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PEEKSKILL, NEW YORK
'CERT,IFICATE.--O.E., ANALYSIS.
*,
Date Analysis Completed -13112
SAMPLE OF WATER FROM
•
MARKED
Date Taken —Date of Beginning Analysis
Residual Chlorine N H 3 ----Nitrites P H 7,5—
Bacterial Colonies per c. c. Agar at 37° C. 24 Ms.
Results of Inoculations Made:
Inoculations Gas Formers at 24 EIrs. % gas 48 Hrs.,: % gas Confirmed
five 0.1 G c.
five 1.0 c. c.
five 10.0 c. c.
91
Media used , Lactrose Broth X. E M B Agar Brilliant Green Bile
Bacten"a of the Bacillus Coli Tye Present in 0________ of 10 c. r. Inoculations
Confirmed Test - - - --- — - - — — ------------ _—Completed Test - -_-
M. P. N. of Members of Coli-Aerogenes Group Present
REMARKS
ANALUED BY
M
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF, HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
�'{ ais' ��ep�,; is., qo.. be�osrrpleteck =�y- wr�ll�driNet�ai�d -sty €fat#- t��ut}t�Y =�al�����e�4 t�saherwv+th �Iai�Fatorry- 'Peportiro�'�•
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
OWNER
NAME
v
ADDRESS
F D �0
�/U M
LOCATION
OF WELL
i/
(No. 6 Street)
t)
(Town)
U
(Lot Number)
PROPOSED
USE OF
WELL
DOMESTIC
❑ SUPPLY
BUSINESS
❑ ESTABLISHMENT
❑ INDUSTRIAL
❑ FARM
El CONDITIONING
❑ TEST WELL
❑ OTHER
(Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED
AIR PERCUSSION
CABLE
El P PERCUSSION
❑ OTHER )
CASING
DETAILS
LENGTH (feet)
:� S
DIAMETER (inches)
WEIGHT PER FOOT
/L
11x THREADED El WELDED"
DRI
XYES
E* SHOE
FIND
VW CASING
N YES
LJ
?—
NO
YIELD
TEST
❑BAILED
HOURS
❑PUMPED JL COMPRESSED AIR
G.P.M.
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE — STATIC (Specify feet)
fleet)
DURING YIELD TEST i
±Depth
_
f eet below Land surface: 1,56
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (leaf)
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches)
FROM (feet)
TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
),5-
d 5L
Figo0c o L
�;T
C 4 Tiaty h% 15 0
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
j
3
U
�
DATE WELL COMPLETED
�f3N- 172
DATE OF REPORT
-F - Ig7Z
WELL DRILLER (Signature)
Ann. "5 _.F.•" � s�L"kLWl�YI r�.W"Mgo �tTY �A? ' x
-
Ff ¢ y
y } �$
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4
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-02
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sad
IN ZZ or sub A to Ad-I&MPAM 66 job ce
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the my'' io 0- V y�
c � V
QgIve. Map,
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'TRUE P,g&L�D &—ki WA.)
TWO
WIN XT
how
,, y
a ENT OF HEALTH;
. PUTNAM COUNTY DEPARTM
'
D- Won of. Enwroifr i6h'6 Health Services (Carmel N. `Y 10512
"cn i st4 .. , �
CONSTRUCTION PERMIT_.F,OR SEWAGE :DISPOSAL SYSTEM�{✓g/ 7 �✓T.V�� 'V4tc�y
o14XMAP O�Town or Village ' r---
c
Loeated a{n/S�7'
v
Subdivision " Y Lot JOb
s "^f E c ut ar �� '? -.
Owner [� m x D t ` ` Address o E,EKSIf /f
Budding Type Lot Area'"
_ ^ � QUO SCrU
Number of bedrooms Total Habitable Space �'�- Square Feet
V
,Separate,Sewerage. System to consist of Gal Septic Tank 23� K` lineal feet X witlth trench
r
h Tobe. constructed by AddressNOP ✓s'� L�o'bv' �DH9'Y/,tld�if
+,
Water Supply Public Supply From'.` o
Private Supply to be drilled by ''4LAM�'JfL/ x
Adtlress
olf—. r-
Other Requirements
I represent that 1 am wholly and co' rTSi, ign and location; of t6,
he .proposed systems) ;1) that the separate sewage disposal system
above described wili`be constructed 'ment there io,a d ain accordance with thestandards; rules an regulations o e. ' u nam
County?. Department of ..Heat h'' o o th Certificate of Construcf{on ,Compliance sat�sfacfory to .the Commissioner of- Health,will
e
lbe submitted to�� he Departrnen '�
"a•'.
place in good operating ;conditi a
,pa
ahce of, the approyal'of. the Ce fi
e. of
-will be. located as "shown onahe,ap e
pia a
County, Department of ,Health
tip „82'12
ri
x lv^ Address
furn�shetl the owner his •successors he irsgrFassigns.::by'therbuilder, that said,builder will`
sp '_I system during ;the period of .1w6—p) years ommediaiely foilowing thedaie of the Niu-
pli ce of the on al!system.or any r " "epairs'thereto 2)1that the drilled. well described above
wU fa-installed i ccortlance =wd the sta aids rules and regulat,�ons of the Putnam
APPROVED FOR - CONSTRUCTION This,approvai expires one
revocable for cause or may be amended or modified-when- con'sia
requires w per Approved for disposal of domestic
License Np.
r, }t ate assued unless construction` of the- building ;lids ;been'.uhtlertaken and is
aces .y by the{Commissi,oner ;of Health Any chan,ge:oCalteration,of construction
>o ;private water supy,orly
pl
Title-
-.mod.
