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HomeMy WebLinkAbout3703DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.17 -1 -36 BOX 29 lirm ' 9 RICO, : : I.IL '. . r ' I � `` , x .I . � .' : . T IN ' ', .' : . NN IN . 1 I is 3rr-, y •, 6 � IS I NN. I • ,' ,, 03703 m C3 „r ,.."-WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3)71 Division of Environmental Health Services COUNTY OFFICE BUILDING CARMEL, NEW YORK This rtpertTTlg:tci lie coeipleted �y -vveil driller- and- 4ebmitted o _ot+nty '.NeMth - Departmto toget, er. witft,lab6ra'torq 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 r OWNER NAME �j. ADDRESS IN r�. "cclll00/ LOCATION OF WELL f VF o. & Street p own) (L Number) PROPOSED USE OF WELL Q DOMESTIC ❑ SUPPLY 6�' BUSINESS F-] ESTABLISHMENT El INDUSTRIAL ❑ FARM ❑ CONDITIONING ❑ TEST WELL if ) ❑ (Specify) EQUILPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION CABLE ❑ PERCUSSION ER ❑ (S(Specify) CASING DETAILS LENGTH (feet) - DIAMETER(lnchesJ WEIGHT PER FOOT ® THREADED ❑ WELDED DIVE SHOE � YES ❑ NO L^J CASING GROUTED YES ONO YIELD TEST ❑ BAILED HOURS ❑ PUMPED ® COMPRESSED AIR 4 G.P.M. / YIELD (G.P.M. / WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) DURING YIELD TEST [feet) Depth of Completed Well ( -/G+ / in feet below Land surface: G 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 If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL fOMPLE T DATE OF REPORT WELL DRILCI� Signatur y Owner o_r,_Fu_rqNaser f Building Municipality a Building Constr cted by Section Location J 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.o.r 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 o -r 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 negl.i °gent act of the occu- pant of the building utilizing the.system.` The undersigned further agrees to accept as conclusive the ,de- terminaaion...of-the Directo;r.of the Division. of. Env- ronmenual Health vice's-6f 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 cyst,` Dated this_ day of _ 19 Signature Title tlr corporation, give name and address) — — — — —— ®a_ _ -10 -5 — _ — — —————— 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 �•�a d }te aF h� x Z gh �'��� .`�f 1 SaqurAY f rYn .� h H� `s '� K ej7 f / - ''x' ^! ... e.. t ,."T.�•� . i _ . .,.� �:':.. ,4:..w,e� _ac,ae df_ vds. _. .w- . s'z ,,cb -. v'� rxw-F: 7 . , -�+e � t.. '`r�" # F- terra: .,+r" i;{t.' �a} i'�' 'r �� . •.+..e i� . ��. {e ^ .ix .._ �: Y..r r a ..m., -'.� '�,4 - r f .... r. :s -.rn : _.- ro. <.... _...: i.._. LOT'3 / SEG A, Of. C1 PUTNAM ACRES N � �• �, t,,` ��t '-�' � �. '' �u + � — ; 25703 ` \ r ° }� s -� 3t, i + b \; styA 'tiff t• �! .. s\ .\� �`"* \ ti t \ 5s;4G2 S \ \ ll( m \ \ /. O a 3 GAP 6T 48iV s 12 3x2+. is F� Y k i.3} 4, � u f..4•a .. .. � ,�QN� c .. _. s y i;•4930 >: ! a CL'NG a ca '3 { f 1i � ! �cr l 34,f. � ` � •' � At .,f Z � V fi, 40f3 ', 3pR 2 Ip 1 �; s N 4 s�c u h t.sp 4piC 4p evo S � i r r i L qNE ., ti REF '` � �� Her�tp � Ect1= pertfe� . Q G@ � ; q��� ��•,� � e f(1� �R9/N B%5 (:pI70� S�3tllByQ�S , PARG.EL SHOWN HEREON KNObYN AS 10r4 u N S;UBD/V/S %ON hfAPSEG B Of PUT�NAM tV rl, { x t B� FRO,w,uHOaz: e�€ & r.•'s e?�ao®,��1 � �,, �e rys�q� . - .; �._ .. yY� M1�r tiiA 41 i � ` ` ' i -' r.'b5,"?�.�i rc. ��� �. °VCs u �' "'^ ✓ .'Y. i .3,.� .. ,+ • - PUINA] i -isi6h' v of- u dd" iVision ',6wner Building Type` Lot Ai Number of 'Bedrooms. � Separate Sewerage Systelfti-to.clonsist of .2 To be constructed by Water: Supply: %Supply From Pi sul5pfy"•tor be drilled by ­:,Addi % .Other Rdquiirements I represbri ­ j am Wholly and compike1q, r6ipdrfsib&� _164.