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HomeMy WebLinkAbout3144DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdoes.com 631- 589 -8100 63. -438 BOX 25 03144 4 1OL 3 ' I` l 1 1 I ML L .` `. I L� it -� =� 03144 f t T F C� `p�yy r a PUTNAM COUNTYPA3'I ENT OF fHEALT H z d s Diwslon;•of Env /conmenta/ Heald► S�erv�ces Gaimel,,;N Y :10512= r rcoTici�/►rF nF'_G�RISTR!!- 'f!^ ^il�ii�� !!►FirF X44 ccvyer•. iccnce cT�ltA •n CV --ToWI�Or, village,; , ,ir T � .L'ocated at_ '�C * '• ` Section tw ° � Block ,,{{ Lot s 7 Jofi k Separate Sewerage System built, Addressa Red S a ` �SOO Consisting of Gal `Septici Tank w�-�� Uneal Feet >X width trench •: Other requirements. u; � t Maier'Su PPIY P hc..Supp1Y. :From ` I Private Supply Drilled BY jyliC Address �E',Wc� . 0 1 Q TM}F 3 Building Type �� �� No of Bedrooms Date Permit Issued 1 - + (] ,Has Erosion Control Been Completed '� ¢^ 'I certify that heaystem(s) as listed servtn,g the above premises were constructed esseritially shown:onrtheMplans�oi the complet rk (copies`of which a _ ; e attached) and m`accorda a with the standards; `rules and regulations plans filed :a a permit issued by the P Hain nt ,:Department o ealth: Date r Certrf�ed by ` ` . P R A a, -, .. Address '`License. � ,Y c , _, (� _•. cure the correction of any unsanitary if Any person, occupying premises served by the above system shall prompt take such action as may be necessary to'se conditions resulting 'from' such ,usage. Approval of 'the. separate; sewerage system;shaif become null and void as wpn as a ,public sanitary "sewer ,becomes, available and the- approval of the private watei; supply shall become null and void when ,a: public water ,supply tiecome5 available.', - Such'.approvals are subJe „`toy modification•;or change when, in the.fudgmerit of thetCommissioner of Health such ,revocation modrfication or change is necessary. I <iCLL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT .OF HEALTH 3)71 ° Division of Environmental Health Services I' r. COUNTY OFFICE BUILDING - CARMEL. NEW YORK' by driller to County Health Department together:with laboratory rerport of This report is to be completed well and submitted analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance.is issued.' L r ri'Ui� 1 11%i�J P` �l: JiJT31Viti'( I`tly �111� ITV 3u `C1i`i b i C`C}S`tIIV I' OWNER NAME ,e yJG / ADDRESS �BT�R� UJ '(Town) .(Lot Number) (No. & Street)y� LOCATION OF WELL p t9 BUSINESS ® El TEST WELL PROPOSED DOMESTIC ESTABLISHMENT FARM LJ USE OF WELL El CONDITIONING (Specif) SUPPLY INDUSTRIAL , DRILLING ^ PERCUSSION OTHER (Specify) EQUIPMENT ROTARY L_J AIR PERCUSSION CASING LENGTH (font) DIAMETTER(lnches) WEIGHT PER FOOT DRIVE SHOE WAS t ASINtQj 'U't L z ❑ ® ❑ E CASINGS / O (C f THREADED WELDED YES NO YES t_J NO HOURS G.P.M. YIELD (G.P.M.) YIELD TEST jn� BAILED PUMPED [dLNL COMPRESSED AIR a ��. 