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PUTNAM COUNTY; DEPARTMENT OF HEALTH
Division of Environmental Health Services, "Carme% N Y 1051 '
'CERTIfICATE.OF CONSTRUCTION COMPLIANCE FQRSEWAGE DISPOSAL SYSTEM O
Towyn or* •Village
i d "a • - Section Block
Locate
Owner` - Cot
separate Sewerage System built' 'by: Address
Consisting of Gal Septic Ta r lineal Feet -X•" width trench
SOfher requirements '
r . • Water Supply:. Public Sup From -
Private SuPPIy` D e 8Y
Building Type No. of Bedrooms. - Date Permit Issued
Has Erosion •Control' Been Completed .
i . I cart if' that tFiesystem- j as lister 9 ; p ... ,_ - a P
fi y (s d serum the above remise_ s were constructed essent s shown onahe plans of the' com lefed work' copies of which are
I attached), and 'in ac ordance with the standards rules and regulations plans filetl, he permit ` sue y' t Putnam. County :Department of Health.
4 'Date - -' ertified uby P:E. R.A.
aAddress ' p License
t f
".Any person, occupyir!g premises served b'y the above system(s),shall' promptly take such action as maytie necessary to` secure the correction. of any unsanitary
'condit'ions 'resulting' from such usage.' Approval of , the :separate sew@ rage system - shall. become' null and void as soon as:',a public sanitary sewer becomes
- available ari I -the approval of the private water supply shall become null'antl voitl 'vrhen a'public - water .supply ;becomes available. Such approvals are,
subject 'to ,modification, or' change when,- in the judgment of the Commissioner of. Health;, such revocation; modification or'change'is• necessary.
Date ! 3 BY Title
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APPROVFM
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PUTN Of HEAM
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RI: -DIVISION-
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ENTAL HMT% SEMW
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BACTERIOLOGY , PARASITQLOGY .VIROLOGY - 4, W -362
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SOURCE'OF MATERIAL x❑
REQUEST k❑
x Y_
-The lathall Corp.
Rt-. 221 Patterson, New York
/9175
.
PUTNAM DIAGNOSTIC LABORATORIES
10'•STONELEIGH AVENUE. - CARMEL, N. Y.
❑ Blood --
❑ SMEAR CULTURE
❑ Sputum,
=❑ Routi a
El Nose ' ..: _
❑ T. B.,
D;Thrqpt,
❑ Diphtheria,,'.
❑. Spinal-; Fluid
0 Fungus. . °w
❑- Urine .
O G C.
❑ Feces .
:❑
Pus From
❑
Othe 6 ioLJ�N-
,❑
'
0'
❑ Ova', and Parasites',
Viral Studies
❑ SENSITIVITY.
s. Ns.
RESIST.
STAPHLOCOCCUS
p Aerobacter
Chloramphenicol : ,
❑ Non -Remo. -Coag. To_ follow
❑. Corynebacterium
Col istin Sulphate,,:
❑Hemolytic -Coag. To;Follow
. ❑`Escherichia .
Declomycin
❑Coag. - Positive, .
❑° Klebsiella
Dihydrostreptomycin
❑ ' "'. "Negative
❑ Paracolo. Bact.
Erythromycin
STREPTOCOCCUS; HEMOLYTIC
_-
❑ Proteus
Neomycin
❑ Alpha. ❑Beta ❑ -Gamma -
❑' Pseudomonas
Nitrofurantoin
❑ Enterococcus
Enteric Pathogens
Ozacillin
El Pneumococcus' ",
❑ Found
Pahal 'a
:❑ Neisseria .:. -: - _,
❑ Not Found
Penicillin
El Hemophilia
_—
Tetracycline
-.
TUBERCULOSIS SMEAR'.
TUBERCULOSIS CULTURE
Triacetylo eandomycin
❑ Acid. Fast- Not Found
❑ Neg. For Acid Fast
Ampicillin
' ,
Q `Acid Fast -Found
❑ Pos.
3:
:
°.❑ Smears; Routine,Neg. °.
❑ O &P Not Found
❑ Cu tures,
❑ O &,P Pos.tive For" _
NO COLIFORM.BACI-LLI ISOLATED FROM 'SPECIMEN SUBMITTED. AT
THE.TIME OF EXAMINATION:, THE WATER WAS.OF GOOD.QUALITY.
