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01547
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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 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
NAME
ADDRESS
OWNER
James & Phyllis Salatino
RD 4, Rosedale Rd., Carmel,NY
LOCATION
(No. 6 Street) (Town) (Lot Number)
OFWELL
Stone Hedge Estates Bullet Hole Rd., Patterson,NY 6
BUSINESS
D ❑ ❑ ❑
PROPOSED
DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF
WELL
❑ SUPPLY INDUSTRIAL ❑ ❑ OTHER
CONDITIONING
DRILLING
COMPRESSED ER
R ROTARY AIR ❑ O(Specify)
El
EQUIPMENT
PERCUSSION P RCLUSSION
CASING
LENGTH (feet)
DIAMETER ( Inches)
WEIGHT PER FOOT
® ❑
DRIVE SHOE
RYES El
(W
R
CASING
DETAILS
30t
61t
19 1bs .
THREADED WELDED
NO
YES
NO
TEST
HOURS .P.M.
6R5 8/
❑ BAILED ® ❑
YIELD (G.P.M.)
8
PUMPED COMPRESSED AIR
WATER
MEASURE FROM LAND SURFACE — STATIC(Speclly /eetJ
DURING YIELD T
TEST [feet)
1
Depth of Completed Well
LEVEL
301 .
in feet below Land surface: 265 t
MAKE
LENGTH OPEN TO AQUIFER (feet)
SCREEN
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
Diameter of well including
GRAVEL SIZE (Inches) FROM (feet) _ TO (feet)
PACKED:
gravel pack (inches):
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location o/ well with distances, to at least
two permanent landmarks.
FEET to FEET
Drilling in overburden
0
10
clay and s
Hit rock at 10 feet
Drilling in rock,set
10
30
casing, gyouted.
"W
265_
Drilling iri rock granite e -
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
DATE OF REPORT
W e
10/3/84
11/13Z84
Owner or Purchaser of Building Section
Con �_CrVxl) r i 4NE5 - Lie -
Bui�1 - Constructe.d. by
U LLBT �v L, 1� Rct
Location - Street Lot
Municipality Subdivision 44ame
0Ne-
Building Type Subdv. Lot #
GUARANTEE 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 guarantee to the owner, his success-
ors, 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 determin-
ation of the Director of the Division of Environmental Health Services
...of-,the-Putnam CoUhty--Department of Health as .to whether or not the fail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
sakiaDated this =day of �1�,� ' 19'zLt Signatures L�4
Title 0 M r (,U-v
Corporation Name if corp.
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.
Division of Environmental Health -Serv'ces; Putnam County Department of Health
IE
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
�.COUNTY..OFF.ICE BUI- LDING,. CARMEL,,_R:, -..Y, ..
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Phyllis Jg. James Sc!�-�iv�o Address 19j It+ H-p1,e �ca�
Located at (Street �� Block L Lot
�lndicate nearest cross street)
�$l�he6�e a Es-6r&s" 54 d C 6- F; 104 Nap# 1784
Municipality P�goh Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to a er Water Level
No. Time From Ground Surface 'in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
4
—� o-
4
5
3 11110 11(3 3¢ Z7 3
.. 2 '1/( T 4- - -- -
3 L112 1 1 ZI ¢ 3
1
2 / /U��
PUTNAM COUNTY
DEPT. OF HEALTH
Notes: 1) Tuts 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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERF) IN TEST HOLES
G.L.
6"
12 ti
18"
�..�
2411
30"
� P�
42"
48
54"
60
66 "%
7211 til® 40 7/
78"
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
`-
INDICATE LEVEL.TO WHICH WATER LEVEL RISES AFTER BEING
ENCOUNTERED.' -'
-- -- TESTS MADE-BY Pte. <.l.:fl. P.i P/ ®���- - _
Date --
DESIGN
Soil Rate Used Min/1 "Drop: S.D..Usable Area Provided - 04
No. of Bedrooms Septic Tank Capacity 1000
,� �..�„ Type M _
Absorption Area Provided By_L. F. x2�+" ,�/`
Q��ssioNA�, h trenc
\A PRr,AV, Fr er N,6,1 P
Name E , ° ° Bignatu
[( ❑❑
y Stl o
Address L
.T)E%
N,
o-
914-272-61
psi o. 292
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: OF THE S1;,J .
Soil Rate Approved Sq. Ft /Gal. Checked by
Date
i
7-A h "(off-.IPl -coil lei
nl Q.
LA,-rGey A, • 7 L o � ox- * o_ i v iI L. C.
�rJK •al�!� �oxc --�, � I I
[loll PDX
i
(
I
A BUILT" 0A JA, .. _
Structure located. from survey by surveyor noted below®_
Well located by: Surveyors survey•_.__
Well drillers report
Engineers mesur9menta� -_
Tank, boxes, pits; gollerie9 d Io.terals Io;ca,ted..b.y.:Controetor
tl4 Enoaeer'S;v .
�? Health dapi;
Field inspection by: Health dept® date:.
Enganeer ® date LPy� I
77721' i
NOTES: i
I) To�(}iL LEIJG�f� o �u�'vb.tJ�cy�:YC: fl �41c -��
uivision of Environmental Ilealth Sorvicee v
Approved as noted for oonfornanco with
. il. oabj.o Vules r. id Regulations of the,
Pc Co ty Rea h D artnent.
ena turn k T 1 q q
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SANITAaX $Y5TEM C ii
OWNER: X.
yai LOCATION Street:
Town :�Str.l?r�}Counly:��TA}!I.-
Sue
Block., — _� -LOT Ns_I'Y2�. _
Builder:
Survey or.
�c_I�AQD
Drawn: Scale:1ti ?3a' Job,
;.°c,A2120
JOHN H PR ENTISS R�E•` l g a
CONSULTING ENGINEER
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