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03703
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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
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 / -
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� 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
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evo
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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
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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