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HomeMy WebLinkAbout0556DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -21.3 BOX 7 I,yti , r. I or ., '. ti f - r , -m 17 A 00556 BRUCE R FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road -Brewster, New York 10S09 1 oil M 1_► LORETTA MO ARI RN M.S.N.. Associate Publi Health Director Director of P nt- Services ATTENTION: ❑ JOSEPH PARAVATI GENE REED All information belgw must be fully completed prior to any scheduling. DATE: ENGINEER OR FIRM: e..t PHONE #: REASON: DEEPS: PERCS: ,K PUMP TEST: a ROAD/STREET: (o (o TOWN: TAX MAP #: SUBDIVISION: �, f t7nrn iaA ' Adi , e, , b Arty nom, LOT#: 3, OWNER: (`�,r�Yie nn�). `fir YYltx et NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES NO ❑ X Proposed SSTSwithin thedrainage basin of West Branch or Boyds Corner Reservoirs. fl Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 13 Proposed SSTS design flow greater than 1000 gallons/day or SPDES Permit required. ❑ ( Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine., the NYCDEP project status (Joint or Delegated) based on the response. If you answered X�g to any of the questions, NYCDEP mast witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: a-: D CON04ENTS: (FIELDTEST) AM: coG: . ; Sheet 1 of_/ - PUTNAIVI COUNTY DEPARTMENYOF HEALTH ;. ,. Lz. 'DIVISION Or ENVIXtONMENTAL HEA T LH 'SERVXCES FIELD ACTIVITY .REPORT `z z ` Town State .r Zip_ ,,Street PERSON IN CHARGE DR TNTFRVTFWFT) ?ii ,�y ' �^ `- T)atQ' _ 7, Name and Title :. TYPE OF FACILITY : }��,OOS� �iST 1�2. '- isu jn- FINDINGS��� �0��4�c�r�vi— %J��.- , c- Y z x v � 4 x- .,,. �. .yam - - .., -- w :r - - - - T - _ Y � � r c: -.- - - , ice` v Signature and Title C'FTVPD - ,. -� � : i � • e" - RFP(1RT RF BY.- I acknowledge receipt of this report: SIGNATI7RE: 02196 �, r Title, - _ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 1vto re-, - �� Address 6j, F Located at (Street) Tax Map Q-3, Block ! Lot a (indicate nearest cross street) Municipality sec -_t� Watershedr�s SOIL PERCOLATION TEST DATA Date of Pre-soaking /�'o j Date of Percolation Test 7 /!� �� NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth ,to Water mater r Grou d F om n e L vel Percola on tt Run Time I1Ia se Time Surface (lynches) Start_ drop Zn Rate Hole No No Start Stop �n Stop Inches M�nllnch 121122- 2-19 2 73 2 33 3 a:��- 3: -E 3® 9, 3 PL 6 a ® /A 4 5 2 943 - �LI'32 4017 JX- ;_s 3 6.413 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES HOLE NO. HOLE NO. Z 7, 5' HOLE NO. Indicate level at which groundwater is encountered a ME' Indicate level at which mottling is observed Ala yt Indicate level to which water level rises after being encountered Deep hole observations made by: �p Date /; Design Professional Name: Address: Signature: Design Professional's Seal 6 'PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES INITIAL. INDIVIDUAL/ GGA SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project M& J- ek County Wk Site Loc Building'construction begun13 Extent Is property within NYC Watershed? ................. EZr Yes F7 No SECTIONS. TOPOGRAPHY (Please check all appropriate'boxes) 1 =�rlly- Rolling Steep slope [ Flat 2. E. Evidence of wetlands Low area subject to flooding Bodies, of wat er .