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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N: Y. 10512
: ;:s E TW1CA-TE GF CONSTP,EUCTION- CE)MPLAAl ,ICE�FG41 ZEih'A'G.E- ,:D18POSA'i.•SY5` tM i;
t�ai�n✓csn✓jwi2- Town or Vilrage
Located at .f�C °/ ,e`:() ^- 1C�
/ l� jI%� %sf ' Section Block -�
Owner % 'e YIA'C Lot Job-
Separate Sewerage System built by
Consisting of 12t)40 Gal. Septic Tank
Other requirements tyj'-6
Water Supply: Public Supply From
Address
lineal Feet X
X Private Supply Drilled By J ���c'= % ,
Address .�jdiE't�GaJ'` .6410AQ Ie%l AE FK; S'/c i L G,
Building Type . �hL l % zL yew No, of Bedrooms Date Permit Issued
Has Erosion Control Been Completed?
width trench
I certify that the system(s), as listed serving the above premises were constructed essentially as shown on the plans of the completed work (copies of which are
attached), and in accordance with the. standards, rules and regulations, plans filed, and the permit issued by the Putnam County Department of Health.
Date `' �` / Certified by ' �� "�' "`' P.E. R.A.
Address 20 74,
117i1 ,ear�r A�l
License No. lz4y o
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a public sanitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner of Health, such revocation, modification or change is necessary.
Title �/
1`'76
YORKTOWN MEDICAL LABORATORY INC.
P.O. Box 99 321, Kear Stre
Y�Oktoi-nilulalght;- N' ADS&- 3203:
UATL UULLLUTEU
RESULTS OF EXAMINATION OF WATER
DWNER DATE RECEIVED
CITY, VILLAGE, TOWN &/OR NAML OF SUPPLY I DATE REPORTED
J'1-Ljl y 4/2 /7�
BACTERIA PER ML. (Agar plate count at 350C).
COLIFORKGROUP (Most, probable No./100ml.)
HARDNESS, TOTAL -ppm
DETERGENTS - ppm
NITRATES (as N) = ppm
IRON, TOTAL - ppm
FLOURIDE (F) - mg./l.
.These results-indicate that the water was !LDE)' of a satisfactory sanitary qudlity when the sa pli was collects
PIK,, j. IIENII-ff `A-?-TETq' EE h LIA-1 t�
-1E 3IR A. H. RADOVANII M T-1 (AS, - CP)
T
Y
WELL COMPLETION REPORT
3/71
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
: ;.�a.Tta� rt port o-s`ta- I?e= cvrr;�llr:ted by weII, -4ril is -. a- nd-- swbn�it7eci;:tc;:Cf u t,� kraal *eta ,'�. apart: ;eat: tugetfasa.,.wa:tl laboratory- re crt:o�,��r =,t:
analysis of water sample indicating water is of satisfactory bacterial quality'bbfore certificate of construction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAMEi
V V � I; � � �., i f �
ADDRESS
F "� :.�" ✓ 1 rfvi� t' /i r �- 1=.6- � t
LOCATION
OF WELL
Z(No. & Street) (Town) (Lot Number)
cj 1/14 G (� r . ✓A /� ��
PROPOSED
USE OF
WELL
BUSINESS ❑ TEST WELL
DOMESTIC ❑ ESTABLISHMENT ❑ FARM
❑ SUPPLY El INDUSTRIAL ❑ CONDITIONING OTHER).
DRILLING
EQUIPMENT
El n COMPRESSED ❑ CABLE OTHER
ROTARY W, AIR PERCUSSION PERCUSSION (Specify)
CASING
DETAILS
LENGTH (feet)
L5
DIAMETER (inches)
WEIGHT PER FOOT
f
X THREADED ❑WELDED
DRIVE SHOErn
❑YES 91 NO
WAS CASING GROUTED?
DYES ❑ NO
YIELD
TEST
jam^ HOURS G.P.M.
❑ BAILED ❑ PUMPED <J COMPRESSED AIR ` 7
YIELD (G.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE '= STATIC (Specify feet)
�..
� . �'� i
DURING YIELD TEST feet)
l
Depth of Completed Well
/
in feet below Land surface: / 3 ) /' cc�"
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
v
iSF a C— .t�:tVl`
- .. _. . _ ... j - - - -- • -.
l
5Gr^L��
_ . _
_ 1.
C' 6 ILI C P ( J,31J IF: It
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
t°
N
DATE WELL COMPLETED
11/01, 7 i
DATE OF REPORT
J �K: - 7 r
WELL DRILLER (Signature) f%r f��� l
/inn
°r�
__.l ?1JL� J' c7 ��'i;J'C•L1 %'.,- 01 '
Muni C:.ipc,.1 gty
T iT .1_ G'. i, n U �: �' I 1: , 'r; X' i< d b y
Location Stvaot lil.oclti.
=,ui L a,r)g Type 4-
v
GtJARAI`I`.0 0,F Si:PPR,..`I'E SEIIAGE SYST': i
I represent that I ara i-,h.ol.ly and completely respoznsible for tho
location, construction and drainau re of the sewaS•e
disposal s;st�em- the above a cn cr_ l)-e d I)L o pe.» . ty, and. that i}..- , CLas been
cn.
constructed as shoim, On the a.pp::'oved plan or approved alii.end --mint therc o,
and in accc? dance ,•rith tree standards, .rules and renulati.ons of th.e Pu -cream
County Department of ,ealth, and hereby guaranty to the c,.rner, his succes-
sors, b. —Irs or assi'_'ns, to place :in goodvoper8tin` condition any part- of
said sySt I,I constructed by r_e :•:hick fails to onerate for a. period of t1wo
year,,,, l.I'L'ii ;diately Ioi.1 o ing true date of .niti_ai. uS;e of tr: sewage dis:)osal
UyS tf m, or any repair's :Facie by Jae to such System, except i,,here the failure
to operatci 2; o- U::r1v _s caused by the ,.i llful or ne.gl:i Trent act of the occu-
pant of the building utilizing the system.
Jn�l.e un.ac: z °s.' o -nea .Curtih�:J afzrees to accept as conelusive the de-
termin�_itlon Of the r)ireC±;oi' of to Div9_sion U. Y "l1V:Lro:;i?.enll a.l Healtia Ser-
vices of tree Putnam Couunty Departr_en.t of Hea_ltr2 as to i•:?-Iether or not the
f' ilul,e of th to ouei ate Cau3ed b -Nr the. ':11 ._1 -iul or neglirrent:
act of the occunart of the bui.ldin� utili.zi.n the s-rst ^:�.
Dated this - /� day of 1 si'g'nature 0
'1119 e V /lf
Tit�.c
er/'a'x /��� 1 0 OJ7 p7 t i U21, bi'Tv n.aF1U
12r`� ,✓ and add. e s s )
THREE (3) COPIES ARE R'E UIRED WITH T�IRET] (3) COPIES OF FINAL PLANS B FORIT,"
CERTIFICATE OF COEi',,ETI0N WILL BE ISSUED.
GUARANTOR IS REQUi_R 'D TO FILE NOTICi,J OF DAI E OF FIRST US:� OF SYS?'Efii.
Division of.3lnvironmental Health Services, Putnam County Department of Healt.-i