0
i
YELL COMPLETION REPORT PUTNAM COUNTY DEVARTMENT OF IMALTfi
171 Division at Environmental Ncelth ;_rivlcus
COUNTY OFFICE IJUILDING • CARAMEL, NEW YORK.
?hie report is to be completed by w! II driller and asst . :;it: d *a County Health Dell:triment to ^.ether with laboratory report of
analysis of water sample indicating water is of satisfaciery bacterial quality before certificate of construction coriipliancc Is issued.
REPORT MUST 13E SU2:f.11TTED % ITHIN 30 DAYS OF t:-LL C01.Sf'LETION
OWNER
NAME ADDRESS
Kathall Corporation Box H, Mahopac, New York 10541
(Flo. 6 Streot) (Town) (Lot U;;r:Ler)
Route 22, Patterson, New York
LOCATION
OF WELL.
PROPOSED
USE OF
WELL
--- euslNCSS -
® DOMESTIC � ESTAELISHMENT � FARM U TEST WELL
OTHER
SUPPLY INDUSTRIAL CONDITIONING (Spec fy)
DRILLING
EOU(PMENT
(—j
9 J
Q COMPRESSED CABLE ❑ OTHER
ROTARY AIR PERCUSSION PERCUSSION (Spe :if 1.)
CASING
DETAflS
LENGTH fleet) I DIAMETZR(inches)
O _
WEIGHT PER FOOT
"' 9 "1bS (X THREADED ❑ WELDED
C ?IVE SHOE
AYES ❑NO
�q� ASINv GrrO11I
I J,-I S u NO
YlElb
TEST
j �[� 'HOURS G.P.M.
CJ BAILED ) 1 PUMPED 1:1 COMPRESSED AIR . 5 45
JYIELD (G.P.M.)
45
HATER
LEVEL
MEASURE FROM LAND SUkFACE— STATIC(SpeeNylectJ
26t
DURING YIELD TEST teat)
�
Depth of Completed Well 160 f t
in feet below Land surface:
SCREEN
LENGTH OPEN TO AQUIFER fleet)
DETAILS
SLOT SIZE
-
DIAMETER (inches)
IF GRAVEL
PACKED:
Diameter of well including
giavel pock. (lnchesl:
GRAVEL SIZE (inches) Fi4om (toot) TO (toot)
I I
•T►I FWM LAND SURFACE!
1 FORMATION DESCRIPTION
Drilling in overburden (c
Sketch erect tota,,.On of Well Wi! :R di$OnCes, to at least '
two permanent landmarks.
ici i i� Ili i
0 19
ay and boulders
a- - —`- - - -- _ -- -- - - -
� r
Hit solid rock at 19 ft.
19
30
Drilling —set casing —grou
30.
160
Drilling in rock
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
-
r ,
rc)ia::ei.� oL l :uild�.n• Mu�t.i i
i l ,r�l
Y . . •
.. .
C:+'
Ldiild' C 0 1 1:i tru C�Vc d by y Seption •
it on - Street . _ Block
'! d 1`Ype Lot.
GUARANTY OF .'SEPAR \TE SI:•,A, GE SYSTE "I
X represent that I am � :and e��? y responsible for the lcc�ltion;
;manshio, material, :construction, and draiawge '.of, -t11e se-,.rage ,disposal. 'sv.siem
,Di- the above described property, and that it has -been 'c-onstructed as sho::n on
approved plan or approved amend„ lent thereto, and in accordance with the standarc':s,
!s and regulations of • the Putman` County`.Department of Heal;:}i; and hereby guaran
lle •o:mer., his successors, heirs . or assigns; to place in gcod op -crating conditio:l
part of -said system constructed, by me: c•:hieh fails .to operate, for a period of.tL o
,s :.immediately follc:ing the'' date of initial use of the sewage disposal s;l.s :en, . or
repa Irs made by_.me to such s }stem, .except' where the failure to operate, properly
�nuse�� .u�• .111d' Willful Ur IIL-Y,LL ;tii L L% tii 'ChE! o%: �UPCAAS t, vi Ll «r ✓ui1411� .. a . i1Yw1•b
The undersigned further agrees: to 'accept as eonclusiv` i•11e determination ,
:he Director of the Division of Environr:ental Health cervices of the Patn�:m Ccu;.
trtr*enfi of Health as to whether or not: theailur:e of the s�ste��� to ot)er�tte :tilas
;ad. by the 'willful or necliaent act of the occupant of the building utilizing the
3-9 Signature_
. t?
