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03799
1
Owner or Purc a�ser o Bing
Building Constructed by
, mil, PT os- ,4 " " ",
Locat //ion -'Street
Building Type
Muni cipality
Block
Lot
GUARANTY 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 guaranty to the owner, his succes-
sors, 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 sNrstem, 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-
termination of the Director of the Division of Environmental Health Ser-
_-vic_es :of_ the Putnam County Department o ^f Health as ._to whether or not the
failure of the system to operate 'was caused by the'willful,,o.r negligent
act of the occupant of the building utilizing t
Dated this day of �, 7pj 19 j Signa
_ z
Title
'd .� -
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP-7,ETION 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
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
.. , ,_•, COUNTY OFFICE BUILDING - CARMEL NEW YORK
This report is to be completed by well driller and submitted to County Health Department together with laboratory report
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
D
Ah A R-
ADDRESS
D P U
),.-
LOCATION
OF WELL
(, 5 C
(No. 6 Street
i kR "- i>
(Town)
(Lot Number)
PROPOSED
USE OF
WELL
V
DOMESTIC
PUBLIC
❑ SUPPLY
BUSINESS
❑ ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
AIR
❑ CONDITIONING
❑ TEST WELL
OTHER
❑ (Specify)
DRILLING
EQUIPMENT
® ROTARY
COMPRESSED
❑ AIR PERCUSSION
((—��� CABLE
El PERCUSSION -
OTHER
❑ (Specify)
CASING
DETAILS
LENGTH (feet)
), �
DIAMETER (inches)
WEIGHT PER FOOT
/ L5
I
THREADED ❑ WELDED
I
DRI
E SHOE
YES ❑ NO
j�jS CASING ZR U D7
IJ YES 1_ 1 NO
YIELD
TEST
❑ BAILED
HOURS
❑ PUMPED COMPRESSED AIR
G.P.M.
?,,j'�
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST fleet)
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 pack (Inches):
GRAVEL SIZE (inches)
FROM (feet)
TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
4
I
1) U
P6 ty,
a
( I
I
j) � 1 v l� Vy `'
;
( o
'
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
36
3 G F Al
3 a -- 7&6_
_ G F A4
DATE WELL COMPLETED
D ATE OF REPORT
T WELL DRILLER (Signature) Caw
PEEKSKIL;L MEDICAL 1ABORATORY
1879 Ceomoond Rd. �Bdrelay.Plazs Bldr. A "Aot. I
A PER (Agar plate count at 3S C).
COLIFOAM (Most Ie Na /100m1)
D TOTAL ppm
�ACTERI
5
less t h ari ;�2 0 2
r '
Y
DETERGENTS -ppm
NITRATES (as N) - ppm
IRON, TOTAL ppm
d.
m
rPUTNAM COUNTY DEPARTIIIENT =OF, HEALTH
zt �.
Division. of Envir onmenfal Health Services, t^armel iV Y 10512
E
,CONSTRUC,TION PE,RMIT'FOR - -SE , tE - ISPOSA +L, SYSTEM AY •,. , 11 V
r Town or iflege
Located at t fit} A, ii✓if►I k''�AF# BIOCk °
�i '' t
Subdivision} k�lti 1 ®,f`s�4 Z .. Lot; Y ! Job
k
'Owner `�At- D�/y/� l 1� Address I9 LJti1/'I11�
i
Building:.TYPe.�- S'/ -aJj ,Lot Area CJ4�i.�� y✓/��,�:j..
