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BOX 17
01900
S•
r 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 a.nd submitted to County.Hea,th_Qgpartme together with laboratory.report..of _
_...... -- I nt _
`ajnalysls oi'vuatet-sample indicating water Is of'satisfactory Liactenal quality before certificate of construction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
- a
I I
T If yield was tested of different
FEET
300
350
390
-ins drilling, list below
GALLONS PER MINUTE
1
1-14
5
DATE OF REPORT I WELL DRILLER (Signature) % l/ 14W,
MILL DRILLING, INC.
NAME
ADDRESS
OWNER
Robenat
Contractors, Inc.
c/o E. Rader, 11
Overlook.-PTO-2 Lk. Vw. Mnr.
LOCATION
OF WELL
(No. & Street)
East Branch Road
(Town)
Patterson
(Lot Number rew.StE
PROPOSED
❑ DOMESTIC
INESS
El EST B ISHMENT
❑FARM
❑TEST WELL
USE OF
WELL
❑ SUPPLY
El INDUSTRIAL
❑ AIR
CONDITIONING
❑ OTHER
(Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED
AIR PERCUSSION
CABLE
❑ PERCUSSION
❑ (SppeHE Y)
CASING
DETAILS
LENGTH (feet)
6
DIAMETER (inches)
6
717 HT PER FOOT
® THREADED ❑ WELDED
x
O
YES ❑ NO
.x I YES "
NO
YIELD
TEST
❑ BAILED
X HOURS
1:1 PUMPED COMPRESSED AIR
G.P.M.
YIELD (G.P.M.)
WATER
MEASURE FROM LAND SURFACE —STATIC (SpecUy feet)
DURING YIELD TEST [feet)
Depth of Completed Well
LEVEL
20
400
in feet below land surface: 00
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
FEET to FEET
FORMATION DESCRIPTION .
Sketch exact location of well with distances, to at least
two permanent landmarks.
0
10
Silt
and boulders.
60
Broken & soft ledge.
10
60
INCA
.400
Hard granite.
\
`.D
I I
T If yield was tested of different
FEET
300
350
390
-ins drilling, list below
GALLONS PER MINUTE
1
1-14
5
DATE OF REPORT I WELL DRILLER (Signature) % l/ 14W,
MILL DRILLING, INC.
BREWSTER LABORATORIES
BRMSTER'- W.:.Y: ._ _ __. e- ._:......_._ __�.�..> ..�� ._..�.......__........ .
WATER ANALYSIS REPORT
SAMPLE NO. 3423
SOURCE: Robendt Contractors, Inc. - new well
East Branch Road
Patterson,, N.Y.
COLLECTED: May 24,# 1975
BY: Kill Drilling, Inc.
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 collecttd.
Play 31: 1975
'Rdy Bickwit P. E.
Director
� CA-
_7 77'
obenat Contractors Inc. µ_ _Patterson
Owner or Purchaser of Building Municipality
Owner
Building Constructed by
East Branch Road
Location - Street
Modular
Building Type
Filed Map #1428
Section
Block
_6
Lot
GUARANTY CF 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 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-
vic'es of- the° Putnam County D`ePiartm�ent °of' ` Health as to "' the r` or` riot " °th -e
failure of the system to operate was caused by the w' llfiAl or negl' en
act of the occupant of the building utilizing the sy to
Dated this 10th day of July 19751 Signature
L
Title
1I' co p ration, 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 Health Services, Putnam County Department of Health
i t
( ; �L ,- PUTNAM COUNTY DEPARTMENT - OF HEALTH
Division 'of Environmental Health Service's, Carmel N Y 10512
CONSTRUCTION PERMIT OR SEWAGE,DISPOSAL SYSTEM
: Patterson;
Town or, illage:
East Brach o d
Ail
Locat-at arc F 1 ed IIgtk
ed
i
fc 11 Est; tes 6 Job,
S01,584
Subdivision Lof
Rob`en`at Contractors Inc E Rade
wner ' e Address A r.,Oscawana'. Lake _Road
!4' _ Building Type Modu1 aTr Lot Area 1.448 R. 4 Putnam ba11 er, NY 10579 4
= Number?:of Bedrooms 0 three' Total Habitable Space ' 2' z- = 24� t '
p Square Feet
Separate Sewerage System to cons;st of y- 100.0 ";! Gal Septic Tarik 23Q lineal feet 1X 36 1,nCtl width',arench ;
To be constructed by ? Atldress
r
Water-SuPPIy Public Supply "from
_.