.d this day of �L�'.�e, g G
• Title
corporation, give name and. adui.'e�s
:E (3 }. COPIES ARE REQUiPZED .11I Tit TI IRE E..(3) COPIES OF FINAL PLANS' BEFORE CEI:TIFICATi.
VIPLETION I•JILL BE ISSUED.
ZANTOR TS PROUIRED 'TO. FTLE ;NOTICE Or DATE Or FIRST USE. OF .MSTE`i.
- - - - -- ----------------- - - - - -- �---------- - - - - -- - -- ----- - - - -----------
'-sion of Environmental 11calth. Services, Ntnam• County Department of. health
a' PUTNAM COUNTY DEPARTMENT OF' HEALTH
Division 'of Environmental Health devices, Carme% N Y. 10512
CONSTRUCTION PERMIT. FOR SEWAGE DISPOSAL SYSTEM
Town or ill —age „
i .
Located at t:�l. '� " Section /� Block '
r? Subdivision/ Lot Job
Owner �/�✓a Address - _ -�QX—
Building Type ��T —/. /��C/ =� Lot Area s .7 -I ``'
�iJ Std
Number of4"Opesp"s fE�� DES /eS�l! J SEo eN r �.P Total Habitable Space. Square Feet
f Separate Sewerage System to "consist of Gal: Septic tank ✓�� lineal feet X ✓� width trench
'To be constructed by� ..— .Qi�/�iy,� Address
Water Supply: Public- SupPiy From
` k. " Private-Supply to be: drilled, by
A��ddr��ess ► A . . /.��/�. .
Other Requirement T`�1�����1�.���� Awe�.,,�RE.4t EsTA�F' a�FioE
�CT1lA� ,c<p by. jro /3E L Ess' Ti5/�N Off? /'iN y va��, I
I represent that I am wholly and :completely responsible for the design and _location of the';proposed systems) 1) that, the separate Sawa a disposal system_
9
n the 'a'
above described•whl be constructed as.shown qp t ppr6, ed amendment -there to and m accordance with the standards rules an regulations o e,. Putnam i
County, Department `of Heaath, and,fhat on completion thereof a':' Certrficate of 'Construction Compliance" eatisfactor to the Commissioner of Health will
Y
be submitted .to-•the Departmeht, and_a written guarantee will be furnished the' owner,'6."'successors,,heirs or assigns by the builder. that said builder will.
R
place
in good; "operating_:condition any, -part of;:said sewage disposal system duri the period of -two (2) years immediately following thedate of-the issu -.�
ance: of the approval _of ;the 'Certificate -of Construction` Compliance of `the o ` al system,or'an. y repairs- thereto; 2j'that the_'drilled' well. described above
wih belocated'as shown,'on'the approved plan and that said,well will be install r accordance with` a sta Ards, rules and regu a ions of ;;.the 'Putnam` '
;County Department of Health
2
Date � '� Signed P.E. JG —'RSA.
i
r Address License No. 'APP.ROVED FOR CONSTRUCTION This approval expires one and-,is' }
p ygar from the date issued struction of the building has been undertaken ,
'_evocable for .causvor may be amended or modified when considered necessary by' -the Commissi of Health. Any change or al4oration;of construction
quires a new ermIt. Approved for disposal of domestic y a to supply only. J
BY Title
0
I+ T)t, :,11 CI
Insp . by :
n"ITIAL SINE ITISPECTIOId
Yes
No
Ccmments
ProPerty lines or corners found .
.
Can estimate house location
_
Will driveway need cut
Must trees be removed -note these
Is deep hole r.elpresentative of entire SDS area
_
Additional deep holes needed. . . . . . . .
_
Sufficient SDS area available considering.
• dr:iveway cut, house location, separation
distances, etc. ..
_
DEEP HOLE DATA .
