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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512
CERTIFICATE OF. CO.NST.RUCTION.. .COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM—_. 1�J�y,})/e��'�/ Via'
-7 . .c - "T.. .rte >" 'i •' Kea r�r.r.v T owri is
t�
Located at �/ft1� T"
Owner O� O� "/¢� 45i�` 5.s4y'r1r. _Ze d Lot 01C Jeb Z-1e �
Separate Sewerage System bt by - ��/ " 9 ` Address
Consisting of uilQQ Gal. Septic Tank and��Y
Other requirements /����➢ �
Water Supply:
Public Supply From
61 Private Supply Drilled By
Address
Building Type � gt; Zk_
Has Erosion Control Been Completed? Yf=
No. of Bedrooms -? Pate Permit Issued
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 regulations, plans filed, and the permit Issued by the JPutnam County Department of Health.
c .�R.A.
Date ����� Certified by P.E
Address . License No'.
ell
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 water supply shall become nd void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of theComnjissioner of Health, such_gvocation, modification or change is necessary.
Date
�Jq PUTNAM COUNTY DEPARTMENT OF HEALTH
- ..,Division. of Environmental Health Services,. Carmel; "N..._Y.,.1.0512 :.
" CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Town or Village
Located at -T LF a a'�Iic, ra -- J"Z c
Subdiv � Z 0!
Owner isio 5C' r
Building Type T'f� =° Lot Area `r r
Number of Bedrooms _.3__ Design Flow, 246 L
Separate Sewerage System to consist of r� Gal. Septic Tank
To be constructed by l ga.+^�'.+v"
Water Supply: public Supply From
2Private Supply to be drilled by
Address
Other Requirements
Tax /Map f� ® /B'llo�ck
Lot 10. 277CA) � Y / �€14('��.j A b
Address 1I.' 11613
Total Habitabl Space /" "� Square Feet
and 3 L y 2 tho Asiv I
Address j's�. o;
I represent that I am wholly and completely responsible for the design and location of the probo'sed syste ; 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance wit a standards, rules an regulations o e Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Co lance" satisfactory to the Commissioner of Healthwill
be submitted to the. Department, and a written guarantee will be furnished the owner, his suc ssors, heirs or assigns by the builder, that said builder will
place in good operating condition any part of said sewage disposal system during the periodrof two (2) years immediately following thedate of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be Installed in accor,(lance with the standar$�, rules and regulations of the Putnam
County Department of Health. p �1 / .,I %'/ ®Q t /
Date — Signed 0014 P.E. R.A.
Address � Alc=u I License No.
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless nstruction of 't building has been undertaken and 'is
revocable for cause or may be amended or modified when conside �ita ece ry by the Commissi r of Health. Any change or alteration of construction
requires a new permit. Approved for disposal of domestic sa s age, an ri to r-s I on
BREWSTER LABORATORIES
Box 224 ' BREWSTER, N. Y.
WATER ANALYSIS REPORT
SAMPLE NO. 4 0 9 9
SOURCE: Koschack Construction
Dosoris Lane
Putnam Valley, N.Y.
COLLECTED: August 3, 1978
BY:A. Koschack
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
well
Block 3
Lot 3
Sec Tm 66
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory. sanitary quality when th.4 sample was collected.
August 4, 1978
ti
Roy Bickwit, P. E.
Director
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
t COUNTY.OFFICE• BUILDING_- •.CARWE,.NEW YORK
��t.,_..._; _ ..�._ .....: c7_ �'�••..,,,;.. ��._. __�,... — _,..�... ..... __; ..� .•,� ��..- -...� �... c ,., � 4.rsi,.. 4 _.� ..
This report is to 6e corrip`ieted by we driller anti submitted to`COUnty Health Department together with laboratory report of
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
AL .KOSCHACK
ADDRESS
BOX 163E MAXOPAC a N.Y.