Number ;of Bedrooms Total Habitable Space 'u
are Feet,
r y
Separate: Sewerage System to cohsist of ' ' ®• Gal Septic Tank /_ lineal feetX width trench _- 1
r ,
tt
To be, eonstructed by Ad?lress
Water Supply Public Supply From
ivate. SuPPIy,'to be drilled by
address
Other Requirements n ` r 3} i
I represent that am wholly anticompletely
resPqnSiD i ion tohe proposed'system(s); 1) that the separate sewage'disposal',system '+
ebove;described: will be' constructed as shown on the'a. a e, and maccordance with_#he stan'dirds,`rules an, regu a ions;o, e u nam'
County;- Department ' of' 'Health and that on comp a..C_. ' Construction Cot►ipiiance'` satisfaet -&y to the grnmissionei of Healfh will
e,-'submitted' tothe Department; and a wntten owner his'succeisors,'heirsor assigns by.the:builaer;'that',said builder will -
place `in. good -operating condition' any .part of;; a is st "g the'peria_'d of two "(2j years �mmediatety following thedate'of the isst; "
ante` of the approval_ of...the'Certificate :of Con on the al system.or. any repairs thereto, 2) that the drilled well described above
will be located as shown on the approved lan and a itl`
P ; e� fil+ led cordance with the stand' ds, rules and regulations f the Putnam
County .Department of Health �t Q�tia t h;
T
Datepc
, 'P E � R A.
. '
Address
APPROVED FOR CONSTRUCTION This approval ex y�nro date issued unless construction of •the builCing has been : undertaken and is
`- revocable for cause or4may'be' amended ormodified when.c nary by_the 'Commissioner of 'Flealth Arty'change.,or , alteration•.of construction
requires a new 'permit .Approved for disposal of domestic samte sewage and /or private water_wpply. only
oil . l ?.�
Date BY L S! Title
In
Date.:
4bM9107
Insp. by:-jx
Tl
,CT&PE
INIT-DI'll SIB' 1 13 CTT0jj r No
Yrup,E.,rty lines or corners found. 0 0
A
Can - e s t i ma' e nog location
Wi I ]-driveway ne--d cut • a '0 a 0 a 0 0
Must 'trees be removed-note thbse
Is d,--,ep hole representative of entire SDS area
Additional d---D holes needed . . . . . . . .
Sufficient L'-SM area avcail'able 6onsidering
d.r.iveway cut, house location, sepa.ratior_
distances, etc. • • 0 0
.DEEP HOLE. DATA .' ... ...
Dap c.
Water elevation:
...Rock elevation:
Soils descriT-)tion:4;'/14,
Lkaze:
rmiu 3iT.P, INSPECTION Insp. by:
,Hous-- loccated where shown on approved plan, •
ST)B loc;r?.ted vlhere a-hnrov-a vi • • . . . • .
7-
V1 th of trench avero ge
S-1 o,pe of the line and trench acceptable
Room allowed for expansion trenches
Carer -50--fft. from swarnp.,:7..Ta-�-,!-7'vcou-,-:�e
-6]- -It5il� 1hoff Sty -i,
.pped or .,-.:,a
unnecessarily graded 0 • • • a 0
a. fro-r,-, prop-line. and
.10 Ft. maint ine-1
20 ft.. from house
S -pa -ion o-" -f---nch f--om house well
ralu I Ul
etc. follows plan .
Number 'Der of bedrooms checks
one s rubble etc..&eater
St s...bru h., sttmts.
om nearest trench
tb-an 15 ft. tr
.15 Ft. of peripheral. soil horizontally from
t-re.nlch
Junction boxes prcpe--,--,-I-y set
Could surface ruh off from driveway, 'roads.,
ground surface, etc. channel -near SDS
area • • • 0 • ...
Does 2.ot drainage appear O.K. ii area of SDS
FINAI C-RADT G OF SITE ACCEPMME,
REVID4 CHECK_ SHUT
Meets Std . ( Remarks
I
es ; No
DOCUMENTS
1... .. r ♦ - _ yam. � - - _. _ ....j. s -. . .. - •* and �Se.a - 1. �� _.
House plans O.K.
Design data Sheet !
Peres presoaked? i
Kin. 30" perc test depth I
Con.st. results for 3 runs
D. Hole log O.K.
Corporate Affidavit for other than individual
Authorization _ for er gineer I
Letter from Water Supply if applicable
If variance requested -such noted on plans & apps.
✓ j
SEPARATION DISC ANC,ES SPECIE= ON PLAN
10' to P. L.
