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HomeMy WebLinkAbout1836DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www . s ca n y o u rd o cs . co m 631- 589 -8100 35.06 -1 -18 BOX 16 ;' '. r, . ; ;� . ,� `m. , r ;_ , � T I r I y , II L '` .T 1. IN I NJ r IN Lo L ' '1 .7 116 . 01836 DATE WELL COMPLETED DATE OF REPORT WELL'DRILLER (Signature) VAI WELL COMPLETION REPORT ' PUTNAM COUNTY DEPARTMENT OF - HEALTH 3/71 Division of Environmental -Health Services COUNTY OFFICE BUILDING -. CARMEL, NEW YORK,., This ,eqq iftg, ���olgpl�Red.lay.WOU- drOJer_ -and" - submitted -to• Count y--- Mealtfl' D• ePar- ttinefiii�4ogetherwiYFr 'iaiior'afory-re�sdrt;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 �i OWNER NAA �✓ «!i �� ADDRESS: ` ��' j� �.: LOCATION (No. 8 Street) . own) (Lot Number) OF WELL •" r / ` ❑ �• ' ❑ e PROPOSED DOMESTIC ESTABLISHMENT : FARM ' :❑ TEST WELL, USE OF WELL PUBLIC ❑ ❑ INDUSTRIAL AIR [] ❑ SUPPLY CONDITIONING ((Specify) t, DRILLING �'j� — COMPRESSED ❑AIR OTHER ❑ EQUIPMENT " -1 L� ROTARY : PERCUSSION ❑PERCUSSION . (specify) CASING LENGTH (feet) : DIAMETER (inches) WEIGHT PER FOOT : , - ©THREADED RR j E SHOE �} LJ C i' DETAILS .. ' . WELDED L�J YES NO -YES ; ,. •. NO YIELD ❑ ❑PUMPEDI HOURS GPM YIELD (O P.M.) TEST BAILED COMPRESSED AIR' WATER MEASURE FROM LAND SURFACE — STATIC(SpecifyfeeTOURMCr ` i Y ELD TEST feet) Depth of Completed Well LEVEL O in feet below Land surfaceS,O ` MAKE LENGTH OPEN TO AQUIFER (feet)' ` SCREEN DETAILS SLOT SIZE DIAME TER (inches) IF GRAVEL Diameter of well including RAVEL SIZE. (inches FR. M (feet) ,; TO (feet) PACKED; gravel pack (inches): DEPTH FROM LAND SURFACE FORMATION DESCRIPTION -Sketch exact location of well with--distances, to at least FEET to FeET _ n two permanent landmarks. . mss° - - If yield was tested at different depths during drilling, list below • FEET GALLONS PER MINUTE _ DATE WELL COMPLETED DATE OF REPORT WELL'DRILLER (Signature) VAI A., Owner or Purchase of building Y.4 Municipality wilding Cons{_ ructed by Section L� y,4.,) /sYD•_L., �•' Location - Skeet Block Buil ng Type Lot . r . GUARANTY .OF SEPARATE SELVAGE 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.amendinent thereto, and in accordance with the�lstandards,: rules and regulations of the Putriam County Department of Health, and hereby'guaranty to the owner, his.successor.s, 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 occupant of the building utilizing +hr, systc. -, The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environmental Health Services 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.--. Dated this day of 19 Signature Title � r%' (if corporation, give name and address) ----------------------------------- - - - - -- - -- ----- J- -- �c — ------------ THREE (3) COPIES ARE REQUIRED WITH THREE .(3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS.RE UIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division-of Environmental Health Services, Putnam County Department of.Health 1 CERTIFICATE OF l F ! Located at �l�d -.' owner .or ' res`e' Separate Sewerage Sysb = COnsistmg,d her requ Water Supply X •. t i R Building Type Has:, Erosion Coritr I B I certify that the SYStehl attached) `and to accor Dace Se:ptembe Any -person .