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BACTERIOLOGY PARASITOLOGY. VIROLOGY' -:4 "
. ANTIBIOTIC -USED
w11.
SOURCE OF MATERIAL 99
-REQUEST p -
` ❑. Blood`: ' =
❑ SMEAR,,.--,O,- °CULTURE Village .Pharmacy` = Water Test
: ❑, sp�tun,
`❑
-",,-0 Routine.:;:: for .Howard Erskine .
I Nose -: -
.•❑ T B :.
❑ hroat =
Q Diphtheria
❑' pma Fluid"
❑ Tungue,
❑ Unne. -:
❑ G C 3 '?
Feces' �,„ ... �
.4%•30/7
' -:.. ❑ _ ,s -- . -
❑ "•Pus From
❑ � � � .
' ter
.
❑
- "
El Ova and Parasites' PUTNAM DIAGNOSTIC `LABORATORIES -
❑ Viral-Studies' 16 STONELEIGH_,AVENUE -, CQRMEL, N. Y.
::[] SENSITIVITY
BENS
RESIST
STAPHLOCOCCUS. p Aero6ecter
Chloiamphenicol
[I Non =Remo. -Coag. To Follow , .•; ❑ Corynebacterium
.Colistin'Sulphate
0 Hemolytic -Coag. To'Follow ❑ Escherichia
Declomycin.
❑ Coag..Positive ❑. Klebsiella
Di h. ydrostreptomycin"
❑ " Negative = (] Paracolo.,Bact.
Erythromycin;-
STREPTOCOCCUS, 'HEMOLYTIC E],Proteus.
Neomycin
=
❑Alpha E], Beta ❑ ,Gamma r ❑ Pseudomonas 1
l 'Nitrofurantoin.
-
Q Enteroos. .Enteric Pathogens l
i ; ,
s ,. vox acillin
-
' E]., Pneumococcus . ' =.' ' ❑ Found
Pana ba
❑. Neis 'seria El Not found
Penicillro
❑Hemophilis
Tetracycline
_
TUBERCULOSIS 'SMEAR TUBERCULOSIS CULTURE - -
x .Tnace"tyloleandomycan,
E] Acid Fast: -Not Found ❑;Neg For'Acid Fast
Ampicillin- ¢ -�'
;,
:.-❑ Acid fast - -Found -❑ :Pos
< -
_..
E7_- Smears, RoutineNeg.. '__ °.Q,O &P >Not Found'-
-
i]- Cultures" ;, (�.O &P'.Posifiye Fgr.
FPresence of
Col:iform Bacteria. ' Less.`thi�n Bog. This sample
4of--water.conforms to the accepted standards of Purity when
collected..
At; the tim =of ekam nat-ion,- the ' -water was of good
y_ quality. -
//e
•�2/73r _ _- =
Any person occupying prem�sesaserved by;the alve systems) shall! promptly take such
:conditions resulting from such u "sage Approval - of the eparate sewerage system shall
available and the approval of the prwate water supply shall become null and void `wher
subject`:,to mod if. i f the Comm ssioner:of He
Date_ �� �/ 3 By2',"•
Ys
:3
o
width trench
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENrOF HEALTH
A
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 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
NAME
ADDRESS
CUSiM ROAD PATTMOl NEW YORK
LOCATION
OF WELL
(No. & Street) (Town) (Lot Number)
YORK
PROPOSED
USE OF
WELL
JiUSINESS
DOMESTIC El ESTABLISHMENT ❑ FARM ❑TEST WELL
❑ SUPPLY 11 INDUSTRIAL El CONDITIONING El CONDITIONING (Specify)
EQUIPLMENT
ER
COMPRESSED IR PERCUSSION 1:1 P PERCUSSION El (Specify)
f] ROTARY ❑ A if )
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
A 3h
WEIGHT PER FOOT
19
Ri THREADED ❑ WELDED
DRIVE SHOE
YES ❑ NO
CASING
R YES
NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED ❑ PUMPED COMPRESSED AIR
YIELD (G.P.M.)