=.Drainage ditches a Rock outcrops -3. Property lines. or corners evident....... .............. I ....... ......................... Q Yes �No 4. Do water courses exist on or adjoin the property? ... ........ I ... * ............. Yes �No 5.. Will these . affect the design of the sewage system. facilities ?............ Yes No 6. 'Do watershed regulations apply in this development? ........... ........ No El Yes 7 Will.extensive grading be necessary? ................................................. Yes [?!�No 8.. Will extensive fill be necessary for SSTS?, ....................................... a Yes- -No' .9. Do filled areas -exist within the SSTS area'? ........................................ =Yes No. If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: and 0 Gravel a Loam Clay Hardpan F7Mixture 11. Observed from: 0 Borings Bari,- cut excavations 12.. Soil borings/excavations observed by on V/2 0 L2 13. Depth to groundwater AjaA.14 on 14. -Depth to mottling A&Aegc on 15. Are test holes representative of primary & reserve areas ....................... .............. E 16. Soil percolation tests made by ',Zy.517-AE Z6AJ 4, on 17. Soil percolation tests witnessed by on , SECTION D (on back) 0 Form ST -1 t SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? 0 Yes -[�J']No 19. Will groundwater or surface drainage require special consideration? .................:... 17.Y. s rZ<o 20.. Will gullies, ditches, etc., be filled'and watercourses be relocated ? ......................... Yes EZfNo SECTION E. REMARKS. 21. If a common water. supply is proposed; has an inspection been made of the existing or proposed source and facilities? .................:.............. ..:....::...................... Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist ?.. ......... E5yes a .No 23. Additional comments 24. Site observer /inspector and title 25. Date(s)-of observation(s)inspection(s) T- /z /® -5 TEST PIT PROFILES Hole # Lot # Hole # 'Lot # Hole # Lot # Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp.. Depth to rock/imp. G.L. G.L. . 0.5 .0.5. 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 - 5.0 6.0 6.0 6.0 7.0 .7.0 7.0 8.0 8.0 ..8.0 9.0 90 9.0 10.0 10.0 10.0 Q 3 C O V U O �o kZ O Qa D C .0� h 0 N 1 Nom- Iv' • 7� E Q�'V /. 3 5 5" ��'t 0� Zoggg3 09a 9� 9kYE II s/o 7 gg. S2 °o0'W N AREA = /8.0.10 ACRES '�'arf 2. a' bough - N N , .0g cone �Zg•� ` A A o o v � �0. �N S SAP F F d dCw a N `• 1 Na F \ . b` well of � b DRIVE All certifications hereon are val,d for map and copies Ihereof only if said map or copies bear the impressed seal of the surveyor whose signature appears hereon. O SURVEYED & PREPARED BY �9 BUNNEY ASSOCIATES LAND SURVEYORS 3 FIELDS LANE, NORTH SALEM NEW YORK 10560 PH. (914)277-3404 N. Y. S IC. No. 48332 i 0\ '' 4 y2 COPYRIGHT C96 Bonney Associates, f Q" /Q ALL RIGH19TS RESERVED ��S- •r /� Unauthorized Duplicalion is a Violation of Applicable Laws Unauthorized alteration or addition to a survey map t bearing a licensed land surveyor's seal is a violation of i Section 7209. sub - division 2, of the New York State Education Law. The location of underground improvements or encroachments, if any exist. are not certified. 