 4 11-16-- 4 5 _ 1 2 3 U1 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. 5 3 4 5 _ 1 2 3 U1 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. `ft-5 S ©0 r1sTD CJ IlC: I; L ST , e t> yro ,OE � (PV). 1)3tc: - � Incp•. try:.... �- /?�v� ' �_ ., INTTTAL SITE, JI- ISPECTI.O ?I Yes NO Cotntticnt ; ,Property lines or corn: -rs found . . .. Can estimate, house location . Will dri.vcway need cut . . . . . . . . . . . . Ylu:it trees be removed -note these Is deep hole xrepresentat;ive of entire SDS area Additional deep holes needed. . . . . . . _ x' -- Sufficient-SLR area available considering driveway cut, houc:•e location, separation distances, etc. . . • . ' _ _ __._._._ DEEP HOLE DATA Dsp'th Water elevation: k)(90 � Rock elevation: AJoijb , Soils d.e:scrit)tion CLM I'SAVD Date: Z FINAL S-T.TE II•TSPECTIG?: Insp, by: - House located wher-a shown on approved plan • . SDS. located where approved __ --- :Iength of trench measured 3 Width of trench avers ae Slope of the line and trench. a.ccepta.bie •°'' rGOr,l - all icd for ex-pan- J oii trenches Over 50 ft. from s,•rzmp,waterc=3e .. Natural soil r_ot.strip'ped or SDS area =1ecessarily graded 10 Pt. maintained *from prop. line and 20 ft. from house . . •C�2r.�e4- - _ Separation of trench frolll house, troll - -etc follows plan - ._..__ - - - -- -- _... -. ------------------ , - -.. —. hIrmiber of bedroo-mus checks . . . . . . . . . Stones, brush, • stur.:ps, rubble, etc. greater than 15 ft. from nearest trench . . .. f 15 Pt. of peripheral soil horizontally from trench .. Jlulci:ion boxes properly set Could surface run off from driveway, roads, • ground surface, etc. chamiel near SDS . al' c, . Does lot of SDS PC) .� FINAL GRI1DJPtTC OF S ACCE1'T11]3IT ' a DAVID D. BRUEN County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services Mr. Roy Fredriksen, P.E. West Lake Boulevard RD #2. Mahopac, New York 10541 Dear Mr. Fredriksen: r.. JOHN Si4woNS. M.D. Deputy Commissioner December 27, 1985 RE ACertificate of Construction Compliance ,. LT 4s -s Fieldstone Roadtnam Valley(T. Lamanna - Fieldstone Road - Putnam Valley (T)" This Department has recently received applications for Certificates of Construction Compliances for the above- captioned properties. Since the construction permit for both of these properties were approved authorizing only the placement of fill in the sewage disposal area, we were surprised to find that the sewage system and well had been constructed without the approval of this office. You are reminded that such construction, without a permit, constitutes a- violation of Article III of the Putnam County Sanitary Code and makes the permittee,(property owner /developer) liable to the penalties provided by law, including prosecution by a fine or imprisonment, or.both such fine and imprisonmment, as prescribed by law. The writer does not feel that legal action is appropriate at this time, -- how*we.