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03262
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1JELT, DRILL E� LPG AND REPORT
- I.,Idcll:,�.. .`LT..
r, 1�1ame o:fyY1'aceYy'� 4age'f
R. Housekeeper
Owner ..+ :;, ':O.:A�e`ss: R, D.. .Putnam Valley, N. Y.
Depth of well ia�te er -� .. Yield : �o. W-6s ate 1 .dis nfecte
r�.i• - rr.�r
fti yes or n'b
Amt. of casing above ground ;`; 8 Below :_;round 20' Voll seal
�n ft packer, cement, grout
Draw a .�: ll. diagram in the space provided below and show -she depth of
�c:-.qa g, the w:1 -1 s. al, kind and thickness -of- forma ions ..enet-rated, water
ibearin� forma-Lions, diameter of drill holes with do " tied lines and
=casing s) with solid lined.
'WELL DIA -.',IR M FORK HUNS PE.I? '1TRA -, D REPLz. I KS
Diameter, in. Depth Lind, thicimess an, d . Type ._.of well...r, e -
in ft.
3f wat r liearing _ drilling mit'�.od rota 17
-Grade Was well dynamited? 75.
25 PUNPIDTG TT�TS
20' casing Details _ �=2 -
Static aater
l.eu j ft
f 50 ...... below r_rade . _.
pumping rate f
} in
_...._ ._ ..... _ ........ , . _........... ..... _ _.._..._.....
Pumping level in
j ft. below .trade
.......... Duratie-n - -of ....... _...._ .
WATER AT LINO OF IT 11aT
i Clear. Cloud;Y _Curbid i
ILecomrended depth of pump in
weal, feet blow ;trade
Wj' La IN
i 200 ,
Sand Eff. size mm ....
i Had, * etjoefaize
Length of screen ft.
i Diam. of screen
250 Type of screen
;.;
Screen` *& enin s x °
' OM EF ...._, .
f _.._......3.5.! :.bedrock
G TS • -
blue granite ..
)raw a sketch o� - the-- - property
)n the back .of this sheet locatiog Drilling start::d . �C6=let: d 6/16/;2
'HE "W',LLL I S :. ,*WAGE DI 3POSAL SUS _- Z i
Well. Driller G k7� z F
Si :nature' ... 4r
R
JA Nt E15 ? _� u s IZ` c PAP . +,3 0; -r ry nn V/_AL_L1(F1
- tom %C -h e ,ems'' ..C�} f' r�17 "1 �..Y� LT:. _.. _ } _rR17,;'rn�,y1,"..ti,a; _I.'."T.''�.:,r -.Q = ••:�-."-.� - - �.� _r
lea •.q,)..� � � .. - iI'•.ch. ..3✓' tl.� o-..w-- a � .;G , -s ... ..rda.,+.e.` r'..,..' �x ..,a:..c.:..i►�.e- �..c.. ...w. �;i.L w �• -:ev.:
M_(AP
Building Const uct6d by
Location - Street Block
�C5 iDcAj`i7A L. j' /O LC.T -7r J
Building Type Lot
GUARANTY OF SEPARATE SET1AGE 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 followinc- 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 11,ivironmental Health Ser-
vices. of the Putnam County Department of Health as to whether or not the
failure o.f -the.: syste.m_. to...n.pe.r. ate was .cause-d by the rrTi _ or_;?ie g.pnt
- aCu ui lu-h U'L-C.I:iGJctr1L ^Of G e U Lllizng t7dY_ tem
Dated this -3o day of 0 c r- 197' -- Signature
Title L)��,�,�
TIf bpr ora won, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF C.OMP,ETION 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
_. _. _ •� n .. a" ta'�1 �:: r .?rn ;....'Y... EE"n...._.;�T' ..ty ,,,z;,..
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
rt„(�
4
r �- �. :{ •�•s- '+�+�•s` •d� i, d4i.Ft_: a.r.Gi, �'.;�'. �. ".. ..... r. - b'-ei: S•� :r....+wowanci•� —.•
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 R. Housekeeper
ADDRESS
LOCATION
OF WELL
(No. & Street) (Town) (Lot Number)
Church Road, Putnam Valley, N.Y. 10579
PROPOSED
USE OF
WELL
BUSINESS
� DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
r] SUPP Y El INDUSTRIAL ❑ CONDITIONING El (SPeif )
DRILLING
EQUIPMENT
COMPRESSED CABLE
El ROTARY ®A R PERCUSSION ❑ PERCUSSION ❑. ((SSpe ify)
CASING
DETAILS
LENGTH (feet)
EN t
DIAMETER(Inches)
61,
WEIGHT PER FOOT
17
n
V—I THREADED El WELDED
DRIVE SHOE
® YES ❑ NO
WAS CASING
❑YES
O D7
NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED ❑ PUMPED ® COMPRESSED AIR 7+ 10
YIELD (G.P.M.)