93, °5ubcYivision Mop O{ SCCfiOn Two - COrrT1 Fi /eI May 231 /96G os Mop N0. 2117A SURVEY OF PROF S/TuATE /N 7-HE TOWN OF PAT7 PUTNAM COM NEW YORK SCALE /" = /00' DA' Certi {'rcofion ' ` �� . `.�L^ (� NIF '------ � | ' � � - � | ' J � xAq 71 Ac±\ � -Min.- Sem"m" (Accessory)� ~m r---*ont- _ _ - Side:-� - xo - , Re°"_ _ _ � xr Fronmve.� . 225 � kox.'uuildin«_tf°ight:' - J8, � L�e�Tp~riou"uo-veraoe: lox | cmm ~_ | vmRO \ ( Nlf -- � ` POZZU TO -- -- .... - - -LO ` NIF '------ � | ' � � - � | ' J � xAq - �� �` �� -�_---� `_- � V^ | &\ ` 1' � 'Rear. � 71 Ac±\ � -Min.- Sem"m" (Accessory)� ~m r---*ont- _ _ - Side:-� - xo - , Re°"_ _ _ � xr Fronmve.� . 225 � kox.'uuildin«_tf°ight:' - J8, � L�e�Tp~riou"uo-veraoe: lox | cmm \ ( Nlf � ` POZZU TO \ / . � \ ' / \ � z | QD »eq" _Min. _Lot Area. /r^a Min. Lot .Width: 25C |���m~- � - � ,m"� - w' - �� �` �� -�_---� `_- � V^ | &\ ` 1' � 'Rear. � «n � -Min.- Sem"m" (Accessory)� ~m r---*ont- _ _ - Side:-� - xo - , Re°"_ _ _ � xr Fronmve.� . 225 � kox.'uuildin«_tf°ight:' - J8, � L�e�Tp~riou"uo-veraoe: lox . L � cmm "Pre-axistinowon-u=m""*g TEST PIT PROFILES - Hole # Lot # Hole #_ Lot # Hole # Lot # Depth to water 4 Id2 kfe Depth to water vt Jz Depth to water ©GC Depth to mottling AIv Q Depth to mottling. Alag 144c,, Depth to mottling e Depth to rock/imp. �- �- Depth to rock/imp. Depth to rock/imp._ 0110per ar�� G.L. G.L. G.L. T, -.5 0.5 15 1� 0.5 0.5 " 1.0 5 "Wt 1.0 1.0 2.0 2.0 , 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 © 6.0 7.0 -¢-V lQd��L. 7.0 7.0 8.0 A��a r5 -�-v �e 8.0 8.0 9.0 9.0 9.0 10.0 de`(. ©- TES, 10.0 10.0 Hole #_ Lot # --3 Hole # �S- Lot #. 3 Dole # Lot # .� Depth to water /%OU C-7- Depth to water 1U0)4,-Q-_ Depth to water /V tv e Depth to mottling Al in e Depth to mottling _ Depth to mottling _IVr Depth to rock/imp. �L - (o Depth to rock/imp. - Depth to rock/imp. t G.L. G.L. G.L... 0.5 0.5 ',, 0.5 1.0 1.0 .1.0 ���`�✓r6a 2.0 2.0 2.0 F` �� �q may � �, a ►y. 3.0 3.0 ,y 3.0 4.0 4.0 ,r < 4.0 5.0 5.0 , o y�l�ow 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 111121-7 TEST PIT PROFILES Hole # 7 Lot #_ Hole # Lot # 3 'Hole # Lot # Depth to water A/ Depth to water , /o kip Depth to water Depth to mottling 4Zd n -(0 Depth to mottling. n p. Depth to mottling Depth to rock/imp. �-2 f9 � Depth to rock/imp. = p ' Depth to rock/imp. . G.L. G.L. 11 G.L. 0.5 �6 ' 0.5 0.5 1.0 1.0 WX 1.0 2.0 /Ova � 2.0 2.0 3.0 6a UXX 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 AQW 7.0 8.0 8.0 � ►yea r s -7 b e 8.0 9.0 9.0 Gammoyr -r' r/ 9.0 10.0 10.0 /1/0 L3, ?Dc4. MFs *10.0 Hole # Lot # Hole # Lot # Hole # Lot # Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 0.5 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0 10 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 RECORD OF PHONE CONVERSATION Time: le a12 d Date: ie !gel? 