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HomeMy WebLinkAbout4616DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.09 -1 -1 BOX 35 04616 PUTNAM . COUNTY DEPARTMENT OF .HEALTH r �( Division of Environmental Health Services, Carmel, N. Y. 10512 CONSTRUCTION PERMIT F-OW SEWAGE DISPOSAL SYSTEM-­' ry j`e t1A �i down or Villllaggee �— ' - - • ociif+ad�at - - _•�,!- �.P:_.�� C =f yc_. �. :: ,� .. � :�. :cam. � :: Block - :�•B - - �- r. -=-<.= . Subdivision Lot - / �Q Job Owner � ➢I.i.i��t �/ d e i.ie Address ! -04 5 t✓ fl«L /4 A+A_ t L)N "5� 11/��� , 4 4- Building Type L;t Dry' &- Lot Area " Number of Bedrooms Total Habitable Space ���^ �_ Jp� Square Feet Separate Sewerage System to consist of s� Gal. Septic Tank lineal feet X width trench To be constructed by t*► , / � �) ' t r ' Address —r c, To ('1111; w S'0AJ Water Supply: Public Supply From Private Supply t be drilled by Address Other Requirements I represent that I am wholly and completely responsible above described will be constructed as shown on the apps County Department of Health, and that on complet be submitted to the Department, and.a written gu place in good operating condition any part of - I ance •of. the approval of the Certificate of Con str ft will be located as shown on the approved plan and t sl County Department of Health. Date j 2.j6 Address APPROVED FOR CONSTRUCTION: This approval revocable for . se or may be amended or modified requires a ne er t. Approved for disposal of Date �. By of the proposed system(s); 1) that the separate sewage disposal system d in accordance with the standards, rules an regulations o e: ' . u nam nstru'tion Compliance" satisfactory to the Commissioner of Healthwill Wh r, his successors, hetrs or assigns by the builder, that said builder will period of two (2) ars Immediately following the date of. the issu- ystem or any repairs thereto; 2)'that the drilled well described above dance wi3f� the shards, rules and re aTfTons of the Putnam ✓Y'.1/ P.E. Lf R.A. l J License No. 32,2 7n i unless construction of the building has been undertaken, and is er Health. Any change or alteration of construction rat at Pply only.. `- Title Ti , . PUTNA COUNTY DEPARTMENT OF HEALTH M Division of Environmental ;Health Services, Carmel, N. Y. 10512 permit _ �cari °cireTF riF'° i SfTfiUCrtl "�tii �MP�LIaNC� FOR " SEWAGE- IDIS06SAL�SYS'iI�MM>`: > =- Al ;p ' (�Q d Owner IN v -- '----- Separate Sewerage System built by by� e ui Consisting of Gal. Septic Tank and Other requirements Water Supply: __7 Public Supply From Private Supply Dr"o Building Type Has Erosion Control Been Completed? Town, or Village �- Tax Map Block Tax Hap Lqk A 16 1 d a -A SUW. Lot tl aP — _ n No, of Bedrooms Date Permit Issued— A I certify that the system(s) as listed serving the above premises were construct the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulati filed plan, and the permit issued by the Putnam County Department Of Health. Date "/ ` " ertifla by y �� P.E. R,A. AddressS, 1 �ICSnlo No. i Any person occupying premises served by the above system(s) shall promptly take top as may be nocw secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage system 119 ' me n as a public sanitary lower becomes available and the approval of the private water supply shall become null and void wh a, becomes available. Such approvals are subject to modification or change when, In the Judgment