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HomeMy WebLinkAbout1637DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.13 -1-44 BOX 15 I I INNS 1 IA . - � IN J �� T 1 I 'T17' , NO , L r ; ON . I FI 01637 `WELL COMPLETION REPORT � PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 f' Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK lfiis' report is;to be dompieted try Well-driller aind'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 I . ADDRESS LOCATION OF WELL (No. 11 Street) (Town) (Lot Number) PROPOSED USE OF WELL ® DOMESTIC ❑ SUPPLY BUSINESS ❑ ESTABLISHMENT ❑ INDUSTRIAL ❑ FARM ❑ AIR CONDITIONING A ❑ TEST WELL El (Specify) DRILLING EQUIPMENT ® ROTARY COMPRESSED AIR PERCUSSION CABLE ❑ PERCUSSION OTHER ❑ (Specify) CASING DETAILS LENGTH (feet) �'r DIAMETER (inches) to WEIGHT PER FOOT . ,/ THREADED El WELDED DRIVE O ®YES F-1 NO CASING YES NO YIELD TEST ❑ BAILED ❑ PUMPED L4 HOURS COMPRESSED AIR O G.P.M. p J YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) V7 DURING YIELD TEST (feet) ., r Depth of Completed Well in feet below Land surface: (� 1 SCREEN DETAILS MAKE 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 a V ' If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPORT WELL DRILLER (Signature) --'-- a , I Owner or Purchaser of Building Building Constructed by 1) t &(-t U 1 Zvi evu f, Location - Street Building Type Municipality Section Block Lot GUARANTY 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 -i•t• ha-s.-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 guaranty to the owner, his succes- sors, 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 de- termination of the Director of the Division of Environmental Health Ser- vices 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. _ da Dated thi s � � - . Title If corporation, give name and 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 Healt4 Servi es, Putnam County Department of Health �s�t ate; ► %�� �n r� �� BREWSTER LABORATORIES Box 224 - BREWSTER, N. Y. vy, 'Vil .did sAimu No. 2821 SOURCE: Jerry Imbo — hose .bibb ffilluieu) Driue Carmel, . N.Y. COLLECTED: BY: Frank Carroll BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 0 per 100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. Not), 89 1972 '-Aoy Bickwit P. E. Director �pFESS�p�q •� '. , IOL r, �� 10, �pFESS�p�q •� '. , r, �� � � �� � '�•i��re,O � : �o _ pA epg� pp� ` ,,++Q. v Ns:vw. .ia•f � .t i .•r I ��..! t }M S�• �• .:.ta �:�y �. t •,...J._., __ _ _ ...� t.._�� }�I PLJTNAIVI �OiJNTX DEPARTII�ENTt® iALT �I Division of; End iromm�ta/ Hea /thy Services, Carmel N Y ,10512 COIVSTRUCTI;ON PER -MIT _FORSEINAGEDISP „OSALSYSTEM' 4' � • Q/ Located =5t Section ¢ _ 2,5 5ubdnrisioh tLkN 7. Vr �t "© Address —/utic ",Building.Type NIAo -Q, LVumber of Bedrooms Total Habitable Space Separate: ' Sewerage System., to cotl5ist of ���% :Gal Septic Tank lineal �fe To be constructed by Address' s x r Water Supply "Public Supply From' Pnvate SupptY to be drifted by } Address` Other Requirements a I represent that 1 4 m wholly and completely: responsible for the design andrlocaUon of ;the proposed - system(W 1). E above described will be constructedas shown on therapproved amendment there to and - �n accordance with the standar "" f ''`H Ith "nd that on nom let�on thereof a 'Certi icat'e of Construction Compliance saUSfa r W r Nn or a �Ilage �- = -'Job.. tluJ � � +� •. 