29 GIRM
WATER
LEVEL
MEASURE FROM LAND SURFACE— STATIC (Specify feet)
DURING YIELD TEST (test)
Depth of Completed Well
in feet below Land surface: 400 ft
SCREEN
MAKE
1
LENGTH OPEN TO AQUIFER (feet)
DETAILS
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
.0
60
rilling in overburden -
it solid rock.at 80 ft.
illi.ng in rock- setting
90
400
Tilling in rock'
QT1 to
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WEL COMPLETED
11/8/72
�4nF REPORT
Or((T4 7x((772%
WELL DRILLER (Signature) • r d „< �/
- 'Y ''�� ✓C✓ ��r:. /
Y'
M Owner or Purc zaser of Building
Building Constructed by
o Al
Municipality
/d
Section
clu_si�/_14 Ay "TL),
Location - Street Block
G'c,G e,- "V. 11q Z_ �
Building Type Lot
GUARANTY OF' SEPARATE SE[IAGE' .SYSTEM
I'represent that I am wholly and corap�eteiy 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. j his succes-
sors, hAirs 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 irimediately following the date of initial use of the sewage disposal
system, or any repairs nade 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-
te'rmination of the Di rector of the Division of Enviro:Lmenrual Health Sell-
vices of the 'Putnam County Departrr_ent of Health as to whether or not zhe
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 7 day of yLy' 19'73 Signature - J
'Title
If corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED 4iITH THREE (3) .COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF CO1v1P,ETION WILL BE ISSUED.
GUARA3\TTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST.. USE OF SYS'T'EM.
Division of Environmental Health, Services, Putnam County Department of h- 'ea1th
e
i
��E OF Nf�
j
;.,Water ,Supply ; / °Publ
`:PrM
i'1
Other Requirements
I iepresent that I am wholly an
eboWde,sciilied will'be- constru
County Department of Healt
tie sub`m4ted to the Depart iii
.place in,;good operating <corid
ante of the approval of the i
will be located as'shawn on he
County Depart'meitiof Health)
'Date � �' � �•°
We
during; the period of two (2)0"aars immediately following +thedate.Of the`issu
or�gmal system 'or any repairs thereto escribed above t
m ordance wdh the standards rules and regu at—T —o s, of 7the °Putnam
P'Ft, % R A
r
cAr�nE�...
date issued unless construction' of the building has beeii undertaken and is
by the come oner;;of Health' Any'`change','or alteration of•° n. .
r�rio ater :'supply' only
Title '�
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 S, //. e&L,0t /AWAddress CUSHe"AI RD,
Located at (Street CysHm.4,) /4b Sec. o Block / Lot `S
�indlcate nearest cross $ ree
Municipality , PAT nea -soA) Watershed Al. y! G .
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse 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
1 ff'SG
to
/S//4
O
2 /.?. a
A? '/G
/b
/G
/G x A¢
o
312Y6
/�
4
17A
1;7A ZS
la: _ZG
3 41
6
l7
/a i
ac)
2 .. .
fir'
5
1
2
3
4
5
Notes: 1) T6gts 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
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE N0. O HOLE NO. HOLE NO.
G.L...
6"
12"
18"
24"
30••� Lv
36..
42"
`t8"
54"
60" C4AY 40A, -7
66" T/��tcES o'Oe- S'gtio
i
72 if
7811
844"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
C�
INDICATE LEVEL TO WITCH WATER LEVEL RISES AFTER BEING
ENCOUNTERED
TESTS MADE BY
Date
DESIGN
Soil Rate.Used GO Min/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity qp d
Gals.' Type
Absorption Area Pro ded By�So(> L.F. x24" —
width trench.
Name G ,vim Signature
Address Oy XlloiA) Rc)etp SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by
A COG 3 /c�
TW OUNTY
r
DEPARTMENT OF HEALTH
Division of Environmental Health Services �31�
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT 4
WELL .LOCATION
Street Address
Cushman ]Road
Town/Village/City Tax
Grid Number
WELL OWNER
Name
r& rs wa
Mailing
r
Address
2 a
MPrivate
O Public 9G V
USE OF WELL
1 - primary
2.- secondary
jKRESIDENTIAL
I BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM ❑ TEST /OBSERVATION
[]INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHTgpm /#
PEOPLE SERVED j" /EST. OF DAILY USAGE -2to gal
REASON FOR
:;.`. DRILLING
NEW SUPPLY
OREPLACE 'EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
aDRILLED
ODRIVEN
E]DUG
13GRAVEL
[:]OTHER
='=IS WELL SITE SUBJECT TO FLOODING? YES X NO
._ -IF WELL IS LOCATED'IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR; NameP•F. Beal & Sons, Inc. Address:PO Box B.,Brewster,NY
:F IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
:,'.` ;DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION [Z] ON SEPARATE SHEET,
(date) (signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
Date
Date
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this p
3. Submit a Well Completion Report on a form p
Health De t�17 of Issue: 19
of Expiration: 1 9
Permit is Non - Transferrable
2/87
White copy= H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
7
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