7 Person calling: 0'2—� ,rr MQRE Phone #: 9-7 63 — 610 P Reason ( ) Inspection: eeps nd /or Peres: _ j QyI Scheduled Field Meeting Time: z e9,' '3 O Date: '51 ///'2' Ap 9 Y N Tentative /to be confirmed() ( ; Town:�� Road /Street: 1 J ? -- 21 3 Tax Map #: oZ Comments: Owhe r Rev 3/ 86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Ewbvnmentil Healtb Servk�ei, Csumel, N Y:10512 eer Must Provide "? t PCB D Permit M POSAL SYSTEM4. CERTIF7 'A P CONSTRUCTIOK COMPLIANCE FOR SEWAGE DIS /L{ To_ of V e i Located at o I r eJ T McPBlockLot, Owner/applicant Name p Form y Subdivlaion Name Subdv. Lot M_ �ZSo✓ . l 1ati� a � ZI _.hZ�(Y� 3d g[ Malft ;Address ` P Date Permit leaded Sewerage System built by 1 It C L Tn Adare.a Coualeting of Gallon Septic Tank and O Water Supplyi Public Supply From —� Address or: _" Private SupP_U Drliled bye• / �v�CD^ �r- Address f Bupdbig Tape (�, °'�• f c _HueErosion Control Been Completedl r Number of Bed oome Has Garbage Grinder Been Installed? � 0.tber Requirements I certify that.the syetam(s)_as listed, servinq the above premises..were'const pied esaeritially,as.shown . on he,plans of the completed work (copies of'which are Attached)r -'and in,accordanc'e *ith the stindards, rules and re ations, in spoor ce with fil p and the permit issued by the Putnam County Department Of Health` oats _� Y� [..� certifled by Address license No. Any parson occupying p►nrnlfas saved, by the above system(:) shall pro , take, such action as may be necessary to secure the correction of any unsanitary conditions resulting from such .usage. - Approval of the separate anAl aye stem, fliall . rise null -and void as soon as a pubt7: sianitary sews Mooinss .available and the.. proval..of the prlvate,,watsr supply shall become n 1 did when ublic water- supply beebmes available. Such approvals are subject to if ton or change .when,, in the Judgment of the Co ner. of H suety rev .. ton; modification or eMnge it ry. y /iJ /. pate `� By TIM . LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FAQ 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS July 11, 1996 Putnam County Health Department 4 Geneva Road Brewster, NY 10509 ATT: Mr. William Hedges RE: Individual SSDS Lot #3 Resubdivision Lot #46 Cornwall Ridge Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing S -1, "As -Built Plan ", dated 7- 10 -96. 2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 7- 10 -96. 3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System ", dated 7- 10 -96. 4. Well Completion and Well Log Report, dated 6- 25 -96. 5. Water Analysis Report, dated 6- 25 -96. 6. Money order in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. 0- -40 Harry W. Nichols, Jr., P.E. HWN:bd 93071 enc. cc: Mr. H. Lipstein w /enc. 07/02/96 16.41 914- 795 -2515 J T EQKERS6 INC WL'1.L VVi'ttl.JrtliJir ar,rwlas office use OnI7 DEPARTMENT - OF HFALTH Division of Rnviror oneal Health services Y puTNAM cOTJXTY DEPARTMENT OF RMTH NELL LOCATION OAS= r G;M njue X ' So wrsne Dr., Pattexean, Lot 3 23- 121.3 WELL OWNER NAME: Harry. Li,patoin AMRSS. 