X rPrivate', Supply .to be drildi by L_
Address
Other , Requirements None F x
1_represent that.l :am wholly and completely r sponsible•for the design and location -,of the proposed "system(s).; `3) .that the'separate'sewage, disposal system
? above tlescribecl will be constructed as'hownon the appr d amendment there to and in acco(dance'with the - standards, rules an regu a• ions o e :Putnam '
County- Department of :' Health, and that on completion thereof'd "Certificate of Construction Compliance" • satisfactory tp, the Commissioner of Healttiwill j
b'e submitted• to'• the Department, and a ,wnt6nm guarantee will be` furnished the owner his successors heirs or assigns by the builder, that said builder :will.
place in good :operat!ng.,condition any. part of •aid sewage disposal system durnpg the pei+od of,two (2y:years immediately following the.da4e,ofthe ls;u -•
ance'of the approval of: the Certificate of Construction.Conipliance. of; 4he original systertl or any.•repairs °theretop2) that the drilled well'd_eseribed above ,
will be, located as shown on the`approJed',plan and that said well will be installed m accordance_ with. -the standards, rules andegula i�f'ons of the :Putnam'
County Department of,'.Flealth
:Date
X75
tr-1' Apr1�1 1
0 ,
• Sign 1L41 A0
Address . A ' ,. 6 O 3 L' icense No. 29206
;APPROVED FO,R CONSTRUCTION This approval expires one r fro he date =s d unless construction --.o f the builtling has bean untlertaken and is..
revoW6le for ,ceu or may be amended .or modrfied when cons retl essary by a om' 9� Ith LHny change -or alteration of construction"
requires` a new ermit pproved for disposat of do" san y sewage d/ � to ater F iii only
Date e BY ` + Title
N
a
PUTNAM COUNTY_ DEPARTMENT - --GY - HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA DISPOSAL SYSTEM FILE NO.
Owne �:-* a X'°" "�� n ', dress AW.Clg 000,09
_ _ � f � � c / � ` ��' l' meta i"� % !�&9 ac.�
Located i ✓i ° S.l "ir- t t� i'!,5 ;,.ti 4/ fib— — : • •yn,
SOIL PERCOLATION DATA • BE SUBMITTED WITH APPLICATIONS
Hole
Number
CLOCK TIME
PERCOLATION
PERCOLATION
No.
Elapse
Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
Water Level
in Inches Soil Rate
Drop in Min. /in drop
Inches
® 1
w
3
5-_
1
3® 0
4
2
5
Notes: 1) TeAts 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
DESCRIPTTON -OF SOIL- �NG�aUED IN TEST``HOi1ES ' _..,_....
DEPTH HOLE NO.
G. L. 1 756-ri Cri
6f1 L ® ®ri,lA.
121t
`o
i
18ir
2411
Lae �,AY�9 411w
30 11
3611
42►r
4811
5411
6011
661f
,s'®
7211
°�1n e<
7811
8411
♦e
w
ICAT
-LEVEL AT_.WHICH...GROUND
INDICATE
LEVEL TO WHICH WATE� LE
!PESTS MADE BY Amin. 1M. /. T° ¢�
AFTER BEING ENCOUNTERED
Date
L.LII✓ 1 V 1V
Soil Rate Used /® rvl "Drop: S.,D. Usable Area Provided
T
No. of Bedrooms K Septic Tank Capacity Q e
Gals. Type
Absorption Area Provided By L O L.F.x2411 width trench. _
Other Moor_
A _
ivame John H. Prentiss, P.E. bi.gn7n r.
Address R.D. 6, Box 353 PRF,k
Carmel. New York 10512
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Che
-pE
�F NE STl�t�j
�° Date
R),te : /7j
11 '.' T'CU' 1_C)} 1 y
yes _
__ }pro,, C
Coll mc�ntS__
Propor. ty a_i.nes or corners found
r
Ca.n 'estimat ; }souse location .
R),te : /7j
11 '.' T'CU' 1_C)} 1 y
yes _
__ }pro,, C
Coll mc�ntS__
Propor. ty a_i.nes or corners found
Ca.n 'estimat ; }souse location .
. . . . . .
Slope of tile line and' trenc. ce to 1
Room allowed for expansion trenches . . .
Over 50 ft. from suamv, i'ratercourse . . _
Natural soil not stripped or SDS area
�: ,nec'essarlly-gra -ded
10 Ft. maintained from prop. line and
20 ft. from house . . . . e
• . , _ .
Separation of trench from house, well
etc. follows plan
Nwiiber of. bedrooms checks
Stcnes, brush, stumps, rubble, etc. greater
than 15 ft. . from nearest trench , V
15 FL- of peripheral soil horizontal t -fir from /
trench . . . . . . . . . . . . . . . t/
Junction boxes properly set
Could surface run off from driveway, roads, .
ground surface, etc. channel near SDS, ,
area. . . .... . . . G .
Does 16t cTra.inar-A nnrPnr n.T'_ -in arPSa nt' RnR
FIFA, GRADING OF_ SI`rE ACCEPTABLE ®
V
! I I
FIFA, GRADING OF_ SI`rE ACCEPTABLE ®
V
! I I
i AS BULL "T° DATA. L
--LL > _ ._ _ 3Ki'' °d, structure located from survey by surveyor notedvbelo%�_
�, n well °located by Su rye. yors survey.-
+ Q weli drillers report-- _tt�• 11_
Engineers
Tank, Doxes, pits, galleries d latera s or.nteo rr t nn +rz;r�
b91 neer: 1
H'eOlthdept: I
'Field inspection by: Health dept❑ daha•
�.:��a �o Eng.lneer Jo datfa
)7
4
NOTES::.
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OWNER. _ _
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