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HomeMy WebLinkAbout0518DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 15. -1 -39.2 BOX 6 I ru .. ... -:: -HA ri r - 81. .�� 'I �' ' 1~ ♦ '. 06 2 00518 A, fi —5 - E —0 Of ty qrr,orq?&!htW,-) Division �C RT[FICATE--DF,-.0 �STRUCU ON COMPLIANCE dkA - .L_ otateai at Ms on e Jeffry 'S - -- 4, e t i a -it nd6l s, Jr 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 'T 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 r "e \' yf�. � 4t.�': :fie`: r3 �' '« + \ `�,.:'`� ` �• Jj+ ` .. � iL . 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