- occu+pying:; contlttions resulttng� ;fro available and the appo subject to rnodtficatior 4- Date 'C x� PiJTNAM k t'Y7DEPAItTMENT71DF w HrLt #i xDiws�gn o`f Enwronmenta/ Health ;Services, Came% cv iY L1051'2 TRUCTION COMPLIANCE ':FOR % SEWAGE DISPOSAL SYSTEM tterson P a Town or {V tlf y to 2,2 s N 'Section c f s Block r Me C1lcit s,l: 1�rc dot e:t,r,� ofWp,espring ado "'S "Forrester Bldrs Inc;. Brewster, New York ilt by yAddress y '375 ,t P�C CO21C t 36 width trench, —Ga1 Septic Tarik �t F lineal Feet X�, �� r u8.supPIY {From rr• # + ,vr,�'Boyd ArteslariWel1S r 4jvy7 §dz p ul` ate` Supply Drilled BY A F cress . <' ROLlte "52 }Carmel' New York s b y S deuce No of Bedrooms `3 'Date Permitaj$sued M- tg510.17 f ' S- r N��y � 1 S z s.w,.. O� Yp QcNq�i,r isted;servmg the above premises were toristructed essentially sli4o` lined work `(64 �� htch are - wtth the standards rules and regulations tplans filed and` ,, Dt is `_d l�. the ii 'Co Depa nt Health. - 19 7 3 „Certified by - .. ., s ... ,_ . L.�:' .. ,.,1 -'wi 1 _ •:is s, . as � 0i. •.% vsa� �. � _ .•... '�' - `f _ vats are '• '_i �r BACTERIOLOGY �/?�RASITOLGY; VkROLOGY 4 ,cANtlsfoftC USED SOURCE Of IAAERIAL p xQ Title `'� ¥N�s �..`�-- '°� � � r - rx- a .p.:. � �� � P` ` —ice �x.� "_+ ---a . r ,Su `+' 3�,-i: ........w..� '�• UngUS f rine �r BACTERIOLOGY �/?�RASITOLGY; VkROLOGY 4 ,cANtlsfoftC USED SOURCE Of IAAERIAL p xQ blood rREC)UEST II SMEAR Fo�:r` -tester Builders - :; Q Rout e .1Putum w ee�t t L(3t Q Dip t arts ` r UngUS f rine `Q G. C. Lsk$e s�rinq M adOw liev�lc pment, ��' Pars rSlln" ' Q" s r ❑ Ova and Pa rasttesJ . PUTNAM :DIAGNOSTIC LABoRATORIE _ :. Q- Yiral . Stu di0s 10 STONELEfGFE;AVENl1E a. GAfiME1, N. Y.. SEN • ';R S T� Q - SENSITJVITTY a STAPH�OCOCC1A Q Aerobactee loramphenteo ` ` ', Q.Non Netito -�oag, To follovw s -Q ;Corynebacti - uib! Art olistin ylpbate " [ .emolytic� cp9. To go ow- �Q_ Esc "erithia ec omycin Q- Coag. Positive', p. lebsielta -` Dihydrosfrepfomycin El NegaNviiF : _ p Paracoto, Bact_ =N Lryth romycin SIRE T O . -$, . E_ OLYT[ Q roteus ` @omytin - ❑ IPha Q iieta Q Gamma - PseudomOhis Nitrofttraritbtn _ , O, Enterocotcus Enteric Pathogens: Oxanfltn "i `Q >r- : ` Q found z ' Pneumoeoeeus y #" , ana be `Q so to - Q Not Found . E1 • em4phtits = • . 2' Tetracyelirse -' TUBERCULOSIS $NEAR TUBERC LOSIS CULTURE riacetyleleandomyctn _ - ; [j cid Fasf -_Not found. Q Neg. Rai 'Fast mptcil .or cid Fast.4aun` .Q Pos... ., , : ineaks, Route -Nag. EJ O & P 'Not, •oartd x. [ U tares, e Q P "RQ3tttve'-For -, ` �, ., )� • - - :fSY x r + . t-SX 34 b S`J• 4S• Tb -1��1= t�+ a 0 .7 S' c>- Spy, �cFV •';� 4-S.. ... ...4.. S1]UC..T IOt:L BoX �'T'YP> `.0 � 6.. ?.. ys. v y_ �' e. -- — -- —.. 0 1_., �q APPROVED �. ,.yY -1 3 (`J Y •? S E OF NEALTN na�r UTN r t .6 .. .'� P HEALTH ERVICB ON F .0 Y .. _....._....... v B. OIR e: [NVIRONMENTAL HEAL .I •>~' • �r °z ?; Mg99 AS BUILT. SEWAGE +DISPOSAL-SYSTEM 5 ,r SHEET .... ..............SLWX............. LOT ' IN VII�fPFIE�US REQUI2EDY:37j FT-- RNC� t,i t, ryNo. 42 `Ptt�,�/ FIELDS INSTALLED= 37-j iTx 3Ga -iNT NfIRE7R�P( ,g;.'' ;''4't�+��'•j OF THE S'V' SYSTEM INSTALLED FAY BIBBO ASSOCIATE 'S CONSULTING ENGINEER DAT E S � GOLDENS BRIDGE, Ai, Y, SCALE: P-2D'