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HomeMy WebLinkAbout0064DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.15 -1 -17 BOX 1 111111104tv ,� , ' ■ 1 I Ir J■■1 , , ' ■, 1 16 L L6111 1 1 , 1 o oom 111111104tv G BACTERIOLOGY PARSITOkOGY VIROLOGY ANTi'sloncusED es SOURCE OF MATERIAL „❑x MtL' W Ri -er ❑ Blood ❑ SAA €AR CULTURE R, u ❑Sputum b E❑ Routifie'1CjYJilII�E'W YOrI� ❑Nose T B x ❑Throat � ; ❑ Diphtheria `{ � � - � 3 � , ❑ p�na u�d `r❑ fungus /1.Ej f 7 I Ot " ` U" �l `-' PUTNAM DIAGNOSTIC LABORATOKIEU Q Ova an Parasites a, ,,��,_. r7l D_ x p. Yiral Studies 10 STONELEIGH AVENUE CARIVIELh fil Y r SENS. RES 5Ty yn` a ❑ "SENSITIVITY STAPHLOCOCCUS s «K p Aerobaeter O w Chloramphen�col, _, "_„ ❑.Non Hemo Coag ;To FolloMC 3❑p Cq"j,_aeterium Cohsfin Sulphate 4 ❑ .Hemolytic Coag To follow ❑ Escherich�a " Declomyc�n , , ,, `„ ,- ❑ Coa [ Klebsiella Dihydrostreptomyc�n r_- ❑ fix ' ,Negative � `. [7 Paracolo Bact : AM _ rythromyun „ € S, REPTOGOCGUS; HE, OLYTIC Proteus � ° x' F �� `'Neomycin ❑ A Phi Q Beta Cl Gamma "Psedomonas s ",Nitrofuianto�n _. _ _,__ x ❑ Enterocoeeu's Entenc' Pathogens Oxacillin ❑ Pneumgooccus a ®Found Panalba ❑ Neissena ❑Not Found .F�- Tetracycline,„ TU,BEItCUL0515 SMEAR TUBERCULOSIS CULTURE ;; naeetylo eandomynn � ❑Acid Fast; Not Found ❑Neg -;For Aci ": Fast Ampicillin `' p Ae�d,rFasf: found. El R y a ✓� ❑t Smears `;Routine Neg _ ,� __ �, ❑ Cu tares - , „ ,� p O &`P ostwe: For 1 A0 \.;1C -1 OEM BA vII,L7 kCI1fi atBWI7:.1' �5`Ii G1 UALrI Y.. , tuner or I1�rc'�a::ci of builda.119 l�uildilig Constructed by See tion Locat on - rcet Block Building Type Lot GUARANTY OF SEPARATE S0,7AGE SYSTEM I represent that I am %•:holly and completely responsible for the location, %workmanship, material, construction and,drainage of the se%,;age 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 x,ules 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 . lti:. f!"Il:SOL) I) -V 'l: t-1'( -? W_1.1.1 the vc i'nn1 The undersigned further agrees to accept as conclusive the determi,ation 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 o the ccupant f the bu' din-- utili ing the system,. , Bated this v day of �' 19 Signature jf r�� Title D. (if corpora ion, give, name and addres ______ ____ - - -___ ___ __ ________ _ __ THREE (3) COPIES ARE REQUIRED WIT }I THREE '(3) COPIES OF FINAL PLANS BEFORE CERTIFI.CATF OF COMPLETION WILL BE IS-SUED. GUARANTOR IS RF.O_UIRED T0! FILE NOTICE OF DATEiFOF FIRST USE OF SYSTEM. Division of Environmental health Services,/Pitnam County Department of Health ' ^ ~ WELL COMPLETION REPORT . _NAM COUNTY DEPARTMENT OF HEALTH 3/71 � oiwmo" of cnwmnmwnm| noo/H` Services couwTv opp|Cc nu|Lo|ws 'cAnmeL,.wswYonK This repo.rt is be completed by well driller and submitted no County Health Department together with laboratory report of analysis uf Water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. � . OWNER ADDRESS LOCATION (No. & Street) (Town) (Lot Number) PROPOSED USE OF WELL BUSINESS 015OMESTIC 6/ 11 ESTABLISHMENT FARM L_tJ TEST WELL PUBLIC AIR OTHER SUPPLY El INDUSTRIAL CONDITIONING (Specify) DRILLING COMPRESSED CABLE OTHER CASING DETAILS LENGTH (feet) DIAMETER (inches) WEIGHT PER FOOT El—TAREADED 1:1 WELDED 'ESHOE n_Y1ES 1:1 NO WAS CASING GROUTED? El YES t< YIELD TEST BAILED 1:1 PUMPED El—t6MPRESSED AIR WATER LEVEL MEASURE FROM LAND SURFACE—STATIC Specilyfeet) DURING YIELD TEST ffeet) Depth of Completed Well in feet below Land surface; SCREEN MAKE LENGTH OPEN iO AQUSFER fleet) DETAILS SLOT SIZE DIAMEYER (Inches) IF GRAVEL PACKED: Diameter of wc gravel pock (in AYEL SIZE (inches) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION h location of wall with distances, to at least 1SWk0e t Pc a r axnencet n I I a n d m a rks. FEET to FEET 4 If y ield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE, OF REPORT WELL DRILLER (Signature) APPROVEO I jl!L 12 1974 CUUN L HL LIP .......... 10 "NMMTAL HEAL Li '0' PC issle4� 16 z Lo<ATIOt (tq. T. � ) \Too 64LLor .<-- . bL-PTIC TA4� FD %3E5 11 L .13 zi a4. 44 upLit4<s eon PT PATTE �or� PdTr4t� �.-( 6C .0 34 �o 47 tool T4 `) b-( 5TE- NI STPOeTL-r) AS PE-P PLA�5 A tJ D p 0 -S A M � Ty 1 L rD E- Sjk c-,b L 6T 0 Er C5 E- %3E5 11 L upLit4<s eon PT PATTE �or� PdTr4t� �.