Dapt h:
lr:ater elevation:
Rock elevation:
• Soils descrittion:
Date:
FINAL SITE INSPECTION Insn. by:
House.located where shown on approved plank ...
s
.. t. .art !r.. (.r11 1.4 u-e f�l�- :J T11 }' %+1) \,yfr
3 00 .. ._ .. .. '.' _!... C• w�
Width of trench average 3 i
Slope of the line and trench acc --ptable
Room allowed for expansion trer_cI^es .
Over 50 ft. from swamp, :•ratercourse ...
_Natural soil not stripped or SDS area
unnecessarily graded . . . . .
10 Ft. . trrsintair_ed from prop -line'. ar_d
20 ft. from house . . .
Separation of trench from house, Drell
etc . follows plan .
Number of bedrooms checks .
Stones, brush, stumps, rubble, etc. greater
than 15 ft. from nearest trench . .
15 Ft. of peripheral soil horizontally from
trench . . . . . . . . . . . . . .. . . .
Junction boxes prope_,ly set
Gotild- surface run off from L driveway, roads,
ground surface,. etc.. channel near SDS
area
Does lot drainage aorear 0.K. in area of SDS
FIND GRADING OF SITE ACCEPTABT E
I j - P-7�. eA. -" v-t,- -
FUTAUlM COUNTY DEP ART��f;�IT Or ?�1 ?ACTH
D LVISI01`d OF E�?`TIRO�?I�1TsTdT/lL iI11'1 211 SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10.512
DESIGN DATA.SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM, FILE NO.
Owner Az!O_ 5 Addre s s�
Located at (Street) Sec. i --Bloc Lot
'� k '(Indicate e nearost cross s r
Municipality Watershed L• e:57z r tr
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
r0
Number CLOCK TI?,ii: PERCOLATION PERCOLATION
apse M-pth to Water Water Level
No. Time From ,Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
ice, l
r
2 a:3e! 3:100 34 l,p �� `� 17
Q
3
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 mad-e from top of hole.
1 /7 .7.•3S/
/7
174. '
17
r
2 a:3e! 3:100 34 l,p �� `� 17
Q
3
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 mad-e from top of hole.
e,s.j 03k
THIS SPACE FOR USE BY FEALTH DEPARTP I T ONLY: `'`:�j� ►ri +'``'��
Soil Rate Approved, Sq. Pt /Cal . Checked by Lbte .
76ST PIT .DATA REQ,UIMD TO 13t,: STJBP /7TTi,D 141.11 APPLICATION
DESCRI�"r101d OP' SOILS ; ?;CCU1` ?`a'•'iP,1?D ;N j'ES7.' IiOJ�ES
DEPTH HOLE, NO. HOLE
NO. HOLE NO.
G. L.
,
6r► T'o /75 0 /Z-.
12"
18"
2411 511- % -Y
30rr
36" _-
42"
48u.
54'''
.60"
,
6G" S /•c T -e 0 r4NP
INTICATT LEVEL AT ITHICH GROUND WATER
IS ENCOUNTERED /Vo/l/j!F
INDICATE =, \/EL TO WHICI: WATER LEVEL
PISES AFTER. BEING ENCOUNTERED AICI a
'PESTS MADE BY DA,tcoc� �/r fcr
7-3 Date
DESIGN
Soil Rate Used/ "Drop:
S.D. Usable Area Provided
No. of Bedrooms Septic Tank
Capacity 900 Gals. pe .
'
Absorption Area Provided By300 L.F.x2411 ST"— ���`���'� >>, rencl.
dame/
.Signature r-_
Address ` l7Y /fL� Mi4�t/d.�l D
SEAL ; >; °•a, : _� _ .. _......
e,s.j 03k
THIS SPACE FOR USE BY FEALTH DEPARTP I T ONLY: `'`:�j� ►ri +'``'��
Soil Rate Approved, Sq. Pt /Cal . Checked by Lbte .
=W
v� LL.
A
TIE7
, 7,
-70 4q9 ram
/Vo
y-WX -
LE 74
Z)
Cfx%�-eelCI-7--D
3oo, r7
3.T /LE % 11DED -500
1-7-11
90 gc.
% . I.
OF
04