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BOX 29
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03786
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�nl, PUTNAM COUNTY ._DEP ARTMENT OF HEALTH
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CERTIFICATE.OF CONSTRUCTION - COMPLIANCE : FOR .- SEWAGE DISPOSAL. SYSTEM':
. .
*-� wn or V Ilaye;
?aiock �^
Owner _ / Formerly - Tex Map Lot CI ,SUbd Iqt $ _
Separate Sewerage System bulit by19 ---- =� Address
Consisting otaj?d pal. Septic .Tank ,and
Other requirements
I
Water Supply: , .'Public Supply from
'✓ Private Supply Drilled By'
I
Address
Building Type lSrc, of Bsarooms Date Permit Issued Q
I
Has Erosion Control Been Completed?.
I:certify that the,system(s) as listed serving the above premises were constructed eseei
of which are attached), and in accordance with the.standards, rules and regulations, 3
Putnam County Department Of Health.' .
Date / csS % 2 -� Ce
Address
Any poison occupying premises served by the above system(s),shall
conditions resulting from such usage..' Approval `of the separate
available and the approval of .the. private water- suppiy.shall 0e drhi
subject to modification or change when; In the Judgment 9f'1t-
Date ' !r .. 8i
Rev. 9 -81
^s
romptly take such.actioo
werage system shall, bea
null intl void when a'-
p
oner of,- Heaallth,
:ially.as shown on the laps of the completed work ( copies
ce with the plan, and the permit issued by the
P.E. R..A.
License No.���+ -�-�
as May be neceewryto secure the correction of any unsanitary
,no null and vold,as soon as a public unitary sewer becomes
ibil ter , supply peeoma` avatlabIO. Suetr. approvals are
ch rev lion, modlflution o►, change Is peesss,ry.
TRIO
YORKTOwN MEDICAL LABORATORY INC.
P.O. Box 99 321 Kear Street LOCATIONS:
)<321 KEAR ST.. YORKTOWN HEIGHTS, N.Y. 10598 245.3203
Yorktown Heights,% N.Y. 10598 ❑ 201 BUTTONWOOD AVE.. PEEKSKILL. N.Y. 10566 737.8777
❑ 495 - MEGAN ST. MT._KISCO,.N.Y. 10549-666-1335
245-3203 ❑ STONELEIGH AVE. (NEAR HOSPITAL), CARMEL. N. Y, 10512 Y18.
LAB # 0593
DATE TAKEN 1 5
�- -� DATE RECEIVED:
JOHN BUSHELL DATE REPORTED: 1/17/85
'SAMPLE SOURCE: Well at Spout Brook Rc
1321 EDCRIS RD, - Putnam Valley, NY
YORKTOWN HEIGHTS9 NEW YORK-10598
REFERRED BY: - - - -
L -j JOHN BUSHELL
• COLLECTED BY;
LABORATORY REPORT 245 -7228
mg /L
❑ ACIDITY ............................ ............................... ❑ ALUMINUM .......:........................ ...............................
❑ ALKALINITY ............................ ..................... ❑ ANTIMONY ...............................................................
9,BACTERIA,TOTAL /mL .................. q........................ ❑ ARSENIC .................................... ...............................
❑ SOD. 5, DAY ........................... ............................... O BARIUM ................ ............................... ....................
❑ BROMIDE ............................................................ ❑ BERYLLIUM ............ ............................... ................
❑ CARBON DIOXIDE, FREE ........ ............................... ❑ BISMUTH ..................................... ...............................
❑ CHLORIDE ............................ ............................... ❑ BORON ........................................ ......:........................
❑. CHLORINE ............................ :.............................. O CADMIUM ....................:.......`........ ...............................
❑ COD ........................ ............................... . ......... ❑ CALCIUM .................................... ...............................
❑':COLOR ................:............... ............................... ❑ CHROMIUM (tot.) ............................ ...............................
