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00039
' PUTNAM COUNTY`"DEPARTMENT OF HEALTH
_
Dlvis/on of Enl!ironmenal . Hea /th Services Carmel -N. Y. 10512 5
„'CERTIFICATE, OF CONSTRUCTION FOR DISPOSAL SYSTEM
CONIPLIACE SEWAGE
_.
TovJn or Village
Located at /^�+YJOniI/ /�Gf Se. i on
lock �
;
Pe/" i
°S O
Owner -4r"°. Lot _,
Job
Separate sewerage System built by — Address
�j��y�r-
Consisting Gal: Septic Tank I�neal Feet :X
` yt
width
_of
O `
.Other requirements"
Water Supply Public Supply From
rivate Supply Drilled BY
Address. v
Build�n9yTYPe �C1'2Ts% P No. of - Bedrooms ;Date Permit Issued
-
Ho'.. Erosion Control Been Completed
I certify, that the'system(s), as listed servmgaheEabove premises were constructed essentially as'shown on'the plans of
the completetl work (copies of which are
:attached] and "in'.accordance with the standards rules and';regulafions plans filed and the< permit issued by ; t
nam County epartment of Health.
K
Date / % 5 CertifyeA by �-' •
—�—
P E -R A
x
- �' - Address � � -
License No Ile
'Any'-person occupying premiiiis served by the above systern(s) shall promptly take such acUci as maybe necessary
t_6 secure the correction of any unsanitary:'-
,:.
conditions resulting_ from such 'usage. `Approval of the sepa "r_ate 'sewerage system 'shall become null and;voitl as
soon as `a public - sanitary, sewer becomes }
- available and the'approval of .the; private. water- supply shall become null,and void When .-a public water. supply becomes available. Such approvals are;
subject mo'dif. ication'or change When, .m tib,'Judgmen$, of tfi commis'sioner 4f Health; such `revocation; modKicati.on or?- change,is necessary
Date / gy / � d �jl� -�
�. YTitle
BREWSTER LABORATORIES
Box 424 - BREWSTER, N.Y. .,
WATER ANALYSIS REPORT
SAMPLE NO. 2914
SOURCE: Stuart Keebl er faucet •+ well supply
Harmony Road
Piz t t ersonp New York
COLLECTED: March 31 p 1973
BY: Frank Aautilia
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method Q per 100 ml.
This result
indicates the
source of
the tamplr was
of tatisfaetory sanitary
l
quality when
the sample
was eolleetrd.
April 7p 1973
RoY Ackwit P. E.
�j
y
/7
' WELL COMPLETION REPORT - PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environn)ertial,44alth 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 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
,•M
"•`
NAME
ADDRESS
-iii OWNER
Stuart Kee ler
Harmon j Rd. Pattersmn N.Y.
. LOCATION
(No. a Street) (Town) (Lot Number)
• OF WELL
TTarmony d Patterson N.Y.
� ❑ ❑ ❑
PROPOSED
DOMESTIC ESTABLISHMENT FARM. TEST WELL
USE OF
WELL
PUBLIC AIR (S(Specify)
❑ ❑
SUPP Y INDUSTRIAL ❑ CONDITIONING ❑
?x DRILLING
'
j �,� COMPRESSED CABLE OTHER
❑ ❑ ❑
_ EQUIPMENT
L1 ROTARY AIR PERCUSSION PERCUSSION (Specify)
"
s t .CASING
DETAILS
LENGTH (loaf)
DIAMETER(InchesJ
WEIGHT PER FOOT
THREADED El WELDED
SHOE
YES ❑ NO
C`)C3TFT
YES
NO
6
l •
YIELD
HOURS G.P.M.
❑
YIELD (G.P.M.)
TEST
BAILED ❑ PUMPED COMPRESSED AIR 8 8
ate.
WATER
MEASURE FROM LAND SURFACE —STATIC (Specllyleet)
DURING YIELD TEST fleet)
Depth of Completed Well
LEVEL
in feet below land surface:
MAKE
LENGTH OPE9 TO AQUIFER (feet)
, I
!` SCREEN
.
DETAILS
SLOT SIZE
DIAMETER (Inches)
GRAVEL SIZE (Inches) FROM (lest) TO (leap
IF GRAVEL
Diameter of well including
r
PACKED:
gravel pack (inches):
T DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of wall with distances, to at least
^ FEET to FEET
two permanent landmarks.
