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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
..........
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,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