❑ CYANIDE .......................... ............................... O CHROMIUM (hexavalent) .................... ...............................
❑ DETERGENT, ANIONIC ............ .......................i....... O COBALT ................................,... ...............................
❑ FLUO RIDE ........................................................... O COPPER ................ ...............................
❑ HARDNESS ............................ ............................... O COLD ....... ............................... ...............................
❑ MPN COLIFORM COUNT/ 100 ml . .............................:. ❑ IRON ........................................ ...............................
(MFT COLIFORM COUNT/ 100 ml .....Q ................. ❑ LEAD ....................................... ...............................
❑.CONFI.RMATORYTEST. .... ❑ LITHIUM
❑ . .......................... ..........
:..
NITROGEN, AMMONIA "O'MAGNESI'JPA-
❑ NITROGEN, KJELDAHL ........... ............................... O MANGANESE ...............................................................
❑ NITROGEN, NITRATE ............ ............................... ❑ MERCURY .................................... ...............................
ONITROGEN, ORGANIC ............ ............................... ❑.NICKEL ....... ............................... .................... .....
❑ ODOR ............................................................... ❑ PALLADIUM ................................ ...............................
❑ OIL & GREASE .....:.................. ................... ............. O POTASSIUM ................................ ...............................
❑ PH ............................ .. ❑ RHODIUM ....... ......................... ...............................
❑ PHENOL ....................:... ............................... .. ❑ SELENIUM .................................... ...............................
❑ PHOSPHATE tortho) ..............:. ............................... O SILICON ................................... ...............................
❑ PHOSPHATE (condensed) ............ ............................... ❑ SILVER ........................................ ........................ :......
❑PHOSPHATE (total) ................ ............................... ❑ SODIUM ... ............................... :....................................
❑ SOLIDS, SETTLEABLE, ml /L .... ............................... ❑ TIN ............................................ ...............................
❑ SOLIDS, SUSPENDED ............. ............................... ❑ ZINC ...........:................................ ...............................
- -- ❑ SOLIDS, DISSOLVED ................................ .......s..... ❑ ........... ..................................... ...............................
❑ SOLIDS, TOTAL ..................... ............................... ❑ ................. ............................... , ...........................r...
.❑ SOLIDS. VOLATILE ......................... : ............. :......... ❑ REMARKS:..................................... ...............................
❑ SPECIFIC CONDUCTANCE ......... ............................... O .............................................. .............................., .
❑ SULFATE ............................. ............................... ❑ .................................................... ...............................
❑ SULFIDE ............................. ............................... 7 ................................................... ...................:...........
OSULFITE ................................................... :........ ❑ ................................................. :.................................
❑ SURFACTANTS
❑ TURBIDITY ......................... ............................... ❑ .................................................... ...............................
THESE RESULTS INDICATE THAT THF. WATER WASH• OF A SATISFACTORY SANITARY QUALITY WHEN
THE SAMPLE WAS COLLECTED' QQ
��TyyHHE�ESEpp�REEKSgULTS INDICATE THAT THE WATER DID MEET THE SATISFACTOR HEMICAL QUALITY 01"
FORYP,&STA TEADMINISTRATIVE RULES.& REGULATIONS, D(RINK(,1I/1pN�yIG W fC�RU.IFIARDS S (P FtT 72),
r� //
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OFT HEALTH
3/71 Division of Environmental Health. Se 4cec
COUNTY OFFICE BUILDING • CARMEL, NEW YORK
This report is to be completed by well driller and submitted to County Health Department together with laboratoey re . rt of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance istued.
REVQ€1T - 1��l.11 ,- �BE,�S!!RIVl�TTEQ 1i!I.6TNl l�3( DAYS OF WELL
L "CnlN1PLETIAN.
Yr�
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lk
NAME
ADDRESS
OWNER
LOCATION
No. 8 Street)
(Town)
(Lof Num
. r)
OF WELL
s• %U .I
/.