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
DESORIS LANE PUTH M VALLEY 3 '
PROPOSED
USE OF
WELL
BUSINESS
® DOMESTIC ❑ ESTABLISHMENT ❑ .FARM ❑ TEST WELL
❑ OTHER
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Spefy)
DRILLING
EQUIPMENT
® COMPRESSED ❑ CABLE ❑ OTHER
ROTARY AIR PERCUSSION PERCUSSION (Specify)
CASING
DETAILS
LENGTH (feet)
Z1®
DIAMETER (inches)
6t1
WEIGHT PER FOOT
17#
® THREADED ❑ WELDED
DRIVE SHOE
L rYES FIND
�G
YES
D?
NO
YIELD
TEST
HOURS G.P.M.
1:1 BAILED ❑ PUMPED FJ COMPRESSED AIR 6 3
YIELD (
(G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC (Speclfy feet)
251
DURING YIELD TEST feet)
j
465
Depth of Completed Well
in feet below Land surface: 465
SCREEN
DETAILS
MAKE
>=sa assz >s�svaatrstas�---- �— ssarsssass�
LENGTH OPEN TO AQUIFER (feet)
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
0
10
CLAY,
WELL IS EXPOSED 18If ABOVE GRADE.
10
21
DARK GREY GRANITE.
21
465
DARK GREY GRANITE WITH SOME
QUARTZ®
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPIETE7
DATE OF REPORT
WELL DRILLER (Signature) /�
• • p
NT
Owner or Purchaser of Building Municipality
4� S C Nog C /<�" C_ c-;, A-IS %' / /Ise C
Building Constructed by
C7 29cf>ei_!9 2- o9AJ�`
Location - Street
CdL(=> V / f
Building Type
Section
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 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 -.
_.�T e "s of thw .. �rt'ri m CoL�r±y.. -,fie Ear. tment` o =HeaI Gh��as 50 whet -h or..no_t , t -he .
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the syst
Dated this _ day of 19 !A C 19-7? Signature
Title Ko S c t-F c/C c o,V ,S?-
If corporation, give name
and address)
c>,x I b hir?N®PPG I-Ac-
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP.TTETION 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
111SV1.1'.:7 lil!!S'l .�CIISIS
a. moots St Remarks
E;S WO
DOOMIGET ITS "N
House plans 0. K.
Dasi.cn data sh °et
Peres presoak. -d19 �
Min., 3011 perc test depth
Cont. results for 3 runs I
D. Hole log 0. K. I
Corporate Affidavit for other than individual
Authorization for engineer A I
Intter from Water Supply if' applicable A) If vari.anc° requested -such noised on plans & apps.
D TjjTLS
if change is proposed,}
Exist- i ng contours shown show new contours) i
Slop --s for driveway cuts, etc. shovin I I
eater service line location
F'ootirZ, drain, etc. location I I
Pop slop.-, bottom slope of fill ; A) I i
Percolation tests and deep test pit location
Deptic rani: size and conformance• to std. _ I
5 B.R. house minimum
-louse setback, shown I
t u v ater wiT mm "u I L "o1• FL shown -J -�- - -- - -� ► i t
Plan and profile SDS I ,�
All other
-.� sue-... s l • w.rel e :fs and e�SrDS c c t•. o ....s,.:.. :e a
r _ 2..�0
..0,.. '
�
� y
4-1 - T a
Property boundaries (metes and bounds- clearly sho
.,_. _. r... .. .at
E ARr'1 OT i DISTANCES SPECIFIED ONT PLAN
DI to P. L.
D to Foundation walls i I
D' to Nearest well
D' to stream, march, lake, etc. jincl .expansion ) I i
5' to Curtain drain 1 rJ • I AW
to water lire (pits -20' ) I
5' to storm drain I
to large trees ! C
)' from foundation to septic tank ! i
5' to pipe from leader drain & fom ng drain
J.
�d PUTNAM COUNTY DEPARTMENT OF'HEALTH
DIVISION OF ENVIROAIMENTAL HEALTH SERVICES
.Date ,.. � 6ZZ ;Z
Re z Property of
Located at Q Solels L>l/1J�
Section i L'!U. A9 Block Lot
Gentlemen:
This letter is to authorize
..a duly
licensed professional engineer v 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 pro-
visions of Article 145 or 147, Education Law, the Public Health Law,. and the
Putnam County Sanitary Code.