of t e mmissioner of H h,, t modification or change fnoly, Date f 8Y _T d Public Health Director Alan Sammitt 95.Barger St. Putnam Valley NY 10579 Dear Mr. Sammitt: L0RET7A. ,KQL-LNAR1 RN.,. M.S.N. associate Public Health - Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 September 14, 1999 Re: Addition- Sammitt - Barger St. No Increases in Number of Bedrooms (T) Putnam Valley Tax # 85.09 -1 -1 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated September 14, 1999 The addition is approved with the following conditions: 1. 2. 3. The total number of bedrooms must remain at h ee without prior approval by this Department. The area of the existing sewage disposal system, and its expansion area, must be .maintained. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets,.etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you have any questions, please contact me at your convenience. ML:kg cc:BI Very truly yours, Michael Luke Public Health Technician a / -�. `�Q.w:':._ ........ A. s- .,;+. mss•. -� -;, ;.::�.::'.., BRUCE R. FOLEY . W •g+b -d ic, . • 'e. ; rRiiblie Btrictcir DEPART N ENT OF B EALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278 - 6130 Fax (914) 278 - 7921 PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY) STR]EFT �U r� e f S ti TOWN �u'T Vu l l'c TX MAP #. NAME.RL_fAr4 JArrn,, A rE. —P1 wr,. -2v S�S�P('Nl) # a('77 - l MAILING ADDRES S '� C, r �� P_ r fT 0 -Fn m V/1- l ` r'a� All. ` X DESCRIPTION OF ADDITION -;c NUMBER OF EXISTING BEIDROOMS3 PROPOSED # OF BEIDROOMS3 (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) *Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. e- Aibn�is i folio. .c- Phihor Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00 �. 2. Sketches of existing floor plan (drawn to scale, all living area including abasement) # Non - professional sketches are acceptable J 3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) * Non- professional sketches are acceptable � 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. f Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE Comments Feb 98 Yutnam County oivieion of Environmental Health' 00#1 i b �A % i lj .DA T h a XT • . � rn`rrl � ;• i:i,nfux•mni�ua n,1 ' r approve au .. p). cabl,c J'1: I :, .1•at :unw oft the...- - - L'owili`1[ 1 ,'•irk- .:tilaSiC= i gn�i;uro tt10 ,. �a�e ♦ a c T' i , 0046 c� fle Ids ikS6 I�- i •' ��' 'c /Jill, j��� II 4 Leo -a ' Y• fnr C� ENCE Cti , O r±`T V • .rG�iS' Si s ti 41 o Of Piny f� � r � E • '• J. i o ! �C�n•�4C 'f�\ I4 LN ��Cwr �u �C hn6l �s ; nF o Kul - �' :.::... _ .... , b u 1 O V1 h. - F�� ru*a on a .CI.44"S 7(o Wit.. TWC. - . 6 544XGP. ,plWMA� 6YSTEM AYoUT. JOEL LAWRENCE GREENBERG �1 DATE ARCHITECT - TOWN PLANNER - .1 .M - G� YUPCOOT MOUTH AFDOL5011 481 �� _ I, Yobopae, Mow V*Fk 10641 A G 5: S' 1 T P- E" a - -- r(� (914) 426 #GIi FCC -UI Yn� v "11 1�•. A. -ol �51�0 3 �d'• �� fig'- 8 approve au .. p). cabl,c J'1: I :, .1•at :unw oft the...- - - L'owili`1[ 1 ,'•irk- .:tilaSiC= i gn�i;uro tt10 ,. �a�e ♦ a c T' i , 0046 c� fle Ids ikS6 I�- i •' ��' 'c /Jill, j��� II 4 Leo -a ' Y• fnr C� ENCE Cti , O r±`T V • .rG�iS' Si s ti 41 o Of Piny f� � r � E • '• J. i o ! �C�n•�4C 'f�\ I4 LN ��Cwr �u �C hn6l �s ; nF o Kul - �' :.::... _ .... , b u 1 O V1 h. - F�� ru*a on a .CI.44"S 7(o Wit.. TWC. - . 6 544XGP. ,plWMA� 6YSTEM AYoUT. JOEL LAWRENCE GREENBERG �1 DATE ARCHITECT - TOWN PLANNER - .1 .M - G� YUPCOOT MOUTH AFDOL5011 481 �� _ I, Yobopae, Mow V*Fk 10641 A G 5: S' 1 T P- E" a - -- r(� (914) 426 #GIi FCC -UI Yn� v "11 1�•. 