D BUSINESS
F-1
❑ TEST WELL
PROPOSED
DOMESTIC
ESTABLISHMENT
FARM.
USE ELL OF
PULIC
❑SUPPLY
❑INDUSTRIAL
AIR
❑ CONDITIONING
❑ OP. ER)
4
DRILLING
COMPRESSED
❑
CABLE
❑ PERCUSSION
❑ OTHER
(Specify)
G
EQUIPMENT
ROTARY
.AIR PERCUSSION
LENGTH (feet)
t
DIAMETER (inches) WEIGHT PER FOOT
❑
H A N� —j TF�S-
❑ MYES 06
DETAI S
DETAILS
'� �
� 1
THREADED - WELDED
YES NO .
.
HOURS
GPM.
YIELD (G.P.M.)
F,
YIELD
❑BAILED '.
{OMPRESSED
E:
TEST '.
. -
PUMPED
AIR
WATER
MEASURE FROM LAND SURFACE = STATIC (Specify feet)
DURING YIELD .-TEST feet)
i
Depth of Completed Well !
"
GG
in feet below Land surface. Z ...,
LEVEL
MAKE
LENGTH OPEN TO AQUIFER
(feet)
Fx
L. .
SCREEN
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
Diameter of well including
GRAVEL SIZE (Inches)
FROM fleet)
TO (
t)
-
PACKED:
gr8vel pork (Inches):..... v ......
.:... :::. .......... _ -
DEPTH FROM LAND SURFACE .:
,,..
FORMATION DESCRIPTION
Sketch exact
two permanent
location of well with d /stances, to at least
landmarks............ .... .. .. ....
s
P ?; •_
FEET to FEET
/
�
x
;,.
i♦::
s:
3..
{
r:
if yield was tested of different depths during drilling, list below
FEET
GALLONS PER MINUTE
as`
DATE WELL rO
Pl ED
DATE.OF.REPORT
WEl LER
i natur
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t
lk
V #0.4
C,V L �✓t J �i� 6�
�u�
O�w+ner or Purchaser
or-Building
Section
_ .. -'�ri�i3.din� "C`oYis'YGY•ixii..t`e'ct
., -oc
' by �"° �'
IZ
Location - Street
Lot
OW7
Municipality.
Building Type
Subdivision Name
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 de termin-
ation ..of_..the..Di- r.ec.tor- of the Division. of-En-v:ir:onmental Health- ;S.ervi_c.es
of the Pu£iiam C:ounty'Department of Health` as to whether or not the fail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the syste .Ln.
Dated this l� day of Jd9A-d 19 Signature
6r
Title 0
SAfnt, A9 ABL)LIty-
Corporation 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
s x,0`00 -oo E
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450.04 a
f? REra'G. SJ
1NSTi4LLt D 4 0
/DOO G4L. MASONR % SEPTIC TANK, m
2G0 Lird. FT. @ 29" iP.Cl'ICH
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? SEP T/C S >'s T ?r9
�TOh'N 8USH�LL
?OT 23
SPRov�' BFsooK ; =RO•
?-G':,n/ OF P I �4" Y
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CONSTRUCTION PE
i
L:ocaied ai
Subtlrvision
boner /Address
8uiltl,ng Sype
Numberyof Bedrooms
t ,
� Separate _i5ewe►a`ge� Syste
To be zcgnst►ucted by
water Supply -
Other Requirements
l County b,epartrr a t►of i
! /
at '
.A'PPROVED tFOR.JC014ST.
revocable- „tort Cause or maj
regwres. b; new peFmit
Coate
Rev 9 8 j E
, .
