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BOX 5
00161
1,
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1.
161
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00161
Located at..: Cushman Road: r'
owner Charlotte &.Daniel.E Coombs Lot
Separate Sewerage System built by
Roder Mayes Construct? on Co . ` Address<
I1eAA rj
Consisting of 1000.GaIrj Sept ic Tank ft, lineal Feef
Other-i requirements
None
Water Supply Public Supply From
X .. Albe
Private Supply Drilled By rt
Address
Patterson, N. ... 63
C
Building Type IFrame. No of Bedrooms l hl^
Has Erosion Control Been Complefed? `mss
I certify that the system(s), as- Jisted serving the above premises were constructed'esseniially as shown /o
attachedj;`and in accordance with the standards, rule3'and regutations`plans 4 iled nd;the permit -i
Date, C ert rf red' _by
R D`: ,6 Boxy, X53 armel: NY,.1 <05
Address
tL
License Not 29201
Any,person occupying premises served by the above aystem(s) „sliall promptly take such action as may be necessaryto secure the correction "of'any
conditions res
ultmg ;from such usage. .Approval of .she separate sewers m shall' become nuiF and void 5s soon as , a public sanitary, sew
available and the approval :of the :private water supply „shall become n' and voi whe blic;wet "r. ply ;becomes available Such a'
sub)ect.to'mod� ica4ion r,;change .when, in
the Judgment of_th'e; mm�ssio of , salt ch r mod MicBtion or change is neces
i ate ,� �..� • Tit
TIC u_ _ _ SED�.=
OF MATERIAI
BCTIOLOGY PARASITOLOGY , VIROLOGY - 4
W -175 a
I REQUEST •x }a11ie1 COOtnbS
0 SMEAR 11 CULTURE Ridge Rd., :RD #6, Bo.X 304,
0 Routi
0,T. B.. -Hopewell.
[] Diphtheria
"0. Fungus.
918/76
CI �, C.
_ Wat"e:r Culture_
0__ i ' Water From Cushman -'Rd., Patterson; New York
D
a PUTNAM DIAGNOSTIC LABORATORIES
0 Ova and Parasites f0,4TONELEIGH /fiVENUE CARMEL, N. Y.
:O Viral Studiesj. . • _
RESISTANT I S f 1, 1 R I 1_ INTERMEDIATE I S I'llR L s
DOXYCYCLINE IVIBRAMYCINI
LINCOMYCIN
OXYTETRACYCL,INE '
METHICILLIN
AMPICI LLIN
NAFCI LON'
HACITRACIN >;:`L -:. ' , " . •:
. _
..
. `
•NALIDIXIC. =ACID ,, .-
CA'REIENICILLIN- ;
-
`:
NEOMYCIN
CEPHALOTHIN
FURADANTIN IMACRODANTIN
CHLORAMPHENICOL
OXACILLIN
CLINDAMYCIN
PENIMLLiN G `
COLYMYCIN POLYMYXIN : g
ERYTHROMYCIN, STREPTOMYCIN
GENTAMICIN TETRACYCLINE
KANAMYCIN VANCOMYCIN
MANDELAMINE DACTR.IM
*N
Antihiotia ApM
CHART COPY
NO COL -FO S A ILLS :ISOLAT FRO(SPECIMEN SIJBKIi D.
THE TIME OF EXAMINATION-,-THE WATER WAS OF�_GOOD QUALITY.
. r
4
WELL COMPLETION REPORT PUTNAM- COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING -CARMEL, NEW YORK
This. report is to be completed by well driller and submitted to Codnty 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
NAME
w mb S
ADDRESS' p S n
�1 .. kyV�M-
LOCATION
OF WELL
(No. d Street) (Town) ' (Lot Number) '
PROPOSED
USE OF
WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (specify)
DRILLING
EQUIPMENT
(�
ROTARY 46j�
COMPRESSED ❑ CABLE ❑ OTHER
AIR PERCUSSION PERCUSSION (Specify)
CASING
DETAILS
LENGTH (teat)
V
DIAMETER (inches)
WEIGHT PER FOOT
l�
THREADED ❑WELDED
E S O E
YES ❑ NO
W.AS CASING GROUTED?
