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WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
is'to 6e �mNifeii` y'weii unller and °sLimiti�u'io "�ouniy iieaitri'Uepartrnerif iogeYi af- i,:ifli tauu aior"°'repon'ciT` "'�
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
NAME
ADDRESS
OWNER
C E
P VINA14
LOCATION
(No. Street) (Town) (Lot Number)
OF WELL
/�
6 k D 1. U C D 0r.VA M R AX is
(� BUSINESS
❑ ❑ ❑
PROPOSED
IL] DOMESTIC ESTABLISHMENT FARM TEST WELL
USE OF
WELL
❑ ❑ ❑ CONDITIONING ❑ (S(Specify)
SUPPLY INDUSTRIAL
DRILLING
COMPRESSED ❑ CABLE ❑ OTHER
C?J PERCUSSION
EQUIPMENT
ROTARY AIR PERCUSSION (Specify)
CASING
LENGTH (feet)
DIAMETER (inches)
WEIGHT PER FOOT
;
z- 1:1
SHOE
�
-
G
DETAILS
3S
�.
/� _
_
THREADED -- WELDED]
YES NO
j
YES
NO
YIELD
HOURS G.P.M.
❑ ❑ ®
YIELD (G.P.M.)
TEST
BAILED PUMPED COMPRESSED AIR
:�.t.
WATER
MEASURE FROM LAND SURFACE —STATIC (Speclfyleet)
DURING YIELD TEST [feet)
Depth of Completed Well
LEVEL
l�^
in feet below Land surface: /
MAKE
LENGTH OPEN TO AQUIFER (feet)
SCREEN
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
Diameter of well including
GRAVEL SIZE (Inches)
FROM (feel)
TO (feet)
PACKED:
gravel pack (Inches):
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
26
TOP , a j. -- -), d c
ED lqoc.
Rock
u PVT[
s.0 v T( 6
C1 M. Pi U r I il V A T / 47 D its
If yield was tested at different depths during drilling, list below
FEET
PER MINUTE
GALLONS
p C ftv [Z c fir &)
DATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
C, /0715T
1
o,
� 0
Owner or PurchasO of Building Municipality/
Building Constructed by Section
/Zf/& amz A e �
Location - Street
Building Type
Block
�r
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 of the building utilizing the system..
The undersigned further agrees to accept as conclusive the de-
termination of the Director of the .Division of Environmental .Health Ser-
:.., L.c - �.m ,;,- _,,� i„�.ar��;�a��V 01 t�Ealuri as to �nhetuei o2 riot the
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system.
Dated thi s day of 19 76 Signature .
or
T i tl e3 jG�Ui.
(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
lan.
-, f
. ............
lit iti.
10�
6kPPROVEQ--.--
K&TH IERVW
Gentlemen:
PUTNAM COUNTY DEPARTLIENT OF HEALTH
1%1 JJ.U�V�0 '""'VlifUNl`'1tLV•1�AL 1'EAi:14- SERVI.EsJ ' :.
Date V �4n/� _5', 7_3
Re: Property of /T/C_/Y.In p AloY.V'I,E's
Located at QLip
% -�Z Block / Lot
This letter is to authorize ZIA (/G,S/N� �
a duly licensed professional engineer or registered architect
(Indicate)
to apply-for a Construction Permit for a separate sewage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, 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
1.47. F.du - a 14 to Law, .tire .Ptbl ic- l eal.th Lacy, wLd the Putnam Cc`wnty qqj, i- _
tary Code.
0 il'F� °�y� Very truly yours,
1gnP_ d
Owner of Troperty
Countersigned:
Address
P.E., R.A., #
--s- -= Telephone
addr. ss
Telephone ••--- _________._.._
M
1
-0-JELL COMPLET10114. FIE.P.Of-ItT
W-11
II
PUTNAM COUNTY DEPARTMENT OF HEALI-t-
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CAN,MEL, NEW Y0,RK
this report is to bexompleted by well driller and submitted to County Health Department together with laboratory report of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued.
MST 13'E' SUBMITTED -WITHIN 30 DMY�S` Ll"
OF COMPLETION
OWNER
LOCATION
OF WELL
YROPOSED
USE OF
WELL
NAME
I- _. I ,
(No. & Street) (Town) (1,ot Ilumber)
l!2
BUSINESS
n DOMESTIC ESTABLISHMENT FARM TEST WELL
PUBLIC n AIR OTHER
El SUPPLY' 11 INDUSTRIAL L.1 CONDITIONING (Specify) 0
DRILLING
EQUIPMENT
COMPRESSED n CABLE OTHER
LJ ROTARY AIR PERCUSSION PERCUSSION El (specify)
CASING
DETA
LENIGTH (feet) DfX_�,_ET_Fk_(inchesjj_W_C1_GHT PER FOOT
1_�,
THREADED n WELDED
E)RIV E SHOE
YES 0 NO
WAS NG R TED?
DYES NO
YIELD
TESL
HOURS G.P.A.
F11 BAILED 0 PUMPED PKI COMPRESSED AIR
. .1
YIELD (G.P.M.)