[r/v/�ivn U /k'IC: / /Y //WII / /CIILOI
T FOR SEWAGE DISPOSAL SYSTEM = � � ,�
e La L Lot # /j.�7 Rei
p �i
Fa L Da
�.J ►- I �k�- Lot Ar(eea��
Design Flow
consist of - k�./� ' Gal Septic Tank an
!� i7 z
r 51�
ht $upplY From -
x
ate Supply tg De dolled bye
s * i
k
MS ;,!u s nd aqua wns , 'of the' Putnam
P
L pose
n;• i
n of he building has beeK undertaken and is
h Any eliange or alteration of construction '1
a Title
AL�TH '” Permit #!J
pV
7. _
:Y 1,0512
down o► ,1 lags
_1
us Approval
,. -,1
Mly�❑ --, -
-
e
7/ be
w
v a
,I
4,_ <,, w z F
a
sLem(s) ,1 ^j that `the sppa ►ate;sewaga
disposal system; )
MS ;,!u s nd aqua wns , 'of the' Putnam
P
L pose
n;• i
n of he building has beeK undertaken and is
h Any eliange or alteration of construction '1
a Title
a �
� � Located at>- s
4 n- uodnriswn `
1 } 1 J
Design -3F
Lml to consist:,�of -,_
Piwate
Adores
�.�Other Requirements
k v J s
Y
ay «*
� y .� •iXe t ' r'
qwn or, Vi,llagw af. z s i
f?ls
PUINAM CUON'.l'Y
�. ',.;o.m� ..�. -:y.� ^kk � :T •. tH• � . ,J ., JLC....M�(t '�� V 1, �S'1'(')>'3' �i` i �` �i� �! .C,
r
UI,I''AR'1 W:N`l' Of' 111::A1,TI1
Date
Re : Property of -roMw7 �.. 11b%j
Located at 45VV-oui -�,00� �oA•a
5 Section Block Lot Z
Gentlemen:
This letter is to authorize T. MICHAEL DALY 1
'a duly licensed professional engineer x 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 necesspry papers on my behalf in
corineceiun With this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
tary.Code:
Qn- Law,:the Riblic Health: Las.;- and the Putra�n County Sani-
Very truly yours,
Signed
(Xvner of Property
Counters ned:
Q�. ) YO
Addre ss
48468 72PT�
6�x 243 , Shen=ck, N.Y. 10587 Telephone
Address
914 248 -7494
Telephone
k *rW
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'
BIJ�!l'D1 G, - CirStl2vJ1i1Sj '1�•'.1• -1': ':L1
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner W" o Address I ( �i:;,C_4 te, +
Located at (Street 6TFFE-Te- �I �ou� . Vp�. Block Lot Z 3
nearest cross street)
Municipality Py'ra1�z ._Watershed
. SOIL PERCOLATION TEST..DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number_ C
CLOCK T
TIME P
PERCOLATION P
PERCOLATION
Run a
Start -Stop M
ape e
eeppth to Water W
Water Level
Soil Rate
2 2
2 ►
►-z �S I
I
3 0
0- 2
! 4 -
-
4 5 0
0 z, l
l� (9 1
1 z
z
'7-
3 . xf 2. 2
AD
.._ 16 1i Z
2 y - 7� 2, S9 C) \ 2
3
4 ,o _ 2 7 a`� s 9 + 2
3 5
Nk 41
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.
Address
THIS SPACE FOR USE BY HEALTH DEPARTPCNT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Date
TEST PIT DATA REQUIRED TO-BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH
s,
HOLE NO. j HOLE NO. -Z HOLE NO.
6"
.121
18 n.
24"
30"
�j , ► .
3611
`(
48"
6o"
78"
84"
INDICATE
LEVEL AT WHICH GROUND WATER IS ENCOUNTERED o
INDICATE
LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY �,� Date 1 l '
'
Soil Rate
Used �Mi 1 "Drop: S.D. Usable Area .Provided o -man (A
No. of Bedrooms Septic ''Tank Capacity 1000 Gals.,..° Type `.. p' gy
Absorption Area Provided b'j � 1
By 5 L. F. x24 width trench.
_Z
��
Address
THIS SPACE FOR USE BY HEALTH DEPARTPCNT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Date