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ti 1,'ELL C MPLETION REPORT PU'TNAM COUNTY DEPAR•rmENT OF I•IEAL
301 Division of Environmental floaith Sorvices
COUNTY OFFICE 13UILDING - .CARM%I_, NEW YORI<
o �
This report is to be completed by well driller and su!,:-nitted to County Health Department together with laboratory rep_ ort of
analysis
of water Sam ple,indicating; bacterial quality before "certificate of eonsYruction compliance i "s issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NA �L�C�S. r __ ✓
7VL/
ADDRESS
LOCATION
OF WELL
(No. d /Street) c / ( (TTuwn) / (Lot Number)
Al� VC J
PROPOSED
USE OF
EII
WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT D FARM L_ J TEST WELL
PUBLIC j(��
SUPPLY INDUSTRIAL L.I CONDITIONING FJ OTHER if )
DRILLING
EQUIPMENT
COMPRESSED CABLE OTHER
ROTARY AIR PERCUSSION PERCUSSION (Specify)
CASING
DETAILS
LENGTH (feet)
t
DIAMETER(inchesJ
r
Y,'EIGHT PER FOOT DF7t'E SHOE
I THREADED ❑ WELDED I 1 YES ❑ NO
,[[w��AS eA ING
OYES
ROU ETA?
ONO
TEST `^
D BAILED � l_J PUMPED �`J
_
COMPRESSED AIR HOURS G.P.A.
YIELD tt3.P.h�t.)`'
dJ
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Spec /fy /aet)
DURING YIELD TEST float)
l ±D.,)t'n
of Comple7od Well
feet below land surface:
SCREEN
MAKE
LENGTH OPEN :O AQUIFER (lest)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pock (inches):
GRAVEL SIZE (Inches)
FROM (loot)
TO f/oet)
DEPTH FROM LAND SU?FACEI
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET io $CcT
3
1.
r p.
1C
.f
If yield was tested at different depths during drilling, list below,
FEET
GALLONS PER MINUTE
)ATE WELL COMP "D,[
DATE OF FtEPOR•F
L.ER (1,51 nature)
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Owner o Purchaser.of Building. Municipality
-rl�� Sef) tfe frC
Building Constructed by Section
0 x /.ael.oe.. `C'}�
Location - S.t:reet Block
f. _
Building -Type Lot
GUARANTY OF SEPARATE SEWAGE SYSTEM
I represent that I am wholly and completely responsible for the
location, workmanship, material, construction aiid drainage of the sewage
disposal system serving the above described property,-and that it has been
constructed as shown.on the approved plan or approved amendment thereto,
and in accordance with the standards, rules and regulations of the Putnam
County Department of Health, and hereby guaranty to the owner, his succes-
sors, heirs or assigns, to place in good operating condition any part of
said system constructed by me which fails to operate for a period of two
years immediately following the date of initial use of the sewage disposal
system, or any repairs made by me to such system, except where the failure
to operate properly is caused by the willful@ r egl'gent act of the oc„�u-
pantnof he uil$ing ut' lining he sys, e '
_Q CC z uXcw►
T undersigned further agrees to accept as co lusive the e-
termination f the Director of the. Division of Environmen al 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 neglige
act of the occupant of the building utilizing the sy
'�
Dated this day of .� 1914 Signature
Title 12 R
corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMP.7,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