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01735
Date'
,.r.6,cernTy,inac ine,sy
� attached):Nand �n-,a
Date �'�
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
*71. Division of Environmental Hoalth Servicos
COUNTY.OFFICE 13UILDING - CARMEL, NEW YORK.
+tF..s--to- _he- comvpjtf,t:.y !Iad,rtlier •and su• te irtment.tagether. with laboratory repot of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction comp lance is issued.
REPORT MUST RE SUDMITTED V71THIN 30 DAYS OF WE'LL COMPLETION
OWNER
NAME
n
7-ADDRESS
LOCATION
OF WELL
(No. treot)
(Town)
(Lot Number)
lROPOSED
USE OF
WELL
L�' DOMESTIC
SUPPLY
ESS
D ESTA6l SHMENT
INDUSTRIAL
C� FARM
C� CONDITIONING
CI TEST WELL
(Specify)
DRIVING
EQUIPMENT
'
ROTARY
L1 AIR PERCUSSION
D PERCUSSION
Q OTHER
) .
CASING
DETAILS
LENGTH (feet)
20
DIAMETER(inches)
6
VIEIGHT PER FOOT
1: g
0 THREADED ❑ WELDED
RIVE SHOE
• ®YES ❑ NO.
WAS CASING f"OUTED?
[2 YES U NO
YIELD
TEST
BAILED
HOURS .
PUMPED ® COMPRESSED AIR 2
G.P.M.
5
YIELD (G.P.M.) '-
5
WATER
LEVEL
MEASURE FROM LAND. 5URFACE —STATIC (Specif fact)
401
DURING YIELD TEST fleet)
i
'total draw
Death of Comple!ad Well 420
in feet below land.surface:
SCREEN
MAKE
•
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF RAVEL
TPA(C KED :
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches)
FROM (feet) TO (loaf)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
overburden
Skoteh exact location of well with distances, to at least
two permanent landmarks.
t. —.-
O 10
DEC 19
JOHN H.
10
420 -
led e_..
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
5/22/77
0
BREWST R LABORATORIES
Box 224 - BREWSTER, N. Y.
WATER ANALYSIS REPORT
SAMPLE NO. 3992
SOURCE: Richard Gregory
Hayt Road
Patterson, N.Y.
COLLECTED: December 5, 1977
By: Harold Haviland
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
faucet - well Lot 1
This result indicates the source 'of the sample was
of satisfactory sanitary quality when the sample was collected.
December 9, 1977
0 per 100 ml.
OR 4 I
°'JOHN IL— 'i 0 F'.�
H. PFR
'R4 Bickwit P. E.
Director
4 1
Geraldine M. & Richard J. Gregory-
CA
L %t1% .7JIV ✓sue,,. � �.' �� (�,,./ `Q
W��a� �a� ur�..,��r d u ri,�;.... un d p�. • . � -... . _ _
John'C,ai o
Maspernic Realty Subd
Hayt`. Road
V100 .40a, Toot
Frame
o wo
QUARANTY OF SHFARAT4 SEWAGE SYSTEM
I ropmont that I am wholly and eQmpl-otely reepRns0-1P for 044
tr+�r ar ships m+�terial� Goo,str4ption and dr4, gage of the AWa
�diePoaal. aymtem eerving the above doagr .aed pmpertyp P.P4 that it hes bapn
c,Q �tz'uQt�d ae ShQWn oil the appx'aved P�An or 4pprOVed _ endment thereto,
and. in atceoxc lee with the standards ru�.es And regul4tIone or tho 1p,
ount o a 't 9nt o ea .t4$ .and hereby guaranty to the owner, hi. p s oce .
aars.: hobo or.as.si,gus, to Pla0,a in good opera.tin 0anditlon any part of
said optom Qohstruotod by tie which fa to Qperato eQr a por%od of two
yoAV1a 94140e1y following the dgte of initigl use of the sewage di;sposatl
systemo or Any ropairs mado by me to 64,01 sy'stemt expept where the >failktro
to Qpe!ra a px'a erly is Qaused by tha w ,].l 'ul or th1 x e Popp-
Pont of .the 44,114168 utilizing the ayptam,
Choi imderai.gpad Further agrees to apoept as oonglu,ei,va the 49"
gyra Lion !9f the
Director of the 01vi4ion of k�tr� raru�ie�zai. Hea th $sr
of _tha . Fgt.A a. -.CQ ty. T .e aartme�?r.. , � �.� ..th R g. to whet -b r HY w
•- - -_- ,.. .. .. , .Qf .. ,.� - -� - the .