412 WATER MEASURE FROM LAND SURFACE— STATItr (Specify feel) s DURING YIELD TEST fteet) Depth of Completed Well �^ below Land a �v LEVEL <3 �} , CV in feet surface: MAKE ILENGTH OPEN TO AQUIFER (feet) SCREEN DETAILS SLOT 5 DEPTH.FROM LAND SURFACE FEET to FEET .3 L� DIAMETER (Inches) IF GRAVEL Diameter of well including GRAVEL SIZE (inches) FROM (feet) TO PACKED: .gravel pock (Inches): ' FORMATION DESCRIPTION Sketch execs location of well with distances, to at least two permanent landmarks. I I If yield was tested at different FEET DATE WELL COMPLETED wk,4.e 594ivri during drilling, list below GALLONS PER MINUTE G WELL GRILLER (Signatu re) ��`h S��f� •�� `1 1 a. s., �• :} r alts "`1 � o- .i 4 t I f t 4 t )•' y USA te1 ' t us yo Oil a. i. Y {i+^• S ff VAR 1f f.f Fc z - C> 11 L A Ef, Mhp _ i VV y� Me . r ? Egon � Ka,t 'f 1 1 I t• ) !� is•.., 5 1 qwfy fx"���Y'"r}F`U,� i't'�ylYwi erl G�`� ��'�" 'f �t. ie �' i J l l i r i f � � � � ••'� �" K ,J. ! kW11-11 •l � 4 y >• r r e,� r�, l i z !yr 'y a . 4 t�{ Z ,may 4 N S r t a # 3 i...�.r �4 v}• " .; S• .•46'x% i K4 l,.,pit3�t G5' �'d��t "#� 4� MY`�0i •a`i>:%'_• S i, �>': -� r 1 r y ' � r,e 4h.o., !..t.nL`.•nYGr: 'A`;;n, b'tJEr'.+�{t?f ,'�'.T.2 rr'!S "TMai .. •t'T_°'rn`I?5;��. ,fl wa,. ".r ? �,rr. _. ... _ -- ' 15,(: :Ct A.T. S.J,�• S 1 STE i S�4,� `Z-433 SAT lY ?A>+1 •l' Z " FOR-1- ' AGK EsuA4v l "T L_oT 'TOwla of 'X>UTNAM VALLEY ..ti ��}�r9r.��abnv r4c✓�wY ra-. � ry..:e. d}�` -. •La<...s'a�.�•�n.. _ rgwh..��v.�•+.� _ :r- uw::Yr�w +avp r-.a... -.. e. �•..: a.odY::w�v�Ar4S.r+.w ru.:•q.nw+.:ro• io S i2 13 41 3 (°°. 1-AU NQR�, `rA F•11G WASrZ Off/• S 30 °- JAN 61973- lo r '•1i; VIST N' OF � S \Yf�'��;cyr67f1fJ:UEi'JTr1 iCALTN SFR� /Iri:• 4 � 1 �q "ill '� �,�1•� �{t !4 ' [ alb, 1 tw, .'M. °' - 4!r•�- ....• .r ..�. .:.+u � 204A AREAA.T To i Q 3-05 Q 78910a12131 i5ao c AL...'SEPTIC TA►JK, t ;�.a9 tix .N � ', '� do 1 A . 31 I4,3'Is7 64� -6 82 a;e l3 88 si — - - 3 14s 1 �69 72' 82 89 - - - 80 �u ' I 5 Tp V� �• . , , ��1 A' SOCIATE S +711 1 a ' ` r eA iz M E l� NEW Yo a IZ: `0 Q bi i5ao c AL...'SEPTIC TA►JK, t ;�.a9 tix .N � ', '� do !n ,5oa 1-1` c,F �� Ti2EiJC�! • Vj 5Ta LtrEb p,,�(: 5'• N I GG S Tp V� �• . , , ��1 A' SOCIATE S +711 1 a ' ` r eA iz M E l� NEW Yo a IZ: ^'�,: �, `. t5 `T' `:y� �.; i ,�� Address � } g � A fit' Cam. To4al Habitable Space K A r� � "� �� lineal ifeet'•°X -� ;. xk x � . Address �', � "s a � _ r w- ��> �, �.�a= �`.�,. " ,., � ?