09/67/1999 14:07 9145262130 TOWN OF PV 09-.9,7-1999 0I:43FM FROM FOUR SEASONS WESTCHESTER TO 01 526200 P.02 DEPARTMENT OF HEALTH Division .01 ln4owental Health serAC00 4 CunavS Road, brawstv, NGw York 10509 1 (914) 278-GUO Putnam County Dept. of Health 4 Nova Road 8gowwr. NY 10509 Tax Map Town CiNdlemen: DAM M VOLK A.& LAW"D Publig.R664h GW@clar According to records rnainlaiatd by the TmNm, the sbove noted ftdling in compliance Nylth Town code and the total number of bedroom$ on T@Qord This inforingion has been obtain'ed ftom- CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: OTHFIR VrAi , 049 PAGE �VOAAIW- TOTAL P.02 J. 4. PEPARThWff OF HEALTH Divhkn of EninkmmosaW "Orr &1`146lk QrwW, AL Y. 10612 CERTIFIXATE OF C-MNWRUCTIOM COMPUANCE FOR SEWAGE DISPOUL SYSIEVA & -- Virl-* J. , Town or VWANp TU Owner Separate s sysern bulk by Canwalft of I 'Iftj 9 $*Due Tank and Other rewwaments WMw Supply, public supply pr=n Prbaw Supply Driq" ey 9VlldhV TMe St f o. n of aftwooms Mal Wxo"n Ca!r&�*l Oft" COnmtsd? r MWVIXW the Above 0 SJUM*wd), acocc&a0m wi :00"ftuct." f' t— C—ty Dail-twent of NO&Lth. f th@ XUIGR as¢ rsjWLatZa� . is oats 14 ewtlfMd by f rz, AdWen Awy pwmn Occupy". "of Ur"s by an above iffyd"ll Shall PromptPY . 911110 MCI% 0000tions reaultwe -. *14prpAch Usapa; Aagrwml of the "Wate WwWa" WOM 11"flable &W the a , . . PINFOVal- Of the prfwto water al WANOd to Modtfloatim 4W:Vh&n" w 8UPPRY $hall become null an . voo wftw a In the Wd""Mf Of tr MMISUdbanwr of moe su CA 44 CMIS X44 saw. "IL V Cau PWMR ism" F0.4 at the at,gleo.a Mck Cowles am the parwit Uwasi %W the Ipwit "nawy Maw. Ma'a SWOU101% Such avjl�=, tari a or Ch"" Is " , 1, - TKID pal ut CS) LD CS) -4 LD LID LD I.- CS) -i LD Ut -1 0 9 -U -U I> M ,J) S' iY a is . ; I - is ! 11 1 1. I. 1. P P TN CO NTY DEP TM NT 0 HEA 7N 0 o OUSMPLA 3 A PRO ED F R EDR.,,M OUN' ON S(1} m R Olms P silliatd ei & I itle 15 CIS P TN CO NTY DEP TM NT 0 HEA 7N o OUSMPLA 3 A PRO ED F R EDR.,,M OUN' ON S(1} m R Olms silliatd ei & I itle 15 CIS PUTNAM COUNTY DEPARTMENT OF HEALTH _a DIVISION OF ENVIRONMENTAL HEALTH SERVICES -:: ,i ... ✓: �.a •-•'. •.e :4.. .. y ._" ', r >.. .. R' \5 ... � ... .. .i:.. -:.4.t .iW x.1 a .. •i. M. ?-' .a( -' �..= : r .: =� -.": .' r — � � —•. Date Re: Property of Located at (T) P tmu"' W Subdivision of Subdv. Lot # of Filed Map # 9 Date t0 _jf�! Gentlemen: , This letter is to authorize i�/► 1� Len a duly licensed professional engineer 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 s} 3tefii ''sya� enls : in conFormi y �rrtYr i e° p v s ors c� A tia. -e 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned: R.A. # 02", -11 Very truly yours, Signed Owner tof �op�erty 'rte V • Y - i III I. �j Address bf—"V" uaUe" V'(A d dr e s s v2^ ✓ DTI own Tele hone Telephone PUTNAM COl NTY DIFP1R'i, "fNT or 1117Aull • DTVTST0N OF. FNVTF0N, *- ;\TAT, IIFALTII SF'R%I[CrS .. .�, - -�. .. - ��- •�'- - ~`°�- ` Date Re • Property of r• Located . a t •4k'G� f4 Uy'��,�j Ml.y.� G'�AL.G -Ei Se Block Lot Gentlemen: This letter is to authorize ` STANLEY J. LANDER -- a duly licensed professional engineer 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. Co tersigned Very truly Vours, Signed��� 1 Owner o operty 3o 43 Vii c A lye ,�3,;�D,� �/� 10033 Address P.E. 32,711D _e hone Address COO ate .rcrleo ®. BOX, 267 MIAWA , W. , Y. 10501 J Telephone 0 1 A L F) D 17 " P", CT* 1'. 