•: ;C411mve PC tho 'system to .operate waa osused by the w iilful or ne i��t�t
act oil thy. ± �a uwit of tho bial .d4ng >At$xWPg the pystQm,
And address)
ql a ! W RT dP ai R► A ti ® A ep +4 �n A sr tv Om A 1q1 1A a RI !R 1!R R, W R R or W
( 3) M143 HE WITH .TH t �� c_k' k' NAL, F A t PMAX
GUARMTOR R UZRE TO FILE Q' CE OF aA�E OF FIRST UsE OF aYSTa�±t�
wD + Z'�}"q' R!Re'+►'Tn 4e"'7�' fi?!aTr �FwT�"*!..� !!l?!7*�� M, � Mvl MIMI P.M—�t.
�► �r ee n Rn er .n .+� ens e� .- w e� e+ m 24 S1 m ai ee 0" m I" w 4A p m m 0.e
i,uilof Eviszta�+a1 thrviA�>t�><ot�reprtt 9�,a�,
'uGl -d'Y U'1 [IG 1'1, v ni�.Ildiu v. ul oyvly
weer or rurqFiser or u ng
John Calbo
Bq7lding Conatruotfd by
Hayt Road
oca on tree
Frame
Muldirig Typo
I�PLL�: 1:a Vii
Municipality
Maspernic Realty Subd.
ec ott _
Block
2
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 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 guaranty to the owner, his succoo-
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 $or"
vices :of the Pl�txtatn.•rc��.n?ty _L?epsrtapn° of :ley:
Ch as to �,ahothar o.= ;iot ttie
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system.
Dated this ,;
day of IN CL_el�eeeej9 7 signature
Title D
corporatidn, g v® name
and address)
THREE (3) COPIES ARE REC4UIRED'WITH THREE (3) COPIES OF FINAL PLANS j3EFQU
CERTIFICATE OF COMPLETION WILL HE ISSUED.
GUARANTOR IS RE UIRED TO FIRE '`Ty'`QTICF, OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental health Services, Putnam County Department or Heal
PlYPFAM C01rr4',1.'Y n;:.PARTr:r. ?;'r OF 11R.ALI'li
DIV'FSION 03 ];i;Vlli�)':i`E "i'I'.AT, I!1?A7 !'Ii S'a�VIC1 ry
.CfJi)i�'�`Y _ OFFICI . rt?: t >>I, L'7, _ C,'� t� ;L,,. �T _ _:Y_r: ? �?`1] {'
DESIGN DATA SHEET- SE FA RATE DISPOSAL SYSTEM FILL NO.
Owne �4/,•�Q ��,�,Caal Address, dv� /Pair ,yr•/,t14 p„Lg/�/
Located at ( Street - � � 6 I,ct
In. ca � 2 - -_
:� ��:.res cz °oss st1°ee:t
Municipality Wat•ershcd_C�o.� - --
SOIL PER ^vOLP:`I'IO ?' TEST n'.'TA RrnUIRrD TO B� S�iBiL ^`.I' ? „J lrl`.i'?i r1 ?';'1:IC:.�'.l''t0-':.`.'.
Number CLOCK TI1,75, PT? RCOLATIO''v L PERCOLATION
Run Elapse D�pE zi o •rarer -- Water Le. vo
No. Time From Ground Surface in Inches Soil Rate
Start -Stop D';in. Start Stop Drop in Mein. /in drop
Inches Inches Inches ,
IT fz-
4
L
3
Notes: 1) Tests to be repeated. at Name depth'unt.il aI>II>roxi.mately equal soil.
rates are obtained at each percolati_on tcst hole. All data to be submij,ted
for i,ov:i.ew. .
2) Wpth measurements to be made from top of hole.
DEPTH
61.1
THO"T
PIT DATA 11,0 N";
1'19'11
AIT1.143AT'I"014
OP ',O'IT,'.,
I 10 IIP n.
2
]MLE P10.
1211 1
'00"V4,
.2)111
30-.11
3rff
4211 S'd y
4811-
5411
6011
6611:
7211
7811
8411
,.ICOC
Jj\'DTCATE Ix' A -17 1, 1 FL C -11 G"• 0 U 1,1• V, A 3 1 S E' TTTERED Alone
INDICATE L0kFEIL TO LATER 11NEL RISES APT' '!,� R 11 -3 T,,' I N G ET�"COI)-,*,TI!,Pi"ID/1/0,)o
TESTS MLADE BY A,, 1,1111AA i A 7- 40qfm,.o� .—A
— — — -------
S.D."Usable Area Provided —��f
No. of Dadrooms-1;ee,0 Septic Tank Capacity l000 Gels. qype A/If X
3611
.Absorption Area Provided Fiy� L. F. x24- -1-h10
—width T-rei c
Other
AYI 3"
MV a I I —1c John H. Prentiss, P E 1 r P A
Address F.I.P. 65, Box 353
rrirninl, NY 10512
THIS SPACE FOR USE BY 142AINJI DEPARTIILE?IT ON
Soil Rate Approved Sq.. 11T./Gal.