-- �- --�r-r �� �`x �+ � i 'TJT iY Fl Fl1y VI ly �( � � � t � � ' sTdle �': PUTNANi COU'ITY 0-7 JD �ZT T. fM:'-' D. rl f7 DEISIGLN D.A!a SHEET SF? RATE SE:': GE DISPOSAL Sv,ST:"'-' FILE O,xme r SALT Add-..e--,s Loca -te.d.at Sec. 2 c, Block Lot, --7 Z' E S c ID E, -3 s -Cr (Indicate* I Hu-'icioali ty Le TEST DATA PZOUIRT'D 7-0 BE Si: '-'T -TED 2PPLI CATTr,)�', Hole. NL .—:Der C F.C,- J- 1! p f. 7 A T PEPCOL.. fTi .tin '-o E e r Le%-el No o. 71 iri:e Fro- c'-._s ' soil -Ra.--e Start S Loo b!i'- S. La:' S to:) Droo in `lilt./In . 'f V0 n C s I ncr ez I r. c S A5': 00 /7- 2 A� 3 s za; 2 3 /t:2- 65 61, 1. 2 5 Notes: 1) Tests to he repe-=ted at sa-e tairle-, at aacl- perColat-lion test ho Lm- All -op Of mc.-�=! SO;'L rat'--es :re 0 t a to he s,-,'-n m. =tea for Sic-:a t U re Address _3�f C��vQ € _ SE:�sf� c Pli N-A�f CCi.'`iY D E P`.?T EE. "•T 0- HE�LT i So' i1 Rare 1nJYO-Vef Sc. Ft. /Gal. Checked Date TEST ._! J_.T� _._j_�'!.�u =0 _— Oc;W_r!1lEU ,.__:L A-jlPLTC..1T0_ DESC =�T PTIC� 0=' S. 1,S ^`._n �! ^R_..Di T. - -ST HOLES DEPTH HJLE NO .Hor, \0. HOLE NO. - 6rt 12f, 18 rr 24" 3.0 : C,L A.Y E L_. A-- �. 36" 42:, 491, 0 0'` F� r 2:. , r INDTC TE L=k't.L am t.;H1Ct. r Gn- `:D ij TT R TS = u \C0T'\ "' N: T-) T cap- T:-L , io c .; �_:-: r a�� L -� El R,:E AFTER s�y' , 'zN cOJ� TE,ED TECiS "'_l DE E'i' Date ' 5011. r,= --n r,j`4 _y�il'/l`' D----) S.D. ?'c !� %O. OI u00�00' -S Sep t is T ank, CG __�j' /goo s tir r�•rrrr<<r Z��c ,� l�asOr �iO P t ri.ec t'i'Ot'ic:ed $ coca L F. y &.- 2'-'* ,r .� ti �rEH '� :i5 �;} tch Older _ _ Sic-:a t U re Address _3�f C��vQ € _ SE:�sf� c Pli N-A�f CCi.'`iY D E P`.?T EE. "•T 0- HE�LT i So' i1 Rare 1nJYO-Vef Sc. Ft. /Gal. Checked Date P,el v6 tvw)- ol 404=4710& 4 (.Iv,-,A r- I IVA S 0 A v v r, J4 f, a --r-4 12 W,' L 4 1 1 li I . I - 1 , ; I I Z. I MAC CA 710,y I F 7� .To p F 'C! N S T NbC TF r, - !N AC(QR RULES AND _ T 1,jN F; clI' -niE . cow,� -,.-y APARTMENT 610 ALYH. r, ©44 1W 'SY S I L'M 5 HALA- N01 OLA3ACKFILLED UN I'l, S �, F. 7 1)) OY D�4AzN -.fr H- C, 1: PA A, RF!) N G NE R A NO I'l 1r,. LO CAL HEAUz, V w S QP A NK Y 1 1) to C> F• T 0 C N CH W ;Ti hl :Pit PE. F It .-SSO 776Af —01�6 K JrCb ED' PPR OF Z. T F ALYli By K SERV AL R EALT ICE is 0, ar ii St -_IJ U, ;iN J ki M C C 4 r 'riot 21i r!t; -74,N. K 404=4710& 4 (.Iv,-,A r- I IVA S 0 A v v r, J4 f, a --r-4 12 W,' L 4 1 1 li I . I - 1 , ; I I Z. I MAC CA 710,y I F 7� .To p F 'C! N S T NbC TF r, - !N AC(QR RULES AND _ T 1,jN F; clI' -niE . cow,� -,.-y APARTMENT 610 ALYH. r, ©44 1W 'SY S I L'M 5 HALA- N01 OLA3ACKFILLED UN I'l, S �, F. 7 1)) OY D�4AzN -.fr H- C, 1: PA A, RF!) N G NE R A NO I'l 1r,. LO CAL HEAUz, V w S QP A NK Y 1 1) to C> F• T 0 C N CH W ;Ti hl :Pit PE. F It .-SSO 776Af —01�6 K JrCb ED' PPR OF Z. T F ALYli By K SERV AL R EALT ICE is 0, ar ii St