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00764
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
ADDRESS e- 7
LOCATION
OF WELL
(No. a Street own)
(Lot Number)
PROPOSED
USE OF
WELL
KDOMESTIC
11 SUPP Y
BUSINESS
E] ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
❑ CONDITIONING
❑ TEST WELL
❑ ((Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED
AIR PERCUSSION
CABLE
❑ PERCUSSION
OTHER
❑ (Specify)
CASING
DETAILS
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
THREADED WELDED
O
YES
NO
CASING
YES
nUT
NO
YIELD
TEST
❑ BAILED
HOURS
PUMPED COMPRESSED AIR
G.P.M.
YIELD (G.P.M.)
O
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST [feet) +-
Depth of Completed Well
in feat below land surface:
SCREEN
DETAILS
.
MAKE
LENGTH OPEN TO AQUIFER (feet)'
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
!,
4
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE.
DATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
iW
June 16, 1978
Stepney Water Laboratory, INC. Date Rec' d 6Z1 8
22 WOODLAND DRIVE Date Tested 1 8
EASTON, CONNECTICUT 06612
268 -5163 Sample No. 2224
REPORT OF EXAMINATION OF POTABLE WATER
Type of 'Analysis: For C of 0 X Bacterial X Chemical
Name of Owner: NORMAN McGRATH (Andron Construction)
Source of Sample: COUCH ROAD, PATTERSON, NEW YORK
No. Street Town
Date Collected 6/15/78 New Well X-:. Old Well Stream
Type of Water: Untreated X Treated From Distribution X
Reason for Examination: CERTIFICATE OF OCCUPANCY
Technical Data
1. Chemical and Physical: Color Odor Turbitity ph
Nitrite (N) Nitrate (N) Ammonia (N) • Chloride
Iron Manganese Fluoride Alkalinity
Total Hardness ABS Sulphate
Lead Copper
2. Bacteriological; Membrane Filter Test
Coliform colonies per 100 ml NONE
3. Conclusions:
X a. Results of analysis of this sample are satisfactory and meet the
requirements for a potable water XXXXXXXXXX . (BACTERIOLOGICALLY POTABLE)
b. This sample is not satisfactory since it does not meet the
bacterial requirements for a potable water
c. This sample is unsatisfactory as a potable water because certain
physical. or chemical constituents are above acceptable limits. These are
as follows:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Special Comments:
S PNEY WATER L 0 ORY, INC.
By �Cons� a `G. L nardos, M.'Sc.
Director
Approved Public Health Laboratory
License No. PH -0446 '
QWA0x-1--qP`?A-r41*oFor FUTC1154
CI6
4
NIT
ma'd
1A 0
GUARANTY OF SEPARATE SEWAGE- SYSTE14
...I represent that I am. wholly And completely rqpppnpjbjC for the
1094 qrjM4xxph1pf m drainage of the #qWggq
w material., construction an
diappa4l lyptem' serving the above described property,: and that It
has boon
oo4structpo As shown on the approved plan or approved amendment -thereto,
and-in accordance with the standards, rules and regulations of the P4tpam
County J?ppartmapt of H eAlt4 and hereby guaranty to the owner, hi
heirs or assign-go to place in good operating condition sops P ion Any part of
said pygtpm constructed by me vihich fails to operate for a period of two
years .9414tely following the 4AtP pf initial use of. the Pewago 4isponAl
system : or An mad by me to -such py except where.the f
-y rppairs 6 A
A made I . _ - - willful such_ -4 t failure
-to - ov * t pr6perl s caused by the willful or qeg116ent, act of tho. o
p4nt of the building utilizing the system,
T agrees. to accept as 0onpliasive
The Undersigned further _the 00."
of the Director of the Division of Epivirprmiental Health $or,
Vices -of the Putilwn County Pop,artment or Nolth as to whether or not the,
rA t ure' tt tho:. system -to.opemte was capped by the willful or negligent
49t or the Qcqgp4nt or the building utilt;Ipg the apsteftk-
ID044 f 9 Signature .�
Title
T7 Porpor4flon, ."04m
91 VQ e
And address)
" -0 -M " '" " " " " " " " - M M " " M " T. M - M M "M' - - " " W 0. - M " "
THREE (3) CW14a ARE R.ECAUIMM WITH Tgng (3) COP ES OF FINAL PJAM - AEFn!RE
CERTIFICATE QQ ISSUED
I:M? _.TION WXLL BE
GUARANTOR 13 1HED TO FILE LOTIC4 OF �ATE OF FIRST USE OF SYSTEM,
P Won, Pf B
01 Povimumeptal Health $Prvioeap put;lam County Department of 11041th
PUTNAM COUNTY DEPARTMENT OF HEALTH
Divisionof '. Environments/ Health Services, irermel N.' "Y 10512'
CONSTRUCTION 'PERMIT_FOR SEWAGE. 'DISP.OSAL SYSTEM TT lll�
7 op or illage
A
Located at ILlov-VAL J f� 1= 1�-�, Section Block
Subdivision Lot t - ( Job 7 Z A,4
Owner A i14L RACE �' �/ 1 A.i♦ Address
Building Type
R � Lot Area
Number of Bedrooms �' � Total .Habitable Space• ,Square Feet �
C O CO lineal feet . X' ' , L�
Separate,5ewerage,.System to consist'oIf IG7ri Gal. Septic Tank width trench
To: be constructed .by. Address
Water SuP,PIy: Pdblic.Sdpply From
�.,
--)(_:Private'SupPly to, be drilled by
Address
Other. Requirements' .
