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83.16 -1 -6
BOX 30
-9 NqNNm
9 IN 1161
I IN
,� 16 - �
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PEEKSK'ILL MEDICAL LASBORATORY 3 x '� `'
�-`-`'
µb r P- a: , a ¢ 3
1879: C, o- Rd Maple Terrace Bldg ",A-" 3
f -6nd
,. .»
Peekskill New York.t fr R t 87,t
..APE
lys .:a -}.
z
z
DnTt COLLECTED
RESULTS OF EXAMINATION OF WATER
fr,
t
34 3 7,3 -' l
(owrrER w {
N
EI
D EC VED
WS,
A 4
CITY VILLAGE TOWN & /OR NAME �G- SUPPLY`S sk g r
DATE REPORTED
RD3 PITTNAM VAI,LE
SAMPLING POINT; r x _p�xtiP
` LOT-`
#5 tTPPSALA DR F?UTNAM VALLEK ,r
�" - - - t-
BACT+ERIA PER ML (Agar plate countat 35° ') s
_
COLIFORM�GRQUP(MostpiobableNo /I.00mI) A'a
RESIDUAL CHLORINE AS RECORDED AT
r _
ItESS_ THAN . ?
S A
MPLING POINT 3 POINT,OF ;TREATMENT]
n a z
CHLORIDES(CI) mg /1
NITRATES (as N) mg /l ; a
x
;q�>
,°
-
FLOURIDE
t
}
y
; A:""'.n CF
,� 3.}t E.an4
These resu lts >Sdicate that the waterfwas S of q'sah�fdctorg sanitary..,quahty,wlien the sample was collected
'i4 �3v` zn 'yK •y.wt aH fi„ § "4 s. sA 'Sr.. :i n1l
�� 7 . .q >i,r .s-.3' ,•' -fir.`
m
_7MI, DR III I'LS LOG.. AIIMP,�or�T�-
ame" Q,,r vlac a,,�ty, Village O�own
Owner P.O. Address
Depth of wcll_ZLS:, Diam_et_er W as - 77 fr 7 1 Fs I n-Te-c-t-e-d-
Z_ _Z�2_.
ft. in. gpm yes or no
Amt. of casing above ground Ar Below ,.•round c;20 W,,.11 seal
in ft packerj cement, grout
Draw a diagram in the space provided below and show -'Q-he depth of
iczsing, the wcll s,: al. kind and thickness of form4ions -lenetrated, water
.Ibearinj3 formations, diameter of drill holes with dotted lines and
.casing(s) with solid lined. ,
T-.,' D REPL�.:
FORKaTIUNS PEII_-_'TIZA
eter, in. Depth
,Di= L.1 d, thickness and Type of well
in ft. if wat--,r bearing drilling mithod,,, � .
Grade Was well dynamited7
':TS
25 PUMPING 713
50
75
571"w a sketch of the property
on the back of this sheet locatiog
22'.1 SJVIAGE DISPOSAL SYS-.�.!_IZ
Details ,
eater
16vel I in ft.
raze
MU
rumping level in
ft.. below .:trade
Duration of
test in hrs.
VMM.11 AT END OF Ii) T
Clear,,---- Cloudy ;.P
_-urbid
Recommended depth of pump in
well, feet b,.-.low --rade
W,:ILS' IN ---)AT-TD & GRi V
Sand Eff. sizo mm I
o
UnAd.eftefsize
Length of screen ft.
Diam. of screen
Type of screen
Screen GpeninRs x
Drilling start,--,d C�;mplet:--d,
Well Driller
a
I
Building Type
iLnV-3.cipa1 ty
10
Block i
6
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 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-
termination of the Director of the Division of Environmental Health Ser-
vices of the Putnam County Department of Health as to whether or not the
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system.
Dated this Al day of d,c,j4 19 ;13 Signatulqp
Title:
Ii' corporat on, give name
and addre s
A ,,��'
- - - - - -
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP,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
Owner or
Purchaser of
Building
Building
ConrstructE
by
Location
- Street
_ _RP-51 nei A
� fi' 1 !Al' ,
Building Type
iLnV-3.cipa1 ty
10
Block i
6
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 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-
termination of the Director of the Division of Environmental Health Ser-
vices of the Putnam County Department of Health as to whether or not the
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system.
Dated this Al day of d,c,j4 19 ;13 Signatulqp
Title:
Ii' corporat on, give name
and addre s
A ,,��'
- - - - - -
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP,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
° PUTNAM COUNT
5 M1�
Division of Envionmen
CONSTRUCTION PERMIT_- POR.,SEWAGE .;DISPOSAL S.
-Subdivision
Owner Dt's� eG r-? lfff - -�"/"C
Building_Type 'Lot 'A' rea
Numtier.:of Bedrooms fl�
�Separate5ewerage .System_• to consist of ��°
To be constructed by
� � I
Y DEPAR';CMENT OF HEALTH
ia/ Heal h Services Carmel , N. Y f0
YSTEM,'
a r K
7_7 ;,!/ � F
S*+r*r�
" 0
Lot
' Adtlress
n v•
h
Total Habitable Space
;,Gal Septic'7ank `' � �'� li�h(�ea /t
4ddrn5c
Town .or'. Village %-
Job
S4uare' Feet
k
feet X� fy f —.width: ;trench i
Water SupplY public Supply From s v
Private Supply to be drilled by.
-'Address t! '/►%A1` L Q6 r i x
Other 'Requ(rements
O • ..r..