18r,81mc Cornwall Builders 2005 D w W ndmox NY 12350 USE OF WELL M RESIDENTIAL D PUBLIC $UPPLY O AIRlCONO,lHEAT PUMP 13 ABANDONED I- pdmary 2- secondary 0 BUSINESS C I FARM D TEST /OBSERVATION Q OTHER (specify) p INDUSTRIAL O INSTITUTIONAL 0 STAND-BY 0 iMOUNT OF USE YIELD SOUGHT - 9pm, /NO. PEOPLE SERVED - ___r --�/ EST. OF DAILY USAGE.. r gal. REASON FOR DRILLING 0 NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY 0 TEST'IOBSERVATION 0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WFLL DEPTH DATA WELL DEPTH - -- -..320 _ ft. STATIC WATER LEVEL 220 .�..tt. DATE MEASURED 5/14,.r�.... DRILLING L] ROTARY [A COMPRESSED AIR PERCUSSION 0 DUG EQUIPMENT 0 WELL POINT d CAKE PERCUSSION DYNER (SPOCRYlt WELL TYPE D SCRaw Q OPEN END CASING ® OPEN HOLE IN BMROCK 0 m" TOTAL LENGTH 20_ _ tL MATERIALS; V STEEL Q M AnC 13 Q' LENGTH BELOW GRADE 19 It JOINTS: p W411140 V THREADM 0 M. A CASING DIAMETER -6 - in. SEAL- d CEMENT EROUT 91 SENTONITE C]4Y}1d1 DETAILS WEIGHT PER FOOT 17 Ib.lft. DRIVE SHOE O YES B NO I UWEA: 0YE5 ONO SCREEN DETAILStcst D"Em paI nor s,t'f Lumpi lfl) o£PTtt1D SCRwi 00 90fl o t�teo GRAVEL PACK o Na size: OF P ACK In, OWN aft_ r<. WELL YIELD TEST ; If detailed p�Impin9 WELL LOG are a al"IDle Oa se�oattlltidaSCCriptiQns � amtpses JAM= U PUMPED tests were done w in• 13 COMPIi£5S£t► AIR ; formation attsched'w �, w,rar I ear fflAAtATWtd 918Cigflsgr9 ce!! o I ❑YES O Nt3 R, �;r Wtit, %M iL OUIRA;r W tmn. DRAWOO" 1'IUD "m- w 2 Clay 2 320 x 6 gru Granite 920 s WATO O MIM TEMP. QUAUTY O C,I OMY HAROMM Q COLOr1E0 ANALYM DY£A ONO ANALYMSATMHSY ia'YES ONO STOR&ON TANS.; TYPF- Wa11- X -Trol WX-251 CAP 19.2 GA�,. 62,0 O t>ataA� 3. T. Eckarr�oa, Inc. FUNP f fIgATIff .� U ra ble -- rAPACf1Y.. -- I y� lint 6 Va1_linl pM 300 moa0 L 4FO7G07 VO(YAGC,.13 (�p.2L4 Y- emu, 161.3 haute 9W Hilton. NY 12547 Vice Presi ent PUI'NAM C N-fY DEPAR24&gr OF HEALTH DIVISION OF ENTIR0NMEt7"i.AL REALM SERVICES owner or Purchaser of Building .5a- t•, e Building Constructed by S� �rry n Location -- Street pa4 Grc4, s /Municipality / Building Type Section Block Lot SG �✓p�f�ilSlGS " Go r �{(� Govt w4" /l�� Subdivision Name 5 3 Subdivision Lot r GU_ARAWEE OF SUBSURFACE SEStiZAG.E DISPOSAL, 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 sham 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 guarantee to the owner, his successors, 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 approval of the "Certificate of Construction'Compliance" for 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 occupant.of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environbantal Health Services 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 system. Dated this day of ; 19-IQ General Con ac or (Owner) - Signature at-L-Lli.J/ &,-1 Ide,,f Corporation Naze (if Corp.) Address rev. 9/85 mk Signature Title, S66 '2k4 Corporation Of rp.) Address � PU 1gAM '00U`r1'Y DEPA�fi OF REALM DIVISION OF E<NVIR0L1EAL HEALTH SERVICES Owner or Purchaser of Building S a' u, e Building Constructed by SnIVY 5:•' �1 Location - Street pa� c r c�, Municipality Building Type 0-3, l . 