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BOX 26
03263
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03263
�- Owner.-` _'�✓ � %�
'Separate= Sewerage 5+
Co,nsistii
y�' -Other 'ri
Water Supply
1Has. Ero'sior'
'I certify�ahz
~attaclietlj;;_a
.Date
4�
:Any person,
conditions.: i
;,, -ava i la_p le .an
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Date
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`V ELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTI-
3 /,?r'' Division of Environmental liealth Services
COUNTY OFFICE BUILDING CARMEL, NEW YORK
This report is to be completed by well driller and submitted to County Health Department together with laboratory report of
analysis of °water sarnple indicating water.is of satisfactory bacterial quality before certificate of construction compliance is issued.
REPORT MUST BE SUBMI'T'TED WITHIN 30 DAYS OF WELL COMPLETION v
OWNER
NAME Gt y� r�i
7
1
AD S5.
.
LOCATION
OF WELL
--
(No '
. & Street] (Town) (Lot Number)
�• .�
°
YP.OPOSfi)-
USE Of
WELL
DOMESTIC- BUSINESS L-J iE57 WELL El
ESTABLISHMENT FARM
El SUPPLY INDUSTRIAL D CONDITIONING' OTHER) °
DRILLING
EQUIPMENT
COMPRESSED CABLE OTHER
+ + —�! ROTARY _ AIR PEP.CUSSION PERCUSSION E (Specify)
CASING
— DETAILS
LENGTH (feet)
,
DIAMETER (inches)',
.
WEIGHT PER FOOT
%S
j�} DRIVE SHOE
1Ly THREADED , . N'ECDCD j YES E No
WAS CAS!NG GROUTED?
❑ YES , :10
YIELD
TEST. _
ff
L� #S41LfD Lj. PUMPED.
HOURS G.P:FA
.'COMPRESSED, `AIR Q
YIELD (G:P M;)
_�
—
R— WATER
LEVEL .
MEASUE'FROtd LAND 5URFA /E- STATIC 75pec /fy tee ),,DUP.ING
rat
YtELO TEST ((eet)
1
Depth of. Coinpleted.Well f
in feet below land surface: —o
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (leer)
- DETAILS
SLOT SIZE
DIAMETER (inches)
IF GfiAVEI
PACKED:
Diameter.of well including
gravel pack (lndhes):
GRAYEL SIZE (inches) FROM (feet) TO (fact)
DEPTH FROM LAND SURFACE
FORMATIOtJ DDESCRIPTION
Sketch exact location of we with distances, fo.st /east
permanent
two landmarks. '
—' —
FEET to FEET`
o
3n
If yield was tested at different depths during driIiinc;jist below
FEET
GALLONS.PER MINUTE
DATE WELL COMMIM p
p qq
I OAT C:OF :1 Ef?:7F:T
..
1165.'
YORKTOWN MEDICAL LABORATORY INC.
P.O. Box 99 321, Wr Street
DATE, COLLECTED
RESULTS OF EXAMINATION OF WATER
CITY, VIL
TXMT.T. � Q ,SOT "PP ()VP RT'11\TPTq_P. T)P-
BACTPERIA-PER ML. (Agar plate count at 350C).
COLIFORM.*GROUP (Most, probable N6.,/100ml.).
T._FR!.:' rPRAI\T 2-P
HARDNESS, TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N). ppm
IRON, TOTAL - ppm,
FLOURIDE (F) mg./i.
,These resulis"indicqt I e that the water was YFiS of a satisfactory sanitary qudhty when the s le was collected.