20' to Foundation walls
00' to Nearest well !
50' to stream, march, lake, etc. incl.expansion .
15' to Curtain drain i __
10' to water line (pits -20' ) +
15' to storm drain !
10' to large trees !
10' from foundation to septic tank I
5' to pipe from leader drain & footing drain
DE'PA.ILS
f change is proposedExisting
contours shown new contours)
Rhow
Slopes for driveway cuts, etc. shown
✓
1 a A
Water service line location
Footing.drain, etc. location
I
!
Top slope, bottom-.slope of fill
!
!
Ab A
Percolation tests and deep test p1_t location
Septic tank size and conformance to std..
3 B. R. house minimum
i ✓
I
House setback shown
I
l'j 1 t. i � • I i . I , ._ '1. .. - n.!_.�_ i `'i ri i T .4 .L
' �
1
H11 -%Jd, G(✓x' W! L ILLil :)lJ i 1� . U.L J.-_U 81iowli
1 ✓ j
Plan and profile SDS
✓
All other wells and SD5 closer 200'
,/
I
shown or reference made
1:
Property boundaries (metes and bounds - clearly
shoes
i
.
i
i
�
SEPARATION DISC ANC,ES SPECIE= ON PLAN
10' to P. L.
20' to Foundation walls
00' to Nearest well !
50' to stream, march, lake, etc. incl.expansion .
15' to Curtain drain i __
10' to water line (pits -20' ) +
15' to storm drain !
10' to large trees !
10' from foundation to septic tank I
5' to pipe from leader drain & footing drain
FUTNAM, COUNTY DEPARUMEN9.' OF HEALTH
:DIVISION OF EN:VIRONMP�ITAL_ t {E?1'L5'H;
Date 11-11-73
Re : Property of .
" Located ati�! Awr.✓ -� �A� 4.:+�
S n Block 3 Lot
Gentlemen:
This letter is to authorize cf: STM
a duly licensed professional engineer° or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system; to
cserve 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
l: ViltiC�.: L_LUJI W! LIL L11J_: 111d Li Lfel' IkAIIkA W.'UEJef'Vi_Se Lllk' C OJIS LI'LIC"L3.011 0 7a_LU
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the.. Public Health.:Law, and the Putnam County :Sani- -
tart' Code.
Very truly yours,
Signed j 'al 1
- Owner v ope ty
4't j4A
Mddras-z
P.E., Imo, #
..�; 411 4 5
phone
ss STANLEY I LAN ®0R
BOX 267
. U 0
Telephone
R -`
, - PUTNAM .CO, TY .._ ..... .....
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner &"A11.DAM, fZ 3'6 Address
Located at (Street o c , 4LA 46 Block '� Lot _
�Indiyxgte nearestcross street)
Municipalit Z Watershed , r,�icc Ge,d L ow
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Depth to Water Water ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
2 IZ- o q i 4' �LZ
3 Z "a 18 lam? -'Ir 8 'S o
30 .0-9
4
2
3
W
Notes: 1) Tuts 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.
TEST PIT DATA REWIRED TO BE SUBMITTED WITH APPLICATION.:—_
OF 'SOILS
DEPTH HOLE NO, _Pi HOLE NO. R - HOLE NO.
G. L.
611 7R_,4Ce
0 f. tee, ��ee
121t
30t'
3611
42
48
5411
6011
66
7211
84 't
-7
E'_ I '-'P -TTD I ENCOUNTERED IAk VA-
1111DICA.11 Z EL AT G ZOU WATER-*
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
-TESTS MADE BY
ZeMAQe1Z- Da te
DESIGN
Soil Rate Used__45' Min/1"Drop: S.D. Usable Area Provided__3 J�v
No. of Bedrooms-;' Septic . Tank Capacity V-0 Gals. Type
Absorption Area Reovided Byf:3,L L.F. x2411 7 3b" width tren2c.
Other
Address
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved Sq. Ft/
by
Date
I