YES
NO
YIELD
TEST
HOURS G.P.M.
❑.BAILED ❑ PUMPED COMPRESSED AIR b Q
YIELD (G.P.M.)
SL v
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST ffest)
'J tf a
Depth of Completed Well J7
in feet-below Land surface:
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (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
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
U — "-
DATE OF REPORT
WELL DRILLER (Signature)
&�- 1�� -
NO
o
Owner or Purchaser of Building Municipality
BuIlIding Constructed by
Location - Street
Section
Building Type Lo
EO
GUARANTY OF SEPARATE SEWAGE-SY'9'TEM
I rgresent that I am wholly and compleffily responsible for the
location, wor m riship, material, construction aqd drainage of the sewage-
-disposal system, rving the above described prpferty, and that it has been.
constructed as sho on the approved plan or roved amendment thereto I
.',and in accordance w*th the standards, rules.4pp nd regulations of the Putnam
County Department of ealth, and hereby gu. -ranty to the owner, his succes-
sors. Igns to place in gooc 4perating condition any part.-of
sors,,� heirs ,or ass"
said ' system'cons t ru c t e by me which fai ��S-' to operate . or a period of two
_.years immediately follow, -gig the date 9/d initial use of:' the sewage disposal
system, or y me any repairs ma b toAsuch system, except where the failure
W
to operate properly is caus by t.46' willful or negligent t of
the occu
pant of the building tili
14 1 1 z i t e system. 7zp
The undergign d fdrthl agrees to accept as conclusive 'th6'-de-
termination of the Direct' oIf th Division of Environmenta:l Health Se'r-
vices of the Putnam Co-inty D,6/partm t 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 thebuildL u 'lizing the system.
Dated this day of �, x/j
I - Signature
*tl
Uf cotfporatAbn, give name
and address)
- - - - - - - - - — — —
7 — — — — — —
THREE (3) Cq.-;PIES ARE REQUIRED WITH THREE (3) COPIES F FINAL PLANS BEFORE
T
CERT175ICA7 OF COMP.,ETION.WILL BE ISSUED.
I ST
S 0
GUARXTOR IS .REQUIRED TO FILE NOTICE OF/DATE OF FIRST US OF SYSTEM.
- - - - - - - - - - - - - - - - - - --- - - - - ---- - - - -
of Environmental Health Services, Putnam County -Department .of . Health
N
_. I
REVIEGT G`ITFCK SHEET
r
Meets Std. ( Remarks
'e s No ,
DOME' NTS ..'
House plans O.K.,
Design data sheet ! '
Peres presoaked? I
Kin. 30" perc test. depth
Const. results for 3 runs I I
D. Hole log 0. K. I !
Corporate Affidavit for'othe.- than individual ! !
Authorization for engineer ! I
Letter from Water Supply if applicable i
If variance requested -such noted on plans & apps.:
DETAILS
if change is proposed,) /
}existing contours shown show new contours) 1/
Slopes,for driveway cuts, etc. .shown..
Water service line location
- Footing..drain'' etc. location _ I
Top slope, bottom slope of fill! !
'Percolation tests and deep.test pit location !
Septic tank size and conformance to std. - !
3 B. R, house -minimum I _
House setback shown I
T'ii 3 � I
.: li1.l �'Wa Le:V W-L UILL11 )t� 1 U . U1-- .raj' .6!: UW11 -
I
Plan and prof-' le SDS I . ......:..:.........: :.:......:,
All other. wells•and SAS :closer. 2001 I
shown or' reference made
Property boundaries (metes and bounds - clearly show.
.SEPARATION DISTAI LACES SPECIFIED ON PLE1N -
10' to P.L.
20' to Foundation walls ! !
100' to Nearest well
50' to stream, march, lake, etc: incl.expansion
15' to Curtain drain ;, l
10' to water line (pits -20' ) i l 1
15' to storm drain ! I _
10' to large.trees !
