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00071
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PUTNAM COUNTY` DEPARTMENT -OF HEALTH
Division of, , Envi�c �men6l Health Services Carinel, N. Y. 10512
CERTIFICATE :OF.CONSTRUCTION COMPLIANCE FOR ,SEWAGE :DISPOSAL SYSTEM
C%%
/f�l�.��
..town or Village
Located at �`� 6 Section Block '
Owner ° i- /f/iiL4 Lot Job
Separate Sewerage System built by J Address
Consisting of 'Gal. Septic Tank lineal Feet X v't width trench
Other `requirements
Water Supply: Public Supply From
Private Supply Drilled By
-Addy ss .
Building Type No. of Beilroonis Date Permit Issued
Has Erosion, Control* Been Completeda
I certify that 'the system(s).,as listed serving the above premises were constructed enentwlVs shown on the plans of the co'rnpleted work (copies of which ate,
attached), and in accordance with the standartls, rules and regulations, -plans fil a the permit ued the utnam unty Departure of Health.
s✓
Date Certified by P: E. R.A.
Address License No
} .a
Any,:,person occupying 'premises served ;t y�the above system(s) Shall .promptly :take such . action as may be necessa y to secure the Correction of :any, unsanitary
conditions resulting .froth, such. usage. ApproGal.of the separate'sewerage system shall become null and void as:soon:as _ -a public, becomes
available and the approval -of 'the piivate water, supply shall.become;null and void when 'a :public watei supply • becomes available. 'Such: approvals are
subject to modification or change when ;. in thejudgment of the;;Co _ issioner of , Health, such revocation, modification or change 4s necessary.
Date ! By s� Title
iS�r e3 ra e h roe s° Ursa :nsp�'j-
BACTERIOLOGY - PARASITOLOGY •VIROLOGY 4 h t
e
4
z`,.,•
'a
n'
_ . ..
ANTIBIOTIC USED
J7240 ' K
i.
TJerrll Industries,' IfC y ;-
1 .
ti
Lot T\TO: '. "5 y p`1aPlewood. x/23 /74
t`
Hold - will .peck ,'u� :results
_
`PUTNAM .DIAGNOSTIC .LABO[tATORIES . ;,,
10 STONELEIGH'AVENUE.': CARMEL
SOIIRCE.OF MATERIAL F1
REQUEST x❑
❑,Blood -
❑ SMEAR CULTURE
❑,Sputum.
❑ Rout"1Shk11
E] Nose,
(D T. B.
• Throat -
❑ Diphtheria
• Spinal Fluid
❑ Fungus
❑, Urine •'
❑ G. C.
❑:Feces...
❑
Pus. From .
❑
Other
❑
❑
;.
❑Ova and Parasites
❑ Viral Studies
❑ SENSITIVITY %.
BENS.
RESIST.
STAPHLOCOCCUS ❑ Aerobacter ,'
"
.= Ghloiamphenicol
❑ Non - Hemo. -Coag. To Follow ❑- Corynebacterium
k ::'Colistin'Sulphate
-
•
❑ Hemolytic -Coag. To Follow ..❑ Escherichia."
°.Declomycin
❑Coag. Positive ;. ❑ Klebsiella
.'= DihydrostreptomVcin
❑ Negative ❑' Paracolo..Bact:
Erythromycin' .
STREPTOCOCCUS, HEMOLYTIC ❑. Proteus
Neomycin,
❑Alpha: ❑ Beta ❑ Gamma •:; 0.33eudomonas :'. 5 `
F� +Nrtrafurantoin; •,
❑ Enterococcus Enteric Pathogens
1 °Oxacdlin
❑ Pneumococcus' ❑Found::: , ^}j ., . f., `
P.anaIba .,
❑ Neisseria ; ,E] Not
*Penicillin
❑ Hemophilis
tTetracycline
TUBERCULOSIS SMEAR " TUBERCULOSIS. CULTURE
;Triacetyloleandomycin
❑ Acid Fast -Not Found = '❑ Neg. For Acid Fast ..:; .
