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01731
PUTNAM COUNTY DEPARTMENT OF HEALTH �AP
DIVISION OF ENVIRONMENTAL HEALTH SERVICE-
COUNTY OFFICE BUILDING, CARMEL, N. Y. 1Q512CP
DESIGN TA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM T,
Cr.
Owner _W k o v% Address OI 4
Located at ( Street � 5 Blpck 16. Lot q
indicate nearest cross s ree�•En Le*. #Z
Municips,lit Watershed �j►a•�M
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Depth to Water Water Level.
No. Time From Ground Surface in Inches Soil Rate
Stara -Stop Min. Start, Stop Drop in Min. /in drop
Inches Inches ' Inches
�-_• ��A 4
s s' ys"_ �� 9i�4 /y 34 ri -7
F
4
5
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 ENCOUNTERED IN TEST HOLES `
DEPTH HOLE NO.- HOLE NO. HOLE NO.
611 8
18"
211 " V.
3 011
3611
42"
48
5 4
6011 _
lose
6 It
6 film e-
t
7211 .
78�, . .
INDICATE LEVEL AT WHICH GROUND ER IS ENCOUNTERED Wa4e
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 00.**
TESTS MADE BY Date J�JV * '
~Soil Rate Used Drop: S.D. Usable Area Provided I* ° ~
No. of Bedrooms Septic.'Tank Capacity q* Gals. Type _
Absorption Area Provide By L.F.x24" width trench.
Other
Q�.pfESSIONA('F..tr.:
ti
lvauro — r 1 o o I� 4.. 1 1; e
Address R'C - 9a FAIR ST.
CARMLL. 12
THIS SPACE FM- USE BY HEALTH DEPARTMENT
Soil Rate Approved Sq. Ft /Gal.
M
No. 292'
� #cFSby Date
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Tank inside length-,
Tank inside widllh-
LAquid level_. 9
capacity_ -j-OQ4:t
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N-DOXeS 4—
Ft4l- section
Gal___- 5/S4*1
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PU-- Department Of Health
DiViBion of _Lnviroilm"tal ilealth BOXVIOGS
00 with
APP ns of the
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ofESSION4,
me
6 'TA
trucfure located from survey by surveyor noted belowo
1611 fl)Ccifed by: SurveYOr+:; SLIVPy.—
Welt drillers report
En It neef s mesuf erpt;rq s
at. it, vcxes, p,4 .;, galleries a lottiois In-catL-d t)y: Controct:w:
Engineer: Cl
H e 0 Ith do'pt:
inspection by: Health deptIR do I
Field Engineer date '—QC4-1184—
NOTES:
D I ME N SION 5-
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A X
ITARY SYSTEM DESIGN,."AS BOILT"
OWNIER:-G=
LOCATION Street:
�1 --F 7p— , �A-I A -
- �-PWAP P b
T a w n �e ,trg�. - 7 C of j r S t o I e
SO B Df\/l S-
ION:e-f77
'me P;LrA-y62,7
Block,._ —.LOT N°_
Bull de r:
D F a w n.: � , oti 'N
-- i4 _2
J O H N H, R E N T I S 5 PE Tw -
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 /% Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
jrhis 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.
_y 1. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
Nelson
AD
ADD c Road Brewster, NY
LOCATION
(No. 6 Street) (Town) (Lot Number)
OF WELL
SAME
BUSINESS
❑ ❑ ❑
PROPOSED
DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF
WELL
❑ SUPPLY ❑ INDUSTRIAL ❑ ❑
CONDITIONING ((Specify)
COMPRESSED CABLE
® ROTARY AIR 1:1 El
EQUIPLMENT
PERCUSSION P PERCUSSION ((Specify)
CASING
LENGT( &et)
7
DIAMET (Inches)
WEI HT PER FOOT
9 lbS
® THREADED ❑ WELDED
R
YES ❑ NO
SING �j ?
NYES ] NO
DETAILS
L
YIELD
HOURS 6 G.P.M. LU
BAILED
YIELD (O.Plb
GL VV
TEST
PUMPED COMPRESSED AIR
I
WATER
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST [test)
i
Depth of Completed Well
LEVEL
301
in feet below land surface:
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 of well wltlr distances, to at least
two permanent landmarks.
FEET to FEET
0
8.
Drilling in overburden
clay and ders
Hit rock at 8 feet
8
30
'�U`tE k, set
ccasi
-
A;-.1139,
_
Drilling in rock granite.
. w d
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
L
DATE WELL C]OAl L TEq$
/ �/
REPORT
D10/?9/8
WE LL DRILLER (Signature) /, r
4
V
fl
iii
Box 224 - BREWSTER, N.Y.
(914) 225 -2072
- WATER ANALYSIS REPORT -
SAMPLE NO. 5590 .
SOURCE: Kenneth E. Nelson Well Tank
RFD #6 Old Road
Brewster, New York
COLLECTED: October 29, 1984
BY:
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.
4f.•A
Ff
t
c
AAA
November 1, 1984
C i nd.: & KennAth N.64rnp Tax MaR 80
Owner br Purchaser of-Building Section
Owners 2
� u• ld ng, Constrzcted -by . -
0ld Road (A /K /A Edwards Road)
Location - .Street
Patterson
Municipality
Log
Building Type
9.1
Lot
Ernest. Nelson
Subdivision Name
I
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.._County_:nPna_r_tment. of_ Health :as, tb wt►etYiPrr...or__iaot...thP .faz:i -.._ . -.... u._ __.
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system....
Dated this 13th day of November 19_ 4 Signat
Title
brporati6n Name' (if corp.
Address
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PeRN7. B 9IRF7k
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM." "'J
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Health