1`represent that I `am wholly and completely''res a tl6 ation of,;the proposed ;ystem(s) 1) that :the separate sewage; disposal system
above described" will be constructed:as shown•or to and in accordance,witti i".iiandardr, rules an regu{a "ions of � e Putnam f
County, ,Department of. Health, ,and MO..,o'" a : "C, r of Constructi*on CompUanee" satisfactory to the Commissioner of•Healthw,ll" , f
ale submitted to the- 'Depa`rtment, and, a'w 1 ',g -a. urn the owner his`wccessors, heirs or assigns'bY "trie.builder the i said builder will.''.
place m ;good operating .condition any par $� `id sy e - wring' t period of two (2) years immediately. following,the'date of the issu-
ance..of the °approval- of' ,the - Certificate of on ruct o t ` -rigin s,��'stem.orany repairs thereto 2j} -that the drilled'weli described above . -
will be located as shown on the approved pla n ,at; in` in_a fdance .with the standar rules and "'regulate —ons of- -the Putnam
County Department of Health ,' < O
- I N
Date '7,
' 01Z R A
I C, Address License No�^�
'APPROVED FO -"6N;' This,approvai expires one year -from t�e date issued unl s co✓ ruction of the';building has been undertaken and is
revocable for ,cause or may be,amended or- modeileti when con sidered, necessary. by the Commi goner- "Health. .Any'ctiange 'or alteraf�on' of, construction "
( 7egwres °:a -now -permit. ,Approved for di osal of - domestic wage' 'and, pr, te`; ate
BY `Title 1
PUTNAM COUNTY DEPARTMENT OF HEALTH
D?�IISJODI. :..OF - T1R01�?MENTALR HEALTH..SERVCES----
Date
Re:. Property of 13A? v.z;,c .a+Z- 6�2
Located at J r
sic ill -Block G) 1 Loto
Gentlemen:
This letter • s ette is to authorize STAND
a duly licensed professional engineer or. registered architect
(IndicaTe j--
to apply for a Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the 'standards, rules
i
.or regulations as promulgated by.the Commissioner of the Putnam County
.. Tllk- .. 1........ -4- 1P TT-- -1 4-1, ' �.to -I l r.r. -c—s— r��'r�crs — mcr
1Japarl�la1G11U Vl 11QCL-L U11, CL11U. UV. 5J-�11 a, 11. it�.w JJCbt Jr �JQ.!/V -U vii uiJ V\./LJCJ,11 111
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 Lsw, and the Putnam County Sani-
tary Code.
/Z4,G
Countersigned:
P,E., 7
STANLFY g p ( Seal )
address �VA Z01
245 -
elep one
Very truly yours,
Signed
ner of Prdperty
AdUress /
L_46�
Teieptione
PUTNA -N CO --'*:\'.-iv J �� =`•'� OP
.< - ..-: bc< ..G.- a.c- -+r•t.::: ;.•.•ll`l°1 ?7`'( "iC `1-= `s \�'',Ir'. �.!Ti y� t.T ,P.cti.c.<
DESIG\ DST`. S SS_ SLP. ?A T- Er SE ;'ACE JIS_ ,SQL S. °STS._ FILE 2.0.
C`•' 1 ° -7' �m ��en���eRU�.ys Addr -2`3.
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TEST PIT DATA RE0UI -,D ;0 I=, S,;0`iITTED ::I T.W, APPLIC`.TIO\
DESCRIPTiO�i 0 SOILS = \TERD I` =ST. HOLES
DEPTH HOLE `0: L HOLE \0. p y HOLE NO.
G.L.
611 047
1.2 N E,
is r y
241.
3 0' JA
36"
41'
49
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66"
S
1� t
I \DICATE LLEVEL AT [,,'HTC:r GTIRMU D t %'ATER IS EtiCOU \TDP.E= � (i�•�� /�
i\DICaTE L'; "t _EI, TO t,;HICH r 1TE: LEVEL RT_ =S AFTER BET \G E \COU. TER D
TESTS t_AD •i. Jr 4i��J /��- Date �v %
Soil-. R=ye �'se / .Iz,�1.. DNV�li�� -:� S.D. L's ole �re� rio.�ce
IN o. oI B : 'JC-- — S-'a ic T- -k C, - - r 2c�0 Gs. Z `�, -
A sorptio n ea: Pro:ided B} tre..cn Omer_
Address ~Bs.� L
0
0.3
PUTtia'I COi \I'y DEPaRi``L, \T GF HE "LTH
uiumi22. aJ i
t, he g
as av
r
. uniform_ SIZE
shall be 7z?
J r .
3as.inVert,
�M .. bottom of tt
Al X ? gravel sha.l
J m, mairiMum. T1
used wherev,
i..D ' °� ;c_:. +;4. c t c .� a .'efJv e` ,... -e:.. .Et7;.'Sf.O$r�.»+�r r- e.-W.•. :r,�
x.45 /dam J.�Q y ! fi , :ana' of tf,
t
Ore £3'
d stribfitiol
s . � � � see Cou��ty
' a 7. Run.of.,}fit
y.
�. ,� ` ^� s.I• � r p.8ee fit ". lei
•Installing
skiall have.,+
than 2:5 ga:
- pIt
i 8 All "'
thereof"
9.. During., a-.
heaey 15eds
t rrx 1'a ' ead.er
- .
s ch
5"� { 31 'rJelle161
C "ertifaate
�> will be;issi
s 1
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V!SION 0f
t - ENVIROtIMENTAL HEALTH SERVICES