Ampicillin
❑ Acid Fast -Found ❑ Pos.
r
❑ Smears, Routine Neg. ❑, O & P Not Found
❑ Cultures, ❑ 0 &P Positive For
�?
1r :. .
owner or • Building
del If/
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 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-
vices 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 _ 191=x- Signature
Title ���
(If corporatib , 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 Services, Putnam County Department of Health
-s
" WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
• I
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
OWNER
N
ADDRESS
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
y�
PROPOSED
USE WELL
WELL
( L=� j BUSINESS �
1 uOMESTIC ESTABLISHMENT ❑ FARM 2L TEST WELL
PUBLIC AIR OTHER
El SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING
EQUIPMENT
MPRESSED CABLE OTHER
1—J ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING
DETAILS
LENGTH (feet)
(�
DIAMETER(Inches)
WEIGHT PER OOT
���
��/jjj �
L(J�rHREADED ❑WELDED
RI O
YES ❑ NO
ING Gr ROl T
ES LJ NO
YIELD
TEST
Ir, HOURS G.P.M.
1:1 BAILED ❑ PUMPED L�'f'COMPRESSED AIR - 7+v►
YIELD (G.P.M.)
,;q�
WATER
LEVEL��
MEASURE FROM LAND SUR ACE— STATIC(speclfyfeet)
DURING YIELD TES (feet)
Depth of Completed Well
in feet below Land surface:
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AD IFER (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
,{
r
f,
`� /
' Y 1' l/ r
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DWELL COMPLETED
DA F REPORT
WELL DRILLER (Signature)
0
Ig
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aloe"-, ✓v x'-, '.,c :,.Y
,� a i��;.�� e :
r5 a R z ,,a - a
{ '� PUT�NAM 0 RA IiALT3H
rs/onirofEnwronmental 7Healtb' Serl/ices Camel �N`'Y�1Q5`12'
s a - -r' 4 Es'ex a :. *.r
w r / ` ;mss €".
s t
CONSFA6TION" P,ER'MIT nFOR SEWA "GE DISPOSAL
> 4 � gy / �-�. :: m " x� � a � , $ .; -e5 � � t � Ti -Own, Or iv,I la 8 ., y a •..,. C -
LOCated
Block
b t s`r F
e� r t�"j� Y�f C� Q �1 z s� .. �� t�"is '� 3._.q u�2 ..a J..`s- ,• '' ,-° -i, '� f,„ p
Subd,v,s,on
2 +. s ,t � � s : '. �
. />�?` - ,+ a v,. -fir is r
Owner _ j f�/71i.5 , i AddressQ� Yg r�
BG,Idln9 iLot Area
-. s
t�,d
,N'umber of Bedrooms��E ( k T,Total H b,table Spacer w y Square 'Feet
c5.
. ; "1 ..C.rrr'"' -� N°�' /� // �^,•.. a a �" ,� -
Separate__,SewerageSystem tocoll5ist ofc =/C)d Gal Septic Tank; �- p lineal ,feet X, riCP rw�iith trench ".
.?,
,' -q 3 .. .�'" ✓ - / �'3 _ Y` rt., �m�yy. !` i$ �i`.uu¢" S G rro" 4 S`'
Teo +be coristructedt bye �� �TE� " ►�/�/�� 4 Address -¢'
Water Supply, - � Public
a-
z re i� P.r,vate f5upply toy Abe drilled by
J.