7 Feet width trench the "6eoerate 'SEwaae: disposal 'svSfem : i, County Department o _. . ea a ,• be submitted =to'the'Departmjkq and a `written guarantee will be'Alinished the owner his successors heirs`br assigns'by the;bwlder that said bwlder will place m good operating ;condition "any ,pait of said sewage disposal system during the period of two (2) years immediately`= following, ^thedate''of the,issu;;. "; ante of "the approval of the Cerfrf�cate ofu Construction .Gompl�ance of the or' system or any r ;'drilleiJ•'well described above - ,. will tie located as shown on`the approved plan and That said well wUl.'tie insYalle” ccordance *Ith the _stan therstou?est andt regu a ,ions- of '.the Putnam , x County Depar ent Health 4. Date o, y ign �R a q S ed P;E A Address License No T APPROVED FOR CONSTRUCTfAN This';approval expves one year from the date issued •unless construction of 'the 'bu,ldmg has been undertaken and is ti- for -cause or may be amended or modified wherFCOnsidered- necessary by the Comm ner of Health Any. revocabte 'change, or alteration of construction requires a:new permit Approyed, for disposal of, domestic sa a e an or puv water supply •only 4 Date `E ®� BY `��'` emu.`•" r• • l Title - PUTNAM 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. 5 -,-12 -- ( -4 4- Owner CsC e Aub { f­k. 0 Address . ` tc. � ���a ; RA O ?Nc- Located at ( Street) 01 ea Otety � P> Sec. '� @� Block 7-- Lot ( 'Indicate nearest cross ss ree ) Municipality � Watershed 'SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS ,5 2 4 5 1 .. 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. Hole Number CLOCK TIME PERCOLATION PERCOLATION No. Start -Stop Elapse Time Min. Depth to Water Water Level From Ground Surface in Inches Start Stop Drop in Inches Inches Inches Soil Rate Min. /in drop 1 tc7 . I {a'• k 4- 4 XL / 3lo:4S 10''56 P 4 SA ,5 2 4 5 1 .. 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. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST, HOLES.... DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 611 lop 1211 18 It 2411 3011 -.0 It 3611 42' 4811 54 6011 6611 7211 78, 84" :-INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LE VEL__ TO WATCH WATER LEVEL RISES'AFTER BEING ENCOUNTERED .TESTS MADE BY � ,- A_ —1 E—Ensi Date Is DESIGN Soil Rate Used -ii2to Nan/1"Drop: S.D. Usable Area Provided— S,00,0+ No. of Bedrooms Septic Tank Capacity 080 Gals. Type HAS. Absorption Area Provided By.740 L. F. x24 d e !r nch. Address 34 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft/Gal. Checked by ............... Date ss®ee WAA4 iv I tF '+ 5t . N � 4� {� � � { ve « i 'kY w,!J 1_ °1ii � _ -f • � . EnpA,vSio✓ + i ^r 1F al. lS1rS aI r ;? h" ! j t -tJ ft, iVN wd, ti. 1 ! x 6 R, L 11 VE i S - - JuN6�iA'rl < �%kl all i � ,eE 3 /DEaCE i 1440. �� � � uv'k,. , �.'' ' •« LE ✓E, L , i a1.D rA -ci t p op 'If 1 _ Mfrs af7. ! - +l - - AnrK ✓aucTroN � p� tr �M14 .:'Y; { �E..F: l�: SE T/t �f • }O3 J / +_• gYj,EPA ft) Ft' ;'r`.v- aYfi,J :'f'[D IN 1.1Ct(.hC4t`"C , R 4 ,E .iJ!.r '�FjiJ F,- pF N6AL�'F{ I i c�ys Ci IVt MALL N ,T 8k: �Cr4FILLED UNTIL_ P,"_ i',.t r{ rTY ?jr ti,t,ty j r A +tV Lh A `fnE 0C AL HEAL.F CEi APPROVED a r •IR r,• Q - lii, 1 �3 I y r . } �.: FE B 1972 r, pQAtap S <'' Of HEALTH - s. {9 p PUit J.vl FC3R .._G.E.RAt.4.. (.Mf5C3 • :. '... • ,. .. r +.. .. v . ' H !EALT RVICES.' q. ^ ENIRO NME V NTAL v �:.,...� .. PRn �'; gOFlr,r ! .nom, '. �Od`Qp , :/O � .�vv`v`E IYF rr'� ^`;"' "": ".,.•"."...� � 19t3t)L 4 ?Tg' i � �.. J / �^�'} ��S�P�� RTHU �Y` . 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