a
0
lrepresent'that l am wholly and•,completely responsible for the design and ,location of the proposed system(s) 1) that., the' separate sewage disposal system
ati�...
ove.described ' wiil be constructed as shown on the approved amendnientahere to and in accordance with the standards, .rules an regu a ons o �' e Putnam
County Department of .Health, and,that on completion thereof a "Certificate of Construction Compliance" satisfactory .to the.Commissioner of Healthwill ) `.
be' submitted to the bepartment; ;an'd. a .writtbn :guaraniie will be• furnished the owner, his successors, heirs or assigns by the builder, that said builder will
, ..<
place in ;good operating' condition any part of said .sewage disposal - system during the period of two (2) years Immediately following.thedate of the -Issd
ance aof the; approval of ;the Certificate of Construction :Compliance . of'the original system or any repairs thereto; 2) that the drilled v✓ell described above
will -be located as shown bn;the approved plan and that said well will be. installed. in 'accordance. with the andards, rules and regu a ons'.' of the Putnam ;
County Department of Health
Si9ried cS� RE./�— R A
.. -
i Address License No. � /
a+ f in �
g E,.G/
APPROVED *0* CONSTRUCTION: •This. approval.expores one year from the 'date , issued unl co uctio n. o the building has been undertaken an is
revocable for cause 'or may be amended or modified . essary. by the Com iiongr , Health. ?Any change or alteration uction
4 t.
ires a` new emit prove disposal o f dome�3wserTlT ge
requ
1:
.Pft—�•_,
r Oate BY Ti „
-. - -- _._ ... ..... -
tl
0
PUTNAM COUNTY DEPARTMENT OF, HEALTi'
r a — Division of Enwronm`ental Healt h" Services, Carmel N.
CONSTRUCTION PERMI FOR SEWAGE, DISPOSAL SYSTEM
- '� - Town or Village
Located at Section Block
Subdivision Job
r.
Owner - Address oc-
Building Type Lot Area
Number `of' Bedrooms=" �` ' Total Habitable'? ace Square Feet
Separate Sewerage System to consist of ®0� Gal Septic Tank _ line feet X width trench
To" be constructed by Lam/sY.{ Address
Water Supply: 'Public SuPPiY From
_Private Supply to be,.;drilled by
Address
Other' Requirements - X "
I represent that li am :wholly;ano completely responsible for the design andaocat h'e ,propo- d. system(s);`, -) tha the, separate, sewage disposal system
above described:wiil be constructed as shown on'the approved.,pmendmentAhere to'andA accordance with'the andards,.rules an regulations o t e u nam
County Department of Health, and that'on completion thereof a,!Certificate of .Cbnstr tion Compliance'• satisfactory to the Commissioner of Healthwill
be 'submitted to the ,Department `and' a,-written- 'guaranted._Wjll be`furnlshed ,the,owner, his uccencirs, heirs or assigns,by the builder, that said builder will
place in good' operating.'conddion' any part of said Sewagedisposal system'duri a period ofawo (2) years immetliately following 'the date. of the issu
ance of the! approval .of the. Certificate-,of Construction Compliance of;..the' ' i " system or any - repairs thereto; 2) -that the drilled well described above
willTbe located.as shown..oq, the appro.yed; plan- and- thatsa id well will be install' accordance' witn'-'the sta ds,` rules and.regu ation's "'of the Putnam
. ,
County De artme of> Health. ;
Rik R.A.
APPROVED FOR CONSTRUCTION:— This approval ei
revocable for cause_ or may, be
Date .�`• .. amended-
dsmposa eod f ;
wlh
requires a ,ne i l rf.t
-
Er
K
License No.
prtes. >vW,1 ye from the A issued u struction of the building has been, undertaken and is
onside necessar, y is ' of Health. Any, change 'or alteration of Construction
n_e Ai hit. ry`sewa d /or °pr to ' drily.
T it I
0
is
t
AJTNAM 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.
Address
Located at (Street Sec. Block Lot
n ica e nearest cross street7
Municipality. Watershed C� ,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMIA WITH APPLICATIONS
Hole
Number'
CLOCK TIME
PERCOLATION
PERCOLATION
TET
No.
Elapse
Time
Start -Stop Min.
. p o a e.r
From Ground Surface
Start Stop
Inches Inches
WaterTevel.
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
lz
5
l
A:6 4-7
t
2
2
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 made from top of hole.
DEPTH
G.L.
611
TEST P. A REQUIRED TO BE SUBMITTED,WITH APPLICATIt
Dj�_. _PTION OF SOILS ENCOUNTERED -IN TEST HOLES
HOLE NO. HOLE N0. 'p;2 HOLE
A�
4
1211
1811
211'."
3011
3611
4211
4811
5411
6011
6611
7211
7811 Z,
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TOMBICH WA ER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date
Soil Rate Used-7 Mirv1 "Drop: DESIGN S.D. Usable Area Provided J 00o �-
No. of Bedrooms Septic Tank Capacity "W "s. �►IP9
` IW1
Absorption Area Primed By L.F.x24 mss` •� �$t� Fel nc
PM
Address
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by
PE 043$$
Date
P,
Z
APPROVED
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