a a•-._ a F r ddress 7r ' rt`' *z a x e ns.9.as4 3+ Ye:.� •r :. 5„ v�'. S�T'hi 3
R
?•tl �',.� '"t •,,.- z� Other Requ,remehts
•tFC°`� i ,,, , ,,, -946 l - �� 4 s f °�.'+�'. tR ti's -In
Iz
s fi '� a x• ', �a -"f"r k x°a-rr." A xF ?'. `w3' �' }Try. tw'tr;.r
ljb id- sent'Rhat,l- zam'wholl4 and, com�letel " ° -?res `onsi_ble for.:the tlesi n antl "lo' at,on of `the , ro osedf 's'stem s rf;1 ,that °the' "se ar "ate sewa' e. dis owl's Stem F;
P Y P _
above descrtbedw,ll be constructed':as shown: on theapproved amendment there to and -m-accordanee wifh,thestandards: rules an !ire uiat,ons o the u :name;
{ r,' ..x._.,..-y-�..� ,. -� :.-_: ss4..:< -.F y__ - -TM�-:-. g
u
= �Couhty ,Q,epartment of Health: and that on completwn thereof.a 'Certif�catei of,Constrjuctron :Compliance sat,sfactor ,to the.Commisswner of`iHealthw,,IC'.,
sybm,tted to: ^'tthe. D.e artment =and a :ttem= uarantee will, be ;funnish'e- the owner h,3" +successors herrs;or ass, ns -b the�bu,Ider +;fhaY said! builder- wirill 2'`
i 4 `
sa,,:
p_'lace n -;good operat,n'g ;cond,t onf any,.Tpart of sa,d,.sewege gisposal,systern ur,ng;)theoper,otl of two (2). years ,mined,ately followmg«thedate!of� the "ssu
. -�.:� ,_y_, -fin re:. -., -i)-, ;.�;.�- ^..�,_..: -.�° . , �a�...:..,.,. :r= :,,-cam 3�:,ru .�� .x Kr4.�- _n.,6 � _k. ,
-ance:of. -the .approval +of the' @ertrf,cate -of. Construction COm Irance of_ -,the or, I system <; -or any repairs. thereto z2 °ahati he�dr,lledjwell °,tlescra,bed above"
WiIIlbe located as; shown on;the approved&.plan and':th'at sa,d,well will- bet,nstalled• ccordance w, the 55t arils arules4aand:,r ulat,ohs of the." Putgam
County Department of�Health �w3:*xk �5ix e_q F& x °3��'rc.
�;, .�
97�
Date � �l /
r`.r' .+ :.� . �+Y y+:.:.
gAddress L,cense�No -
. ..L- . �,"- , a _ __ '> -'i..- "'` ."` ,, ,w , tea-.. -t .a-r.. a.- .,».,x- A "� : Aa ,.k*'� .rte,- .?
' =A_FPROV;ED` FORiCONST,RUCTaION�Thiska ro a "ez'iresnone earnfroma-he date"!(s d' n "`Yr, o "f "' `'=
PP vm� -P. „_ Y f .. v A s u_Jessco_st uctno theb, dng_.ha�beenundert1aken
z revre`vo`cable for c se or 214 1: be amend d or= mod,fed wheriacons, eticoec se sar"�b Lti d%m "m sionego- fPHealth� An .xchan a orzaYteration of. ons ruction ^?
.r =s. e.... , e 5 r.::- ;.;Y� Yr F.,; ._-. -'�7'� °`';':.s:'" a �+ye• Y's 9 -.�M` ps -..:¢ `
requires a,wnew� t A,pproved;,for�d posal ofydome a tart' sew ge; d orjpr water supply only ,;_ '
'rt'”. `. ,K � � +�- � r ' ,a vy� �y3� -,+• v � J3 'i : f
',s
s.'ttr a ct .Y�^,tse ' wr r aA -:z� s` ':f�-.t 2� :..er* q r� .xr �'r.i"' � a � x� "� e .t si# i �r _x"l4',e• t,r "t.- '� 4, .,"�
o-
„ R M�'VIEW CHECK S=T
��:.i�u,�'- < Meets Std. Remarks
' es No
DOCUMENTS
House plans O.K. 60
Design data.sheet i
Peres presoaked? i
Min. 30” perc test depth j
Con.st. results for 3 runs I
D. Hole log O.K..
Corporate Affidavit for other than individual i AJA i
Authorization. for engineer i i
Letter from Water Supply if applicable
If variance requested -such noted on plans & apps.:
DETAILS
if change is proposed,)
Existing contours shown show new contours)
Slopes for driveway cuts,.etc. shown
Water service line location jou
Footing.. drain, etc. location 1 .0 �g�C
Top slope, bottom slope of fill ! 1 i
Percolation tests and deep test pit location i --; —=
Septic tank size and conformance to std. I
3 B.R. house minimam
House setback shown I
ill F! i __
•phi. t
Aii Wd7 , 1' W11,L1.1.11 50
Plan and profile SP,S ' I ..:..... ..... ...................... .