WATER
LEVEL
— —
MEASURE FROM LAND SURFACE —STATIC (Specily foot,15UPING
.YIELD [!act)
Depth of Completed Well
in feet below Land surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (loot)
• DETAILS
SLOT SIZE
D IA M ETER (Inches)
'
1F GRAVEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (inches) FROM fleet) To (loot)
•
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to of least
two permanent landmarks.
FEET to FEET
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER M114UTE
............
DATE WELE7MP L) ED I .DATE OF REPORT 11WELL'"LLE . R (Si A'Ure)
1 3 73 1 /-�p !
-c.id 2,'.;- +yrr-r, r cr :i� - >rt� -...mss �.: ,•ka, s.:- - .r`C� +- :'.Y+', =t r... ;:s2•�_,...y...y..•.w:+: ^i - ..,SIN .i'�-t'Y'+C'as: r-� .c` �. �s`a -c� z_ �rw.
Owner or Purchase of Building unlcipalit
Building Constructed by
O L9 _Cdi_)KCH
Location - Street
Building Type
Block
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 of the building utilizing the system.
The undersigned further agrees . to accept as conclusive the de -.
Direc.-t..a.r..of. the -D .vis-.i..on o'f - vizor n�al Hc�a1 ±h .Sergi.. .
vices n � cne- i t'na�m Coaftty L'epaz�tm�ent of ��tea7 to a's to whether or not tYie
failure of the system to operate was caused by the willful or negligent
act of the occupant of the building utilizing the system. p
Dated this �J day of k1MO -c1t 193 Signatur w
T it! em4!�Z.f za 'a,,
If corp rat n, give name
/ad address)
Cr-
A, Rg "-v 9P P_
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMK ETION WILL BE ISSUED.
GUARANTOR IS. REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
4
Division of Environmental Health Services,` Putnam County Department of Health
PUTNAM COUNTY DEPARTMENT OF HEALTH
Mq
DIVISION OF ENVIRONMENTAL HEALTH E�i CE_'
COUNTY OFFICE BUILDING, CARMEL, N.Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner —Addre s s.
Located at (Street 040 C,1161,1-cW f0Sec. 7-� Block Lot
�Tn-ffi—c_-aTe nearest cross street)
Municipality Pc/7- V4 Z_ z-,C 2 Watershed
SOIL PERCOLATION TEST DATA'REQUIRED TO BE SUBMITTED WITH APPLICATIONS
5 /111 /_;_1 17
2
4
2
3
5
Notes: 1) Te'�ts to be repeated at same depth until approximatel� equal soil
.ates are obtained at each percolation test hole. All data to e submitted
for review.
2) Depth measurements to be made from top of hole.
hoie
Number
CLOCK TIME
PERCOLATION
PERCOLATION
Ran
NO.
Elapse
Time
Start-Stop Min.
Depth to Water
From Ground
Start
Inches
Surface
Stop
Inches
WaterTFve1
in Inche's Soil Rate
Drop in Min./,in drop
Inches
1,3
4
14
5 /111 /_;_1 17
2
4
2
3
5
Notes: 1) Te'�ts to be repeated at same depth until approximatel� equal soil
.ates are obtained at each percolation test hole. All data to e submitted
for review.
2) Depth measurements to be made from top of hole.
DEPTH
.G.L.
-TEST
HOLE NO.
TTED. WITH APPLICATION-...-
HOLE NO. HOLE NO.
611
1211
1811
2411
3011 Al o G o vivo
36
4211
48" 8 NO
5411
6011
6611
7211
7811
8411
0
M
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
'.TESTS MADE BY Date
DESIGN
Soil- Rate Used//-/,s D1in/1"Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity o o Gals. Type
Absorption AreaProvi deE By 4eal&- L. F. x24 3b v width trench..
pek
gna
Address
THIS
SPACE FOR USE
BY HEALTH DEPARTPENT
ONLY:
Soil
Rate Approved
Sq. Ft/Cal.
Checked by
Date
r
,
Date
-Lt's
PUTNAM COUNTY DEPARTMENT OF HEALTH
Qivision-otEnvironmental Health Services, Carmel, N Y. 10512
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE t4ls- ?YSTEW 1;pi 1,
Town or Village
Tax Map 7_ Block
Located at �• ,.� �•. ,n.-
Lot job
Owner
Separate Sewerage system built by Address
Consisting of of — 02 Gal. Septic Tank and
Other requirements
Nater Supply: — Public Supply From 7 –
Ae,
X0 Private' Supply Drill.d...BY
Addr s
Building Type No. of Bedrooms Date Permit issued
-7
Has Erosion Control Been Completed? Q--
I certify that the system(s) as listed serving the above premises were constructed essenti shown on the plans of the completed work (copies of which ere'-',, attached), and in accordance with the standards, rules and regulations, plans filed the permit i ed by the Putnam C ounty Department of H"6.,-
Date Certified b
Address
any unsanitary
Any sewer becomes I
conditions approvals. Are,
'available and the approval of the private water supply shall become null v id when a public water supply ec
t of the mmissi er of H h tion, ication or change is n
sublect t ofidatiO7 change when, in the judgment such revoca
R Title
0 70,
-..P.F-tFK K LL.-.MED1rALJ;ADQ- RATO.
