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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-compieted-by- weit'driiier and - submitted to County Health'Departmenrtogether with [aboratory-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 N
NAME A
At A
ADDRE C
Ca `
`�� L/_5 7
7p4
LOCATION (
� 1
(N b. & Street) (
(T,o f •
• (Lot Number)
'PROPOSED D
DOMESTIC ❑
BUSINESS
FARM ❑ TEST WELL
DRILLING ❑
ROTARY A
❑ COMPRESSED ❑ C
CABLE ❑ OTHER
CASING L
LENGTH (feet) D
DIAMETER (inches) W
WEIGHT PER FOOT D
THREADED ❑ WELDED ❑
DRIVE SHOE C
O Y
CASING OUTED4
YIELD H
❑ BAILED ❑
HOURS G.P.M. Y
YIELD (G.P.M.) _
_
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Separate
PUTNAM COUNTY DEPARTMENT OF HEALTH,
Sewerage System - o j' ,
Municipality
CONSTRUCTION PERMIT
-- 4x /ria
Located at /�a�'soPa�es Block 3
Subdivision pzAfter Au Lot Job
Owner fr�H�� /LJa,;4Address g
a2„X';N,y, Lot Area /oDOO [
Building Type 1 alt
No. of Bedrooms 77.-ee Total Habitable Space 960 (oh /'F /.) sq.ft.
Separate Sewerage System to consist of loco-Gal. Septic Tank — h3a1 'ee -t
TNRE�
7O Ye �'Es
.To be.constructed by ? Address
Water Supply Public Supply from
Private Supply to be drilled by
Address
Other Requirements °
I represent that-I am wholly and completely responsible for -the design
and location of--the proposed system(s): 1j that the separate 'sewage dis-
op sal.s.stem above described will be 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 that
on completion thereof a "Certificate of Construction Compliance" satis-
factory to the Commissioner of Health will be submitted to the Department,
and a written guarantee 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 the date of the issurance of the approval
of the Certificate of Construction Compliance of the original system or
any repairs - thereto; 2) that the drilled well described above will be
located as shown on the approved plan and that said well will be installed
in.accordance with the standards, rules and regulations of the Putnam County
;Department of Health.
Date efZ1 2,Z20 Signed
APPROVED -FOR CONSTRUCTION: This ap rov expires one ear from the date
issued unless construction of the b ing has been undertaken and is re-
vocable:f.or cause. or..may be amended -.-6r modified..when.considered necessary
by the Commissioner of Health. Any change o lteration of construction
requires anew permit. Approved for disposa or
domestic sanitary sewage.
Date �5 /.3, /%7d By
Cam'
Hole
S
--
- Number
CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water
Water Level
No.
Time
From Ground Surface
in .Inches Soil Rate
Start. Stop Mina
Start Stop.
Drop in Min/in.drop
Inches Inches
Inches
or
-- 2
D,? 51 0 &Z!r ' 3 2-
4
4
S
l
2
Notes:
1)
Tests -to be repeated at same depth until-approximately equal soil. rates are ob-
tained at each percolation test hole. All data to be submitted for review.
2) Depth measurements to'be made from top of hole.
72T=
78"
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE. LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY &77* Date
DESIGN
Soil Rate Used Min/1f1 Drop: S.D. Usable Area Provided boo'
.No. of Bedrooms e Septic Tank Capacity 1d o o Gals. Type /y so.,
Absorption Area-Provided By. Other
Name �oh„ %� �r��z�.'s s Si-nature P c Y
Address SAL., T�Sf
a i
r
PUTNAM COUNTY. DEPARTMENT OF HEALTH
So i1 Kate Approved Sq. Ft./Gal . Checked by �E STAN
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