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02207
1?ev 3 86 PUTNAMTCOUNTY DEPARTMENT OF BE
Division of Environmental Healfls Services, Carmel
CERTIFICATE OF' NSTRUCT r4 COMPLIANCE FOR SEWAGE DISPOS
pd'1.
Owner /applicant Names a
4
MaWng Address �"d7kA ►Yj . !' a,
ITH
�I:Y 10512•^
Engineer Mast ProvideA ) , `�
P C H D Pemit N � :Q • / ✓ /ar
SYSTEM /.'l�G?'r!J u r1. /'
Town ar Vllis+ge• -
Taa Map -$lock —Lot
Sabdlvlsioa Name Subbdv. Lot #
Zip Date'Penmit leaned ���J
nllt.by Address
Separate Sewera ge System b'
nsisting of �O' 0. Gallon Septic Tank and: �GO L� F / •
Water Sapplys Prlh4c,S4PP1Y From Address
roo— a �� Address ors Prv. Spply Drill, /J� �"�i . �� P l �•
BaUding Type Has Erosion Control Been CompletedY
i
Number of Bedrooms 3 Has Garbage•Grinder. Been InstaHe' dY
Other Requirements
I certify that the system(s) as listed serving, the above premises, were constructed asaen 11�.8a po`n �r eep a of the completed work l copies 11. 1.
of which are attached).; and in accordance with the atandarda, raise an8'regulationa in oco' a with he i}�d.pl and the permit issued by the
Putnam C,oun'ty Department Of lfealth.
Date. / � C titled Dy P.E. R.A.
r
Address ` ✓ ■, �leense No.
Any person occupying, premises served Dy th bove system(l) shall.promptlyYake such action btectfpts3 the correction of any unsanitary
llgttl i
conditions resulting from ... usage A' royal of the separate sewerage system shall bscom, 11, _ rvo H` a Dubi,: unitary sewer becomes
available and the approval of the private :water supply shall become: null and vokl when a publi _ tj as •available. Such .approvals are
subject 'to modiflutlo2n or�chan /ge whe/n; /`in tI4.judgment, of the, Commissioner' of Mealth,' wc,h. --r ati�+ cation or'chahoi is: necessary
Date �, / /'! �.X' T TIthi
et>�
1 A1.fT1T T1TT AI�T TTT/1iT
—�'�
a •e
_._ `
DEPARTMENT OF HEALTH
division .Of::Environmental Realtrh .Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
WELL OWNER
STREET AOURESS: wN/ IL Y W'GRIO NUMBER:—
ear Q J �-!•
NAME: A T/ G' � ' AOORESS;d &#"7 1 a/i � BJ
°s ~�� p PUBLICS
USE OF WELL
1 - primary
2 - secondary
)K RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED -
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
. ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT �� gpm. /N0. PEOPLE SERVED -3 / EST. OF DAILY USAGE X10 gal.
REASON FOR
DRILLING
X NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH "2 ,00 ft.
STATIC WATER LEVEL °�°�ft.
DATE MEASURED
DRILLING •
EQUIPMENT
k ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. ;&OPEN HOLE IN BEDROCK O OTHER
CASING
TOTAL LENGTH ft
MATERIALS: V STEEL D PLASTIC O OTHER
LENGTH .BELOW GRADE ft
JOINTS: ❑ WELDED RTHREADED ❑ OTHER
DETAILS
DIAMETER � in.
SEAL: CEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER, FOOT 7 1b. /ft.
DRIVE SHOE:,&YES 0 NO
LINER: ❑ YES ONO
SCREEN
DIAMETER (in)
5107 SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
:.. - _ :: _:: -
OYES O NO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE .
DIAMETER
OF PACK in. I
TOP
DEPTH It.
BOTTOM
DEPTH It.
If detailed pumping
WELL YIELD TESTI�LL
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED 0 OTHER -,OYES ❑ NO
If more detailed formation descriptions or sieve analyses
LOG L7 are available, please attach.
DEPTH FROM
SURFACE
wafer
Bear-
ing
Welf
Dla'
meter
FORMATION DESCRIPTION
calle
ft.
It.
WELL DEPTH
It.
DURATION
hr. min.
DRAWDOWN
It.
YIELD
9Cm-
Land
Surface
a
WATER ❑ CLEAR V TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ❑ NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL. �
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE 2_70HP V
WELL DRILLER NAME
d/
o S y.
n� ol.lrSIGMMRE
der G
(orktown Medical Laboratory, Inc..
321 Kear Street
LAB.. I
Yorktown Heights, N.Y. 10598 Collection Stat ion Used
t
Camel Peekskill
(914k;45-3203 _ _ _..
:Di ►tctdt :A1bOUH: "Pddowa iALi tASQ) - _ <.... Mtd Kisco;,® ,.Nev City_.,
.�.
Date Taken: 1912 -XIA J-aP r/7
Date Received: o Z / /-Pik
Date Reported: /0
;Collected By:
Referred By:
J Sample Source: 3o/ ;
LABORATORY_ REPORT. ON -BACTERIOLOGICAL QUALITY OF WATER..
GENERAL BACTERIA..
Standard Plate Count per 1.0 ml
(Agar plate a 35 °C)
MEMBRANE FILTRATION. TECHNIQUE. .(MFT.)__
_V Total Coliform per 100 m1-
Fecal Coliform per 100 ml
_ Fecal Streptococcus per 100 ml
Yl =. PpOBABLE NUMBFR TECHNIAUF. IMPN)
Total Coliform: _MPN Index per 1,00* ml.''.
Fecal Coliform:
OTHER ANALYSES
MPN Index per 100 ml
Zn
THESE RESULTS INDICATE THAT THE WATER SAMPLE. WA (WAS NOT) (NOT APPLICABLE)
OF A SATISFACTORY SANITARY QUALITY ACCORDING HE NEW YORK STATE DRINKING
WATER TANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
LEGEND
Albert H. Padovani, M.T.
P), Director RDS_.= Recommend.Disinfect-
inR Water Source
< a less than
TNTC m Too ,Numerous Too
PUT RAM COUN'T'Y DEPARTMERr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purchaser of Building
f/
Building Constructed by
3c,i
Location - Street %%
Municipality
/' ��
Building Type
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANTM OF SUBSURFACE SEWAGE DISPOSAL 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 successors, 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 approval of the
!'Certificate of Construction Compliance"_; for- the .sewage disposal system, or any
repairs made by -m'e to such system, except wfie`re °-Elie failure to "ope "rate properly' is
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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.
i-
Dated this day of 19 k4
General ntr ctor (Own ignature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Z _
Corporation Name (if Corp.)
Address
2 3�
a 7
?2�
.73
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