Peekskill, New York 10566
RESULTS OF EXAMINATION OF WATER
hese results indicate t hat the water w-cs Of 0 satisfactory sanitary quality when the sample was collected.
� PUTNAM COUNTY, EPA
Divisimi of -EnvironmentalWealth Services,. Carmel, N. Y 10512
CONSTRUCTION PERMIT FOR WAGE DISPOSAL SYSTEM
Town or age
Subdivision Lot Job
`6wrI Address
Building Type
Lot Area
Number of Bedrooms 'Total Habitable Space Square Feet
'Separate Sewerage system to onost of tineal feet X width trench
To be- constructed by Address.
'Water: Supply: Pubtic Supply: From
Private Supply io be drilled b
Other Requirements
I represent that I am wholly and compl nd location of the proposed syttem(s); 1) that.the separate sewage dis
above-described will be constructed as t andards, rules and regulations 07 am
County Department of Health, and le h Ificate, of Constrdctiorr--Cornpliance�l satisfactory tor the Commissioner of Healthwill
be submitted to the Department, a Ill Ished the qviner,his successors, heirs or assigns by the builder, that said builder will
:-Place in good operatIrI conditiory' p rt I- stem during theperiod of two (�,years lmmediately'foliowing the date of the issu-
ance- of the approval of the Cert'fi Co pi. e f the original system or any repairs thereto; 2) that the drilled well described above
will be located as shown-o i the approv an it [led in accordance with the standards, rules and rei-wations of the Putnam
county Department of -Health'.
Witt
Address License No.
APPROVED FOR-CONSTRUCTION. This approval expires one year from the date -issued. unless construction of tho'building has b4en undertaken and Is
revoc
able for causeor may be,amended or modified when considered necessary, by the, Commissioner of Health., Any change or alteration of construction
requires a new permit.., Approved, --for disp6sat of domestic sariltary sawagg, and/or: private -water supply, only,.
Date- By. Title
' Located' at
Owner
'
'
`
Private, Supply,- �qril! JI
uiieMents
Address, A
APPROVED FOR CONS' iA I
re 0
quires anew permit. Approved for. disp' 'iifof �6 istiCM
Lot
Adi
'*
'.,thestanclards,*(jles -regulations of-"the Put
narh
LIceI
ply only.
PUTN,AM_ COUNTY_ DEPARTMENT OF HEALTH
Division o— "ti�a�"ils' r is rrc`; 'p��`- - -F'a �s ..t,�^,;.�;�,;,r�; °�•"
:ERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Town or Village
_orated at. oz-V `f��H ' 0 A+A? secturn Block...
)wner Lot• / ti
LarYN�k3✓+.1
ieparate Sewerage System built by Address , _, — ,-=- ---- --
Consisting of yw Gal. Septic Tank �04> lineal Feet X ryµ width trench
i
Other requirements
Water Supply: P blic Supply From _..
Private Supply Drilled By
Address
Building Type 1 f I#krllvii.. U,
Has Erosion Control Been Completed?
No.
Bedrooms Date Permit Issued
I certify that the system(s), as listed serving the above re c n
i "' as shown on the plans of the completed work (copies of which are
attached), and in accordance with the standards, r plan
the permit is ed by a Putnam County Department of Health.
° 7-3
Date .
� y
r A
� � License No.,?Zf 74,-
Address
Any person occupying premises served by the above Qj1 pr O
/ uch action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of
shall become null and void as soon as a public sanitary sewer becomes
available and the approval of the private water supply s c
id when a public water su ply becomes available. Such approvals are
subject to mo ficatIon o change when, in the Judgment
of Healt suc vocation ification or change is necessary.
Date By
Title
i
.....�....." ..-... - _� .... - -. � -- • ., _
._. - -...: 794
..� - . _ .
_. ..
YORKTOWWMEDICAL LABORATORY INC
P.O. Box 99 321
Kear Street
Yorktown Heights, N.Y..10598
245-3203
DATE COLLECTED
RESULTS OF -EXAMINATION OF WATER
WNER
DATE RECEIVED
G. Po Go COR ORATION
V 30 -�
:ITY, VILLAGE, TOWN & /OR NAME OF SUPPLY
DATE REPORTED
OLD CHURCH RD. FUTNAN VALLEY N. Y.
4/2/73
IATFT,T,
3ACMRIA PER ML. (Agar plate count at''35 C).
COLIFORM.GROUP (Most probable N6. /l00ml.)
LESS THAN 2 e 2
HARDNESS', TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N) - ppm
IRON, TOTAL - ppm
'LOURIDE (F) - mg. /1.
These resultaYndicxitefhat the water was YES of d satisfactory sanitary qudlity when the s1ple was colleooled.
If /
A. H. P.ADOVANI, M. • . (ASCP)
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