6 1 J 1-1,11T. T JI j A 1'. 11-jup. by: found -,aii esti,-rat: !io,-,.,;c location . 0 0 0 0 0 a 0 a 0 I.L11. drivoi..,ay nz,.:cd cut . 0 r 0 0 a 0 0 0 a 0 0 0 f;u-,,,t trees be mmove-d-note those 0 0 0. 0 0 0 a -,(.,,,--en,'U-a'L,.ive- of entirc s deep liolo rrr).,. SDS area ,Cklition,al de CT) liolcs modod. 0 0 0 0 0 0 kiff.icicnt SDS arca avail ablc considerin," driveway cut, house; location.separapion distances, etc. ITT 110M, 12P-,PA Bopth: I-later elovation: Rock elevation: D Soils descri-ption: IRA L, SITE ITISPECTION Insp. bv: ruse located i-.-,here shown on approved: plan DS) loc-ated'where ap prov,",d Lope Of ti le 1 ir-,6 'and* urencli acceptable )om allowed for expansion trenches, lor 50 ft. fmm s-wai,,m,1-.,a'L1ercourse a 0 a itural soil not stripp--d or SDS area Unnecessarily graded a 0 0 0 .0 a 0 0 Ft, m-aintalr.ed .frorq prop .line and - a a a 0 0 0 ,paration of tr.-Inch from house, well etc.. follo-%.rs plan . . . . 0 .. . . . . 0 . 0 a 0 uiib.-Ir of bedrooms checks 0 0 a 0 0 6 d ,ones, brush., stumps, rubble., etc. greater than 15 ft. from nearest trench a 0 0 • Pt. of peripheral soil. hori L 14. from la�.L i- Zj UCZ,-L.L trench o o. o a o e a o 0-0 0 0 0 notion boxes properly set uld surface run off from driveway, roads, ground surRice., etc. ch-amnel near SDS area 0 0 0 0 "o 0 G 0 0 16t drai'nac-,-. app-car O.R. K in area of SDS KAL GRADIRG OF SITE ACCEPTABLE Y(-,.,3 Comtmont,t 7.- REVIE[•1 CIILCK S - T House plans O.K. Design data sheet ! Peres presoaked? i Kin., 30" perc test depth Cont. results for 3 runs I D. Hole log 0. K. i Corporate Affidavit for.other than individual i Authorization for engineer ! Letter from .Mater Supply if applicable If variance requested -such noted on plans .& apps._ Teets Std. rem —No DE, TAII,S Rhow f charge is proposed,) Existing contours shown new contours). Slopes for driv.-way cuts, etc. shown Water service line location Footing. drain, etc. location I Top slope, bottom slope of fill. Percolation tests and deep test pit location Septic tank size and conformance to std. - -- 3 R.R. house minim-Lin .House setback shown t I 1 l • l n1. .. .1 frost iii 8t r11- T•.i. c,-,-j 1.1v:�. ! K. � �c .i_ l7vJ ! All wa i ei• w i i, a:itj. 50 1' L . ui:. PE Ouuwli Plan and profile_- $W... _ .................:_: y: - -- -Ala- of eiv°wells, arid'::BLS c1o`ser 200' j shown or reference made I Property boundaries (metes and bounds - clearly shown SEPARATION DISTANCES SPECIFIED ON PIX 10' to P. L. 20' to Foundation ;,calls 00' to Nearest well 50' to stream, march, lake, etc.7 15' to Curtain drain 10' to water line (pits -20' 15t. to storm drain 10' to large trees 10' from foundation to septic tank 5' to pipe from leader drain & fc v �„ ll � i I .expansion)-: ! i Remarks Owner or Purchaser o Bui ing Municipality W 4Z M CtRGL t o � Bu ldine /C Cons t to b Section � Lim N Locatio - Street UZ PUKAJIL4 Building Type 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- - =e a�cy=epam e-0 •tYP Dr i n o s- o= -wrhF Y 0n� >0r- e= failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the syste r Dated this 30day of �1 G� -���,y 19 Signature k&Z Title and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLLETION 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 ` _ .. 3. R:..a.. ^e!- -• .I ....T.,.