2EE-Zf 3 Section Block Lot SG Uki5Vtn — ZO Subdivision Name _ 5 3 Subdivision Lot z G(IkRA. -N= OF SUBSURFACE SES�MGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, wor)ananship, 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 Dot of Health, and .hereby guarantee to the ortner, his successors, 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 approval of the "Certificate of Construction Compliance" for 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 occupant.of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environi�ntal Health Services 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 system. Dated this day of 19� General Con ac or (Gwner) - Signature C,_yL-L 1-C, // ,��.�� B lje�Yf Corporation 'tvame (if Corp.) Address rev. 9/85 Ink Signature Title,1.��r LT L Corporation P_ (if rp_) Midress A N A L Y T I C A L R E P O R T RO iy 316 ;Jierion Arc-••.t �4ay.-OxQ1, N1 1251�` 5mvirdTeM (9 14).56.*,)gClf) L A . er 316 ;Jierion Arc-••.t �4ay.-OxQ1, N1 1251�` 5mvirdTeM (9 14).56.*,)gClf) Client Nave: ETL Sample Number; Client I.D,; Date Collected; Date Received: Comments; Federal Id: Collected by: Inorganics Analysis Data Sheet Form I - IN CORNWALL BUILDERS CORP, 162226.01 LOT #3 PA17ERSON TAP 21-JUN-96 21•JUN�96 PAID Project Name: STANDARD Matrix: 1 DrinkH20 Analysis Result Units Method Analyzed EC(1CI A3SEM7 ;" �100hi� 24 `JUN ,fib: Total Collform ABSENT /100 MLS 9223 24-JUN-96 Remarks: Sample passes NYSDOH drinking water standards. 3t5 Putirrhai A.��:.: EnvirdTest.i�2 r�14)562- s ISE DISPOSAL ICATEO ON TN /S PECTEO BY 1CCOROANCE ESZ114 YOIVS !NT OF HEAL JH -LENT OFHEALTH 0 r LOT 3 115 SHOWN n CORNWALL RIDGE" 'TY C65ReK 5 OFF /LE � L/O I 'L SEWE�2 ,N CLEANOUTlC /o) (rYP) L/a I W 3 hku I � I A Ex /S rl,r, I �' BE pe00� I ENfE j I 0 WELL I � , I I I ' � I S 00 00 - 00 III/. S. OZ' 00 . 00" W 7 AS- BU /L.T P /HENS /ON CHART (IA N° A B 1 50 15 C D z 10o 7z5 ._..._ 3 - -- 107 - /26 1/ 113 727 5 120 12 y 6 125 161 7 730 162 8 736 189 9 1y2 105 1a 105 0 11 111 71 72 775 72 13 121 73 NOTE: ,yaysE ANO WEcL LocATiO vS 8A "SUR ✓EY Gt< PRC7vEeTY" o.4TEp ✓e// PiFEP,gREI� BY BUNNEY fFSSOG /.4 cutnas %;uunz7 �° serif ,iatsion oY Egyir..Wntal ,zed so noted for conformance K vpro a and geguistions df kpp ble .lth Deis" Goua�y� S oz' 00-'00. VV NOTE: yvuSE AND L✓E�G �UG•QT /O/VS l3ASEp 4N "SUR ✓EY O!< PROPNNEY ��O �� TES 996 F- B Y B T,1 L ox �Va15� rutinsasY'�4ua al gear 'S� eiD` �ivisioa os with conform '. ty,9F Vqrv, ae noted f 1100lations ►pP th DeDaitmeat "C 11 � Tl t1• �Ae}t10 PROJECT : ®P PR( TOWNOF PA 77 CLIENT CORN MLA �J I. BZEKI TE-- BRAWING TITLE AS AS - BUI I- %' D /M�l�1S /ON CfPART </� �� N° A $ 1 g0 l5 C D 2 100 12�} 3. 107 y 113 727 5 120 .121/ 6 125 181 7 130 l82 g 136 18/7, 9 >y2 785 10 105 69 11 111 71 12 175 72 73 721 73 NOTE: yvuSE AND L✓E�G �UG•QT /O/VS l3ASEp 4N "SUR ✓EY O!< PROPNNEY ��O �� TES 996 F- B Y B T,1 L ox �Va15� rutinsasY'�4ua al gear 'S� eiD` �ivisioa os with conform '. ty,9F Vqrv, ae noted f 1100lations ►pP th DeDaitmeat "C 11 � Tl t1• �Ae}t10 PROJECT : ®P PR( TOWNOF PA 77 CLIENT CORN MLA �J I. BZEKI TE-- BRAWING TITLE AS