Lal
A. H. PADOVANI, M. T. (ASCP)
'A
.. ._ .. :.- .. .... .n. c' Xu[..0 +;.. .t -�., �- :�•��—�. Ci+.. �,^..c » �w1. :�� . +.... � ..c .vi..l N ._: a' y ctn ....�.t.4sf:: +.. c-. � - . . -M.. -* i. R�.4 ..'y✓ . u..�� .ate ". +i. ... .. T. �.r+.i la _
Owner or Purchaser o Building
Building Constructed by
Location = Street
Building Type
AFL
Municipality
�7
Block
1/ °/
Lot
GUARANTY OF 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_ o�._.tho )ui3..ding___ut.i1i.7 ng the.. s stem:,,. - _ �M
The undersigned further agrees to accept as conclusive the de-
termination of the Director of the Division of Environmental Health Ser-
vices 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.
� 1
Dated this day of 19`` Signature
Title
If corporation, 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
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Gentlemen:
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property
Located a
Date 72
Block
i-AAHAP
Lot 116 7- j
This letter is to authorize .16,' S 1 AKEY J. LAN®ER
a duly licensed professional engineer L,�or registered architect
(IndicaTeT-
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
o TT
iTlepaltmen�- nueali1L. l , and to
sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
(XlTCaLluti "L=aws "Lill rtiiiiii; FiCcLll;il Law,' and t;iiC i'ui,riatt, °vvui7�y
tart' Code.
r �
Coxriter sign
ed:
elep
Very truly yours,
/!f /r
Signed V
Qjr.,er o p r
ress
ZA2
e ep one
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o. 8 - -,•,
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PUTNAM COUNTY DEPARTMENT OF HEALTH
T
.app.- .f.�:..i, =__.. _ ..�. ..... ... ..... .1�.. _..:.: -9 .. .... ".... :.: .''__.. ..ti.L� ......::'.,: w�:.. �, �..'. i .,..:.wfu;.�.::•.:+v�:w:.:.:��: .-.
_" ffnT 6 "OF - RONMENTAL�HEALTH'SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. P'
Owner •j �. ou51C� Ep�� Address C 4 u P C-4 L20 ��-rA) VALt,� y /J • 7 .
—MIA MA
Located at ( Street '5cjo Q%se '-Dp— iikw. . 72 Block .3 Lot P b 7.1
Indicate neares cross street)
Municipality ?or"AM VALLc Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
apse Depth to Water Water Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
P 131,vvp -31849 i&2- ka 14 3 4,0
2 3: f o
4', o;5
t-5
a °I4
4. i
34',o4.
4.°1
5o.57
i40 °lf3
Iq+
/8
516
2.9
5
25'.46
5o.57
11.0
1116
516
2.9
34: oo
44,01
9
4
5
1
2
3
4
5
Notes: 1) Tuts to be repeated at same depth until approximately
rates are obtained at each percolation test hole. All data to be
for review.
2) Depth measurements to be made from top of hole.
equal soil
submitted
r
i
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
..
.. -�...^ :
T r1T f1 I\ T C TlT �T,L
'1'�T "-.:3• ..., -�:!- _ lT-t�s t� T _ : �''i.r -..!• y-,. ..,....w.��,..:.. ® .,.... ".�
DEPTH
HOLE NO. HOLE NO. �a.- HOLE NO . ])L c�'
G.L.
���,�. �'Pott...
6„
18"
24"
3011
t6
42"
5
4
n
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7 8
- -Ole
8411
"� � rf?7 E! cam..
r+,
il
.. .. r rT•^ T T r f+ _ ... .. _ ..
_
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
�S' 7- ' 72-
TESTS MADE
BY -�5 G , 4A1,P e-. Date
DESIGN
Soil Rate Used o-5'- Min/1 "Drop: S.D. Usable Area Provided Sd-v 4Cr F%
No. of Bedrooms ¢ Septic Tank Capacity !X&po Gals Type 1014-15-oAlle y
Absorption Area Pro ded By/f L.F.x24" — width trench.
STANLEY L LANDER Other
Name BO 267 Signature
Address 'AMAWAI K N Yo 10501 SEAL
"9
rn 1 .-'
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved
Sq. Ft /Cal.
Checked by
Date
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