� - - n, rota. _ „t ,. YJIELL COMPLETION R60 ,11 T ! . ! '' ""' .: PUTNAM: COON Y `b&fflRTMENT OF HEALTH , 3171 Divlsioll ,vttdP""Wriol' Nalth Swvices COUNTY OFFICE'6UILOING - CARMEL, NEW YORK : This . report is to be completed by well driller and submitted to County Health Department together with .laboratory report of bnaly:;i3 of Vaatet ssliiple ind'ICatr°eg.yvatar is of sa'tis?aciory; bacterial pc:ality,before certificate of construction compliance is issued. . FREPVRT MUST BE SUBMITTED WITHIN 30 DAYS OF 'WELL COMPLETION OWNER NAM j ADDRESS LOCATION (No:.6 Street) " (Town) (Lot Numl»r) of WELL �% :: �.. n ` C� Cl PROPOSED x `' Dd STIC ESTABLISHMENT FARM TEST WELL, USE Of WELL [I ❑ AIR CONDITIONING 11 (Specify) ' SUPP Y INDUSTRIAL' DRILLING COMPRESSED a CABLE HER PERCUSSION D ` EQUIPMENT TARP AIR PERCUSSION (tprdfr).; CASING . LENGTH (feet) �.: DIAMETER(Incoes) / // WEIGHT PER FOOT © , ' 'YES NO DETAILS .. (r i THREADED ; WELDED YES NO YIELD HOURS' ; P.M a ❑ COMPRESSED AIR '.. YIELD (G.P.M.) TEST RAILED PUMPED ¢ : WATER MEASURE FROM LAND SURF ACE— STA.TIC(t3peclfy.feet) :., .. DURING.YIELD TEST (feet) Deh of:Cotnpksled We". . below IEYEI in feet MAKE LENQTp.OPEN TO AQUIFER (I"k .. SCREEN DETAILS SLOT SIZE DIAMETER (Inches) :. IF GRAVEL Diametir of. well including• . GRAVEL (h. al: M " , O (feet) '. PACKED r .gravel pack (inches): OE►T11 FROM LAND SURFACE Sketch exact loaaflae of well w1tA dlitinQie, to i1 leaf FEET ro FEET FORMATION DESCRIPTION - two perma"nf )andmatfa:: . If yield was tested at dlffennl depth+ during drilling, list below FEET GALLONS PER MINUTE . DATE .W11. COMPLETED GATE OF REPORT WELL DRILLE R (Sig ttlls) Nrx ;Zi (ORK'OWN MEDICAL LABORATORY INC PA Box 99 321 near Street LOCATIONS: ,� 321 KEAR ST., YORKTODUN HEIGHTS, N.Y, 10598 245 -3203 Yorktown Heights, N.Y. 1�59� ❑ 201 BUTTONWOOQ AVE., PEEKSKILL, N.Y, 10566 737.8777 2�5'32Q3 ❑ 495 MAIN ST., MT. KISCO, N.Y. 10549 666 -3335 0 STON_ELE10H AVE. (NEAR HOSPITAL), CARMEL. N..Y...10512 278.933W LAB # 10778 DATE TAKEN: 2 (9: 3 0 —, DATE RECEIVED:? 2 ((12: 5 r ? 2 WILLIAM O'CONNELL DATE REPORTEDKITCHEN TAP: SAMPLE SOURCE: BARGER STREET REFERRED BY: CROSSROADS PHARMACY L -j W. O' CONNELL COLLECTED. BY: LABORATORY REPORT mg /L 212 -364 -5274 ❑ ACIDITY .................. ..............`` ❑ ALKALINITY ....... ...................... 0 BACTERIA, TOTAL /mL ........ .. ................. �l:j.. ............. ❑ BOD, 5 DAY ................... ............................... // ❑ BROMIDE ................... ............................... ❑ CARBON DIOXIDE, FREE .............................. ❑ CHLORIDE ................... ............................... ❑ CHLORINE ................... ............................... ❑ COD .........:................. ............................... ❑ COLOR ....................................................... ❑ CYANIDE ................... ............................... ❑ DETERGENT, ANIONIC ... ............................... ❑ FLUORIDE ................... ............................... ❑ HARDNESS ................................... ................. ❑ MPN COLIFORM COUNT/ 100 ml ...................... jo MFT COLIFORM COUNT/ 100 ml ...Z) ........... ❑ CONFIRMATORY TEST ... ............................... . ❑.NITROGEN, AMMONIA ... ............................... ❑'NITROGEN; KJELd`AHL. ...:...: .: .::::......:.... ❑ NITROGEN, NITRATE ... ............................... ❑ NITROGEN, ORGANIC ... ............................... ❑ ODOR ....................... ............................... ❑ OIL & GREASE ............... ..........................:...: ❑ PH ........................... ............................... ❑ PHENOL ....................... ............................... ❑ PHOSPHATE (ortho) ....... ............................... ❑ PHOSPHATE (condensed) ... ............................... OPHOSPHATE (total) ....... ............................... ❑ SOLIDS, SETTLEABLE, ml /L .......................... ❑ SOLIDS, SUSPENDED :.......................... ❑ SOLIDS, DISSOLVED ... ............................... ❑ SOLIDS, TOTAL ..... ; ..................................... ❑ SOLIDS, VOLATILE ....... ............................... ❑ SPECIFIC CONDUCTANCE .............................. ❑ SULFATE ................... ............................... ❑ SULFIDE .................... ............................... ❑ SULFITE .................... ............................... OSURFACTANTS ............ ............................... ❑ TURBIDITY ................ ............................... ❑ ALUMINUM ................................ ............................... ❑ ANTIMONY ................................ ............................... ❑ ARSENIC .................................... ............................... ❑ BARIUM ....................................... ............................... ❑ BERYLLIUM ................................ ............................... ❑ BISMUTH .................................... ............................... ❑ BORON ........................................ ............................... OCADMIUM .................................... ............................... ❑ CALCIUM .................................... ............................... ❑ CHROMIUM (tot.) ............................ ............................... ❑ CHROMIUM (heuavalent) ..................................... :............. ❑ COBALT .................................... ............................... ❑ COPPER .................................... ............................... ❑ COLD ........................................ ............................... ❑ IRON ........................................ ............................... ❑ LEAD ........................................ ............................... ❑ LITHIUM .................................... ............................... ❑ MAGNESIUM ................................ ............................... ❑,MANGANESE .....:....... ::. .............................. ....... ❑ MERCURY .................................... ............................... ❑ NICKEL' ........................................ ............................... ❑ PALLADIUM ................................ ............................... ❑ POTASSIUM ................................ ............................... ORHODIUM .................................... ............................... ❑ SELENIUM .................................... ............................... ❑ SILICON .................................... ............................... OSILVER ........................................ . ............................... ❑ SODIUM ........................................ ............................... OTIN ............................................ ............................... ❑ ZINC ............................................ ............................... ❑ .................................................... ............................... O.................................................... ............................... 0 REMARKS: : ................................................................... ❑ .................................................... ............................... ❑ .. ............................................. ...................................... ❑ .................................................... ............................... O. ................................:............. ............................... ❑ .................................................... ............................... ❑ .............. ............ ............................... _._ .......... THESE RESULTS INDICATE THAT THE WATER WAG444 OF A SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED. THESE RESULTS INDICATE THAT THE WATER DID _ MEET THE SATISFACTORY CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE RULES & REGULATIONS, ,DRI,NKKING WATER STANDARDS (PART 72) FOR THE PARAMETERS TESTED. ALBERT H; PADOVANI MJ (ASCP), DIRECTOR.' �� 7AKK- Putnam County Department of heaitb X T J1 koproved fcr conformance wit the. ap t 00 Signature tl a Rte 1-07 flq Ids IkSW 40 - L% Tf W Z" I STY FR N6 c:TS lz N $4, 4,;. H O 5F- /rWn 0110 0 OP/,Olvl 4zn d FLW, ruf iwUn Cv -a v-�s Otuv IKA I kke Xv - .7 6EWAGt PISFMAL 6YSTEM LAIIMT JOEL LAWRENCE GREENBERG ARCHITECT -TOWN PLANNER PATe $49 WUSCOOT NORTH RFD#2,lox 488 wahopec, '.Now York 1054 (914) 62& row PUTNAM COUNTY DEPARTMENT OF HEALTH z DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFOILMATION Name of Project �% i�Gie 5 (T)(V) TMg Year of Construction Size of Parcel SECTION B.' TOPOGRAPHY (Please check all appropriate boxes) 1. Of/my ❑Rolling . ❑Steep Slope entle Slope ❑Flat 2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water ❑Drainage ditches LYRock outcrop S NO 3.. Property lines evident? U - .. _.. .� .. �...... -• 4. Water courses exist on, or adjacent to ro parcel: .. _. . _ � � ..: . ..�.• �=j ".�'.:� ..�...�. _•.. _...._.. _ _ p 5. Existing g individual wells within 200ft of the existin„ SSTS? O SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. []Level 13/Gentle Slope []Steep slope B. ❑ Well drained oderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited ❑Somewhat limited Adequate ft x ft . C D. INS .ECTION No eridence of failure m J 7C _� .. x .. ..i? aiii .: ... :Y ^' n- .r x �pp.x .. v.. ...v. a .. �. -- ... xJ . .. - .. !� • - . Date Inspector DEvidence of failure []Evidence of seasonal failure ----------------------------------------------------------------------------- - - - - -- --- - - - - -- (Indicate North) � y �(1 HOUSE J / ( �i`S (:17-� - (1) Indicate location of SSTS A. Size and type of septic tank gallons 111etdl OConcrete OPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate seibacks,'front street, backyard; and-side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams/wetlands) 1. SECTION E. EXISTING WATER SUPPLY 1JPWS 0Shared well CONi QvI.ENTS : REPAIRS ONLY: As Built Inspection Required: Status: 9-Indi well 0 rille ODuc*r As Built Submitted: As Built Inspection Done: I Inspector: Otasing above ground Ir ♦r r. <Y� C,A1 -e. .4-.0 F. 30 y 7-45�1-1^1 CF /�?,; r tfX)GCG 4 6C 963 -a338 vaych ,4R elz 13, 1976 ,*,L&Z.3z Q7 /V 6l 05= Ao 011 90. OC7 / AP