10
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST jfeet)
Depth of Completed Well
in feet below Land surface: 305'
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
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
1'
101
hardpan
10'
305'
bedrock- blue granite
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
Z16 12;
DATE OF REPORT
WELL DRILLER (signature)
-2COUNT
rnL1 PUTNAM
x.- of, 'E fr,
N Sf' REWAGE'DISPOSAL SY STEMR
-A rea
er of Bedrooms �T�Y Total
ite Sewerage A yygp, Gal Septic >Tank
r "constructed by t O,AOnsisV��o
res.-
pply S`
,Pu
_b _
lic"
Supply _� ,
,
From
_" ,.
�
Frrvata up dulled b
.X_d
TY
-Town-,,or,.,Village
Ob,.4
IV
I; z—C
nCh:,,,
4,v ,
71.
ROVED FOR CONSTRUCTION T h 1 approval "t h 'd t A d'
able for cau3o or may be h,
" amended e
IV
7.
77
t
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Dated etz, i, 4 �, 1 j 1. -
Re: Property of 4> r- -.E 4L
Located at ��
O(� i E- � �✓ ,jli t �� r . f j -ya 12,%- �:
9 ��r
Block Lot � 74
Gentlemen:
This-letter is to authorize . STANLEY J. WDER
a duly licensed professional engineer or registered architect
(IndicaTe—j--
to.apply for a Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated by the Commissioner of the Putnam County
Departuicnt vi Hesitil, and to 911 d11 iiec e�sary papers on my behalf ] n
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani
tary Code.
Countersigned: rf�
P.E., ., # Z7
Very trWly yours,
Signed
ner
ss
I
PUTNAM COUNTY DEPARTMENT OF HEALTH
D1Vl'SI69'dF 1-9 6N --HEALTHISERVICES "' s: `.:` . •:. ___.. �_ :. - .. ., , .
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA S1HEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. '/ ,I
Owner �:, 14.0J5.�EEPE - Address; � � �a�u �� �Nt�6'+I\ ,V1��L�y 14.�
Located at (Street SAN �1SE � iA� AP � Block 3 Lot PLO -7 • 1
�Tndica e
nearest cross s ree
x
Muni cipality ?OTOA -A 'JALiC-y Watershed��,�;�
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
a
iioie
Number CLOCK TIME PERCOLATION PERCOLATION
RUM Elapse Depth to Water a er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
4
5
2 3: v-2.--- 3.2I
t q
t3
16
3
�,
33:23 3:y3
zo
to
4
5
3 •
sA ., .
,— /
1 i.
to
33:25 3;44 t9
t3z.
4
5
- `
1
.
F4
3
4
5 ...
Notes: 1) Te'gts to be repeated at same depth until approximatelyy 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
? = r� -4� -..::: t: -.,' �.ixT^u::,�r1�Sflj :EN^(1T1?,T
PPLICATION
s_
DEPTH HOLE
NO. i HOLE NO. 21
HOLE NO. -3>C-GP 40
G.L. �p�
—54 P ,L-
611
12" 15AUt, -TP- op C Lgy ' AEU ( 0- e oP CLAY
1811.
2411
3011
re ►�
1/
3611
4211
4811
5t1
i y'7 .. '�j ,g
cvYv t;�'`
it
6011
72
`'�;
781,
t
84't
f4fz
` TL'ICATE.L y_AT-.�nJICH GR�L?�ID ?,rATEI IS .ENCOLfiTTrR D
-.U) 1
..
INDICATE LEVEL
TO WHICH WATER RISES AFTER TBEING, ENCOUNTERED
"PESTS MADE BY
5rAAi ���` �;.� tit iZ ,
Date
Soil Rate Used
�.
Area Provided Z,��-
DESIGN
10 Min/1 "Drop: S.D. Usable
4-
No. of Bedrooms
Septic Tank -Ai&-520
Gals. Type IWASvoije
Absorption Area
Pro ded By 2: Gs / 36
1✓„ width trench.
XNL
�— Other
Address
0
THIS SPACE FOR USE BY HEALTH DEPA
Soil Rate Approved Sq. Ft /Cal.
Checked by
Date
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