Countersigned:
P.E., ; # 0
eol - # 7 (0 4)
Address
.._+
M.4 /V
Telephone
Very.truly yours,
Signe
Owne of Property-
Address
61 241
Telephone
w
j�uE SOUTF{
w
o
cX sio"
N
,, ` • Z 9 /.00'
waLL
I
5
D
vSO.P /s' Li9N67
THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM
WAS COiNSTIWTED AS INDICATED ON THIS PLAN AND THAT
�If/4r oNs,
3
v,4TE- .7ttJL;" 31, 1,978
Of NEW
y NPrl F.
l�FF Hv. 042gA� r,�•
"ROFESSlo
THE SYSTEM WAS I <dSPI:CTED BY ME BEFORE IT WAS COVER-
ED OVER THE S7-77-7.11 CHAS CONSTRUCTED IN ACCORDANCE
WITH ALL TEE i;UT:1a AND REGULATIONS OF THE. PUTiNAM
COUNTY DEF.&RTINENT OF HEALTH. /.
cp
PR t. "i"�.t'!_ "D Fog •.
C OA.'..ST. -TIT C
%owt1 of f u7-N,4AI t1ALLC:r
Pri7- A"I 1 00 uivry /v V.
t
P/t o FESS /O Nf3C C 'UF /' c 1/ [�..lN[a S %�i7 ✓. Yo•1 S
C'ON C O/Z b ieO�L�
APP R \/ED
/�ljc i aasi,Q'
DIVISON
HFALTH
27.0
v,4TE- .7ttJL;" 31, 1,978
Of NEW
y NPrl F.
l�FF Hv. 042gA� r,�•
"ROFESSlo
THE SYSTEM WAS I <dSPI:CTED BY ME BEFORE IT WAS COVER-
ED OVER THE S7-77-7.11 CHAS CONSTRUCTED IN ACCORDANCE
WITH ALL TEE i;UT:1a AND REGULATIONS OF THE. PUTiNAM
COUNTY DEF.&RTINENT OF HEALTH. /.
cp
PR t. "i"�.t'!_ "D Fog •.
C OA.'..ST. -TIT C
%owt1 of f u7-N,4AI t1ALLC:r
Pri7- A"I 1 00 uivry /v V.
t
P/t o FESS /O Nf3C C 'UF /' c 1/ [�..lN[a S %�i7 ✓. Yo•1 S
C'ON C O/Z b ieO�L�
APP R \/ED
/�ljc i aasi,Q'
DIVISON
HFALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES .
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner 0 Address Yox 16 -1 A# s
Ilf� i C,_
Located" at ( Street) .D p ZA Sec. Bloc -I- Lot /oV ifr -o,cJ c►Vr47 -J
( MJ1cate ne— a`rs� cross street)
Municipality P4J Ay,+ UC- Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Depth to Water 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
1 11 ,/1 /4-1 3o 2d- �? :z
46 30 C5?
5
3 a; �- �,
�)0�s
6i
2 r� 53; �S 3c� 3 �s/ �� l 0
5
Notes: 1) Tuts 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.
DEPTH
6"
12't
1811
2411
301 1
3611
42"
4811
54"
6011
66"
7211
7811
8411
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO.
HOLE NO. HOLE NO.
a
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED 4/0
INDICATE LEVEL TO VBICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY wit-Low F- 2:a-aeg Date
....... DESIGN,
,Soil Rate Use JL :r /111 Drop: S.D. Usable Area Provided
.No. of Bedrooms -3 Septic Tank Capacity Gals. Type
11 Vj
Absorption Area �Provided By 32S _16t,__ width idth trenc
Other
bignature
Address &--n -7 e0A)LIZ) SEAL
a4M.PW 0- A) Z& 524.
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
A.
Soil Rate Approved Sq. Ft/Gal. Checked by ter`
V N�� i ;''.gat � t \m� # `v
(Ona
JUN 2 9 1977
PUTNAM COUNTY
I,DEPT. OF HEALTR
SDA
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