4
Date
1. 1
'j
')- 5`3 -` "k'
S _SUR -T" `DATA -.
OWNER:y�'ti/ LOCATION Street: ra r:7!a
Town, 7 -'L -� ^County:'t, +LT — .__State:
Sri $`OIVI'SION
M'b p
Block_. LOT N4 y
r ` Survoyor:.
Drawn _ Date Scala Job—'r°
G //;% JOHN H_ PR ENTISS PE Dwq.
s, - .
tru CTure localed,,tr'Dnf sure Dy, Suf Y @_yAr no((tte��.d `below -, l_'�.1 17_
-
Well located by: Surveyors survey.—
Well drillers retort
En- gineer's m®suremepts.0 _
Tank, poxes ", pt9s,golterms S laterats located. by :Conteoctnr:
Engineer--,
-
He0Ithdapt: t..i
Field,: (nspectton.by: Health deptcl date:.
Enggneer date
��
NOTES:
I% .�e•?131 1+ �.. M.` {....li!.;6'. a<:.. �tk,..�: wi�M. �,'- .i..l'<Y "�t...i r*.�� �N.t �"r u.�-
b LM;E:N SION -S
r
1
A - 8
'` ' r'j
A_ C _ 3 t �i - C- ti s _
A - ._.__$.- G
A H
o
A J _— - - - - -8 =J =z_ M- - - --
o
A - K _=�T_B - K.
OWNER:y�'ti/ LOCATION Street: ra r:7!a
Town, 7 -'L -� ^County:'t, +LT — .__State:
Sri $`OIVI'SION
M'b p
Block_. LOT N4 y
r ` Survoyor:.
Drawn _ Date Scala Job—'r°
G //;% JOHN H_ PR ENTISS PE Dwq.
s, - .
` 1
II° TY�IGAL CURTAIN DRAIN 3)Tig Joint pipe Prom sepnt tang To osiw "" 'm vuwes TYPICAL FILL SECTION F1R SLOPING GBOWNU
_Ag -- 4 8a loa to Insure equal distribution may be required, - - -- —
1111 SECTION -
SCHEDULE NP 4 4 hol e e
Ota JL s
Tank insidelengih��'3 p
Tank inside wiaM_
Liqu id Isve1_
Field 4
Width - --
N�IaIerals
Length
I N boxes_
'10 pi=p Cry £fihr Fill section zot r -- ��8 I�
Gal r— Goi /SgFt /Days 9
ruo
- �r�••"` ` , i.S long
Date t
� s`�- d` °• 3 wide d N ee I'7 7 D(
The
current Health Code of the own /Vil
whicht� this t•i-nstailation is to be constr
l
� 8 with in all res-)ects. This applies als
e. v approval; pew`tit issuance; and the field
cation.
qA
2. wa to r� 11
' a.�ater is from auhlic sup4l,y
b. If a private well is shown, .it zhal
eordance with the current Rules & R
9" VillaneiCit,,lCounty;TState; by a corn
driller trho w411 obtain the ne €e>ssa
a a 7
°. 9 / D /' ti•'l + t' wi.e^'i• reouired :cell.: test log. 4ecterio
cation is to he obtained b/ the dri
I t•� �" i �, ®t v JIJo 7� install ed.
.
I / / /' i , tt .4. i• (�) (1 �113'�r�.y� 3)
P sz\ o c+. r o T t►
�` •..t � 5�„�,y4• "C�„c* ` � io i,. , �c��-�R�V��+
J•. ..d i:, ',� : _ I,. _,'.� ,�,G.�.P P 't�., P. , V �t �` i.p`��. r .. t% AIa 6'�fr WQ(I :(�:',%1. ; /COi_ O"F
A.
4.
, ( to Revisions
1 >y 'Z i . a-�' - n 5 N ° Date _ ^
1 �� A N TARX SY�T�M
OWNER �t-
— �EtE/hL.�i.tv:f�._ ��4�K-!�•iZ.tjV_i
LOCATION Streat :_4L� -2 _
oun C
ry
\ r 1 p Qaa¢ESS1UMn N SUBUIVISICN
�o 1k, PRFryT \4q Af1 a
1 _
srm 4 BIG cic'- - -- — - — LOT T
Builder: -- — - — -
.,, Surveyor:?: Houso