-( 6C .0 ,T:PUTNAM COUNTY DEPARTMEN "OF HEALTH J Division of Enwronmental Health Sei0ces, Carme% N Y 10512 ` I CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Tj'�jQO/tJ f :K 1 x " Town .or .Village, Located at"C Sec ion - - t B lock Subdivision - s5 _ r ;- Lot Jo :Owner 'ti�OL. r/10,/OdsTR %E.S _ lam :9 ^^zz Address e Building .Type ' x _ .r ,a -_ ��� ro,x • ' a5p+n ,. Number of Bedrooms " total Habitable Space Square Feet Separate, Sewerage System to consist of �d Gales ,Septic Tank /49 t lineal feet X ..widthf_trench >; �� /J To be constructed byO� Address 'Water SUPPIY 'Pnvate Supply `to be drilled by �O �� 14P, .22F - F a ' Qther Requirement � 1= represent that 144 wholly and completely responsible for the design and location of ,the proposed system(s)' ,1) that ahe separate sewage disposal 'system ! ffi above descr�bed,.will be coonstructed as shown op,the,�ap °proved` amendment-there to andsin accordance witii thes'tandards, rules an- -raga a ions -o - e ,u na County 'Department of„ Health,. and that :on completion thereof a "Certificate of Construction Carripliance" satisfactory to the.Commissioner of Health will .be submitted to-�the 'Department, ,ands written;;guarantee' will be`,'•furn,ishe l the•ovvner his; suceessors, heirs or assign's by the builder that said builder w,,iil h' place in good_ 'operating .condition any part of, said, sewage disposal sysem-during the period a, two (2) years im riediateiy- folxlowing';the,date of "the issu- ance of the ,approval of; the Certificate i f Construction Compliance oP the on al system or any repairs thereto 2)ahat the.driiled: well described above. . Will be.located.as ;hown,on theLapproved plan an( at said well l ccordance °:with Ehe standards rules and 'regulailons -of - "the Put "n8rri County` Department of, ;Health. R' e r� .,Date ��?1`. = s s. Signed: { `• _' �� icFB Address 10f1�Mi99rt/ Y - PE RA License No AP._P.ROVED FO_R'CONSSRUCTIOvN This.:approval expires ;one ear from "the date issued unless,cohstruction; of the building_has`been' undertaken 'A rd is revocable for cause or may. be amended or modif,eii when con a ii.riecessal y ,by .the;,Comrriissioner -of Health Any: change or: alteration -iof'construction' requires a ne permit Ap'Iproved for disposal of:domesti'` Mary sewage n Ater supply only z 1 Date�_��- ", - (/] I 4 /7 �'J�✓G/� .• I / N�,.� w- .. �s.. P cl pt-ca. t m'' a By �S 4; e ° r l `llb 4 . h d�Y95�l-lnaty - rt Putnam County Departi-ilent of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNANI COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for Lot -.12 Maplewood Estates - - — — — — — -- — - _­ - - -- — — — — — — — — — Malcolm — — — P represent L 1#1 0-Afth, ft Wood_:_ that I am an officer or employee of the corporation and am authorized "M b Indd9tries, -Inc. to act for — (name —o' name oi offices f ices at Route 9, Fishkill, N.Y. 12524. Whose officers are — -- — -- — — — — — -- — — -- — — — — — — — — — — — — — — President !Err ap Oak Pt. Clu b W_ Lake Candiewood,'New Milford; Conn.j _(Name ii Xd7r.s;) Vice-President �Mark Ritter 6 Flowdr'Hill Rd., ;Poughkeepsie, -N.Y.— 0,W_ — —_ -_ J­ 7% .1 Z.- . . - I Ii4culit: CHILL rS-_L,_L1't=0,73.J 4. Seeretary M,6iris J. Feltner C/o Fell ve ner:'&­R6vins 239 Park A, New .York-�, N.' 7— and 1Y. e as- u r e r Errol D. Rappaport, — — — — — — — — — — — (Narrie and Addii ss)� and that I am and. will be individually responsi of the corporation with respect to the approval sequent acts relating thereto. C� L/ Sworn to b af 2- me this day Signed of Title ( Y otary L)Yb-ric .3 SAVT W York Puhlic7 tale c: N�wrj' ble for any or all act's reClUested and all sub- I "T PUTNAM COUNTY DEPARTMEDfT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner/ A Address Located at (Street Sec. Block Lot /02 4d;rcate res cross s reet Municipality. �j�dp� ) Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTEEr WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run apse Dep o a er Water Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 3 4 5 1 2 3 M 5 Notes: 1) Teets to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS,ENCOUTERED IN TEST HOLES DEPTH HOLE NO s/. S�f 6 7 HOLE NO. HOLE NO. G.L. % SoiL 6" 12" 18" 2411 3011 361 42" 48" 54 60" 66" 7211 781 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED /✓oA✓e INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY , C. Q Date DESIGN "Drop: Soil Rate UsedB- /O Min/1 S.D. Usable Area Provided Sono No. of Bedrooms Septic Tank Capacity °Jac7 Gals. Type Absorption. Area Provided By 0 L. F.x2411 �'— l X- idth trench. / `�jw 11-1 lgtt4er , 0. ;V X5 P Name igna ure :. U�•• Address SEAL C,nRmr L iJ 'r THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by `�e "taDate