-
a '4 0
10r
Loam.sand, r:f
_
ny 10•`
326
lRock,limegitone,quartz avid
��-
stone
zri
44 "'
2
.. i.'
i
c
'i'Lk.i�
<If yield was tested at different depths during drilling, list below'
- '. ...
FEET GALLONS PER MINUTE
P� r
r
1
_
fYkt t e
�x r ;
OATE WCLL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
x
_b
Owner' or . Purchaser of building
i
Building Constructed by
�7a'rvr� o rw fwd.
Location - Strut
Building Type
Municipality -
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.,'8'hown on
the approved plan or approved amendment thereto, and in accordance with tNe`Istandards,
rules and regulations of the Putnam County Department of Health, and hereby guaranty
to the owner, his successors, 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 occupant of the building utilizing
fihe system.
The undersigned further agrees to accept as conclusive the determination
of the Director of the Division of Environmental Health Services 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 / �� day of 19 Signature
Title
(if corporation, give name and 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.Serviees, Putnam County Department of Health
3 �. .
/ S
Otaner` or Purchaser of building
Alegi � Zen ; &,r-
Building Constructed by
Location - Stree
G�'�C• L r- �'SG7f�
Municipality
Section
Block
1•`.
Building Type 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 thestandards,
rules and regulations of the Putnam County Department of Health, and hereby`.guaranty
to the owner, his successors, 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 occupant of the building utilizing
the system
The undersigned further agrees to accept as conclusive the determination
of the Director of the Division of Environmental Health_ Services 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 tl-iis /9 -a of � 19� Signature
Title
(if corporation, give name and 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 OY FIRST USE OF SYSTEM.
------------------------------------------------------------ ,---------- - - - - -- -
..Division of Environmental Heaith_Services, Putnam County Department of.Health
PUTNAM COUNTY DEPARTMENT OF HEALTH s
r3
Diwsion of Enwronmenfa/ Hea /ih Services 6rrhW N Y 1Q512 K
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM -
Town or- ,V�Ilage, ,
Located at �%_�7oAi., Section Block
Subdivision
Owner ,�� Address ct°�)'/ iE /¢ric9 3
Building TYPer>'P Lot Area
y"
Number- of Bedrooms' t
Habitable Space Square Feet n
separate. Sewerage System':_to consist of"� Gal Septic Tank` "Lc�CJ lineal` feet sX� width trehch
So be constructetl` Y-1
Address _
G
Water.SuPPIY =Public S U P' PIy From _
/- 2 s
Private pply .to be drilled by'.
Su T
Address_ b _
x;
04her F%egUlrement5 ,C /j1°�d+ r %� d p wee z ``
r
I represent, that I am 'wholly and completely responsible for the design a'nd location of. the proposed systems) ._1) ff7a the separate sewage tlisposal system
abo%e'described w,ill.be'cokdructed`as shown on the'approved amendment there to and -in, accordance with thestondards'rules-an -. regu a ions o e ..0 nam,
County Department of ,Health and that'on completion thereof a "Certificate of Construction Compliance satisfacto(y to the :Commissioner of:Health'will
be submitted to the Department and a w'tten guarantee :will be'_furnished the owner, his successors heirs;or ai6i6A,by tfteWgwlder, that said'builder' will J
. place in, good operating conddron'any partr of said sewage" disposal. system d ' t ing ahe.period'of two (2) years Jmriiedlately foilowlng •tt edate of the issu
;,ance.'of'.the approval ,of the Certificate ?0`bonstlluctio6 Compliance_.of' the orig�n5l system `or any - repairs thereto `-2) -that ffidid filled well described- above-
- will be located as,ghown on,the approved plan and th$t said well will be`tnstalled in accordance wifh the: Y Bards rules_ and regula i� ons oof the 'Putnam. -
tCounty ,Department of Health.--,.-, _ K
late Signed —
P:E IR A
Address 3
tiROVED FOR CONSTRUCTION This a roval_:ex ' '
pp Aires one year from Elie date issued unless con ;truction_:of the''bu�lding "has ;been undertaken -'and is*
able for cause'or may be amended ,or'modKied `when considered necessary by the Commissioner' ,of Health: Any change or alteration of ,construction
, pproved for dis� I of dB mastic sandary sews LLe, and/or pnvate water su l only _
s a -new,-permit ' A p P y
��'�iz— _Cs► Tale /� f
FU T NA'- I C CT T Y
DIVIS-Ow v= LNIVIP.
G E. DT
DESIGN: D.:'� S H E T Si 2 A R-A T Er F i LTE c;0
AO
L4 Jq_
A�29
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