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�C RT[FICATE--DF,-.0
�STRUCU ON COMPLIANCE dkA -
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otateai at Ms on
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Jeffry 'S
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qp�raj,p, 'P�4400, 5y*te7(-- a U j
77
_ j .,. -D ia me r ,x'Z IY.Zhe.,pquemeni, ,
";,--YyateF: SYPPIX, . Public -S!Apply,frdm fis
X 'Drilled
,, Private Supply R chards '
t.
Building Frame;
Has ..
76ontrol" n
!be� " completed? ''�;-Now
, I
"
d N11 6ir tify. that-toqsystem(i) ailiii6i
-and :1 ' the standards ;.-:rules 'a and regulations;
j,9,7.3
](7
Date -C&iifWd
Address -3
J
5
:Any , person occupying premises ie.r,v-ed,by'- the .'Ot?,PLve�-,-syit'e', kors�hqll� P,!,o
;,conditions resulting .from such usage ;Approval.'. of _the ,.:§e
"',.aviii Mile and`the:.app:roval :0 iii6Zpifvate water ater stipo�,'.sfialll'"q inp;ip'
subiect;to modification, or ,
Date -Q l 7 71:
.1 7
VR-T,MENT..0 F —HEALTH
dah mal N y;- ,10V2
E DISPOSAL AMST EM, RattorSon
Town . or village
:5079Z
Pat
trench'
lir66kf
ti
k,siihtlally. 0
led ,-.,'- and the
'M
eke such 8Ct
,t4M).ihalP b
6 Id" ',Weh#ii f Heal
ier
X19/72
."
' 'W of I�h ich are
5 shown
�','On the plans �611t'�V'
�e.oei t the -Ouiniiiil lCounty,, p9parji'ment of ;Health.,'
X
—7,
17"
29*201;
ion as inay -4,
b' e necessary th- e" ,
'correction
of ,any unsanitary
ecohelnul' and :,vo_ dasf soon :a a,{pubiic - n t ary; s6wer
becomes
6'-
public, 4pproyals are
h, such'"revocation, .mod atlon%br changenis necessary
t'A
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7
WELL COMPLETION REPORT
3/,71
PUTNAM COUNTY DEPARTMENT OF.HEALTH'
Division of Environmental Health Servlces
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 C�n
J cc/r 1.
ADDRESS
LOCATION
OF WELL
(No. & Street) (Town,)�l (Lot Number)
61A f" S h Q , IY�•c -�- Y�- uA✓fi[ la �t 5 O/V
PROPOSED
USE OF
WELL
BUSINESS
U DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER
EQU PLMENT
ROTARY
❑
COMPRESSED CABLE
AIR PERCUSSION ❑ PERCUSSION ❑ ((Specify)
CASING
DETAILS
LENGTH
eJ o (
MET`E` R(inches)
W/ ES �.
HREADED ❑ WELDED
SHOE
MYES LKO
CASING
YES
0
D
NO
YIELD
TEST
j y HOURS G.P.M.
❑ BAILED El PUMPED Ln COMPRESSED AIR
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
93
DURING YIELD TEST [feet)
i
Depth `of.Completed Well
in feet below land surface:
SCREEN
MAKE
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 FEEL
v�
sr
d.
ti
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE+%
/q�
;334
1 %
DATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature) �'%
�. e 5
Owner or FurchasleP o Bui ding
Building Constructed by
Location - Street
y7tw
Building Type
a Q ,ess!A.
Municipality
Section
Block
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 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 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 building utilizing the s
Dated this day of Acw% 4&c 19,12., Signatur
Title
If corporation, give name
and address)
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.
R�
.�t
1� 1
r�
Division of Environmental Health Services, Putnam County Department of Health
e
r
BREWSTER LABORATORIES
Box 224 - BREWSTER, N. Y.
WATER ANALYSIS REPORT
SAMPLE NO. 2964
SOURCE: Jeffrey G. Stark - faucet - well supply
Brimstone'Road
Patterson, N.Y.
COLLECTED: June 8, 1973
BY: J.G.Stark
BACTERIOLOGICAL EXAMINATION
Cohform Count, MF Method 0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality whtn the sample was collected.
June 9, 1973
jur� g a �9a3
Bickwit P. E.
Director
r �
q� PUTNAM COUNTY DEPARTMENT, OF .HEALTH
k , ' Divaion;. of Enlrironmental Health Services `'Carmel;. N Y• • 10512•
�.
