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HomeMy WebLinkAbout0071DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.15 -1 -31 BOX 1 If ,;�19 J ra� 9 'Tr♦ i�� }� V J 00071 -- r...,.v ---•. �.-- ,- ....- ---- -- rte.---- z-- T''- :rr. ---- -� -. - a- .......�,,. .-- —�" _- —._ _ _ - 51171 - 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 - r , i r ., a % a °r` 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 < 0.`y r'rra 7 090'.'t ""A,- eye C" C 1 N 0. I 0 R"dv X e'l ?+- S 7.Q/ 3 OrLUQ//inq 9rrr.X '. 27.9 Oe d 2•M aa, " � N F/69aE.a6 h ti ry c T .587 °S4'00'� —f -- //8. �g'�• 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. r w i -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. 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