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HomeMy WebLinkAbout0408DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -61 BOX 5 00217 ' T .� ILL 00217 NT MT OF HEALTH' A a; j • Division of : Environmental Hea /ths Services, - Carmel ; N Y °1.0512 CERTIFICATE,.OF' CONSTR;VCTION:>'COMPLIANCE. FOR,.SEWAGE:,DISPOSAL,:SYSTEM;' Town or Village �.T 31 Located at �..E. Zt L. Section Block Z 1. - Owner K,�� %� ! �[fLi7� Aim Lot s. rl . Z .Job + Tl'= :3� rd . 5 Address Alt- Consisting �t� %2yc HELL` built by —,, Separate .Sewerage System _ j of Gal. Septic. Tank �Q© lineal, Feet 'X , width trench 'Other requirements' - Water Supply: .. Public Supply From PO Private Supply Drilled -By i Address Building Type`TArr%�� Z p.= E�.'J�F�Nt=�S NO of Bedrooms Date. Permit 'Issued Has Erosion Control Been - COnpleted? t certify that-the systems) as listed serving the atiove premises were constructed essentially as shown on the plans of the completed work (copies of 'which are attached) `and in accordance with the standards, iules and regulations'plans filed; and ^the permit issued by the utnam County. Department of Health. DateC. i/ 7� Certified by . P.E. iL R. . P, A i No.4,S` <?C`� ' . Atldress _ . License Ariy, person occupying premises!,served by the above systems) shall pro'mpfly take, such'action as;may be necessary to secure the correction of any unsanitary conditions resulting from such , usage . i4pproyal of the•'separate sewerage system shall become null and void as soon as a public sanitary sewer becomes r. available and the a roval'of.''1he pp private.water'supply• shall become null and void when,a •public "water ,supply becomes available. Such approvals are ,•subject. to,, or clh'ange when;.m the judgment of :the Commissioner of Health, such revocation ,.modification, or change•Is necessary. g'` . A /I r s„ y. Title n. 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 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 Ail J n r /7, CJ! C/ /N 91 lJi) ADDRESS SG� LOCATION OF WELL (No. & et) (Town) (Lot Number) �! PROPOSED USE OF WELL (� BUSINESS LJ" DOMESTIC ❑ ESTABLISHMENT ❑ FARM LJ TEST WELL 11 SUPP Y El INDUSTRIAL ❑ CONDITIONING (S(Specify) DRILLING EQUIPMENT ❑ COMPRESSED ❑ CABLE ❑ OTHER ROTARY AIR PERCUSSION PERCUSSION (Specify) CASING DETAILS LENGTH (feet) 7DIAMETER( / 33 J nches) !/ WEIGHT PER FOOT Fj THREADED ❑WELDED D I1VE IS L YES ❑ NO jWAS CASING O TED? LJ YES NO YIELD TEST �y HOURS G.P.M. El BAILED El PUMPED L�J COMPRESSED AIR YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) vV,F DURING YI LD TEST (feet) Depth of Completed Well in feet below Land surface: SCREEN MAKE 41 LENGTH OPEN TO AQUIFER (lest) 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 G 1. WE�I to r14#,FtSD1q BOYD ?UITE Ida" � vNELL 0C), RP'D 3 i! Ail If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE W LL C MPLETED D 7 W DATE OF RE ORT WELL DRILLER (Signature) ROUTS. 52 CAI RII'IEL NLY �/ 0 er or Purchaser o f ilding Building Construct-e by Location Street .Municipality �r Section Block Building Type 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 cons.trueted by me which fails to operate for a period of two years immediate,l5 following the date of initial use of the sewage disposal system, or any repairs trade by me to such sIrstem, 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 uildi,ng utilizing the system. Dated this day of 19_z� Signatur Title c.o rp a an adds -- - - - - - - - - - - - - - - - - - - - - - - - . - - - - Lion , give name THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMK ETION 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 Located' at � /Cd secaon` !.-'/ 0® Block`_ Subdivision' Lot ,ob Owner A 41 A­ Address BuUdin9 t.L7 Lot Area r %L�: 4V79 ' n / T— Number .:of Bedrooms Total Habitable Space —Square Feet Separate Sewerage System to consist of Gal, Septic Tank lineal feet X' ��'! width trench To be constructed by Address Water. Supply: Public Supply From Private 'Supply to be drilled by. Address Other Requirements ;.I represent ,that %1 am wholly and completely responsible for, the design and - location of the.,proposed system(s); 1) that the separate sewage disposal system above described will tie constructed as'shown on the approved amendment:thereao.and in'accordance with'the standards; rulesand regulations o e u ham Co unty Department of Health, and that on completion thereof a "Certificate of. `_Construction .Compliance'* satisfactory to the Commissioner'of,,Healthwill "be submitted to'the Department, and. a written.-guarantee--will be- furnished the. owner,rhis successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of ''said sewage disposal.system during ih'e period'of two`(2) years immediately following thedate of the'issu ance of 'the approval of the 'Certificate of Construction` Compliance 'ofAhe . ornal system or any repairs thereto; 2) that the drilled well'desceibed above will be-- located -as shown on the approved plan and that said well will be. instalie accordance.With the standards rules and - regulations of the Putnam 'County. Departme of :H alth; //. Date igne P E. R.A. Addressgc License No.. APPROVED FOR CONSTRUCTION: This approval expires one year from the date. issued unless con tion of the building has,been undertaken and is revocable for cause or .may be amended or modified `wFien'considered.necessary by the Commissioner 'of' Health. Any change or alteration of construction requires a n w -per it Approved.-for disposal of domestic it se n p supply only. 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A�-E 5 • or -SAKD- . 30` �. 36`. 49 6 0,. - Gi90UAIV \fHT"E R .. _ 66 "` 78'. 8V I \DTC�T L �'c.L AT t:� -SIC r G'OJ \D r,T�.T7R IS INDICATE LE��I, TO'viHICH r TE LEVEL R7- !TER B E \CCiU` -ERRED TESTS "aDE Ev rd A�A6n4 Date' ue _se,� - /1' Urcp. S.D. U -sa21e Are- _ =e^ NCB. Oi iii':_ GC " -5� _sept— ` c Tank CGC'= =_� }'— 1 /.J�C% G=:1 s . Z'irJ ` AbSOrP1:10:1 rirec PI'O': lded E} 3J" width trench. O L hL i C '_— Address_��E,�; �� -- SEAL PLf t:i OL:\Iy D ?•�I'_C ` <T OF I L lLT:I Soil ir; = -e = -�_ oved Sc. Ft. /Gal . Checked } Date