Patterson
PE -.FO
"CONSTRUCTION ;RMITR SEWAGE: DI$PQSA'L SY$TENI,rr.,
or' illege; ,
Bri
.Lo�atetl at mstone Hi 11 Road _ =
Section Block
Subdivision
,lean S egaL .SUbd: of 2` Jdb
- - 4
Judi th &Jeffrey: Star -k W-., :-,96th .Street
Owner - y ¢
r Address X27
;BUilding Type , Frame;.. A ►Ba
dot 13 :358aA� New York, 'New .York. 10025
umber Bed "rooms One *.» *pesJ9' for Three r �x Total Habitable Space 2077' - Square' 'Feet
. Y ..'.10.00 r - ` r -
.., . .. _
Separate Sewerage System to consist of _, GaI .Septic Tank ', •lineal �feet_X width trench
`To be ,-'constructed 'by Address
F
Water' SupPIY. Public `SuPP•,IY 'From a k
Private` Supply', to be drilled •by
71 • € ! _ y. -
�� Addres ;� w r
'Other Regwrements 8� ame te
Di .r x peep 7 -1/2' " SeepageaPi, -ts Two (2)
1 represent that_I am wholly and completely responsible foc. the desi-gn and location of the ,proposetl aystem(s) 1). _ihAt' •t Fie separate sewage ,disposal system
,; above :described ;will.be °constructed as sfiown on the•approyed amentlment:;there to and �n accordance wdh tfie stantlards, rules an ,regu a cons o " e' u nam
�,::Coiinty 90eparfinent of- Health,'!. and that onrcompletion 3hereof a. -= Certificate of'Gonstrucfion Compliance ';'sat:sfactory'fo' the Commissioner of „Health'will
'.'be submdted fo the Department, and ewritten, guarantee will be furnished the ;owner his successors, Reirs or assigns by the builder, that said builder will
<` place''•in goon operating ,contlifion any part' +otesaid sewage disposal isystem during the period of two -(2 )`years rimmediately toll owing. the date of the Issu-
s' >will De•IOGated asshow,n Orl the approved plan and'that said wen wi�l'be instalfed'`.in'
Countyr;Depaitment of 'Health ati,
7/ 14x/72
,Date , Signed
Address
APPROVED FOR CONSTRUCTION Th`°is approval ,expires one year fromthe dat
revocable for cause or may be amended or modifiail when considered necessary by•
S2 ` ;requires' n'ew'- permit', Approved for "disposal .of domesticic sandar� sewage ;a r
.Date : By
0
-C
stem or any repaird, thereto; 2)'that, the drilled well described above
lance with. the sta ards,, rules and ,regula— oT�ns of. the `Putnam
P.E. X R.A.-
- °
,z ` . • 29206
Y,6 51 License, No.
Id unless'konstruction of'the building has been, undertaken and is
iornimssioner
pt. .Heatth ,Any change o`r alteration of construction..
ri rate wafer'supply;
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 e%tp Address ;,,, -Anklme AAW
Located at ( Street /; /�„��/� /e.r Sec . Block Lot Q
indicate neares moss street)
Municipality 1* as* Watershed
,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
RM apse Depth 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
x 4
Notes: 1) Tests to be'repeated at same depth until approximatelyy 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 HOLFS,
DEPTH HOLE NO._
HOLE NO.
HOLE
NO.
G.L. '
6"
12"
18"
' .2411
s
3o It
36..
42,'
4811
z
i 54 it
60" Aa
7211
84 cA
INDICAT LEVEL AT WHICH GRO
WATER IS ENCOUNTERED
AA%*Q
' INDICATE LEVEL TO WHJCH WATER
EL RISES AFTER BEING E%TCOUNTERED
A0641
'PESTS MADE BY
Date
Soil . Rate Used a- Min/1 "Drop:
-
DESIGN
S.D. Usable
Area Provided'. /0 006 •
No. of Bedrooms Oaf Septic
Tank Capacity /v.OV
Gals.
Type Of
Absorption Area Provided By =-
L.F.x24" 36
width width trenc .
Other Tyed
Name o n ren iss,
Address R.D..6, B. 353
Carmel. New York 10512
THIS SPACE FOR USE BY .HEALTH DEPARTPZENT ,
a°
Soil Rate Approved Sq..:
��
Date
j,:i ,.
A
.V,4
;a
Q C ( C
AMi :OUf\,TY
OlPT. OF HEALTH
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