.._.
r
PUTNAM,COUNTY DEPARTMENT OF HEALTH.
DIVISION OF ENVIRONMENTAL HEALTH, SERVICES
"S.
..... _ e.�. 3 :.. r" r' -:. r V � : n k1':'.LtK•`r..,- -..:. V CO .ra: Vw
ri:':L':S: ..i'::::VU..ra•yc...: .I ++',w'. _ - . -Jt. D - i. .tom +P .. .. •w:.r` t
T.Y. . ; J+iG > fi .
DESIGN rDATA` SHEET - SEPARATE SEWAGE�.DISPOSAL SYSTEM FILE NO.
.
Own errjNALD
fR�E. �w.�l Address %55/tloFiTt�cJ!
Located
��s
e `. , p
at Street ��✓se �u o '� �N�PU - ax Ylap
( J°' rte: �'o Block
Lot
( Indicate . nearest..cross.,`street.)
.
Munic.ipalitY vw�j 2j.rnlRr"1 VAiLe� _Watershed ` o 426
SOIL :PERCOLATION TEST.:�DATA..REQUIRED TO: BE `SUBMITTED WITH-'APPLICATION..
Hole'.'
Number
CLOCK TIME PERCOLATION " .
PERCOLATION '
Run
Elapse: Depth to: Water. ;..,. Water Level
No ..
Time From Ground Surface, in Riches ... ;
. . Soih ' Rate
Min. Start. Sto Dro in
Start . ' Stop p <.'.. p. '..
Miri/in.dro p
Inches Inches. Inches..
;.
�� 1'
g�S �' �'2T pia l�� �•��. � �,
/�-�•'• '
�7 L
zg
3
30
3
5
.Notes:
1) Tests
to. be. repeated at same depth `:apps- oximately equal .soil
rates are ob-
*until
tained at each percolation test hole: All ~`data to be submitted for. review.
2) Depth
measur.emrients to be made from top of hole.
78"
N
8 4'f
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
•-TESTS MADE BY Date
®�
Soil Rate Used S Min/l" Drop: S.D. Usable Area Provided S iT _v
. - e /�.�G
No. of Bedrooms Septic Tank Capacity ®v Gals. TYP
Absorption Area Provided By l - L.F� 4�t 36Tf �'dth trench: Other
N1 dery r i ��
Name
STANLEY
.Address BOX ZbTl 4TV. AL '
PUTNAM COUNTY DEPARTMENT OF HE A ' 0.3
Soil Rate Approved Sq. Ft. /Gal. Checked.by Date`
TEST PIT DATA REQUIRED
--
w0 BE "SfJANITTS15'�.W T I °APPLICATION- "' � "
DESCRIPTION OF SOILS ENCOUNTERED IN TEST
HOLES
DEPTH
HOLE .NO.
,HOLE NO. -��..
HOLE ',NO. /a4,1v Ge
6T1
!'
k
12fr
e S�
�•rij� LErr/ %+m��ntr T,�tLt�y�i J�i�f.l�a,Tr�
78"
N
8 4'f
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
•-TESTS MADE BY Date
®�
Soil Rate Used S Min/l" Drop: S.D. Usable Area Provided S iT _v
. - e /�.�G
No. of Bedrooms Septic Tank Capacity ®v Gals. TYP
Absorption Area Provided By l - L.F� 4�t 36Tf �'dth trench: Other
N1 dery r i ��
Name
STANLEY
.Address BOX ZbTl 4TV. AL '
PUTNAM COUNTY DEPARTMENT OF HE A ' 0.3
Soil Rate Approved Sq. Ft. /Gal. Checked.by Date`
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
CATION; O:- .CONSIr -.;A -- WATTER- -•WRLL . _ _ ._._..._.
. ,,....�,
PCHD PERMIT- #
WELL LOCATION
Street Address
w
Town llage City Tax Grid Number
G!J'
WELL OWNER
Name
---
D
Mailing Address
i9 S ,�s�r iGG i ���'�
Private"
O Public
SE OF WELL
primary
2- secondary
SIDENTIAL
DBUSINESS
0 INDUSTRIAL
D PUBLIC SUPPLY Q AIR /COND /HEAT" PUMP
O FARM Q TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
0 ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
MIREPLACE EXISTING SUPPLY ❑ EST /OBSERVATION D ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
/
61-14141, -
;"
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Wz'
Lot No.
WATER WELL CONTRACTOR: Name Address: ; %ter /rfcfU'� -J
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V'�'_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
SKETCH & //SOURCES OF CONTAMINATION
bON SEPARATE SHEET
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above.is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirt; (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise c ntaminate surface or groundwater.
Date of Issue: -�B �/ /'�. 19-- �'�'"'
Date of Expiration 19 Permit Issuing Officia
Permit is Non - Transferrable White copy: HD File Pink copy: owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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