�= r- iii trig . future sroulc?: ahese activities occur, . ,the .Department will have . +no :. other recourse but to institute such action. While it is realized that you cannot be responsible for activities that occur without your knowledge, you are responsible to the permittee and the Department to bring these activities to our .attention as soon as you are aware that they have occurred. Filing of final construction plans and "as- built" plans after the fact is not considered an acceptable practice. In the future, Departmental approvals will be accanpanied by notices to the owners and engineers advising of the nature of our approvals. It is hoped that through these efforts and the cooperation of the designing engineers such as yourself, in advising your clients of the above, sewage systems will be installed in accordance with the requirement of the Putnam County and New York State Department's of Health. t Very yo s{, I f ell (iflr., E. J hn , JK :mk Director Environmental Health Services cc: JK File 9 TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225-3641 AS50 i L-T- 0 I EzTffy 'PIAT 7-Y—I 0/4 T16 1>4AN A, Jr- T•-i7- P/C :5y' I,,IA Tjr- r-OLL5 1-11D f-4i6L; 0.1,1 t� OF I'IfE: P,)T�4,q4) CoAbIrl 'ir-14i Aritl TJC� 14.y,!5. A!> "1- Cji- qCALj-(j• ---------- rT r 2 Tq eLA� kv-Z•4' fW ALL f. .)L)OO GAL. 75UeTIC T, 7 4CIePA,dS"1 O AA . -1 . 8 YJ ELL 377' 'rjjg4L 4ji6T.P4 L ti 4,, 1-3"' QAk O� 5A^ Vi FILL 2"T 7-4,C LLn b&Z-1 (9 0 t4 j -4 Z. -.C-,qLL qorL I Z.0' F-,,' 46, E-- 11) �OIQFQS�rj To Fore -Tq by TIL C01J14�y DC-?T, OF HLAI-PI 2. TIZEtIc,! Q--:5 - -Z f F;.C-T �1-b-f-: —; 771 C-r--r7cw-5 375 FEi-T- ZIP, Jj xi FCE;r 37 7 "-r 700 F t�jt-CiZ- TC) roF- AT Tiwln- ��f PLACLMi�- T T L3,,A I c- V,1c, 4L-i6WEEW. V)iLL RJ T,"AL- PsSw-e--, 4. PQ-Y-0L- Z M`j Ti Ic-+<-CLA1j S. No 'NeLL5 U3- I T'A 100 FF s"T OT- - -5E Fr` LJJq` 20o FF'-T 4 14 0; 1 1 Ez 7 ALL 7V-Er-'5 WITI'- /0 FeEj CIF AP.x:eF-Po, 4kel To -ae- RZM-F-> .6. B,�kL�ijLt?- Tk�, E"i C" Or U-6 .1 C, TZ, -ID SET �L '?"A 6F-A,4•T,/ 5i u,4 Tt) -1 CLEZ -4 Yn A? t4-, 46&6, A15. L<>Tj�S FiLfi:�z wiT4 TIE. Of 4,� PlAf LE,,EX0<,K.- fttmm CountV Dep.4"-t' 01 jajal pe 1) 14c) Y. 4, ;V 5Z C Spproved as noted for oonformance vYtfl applioabla Mass and Regulations of the Put= County Health Department. QFJ Z 7, '104- 121-12 K Data P,0/ Of - NEW ,.N. Tq` C) Ilk" .>S 0 tJ T001,! OF V-ITIi 1xIn 4- !4 2.,5- 4,2??— YJ ELL 377' 'rjjg4L 4ji6T.P4 L ti 4,, 1-3"' QAk O� 5A^ Vi FILL 2"T 7-4,C LLn b&Z-1 (9 0 t4 j -4 Z. -.C-,qLL qorL I Z.0' F-,,' 46, E-- 11) �OIQFQS�rj To Fore -Tq by TIL C01J14�y DC-?T, OF HLAI-PI 2. TIZEtIc,! Q--:5 - -Z f F;.C-T �1-b-f-: —; 771 C-r--r7cw-5 375 FEi-T- ZIP, Jj xi FCE;r 37 7 "-r 700 F t�jt-CiZ- TC) roF- AT Tiwln- ��f PLACLMi�- T T L3,,A I c- V,1c, 4L-i6WEEW. V)iLL RJ T,"AL- PsSw-e--, 4. PQ-Y-0L- Z M`j Ti Ic-+<-CLA1j S. No 'NeLL5 U3- I T'A 100 FF s"T OT- - -5E Fr` LJJq` 20o FF'-T 4 14 0; 1 1 Ez 7 ALL 7V-Er-'5 WITI'- /0 FeEj CIF AP.x:eF-Po, 4kel To -ae- RZM-F-> .6. B,�kL�ijLt?- Tk�, E"i C" Or U-6 .1 C, TZ, -ID SET �L '?"A 6F-A,4•T,/ 5i u,4 Tt) -1 CLEZ -4 Yn A? t4-, 46&6, A15. L<>Tj�S FiLfi:�z wiT4 TIE. Of 4,� PlAf LE,,EX0<,K.- fttmm CountV Dep.4"-t' 01 jajal pe 1) 14c) Y. 4, ;V 5Z C Spproved as noted for oonformance vYtfl applioabla Mass and Regulations of the Put= County Health Department. QFJ Z 7, '104- 121-12 K Data P,0/ Of - NEW ,.N. Tq` C) Ilk" .>S 0 tJ T001,! OF V-ITIi 1xIn 4- !4 2.,5- 4,2??—