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BOX 14
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e u 1Ure)Izn e�� aL ,1:u l ling. Mur �,ul ily:..
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Idir,d Coniitzructed by Section •
tivn - S Free t Block
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ldirg . I`.YPe Lot,
C1)ARANTY OF. SEPARATE SI-vIAGE SYSTEM
I represent that I am wholly' and COMOletely• responsible for. the 'lccation;'
kmanship, material, construction:.and .draina e of the sewage .disposal s_vs,.tem
vino the above described proper i; and that it has been :constructed as sho...n on
approved plan or approved amendment thereto, and..in sccord:mnce with the standar _s.
as. and reo lations of . the Putnam County D`partmient of Health, and hereby .Cruaranty
L-be •o:�iner, his successors,. heirs or assicns., to place in g c o d oP_- ratiT•c*,r.,cond? tio:i
part or said system constructed „bV.me -,Which fails to. operate. 'for a period of t:•:o
rs irnmiediately follc ;ino the: date of initial' use of: the sew e disposal. s %step, or
.irepzirs made . by rye to such system, .except t here the .failure to operate, properly .
'.iat1JtU -UV lire willful Ul' lrE'k':L1'^{C111 t11:i l►f. IJle ou%.;UPcaii� vl �+t: L11i14i1.b Na ..pia. —..p
The undersi -ned further "• acrees to accept as conclus_;Vt the det'ermin::tion :.
_the - I)i2ector of the•...Division_o_i__Env z,oTm—n. al }Icalth. Services_ off. t.,e_ Patn�_:r.
irtr -ent of Ifealth as to whether.'"or "'not the •failure. of t;7e syste,i� to operate a =as
C! by the coil" iu1 or ne ligcnt :act of .the. occupant ,the building utilizing ie0
Lem
�d" this day of..` 19 Signaiizre
Title
• (ii. corporation, give name and aui�zes:
ZE (3) COPIES ARE REOUiP D 11IT1I .TIIREE (3) :COPIES OF FINAL PLANS.- BErORE CERTIFICATE
:OMPLETIO\ I -JILL BE ISSUED. -
MNITOR TS RF.OUIT"ri D TO. FILL NOTICE OF DATE..OF "T'IRS1' USE OF SYSTEM.
-------------------------------- --------------------- - - -- -- -----------------------
- . .11 .
WELL COMPLETION .REPORT
3/51 0
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This.,Eep ,M:is t ®sbe:gomplgted;•by.,well:_dr tL-r and submitted--to.-County.- Health'.�DepartmentLtogether� with =laboratory - report -of
V 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
LOCATION
OF WELL
(No. 8 Street)
a Rd
(Town)
Patterson N.Y
(Lot Number)
PROPOSED
USE OF
WELL
® DOMESTIC
F1 SUPP Y
BUSINESS
❑ ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
F-1 CONDITIONING
❑ TEST WELL
❑ (speHEfy)
DRILLING
EQUIPMENT
® ROTARY
® A R PERCUSSION
❑ PERCUSSION
OTHER
❑ if )
CASING
DETAILS
LENGTH (feet)
20
DIAMETER( inches)
(�
WEICT§PEQ F�T
�f e 4
'j
EJ THREADED ❑ WELDED
DRIVE SHOE
YES ❑ NO
CASING Qj ED
MYES L7D NO
YIELD TEST
❑ BAILED
HOURS
❑ PUMPED ® COMPRESSED AIR 8RS
.P.M.
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
18
DURING YIELD TEST [feet)
350
Depth of Completed Well
in feet below Land surface: 37
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 (loot) TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
0
3
Lo
& sand
3
374
d granite rock
If yield was tested at difFerent depths during drilling, list below
FEET
GALLONS PER MINUTE
100
200
1
275
3
374
5
DATE WELL COMPLETED
1 '"
DATE OF REPORT
- o
WELL DRILLER (Signature)
1.../
l .
4
BREWSTER LABORATORIES
Box 24
SAMPLE No. 3180
SOURCE: Raymond St Martin - faucet - well supply
Bullet Hole Road
Patterson., N.Y.
COLLECTED:
BY: Frank Carroll Well Drilling., Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
May 89 1974
0 per 100 ml.
Roy B c it P. E.
5
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In
r , APPROVED
r
Z. L,P J JAN 161974'
"UTN�AM�iOUNJ4 ..�1�FHEALTH
8Y % /.,i+!�% .......................
DIVISION OF
i ! - `k'lPnNMENTAI HEALTH SERVfM
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j a f
q PUTNA
' Division of
x CONSTRUCTION'' PERMIT FOR SEWAGE` E
Subdivision 1 '
Owner
' Buildihy TYPe
Number of Bedrooms
I - Separate Sewerage system,,,to cohsitt of
To be constructed. by 3
Water Supply ?ubllc Supply From
t
d Private Supply to,'be drill
µ Address . 3 _
T t ,
Other Requirements i r
;I represent'that I -am •wholly and- coinplete�y fresponsit
i atiove describetl `,will be constructed -as shown °,on the al
County Department of4 ,Health and that on comple
COUNTY aDEPARTMENIT OF HEALTH' =
vironmental` Health- ,,Services` Caine% N Y 10512 ' 4 t
Y
4 '
�OSAL `SYSTEM
Towa� ow ygp s, 3..
Address
Total .Habitable Space
l
Square Feot '
Gal Septic Tank r �o lineal feet X `
.-.
width trench
L
by � r t
cc
{ { ;2y5
7 �
PUTNAM COUNTY. DEPARTMENT CF HEgL •TH
DIVISION .OF ENVIRON'VMT.TAL .HEALTH_ SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. ..Y. 10512
r
DESIGN DATA'SHEET- SEPARATE SEWAGE DISPOSAL.SYSTEM FILE NO. "
Owner R,41%yoAip S; ,. 4L1ffD,1y Address UL,L - 1,(o4 12,C A D
Located at (Street ), Sec. Block Lot
(Indicate neares cross street)
—
Municipality 1,914 T %/ZSaiy Watershed Al ,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
5. t
1
3
W�
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.
Hold
.Number' CLOCK
TIME
PERCOLATION
PERCOLATION
Run
No.
Start -Stop
apse.
Time
Min.
Depth to Water
From Ground Surface
Start Stop.
Inches Inches
Wate. Levei
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
1 CAS X19
4�
/3 Gk
—
152
, 73
2 ..30 . 3/
�'
/3r .?
i� •S;
31
/e
5. t
1
3
W�
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 SUL3MITTED WITH APPLICATION.
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. -�.L� HOLE NO. HOLE N0.
G.L.
6++
q
24" V /� i�( 2 N /�/
5AA10 �e -1'2wA-4
48"
5411 •
60►,
6�"
84"
:INDICATE LEVEL AT WHICH GROUND WATER :IS ENCOUNTERED
- INDICATE- -:LEVEL—TO -WHICH WATER LEVEL. RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date
DESIGN
Soil Rate Used :,r Min/1 "Drop: S.D. Usable Area Provided
No. of :Bedrooms 3 Septic Tank Capacity 90Q Gels. Type
Absorption Area Provided By f (a L.F.x24" b"— e width trench.
Ottier
Name, Signature
Address SEAL
THIS .SPACE FOR. USE'. BY HEALTH DEPARTP T, T. ONLY:
Soil.Rate Approved Sq..Ft /Cal. Checked by Date.
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