`th h above described t'Alhat' will be constructed '- s6b Yn onAh ea approved j ?County Department of .Health on completion "be submitted to the', Department `and 6,4466W, guarantee j, place in',go-od. 0 perait - in4 .conditidn any part of said sewage _ante .',of ,the -approval Of °the Certificate .5p. '.,Wjjj, b61ocaiiIdAgshbi orii. the approved ',plan and ,that ;,said ,*.ei County Department of Health`. 'A -APPROVED FOR CONSTRUCTION This approval qNpiires, c rq.VOcabl­ for ,cause or may -arifende-d."di.' th6dii,-i4bld Woet-R,q9!1. 'requires a .,new permit: ibe4kp6tai "ford—, "k.- IC, 12: A N& Town 'be V11 9 ja e'- Section Block �,� �' Lot Job r e si Add Total Habitable Space Square Feet Septic Tank feet width ...trench ' 1 Address V Z�� VII 5 successors heir ii sion'. riii two (2) r m n ter&f6j);isju'- n it any repairs le escro e above :.with t 6 sta ,the Putnam A Any-. a,nge-:or,,alteration -of-construction, . wilter�,, supply r only Title Lj/ PUTNAM COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENTAL HEALTH;SERVICES .-, nri>cia =sue. •- -. ._ -. -- .." .'.G'a,'• -. - cyti ^si ° — Ia cx _-.. _ _ -- .... .s :a.:" '..i .r _ .... DESIGN DATA SHEET --.SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. , Address :�:?4t', i��sir,�' >;i�f� </<' >,r` ";,�• ir:' �,� Located. at (Street)._ i? � i1= `�=- 4i). See . Block. Lot (Indicate nearest cross street) _411 Municipality j- w7+jts��� /1' i � ! ....'Water shed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH. APPLICATION Hole Number CLOCK TIME PERCOLATION PERCOLATION.. Run Elapse. Depth to Water Water Level . No.. Time. From. Ground Surface in Inches Soil.Rate Start Stop Min. Start ..Stop Drop in Min/ih.drop: Inches Inches Inches . 1 `� .'�Jf.� . f'r3. 'l`i j � / � " Z j `s��t �' Z �,.j • i; S". S �?. ✓i'V % t , . 2 4 5 , 2 3 IC-) IS �� /� 2/ �vA' 5 1 . 2 3 4 5 Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are ob- tained at each percolation test hole. All data to be submitted for.review. 2) Depth measurements to be made from top of hole. S 4" 6 Orr. 661! 721f 787 . Ilecicl-- 8 411 . INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED _INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY �% efi r✓ ,✓ �i�r.��:� =rye .- ` , . Date )Y.// DEbiGN Soil Rate Used - Min/1" °Drop: S.- D. Usable Area Provided. ::5 No.. of.Bedrooms Septic Tank Capacity ,� .c�c� .Gals.. Type. Absorption Area Provided By L. F.x2411. 3611��� ch. Other Name Signature Address % y/i ,�'', i.� .� k-0, SE L N 1 {y PUTNAM COUNTY DEPARTMENT OF HEALTH Soil. Rate Approved '��`� Sq. Ft. /Gal. Checked by Date ::.. TEST. IT::nAT�...RE.QTIIP�ED -M(? _ BF.: _SUBMITT_ED.- WITH:APPI,IC�TION _., ...._.. -.:. _ _... - -.- DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES. DEPTH, HOLE N0. �. ,HOLE N0. G HOLE N0. 12 rr 2 41i ., 301} 3.6 r1 42 t1 S 4" 6 Orr. 661! 721f 787 . Ilecicl-- 8 411 . INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED _INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY �% efi r✓ ,✓ �i�r.��:� =rye .- ` , . Date )Y.// DEbiGN Soil Rate Used - Min/1" °Drop: S.- D. Usable Area Provided. ::5 No.. of.Bedrooms Septic Tank Capacity ,� .c�c� .Gals.. Type. Absorption Area Provided By L. F.x2411. 3611��� ch. Other Name Signature Address % y/i ,�'', i.� .� k-0, SE L N 1 {y PUTNAM COUNTY DEPARTMENT OF HEALTH Soil. Rate Approved '��`� Sq. Ft. /Gal. Checked by Date