01 from foundation to septic tank
5 to pipe from leader drain & footiingdrain
11141111AL M9111-11 '09 �.l P11,111C 1111 ON y
Prop: ,.rty lines or co•ners found
Can esti-Twat-, 1-ioucc location.
Vill drivei-1ay need cut
11hvit trees be removed-note these
.1 - * * SD:*3 re:, a
. s deep I)ol.c rop-e�senIL-lative, of entire
Add.itional do.-T) holes Needed. . . o . 0 .
Sufficient SDS area available considering
L
driveway -cut, house location-, -soparation
distances., etc. . . . .. . . . . .
Y
D-R,11,'? ROLE L -I 111A
D.-z,pth:
.1•later elevation:
17ock, elevation: A�t�
Soils descri-T)t-ion: 4&44A
FIRAL SITE ITISPECTIO1,11
ate:
nsT). bv:
11ouse, located vher.- shown on approved plan
ate .7 '-re ap .�d
SM 10c, d"I he prov
Slope of ti le .line and* tr-e----n--c-Tn -acceptable
Room allowed for expansion trenches . . . .
Over. 50 "L't. froim, swamp, vyatercourse.
Natural soil not stripped or SDS area
unnecessarily graded
10 FL. .' L-.a-intai�ae , d from prop.line* and
20 ft. from house
Separation of.trench from house, well
etc.' follows plan
Wuiibor of bedroc-i-is checks
Mcngs brush, stumps, rubble etc. greater
tban 15 ft. from nearest trench
15 Ft. of peripheral soil horizontally from
trench . . . . .... . . . . . . . . . . . . .
'Jilnction boxes. properly set
Could surface run off from driveway, roads,
ground surfp.ce., etc. channel' roar SDS
area .. .. . * 0 '0 0 • IX)--s 16t drainp-r7n Pnnnnr in nrpn n-r
r-111411 GRADING OF. SITE ACCEPTABLE,
y
Pt1`1'ilAPd C�I>71'['Y b %TART 1F;!'!`['- OF IiF�ILT}i
nNISI0r1 OF F; ?�VTROrIM -DITAL I}l_ 1LTIi SERVICES
COUT.!` y' OI'1�'I "CE FLlI1�DIP'G, CA F& N. Y. 10512
DESIGN DATA SHAT- SEPARATE SDdAGE DISPOSAL SYSTEM FILE NO:
Ownere"44 -ewe
ara,.
Located at (Street w "7, otv /� /D Block / Lot
n
ate. nears cross street)
Municipality. Watershed
SOIL PERCOL'1TI0� TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATTOCS
Role
Number CLOCK TTPT PERCOLATION PERCOLATION
Run Eiapse Dap .LO. a er water. eves
No. Time From Ground Surface in'Inche&, Soil Rate
Start -Stop Min. Start Stop ..Drop in., Min. f in drop
Inches Inches Inches
1 >f 2 Z3
2 ID ):f 13
3 /0i4 1_3
3
t
5
�d
Notes.:
l)
Tests to be
repeatod "at samo depth until apProyimatel.y equal soil
rates
are
obtained at'each
percolation test hole. All data to be submitted
for
review,
2 )
Depth mca-urements to be made from top of hole.
i
84"
INDICATE IaTL A . �,,�SCTT GROUriD WATER IS Ei ?COU;JTERED Na.,P
INDICATE `L]EAFEL TO ?•(1 1 CH' 14ATE,R ATE :RISES`AF�TER BEING .ENCOUNTERED .ItAo re
TESTS I ;ADE BY f ✓. ,et t
' DESIGN -
Soil Rate.- Used3 I%iin/1'Drop: S D Usable Area .Provided. /oOG.Ig
No. of Pfedroor.s -7-xe. _Septic Tank 'Capacity. .. e. Gals Type
Absorption .Area Provided b L P k24 ". 3(�'' .� width trench,.
Other
tame .. .._____tea lna
Address_ RA 6. Box 353
C�',v -. X5.12
T11IS SPACE .FOR •.USE BY HEAl;.VH DEPARTIMU
Soil Rake Approved Sq 1-t /Cal
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