All other wells and SDS closer 200 '.
shown, or reference made
Pro-�erty boundaries (metes and bounds- clearly sho-n�t_ i
SEPARATION DISTANCES SPECIFIED ON PLAN
10' -to P. L.
20' to Foundation walls
100' to Nearest well
50' to stream, march, lake, etc. incl
15' to Curtain drain
10' to water lire (pits -20'
15' to storm drain
10' to large trees.
0' from foundation to septic tank
5' to pipe from leader drain & fcozin
.expansion),
I
no
4 " . _t 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.
Ownerhl,5 'I& f//(ilJllsS %2i Address leoUry"E 0 ZL X),
Located at (Stree - -0a,51( 2a/ftD Sec. Block
Indicate neares -cross street)
Municipality, j ���,� t7� 1 Watershed G:
Lot ,5-
SOIL PERCOLATION TEST DATA-REQUIRED TO BE SUBMITTED WITH APPLICATIONS
r
2
3
5
Notes: 1) T6 is to be repeated at same depth until approximatelyy 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.
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse
No'. Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
a er: ve
in Inches
Drop in
Inches'
Soil Rate
Min. /in drop'
lio. S� /o 5
/o
13,0
1 11,X5
C .17 /�
r
2
3
5
Notes: 1) T6 is to be repeated at same depth until approximatelyy 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.
_ -. .. 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.l E%ROL /rtllN57-2ie-s Address /�D � 3 f /�S/ff���L ,{f• }*
Located at (Stree Y<51A2- 13116)Y Sec. Block Lot
Indicate nearest-cross street)
Municipality j T��� �� Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse
No. Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start Stop
Inches. Inches
Water-,Leve
in Inches
Drop in
Inches
'Soil Rate
Min. /in drop.
1 /D.v`" /a : 1515
/o
J 3��
a 3 XI'
/ 3
f
210 SY- //:`
�'
d.�%
o2s
4//.'0,5-- //.70
21 7
5 /,•' /O - //,!S_
2
m
5
Notes: 1) Tests 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.
4
R/CNARD H. GORR
PROFESSIONAL LAND SURVArYOR
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05�-PJ G 4sP" 62 m "V"o
MERROL. INDUS rl?lt s; i NGe
SITUATE IN THE
TOWN OF PATTER30N,
PUTNAM COUNTY, MEW YORK
SCALE / IN. =. 4 D FT. 1973
CERT IFIE/D A O: MERRO L f NDU ST R/ES, INC.
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-Tr Txd prvr�rrr f 'R e�bx'rl Nn'Tr•N SANK F
TNF GN�r.E
We, RICHARD H. GORR B ASSOCIATES, the
surveyors who mode this mop, certify that then
survey shown hereon was comp /eted by us On
,/on • 2 % , 197.E that this mop was com-
pleted by us.. on �/Q "• A9 ,1973, and. that
this survey has, been .prepared in accordance with
the existing Code of Proctrce for Land Surveys
adopted by The New York State Association Of
Professmnal Land Surveyors. ^ Oa ;047a
.4for-. /24,/99 Sf
RICHARD H. GORR 0 ASSOCIATES
by�408 /S
R/CNARD N. GORR ,RL.S. NYS Llc. N.9
NOTES
I. Alteration of this document, except by o licensed Land Surveyor, Is Illegal.
2. A// �ertrficahons are valid for this mop and copies thereof only if the
sold map or copies bear the impressed seal of the surveyor whose slgno-
lure appears hereon
J. Promrsrs being LOT N° S
"SUBDIV ISION MAP OF MAPLEWOOD
as shown on -
sold map Bled on JANUARY 20 1970
in the
PUTNAM County Clerks Office as Map NQ 1166
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