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00144
PUT
NAM COUNTY DEPARTMENT OF HEALTH
Division; of Environmental Health Services, Carmel, N. Y. 10512
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CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM ,1
Town or Village
( jZ.E}SS (2D�Q Tax Map —� d Block I
Located at
Owner ILA /AA M iCiko -Z ' l -War 2'A'- Lot 10' CA) Job
Separate Sewerage System built by e' 'r1 �� �Ti C- : S`iZ")1'> S Address
Consisting of 1002 Gal. Septic Tank and / L � "cam
i
Other requirements
Water Supply: Public Supply From
Private Supply Drilled By J"iLt ' "+' f7'
Address
Building Typen
Has Erosion Control Been Completed? yi✓
1 certify that the system(s) as listed serving the above premises were constru
attached), and in accordance with the standards, rules and regulations, pl
No. of
Date , — C2 — It Certified by
Address
5�P` FPM A.
Date Permit Issued
of the completed Work (copies of which are
the Putnam County Department of Health.
P,E.1 R.A.
License No. `-r ZI S 3
Any person occupying premises served by the above system s) shall promptly tak cB(� ' necessary to secure the correction of any unsanitary
( 81tt►
conditions resulting from such usage. Approval of the separate sewerage system and void as soon as a public sanitary sewer becomes
available and the approval of the private water supply shall become null and when a public water ply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Comm" ion f Health, ch revo i n, dification or change is necessary.
s 7� By Title
Date
PUTNAM ANALYTICAL LABORATORY
10 Stoneleigh Avenue
Collection Depot of YORKTOWN MEDICAL LAB INC.
Carmel, N. Y. 10512 #1018 225 -5563
DATE COLLECTED
RESULTS OF EXAMINATION OF WATER
OWNER DATE RECEIVED
Michael Piazze 1 -4 -78
CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY DATE REPORTED
Harvard Drive RFD #7 Lake Carmel, NY 1 -9 -78
SAMPLING POINT
Ki;ichen Tap Cross Road, Patterson, N&a York
BACTERIA PER ML. (Agar plate count at 35 0C.) COLIFORM GROUP (Most probable No. /100ml.) RESIDUAL CHLORINE AS RECORDED AT
2 0 (MF T) SAMPLING POINT I' POINT OF TREATMENT
CHLORIDES (CI) - mg. /1. NITRATES (as N) • mg. /1.
I
Hardness: 6.0 (MEDIUM HARD)
These results indicate that the water was YES a of a satisfactory sanitary quality when the sample was 7cted.
A. H. PADOVANI, SCP)
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
"d%71 Division of Environmental Health 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
NAME ADDRESS
OWNER i
LOCATION (No. 6 Street) U (Town (Lot Number)
OF WELL 4�
IF GRAVEL Diameter of well including
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances, to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
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If yield was tested at different depths during drilling, list below
FEET I GALLONS PER MINUTE
IF— nc« 1 ....W DATE OF REPORT WELL DRILLER (Signature)
BUSINESS
[]
❑
❑
PROPOSED
DOMESTIC
ESTABLISHMENT
FARM
TEST WELL
USE OF
WELL
❑
❑
❑
❑ OTHER
SUPPLY
INDUSTRIAL
CONDITIONING
)
DRILLING
❑
COMPRESSED
CABLE
OTHER
EQUIPMENT
ROTARY
L4. AIR PERCUSSION
❑ PERCUSSION
❑ (Specify)
CASING
LENGTH (feet)
DIAMETER( Inches)
WEIGHT PER FOOT
X
❑
RIVE SHOE
AYES ❑
CASING
DYES
UT ED?
n NO
DETAILS
/ /
THREADED
WELDED
NO
YIELD
❑
❑
HOURS
G.P.M. y
YIELD (G.P.M.)
T EST
BAILED
PUMPED
COMPRESSED
AIR
WATER
MEASURE FROM LAND SURFACE— TATIC(Specifyfeet)
DURING YIELD TEST [feet)
�
Depth of Completed Well
LEVEL
_
0
in feet below land surface:
MAKE
LENGTH OPEN TO AQUIFER (feet)'
SCREEN
DETAILS
SLOT SIZE
DIAMETER (Inches)
GRAVEL SIZE (inches)
FROM (feet)
TO (feet)
IF GRAVEL Diameter of well including
PACKED: gravel pack (inches):
DEPTH FROM LAND SURFACE Sketch exact location of well with distances, to at least
FEET to FEET FORMATION DESCRIPTION two permanent landmarks.
. r 7 J _n
If yield was tested at different depths during drilling, list below
FEET I GALLONS PER MINUTE
IF— nc« 1 ....W DATE OF REPORT WELL DRILLER (Signature)
_�� CT
Own r or Purchaser of Building Municipa ity
Building Constructed by Section
Location - Street Block
e'Vi w L L L l
Building Type Lot
GUARANTY OF SEPARATE SEWAGE SYSTEM
tin
I repre.sent,. that I. am wrrd --eo -eely responsible for the .
location',. workmanship, material, construction and drair_age 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,otiJner, 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 utilizin the system. `
Ig j�is�, nad. rCesrsiU /ter:
�: n a�LhiGc�e +6 la"VIS) Xrt vewit /s e•'1-c. u, 1 v) Cc" ;q VCAl'enCe ' " +h,, . e-vawf of rL� re pc�i r.
1 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 g Signature
Title
corpora , give n e
and aaddre s
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
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATES SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Ma, I Mag A4jCAl-t�r� li Az�,* Address R E_I71 i`I P'P_yA'a.r� I OS! ?
Located at ( Street PPWS5 A-0 Sec . . 8b Block _Lot 10,2
nd'ica e nearest cross s ree
Municipality, ,cam; - camas Watershed NA
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
lViim'har rT.(V?K TTMTP. P7..Pf!()T.ATT01\T PTP..PnnT.ATTnAT
Run
apse
IDep o f a er l a er Levei
No.
Time
From Ground Surface in Inches
Soil Rate
Start,-Stop
Min.
Start Stop Drop in
Min.. /in drop
(a,
q %'
Inches Inches Inches
s
2 to
I l 't5
!
I 20 1 '> >
I , 0 � `1
�2 .C�
S7
�l
`38
I I'
4 I
r !
► k z� i ��v
13 ?
1
Z
�
2i � 3 -c�
� 15od
2 `Z°
� 251
I 4-
I 2- -2-4- I ,
I
3
4 IC)
i(�57 I
I7
t I O `Z, 0
5
5 Its r
124
1 I IZ�
I I l
30 !
iC
ao
211123�,
I
o
3 t 21 �Z_4- 10
`7
3 2"_
1 I z 5 2 2 5' 2,5 ` O
o
41 i A 7
Notes: 1) Tuts 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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTIONOF SOILS ENCOUNTERED IN.TEST HOLES
DEPTH HOLE NO. S HOLE NO. HOLE NO.
G.L.
�n
12"
18"
2411
3011
36
42"
x+811
5411
60"
66"
72" C04 L tj o
7811
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED OvIoC- ,� 9g
INDICATE LEVE TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED i1 &,>6_
TESTS MADE B cd, trJc9e.vim! Date Q,1W,, --
1JLJ1lr1V
Soil Rate Used_J,41—Min/l "Drop: S. D. Usable
�E OF NCr
No. of Bedrooms Septic Tank Capacity
Absorption Area Provided By 75L.F.x24"
� a
ided G000 Stz
`�het�r``— e�nccf .
Address2°?�
THIS SPACE FOR USE BY .HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by ... Date
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