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WELL COMPLETION REPORT
3/71
a
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This.r..eport,is.to be completed =by yve!! dri!.ler. and- SUbmitted to- Coun ±y Health 0epa.rtment_ together with-laboratory report of
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
OWNER
NAME
LITZRODT, Edgar
ADDRESS
R.D. 3, Box 107A, Putnam Valley, New York
LOCATION
OF WELL
(No. & Street) (Town) (Lot Number)
Oscowana lake Road Putnam Valley
PROPOSED
USE OF
WELL
BUSINESS
® DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
❑ OTHER
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
DRILLING
EQUIPMENT
COMPRESSED CABLE
® ROTARY El A R PERCUSSION ❑ PERCUSSION ope (Specify)
CASING
DETAILS
LENGTH (feet)
21
DIAMETER(inches)
6
WEIGHT PER FOOT
19
�
`LAJ THREADED ❑ WELDED
DRIVE SHOE
❑ YES � NO
WAS CASING GROUTED?
❑ YES � NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED ❑ PUMPED COMPRESSED AIR 6 9
YIELD. (G.P.M.)
9
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST tfeet)
Depth of Completed Well
in feet below Land surface: 105
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
0
8
Overburden
8
20
Medium Rock
.26.--
` -10
Medium to Ha ld-' R oek
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE W LL C MPLETED
2/1 72
DATA F PORT
2/1977
"�i.LW%ff?ftftLING CO. ,
a
Owner or Purc aser of B ding Municipality
Building Constructed by
�� 40-'ez A"Izv Location - Street Block
Buil ing Type 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-
vices of the Putnam County Department of Health as to whether. or not the
t e - sisstc:r� -to o Grate was- c-ausc -d- :�
y p� `- y--the- -will"ul or- negligent-
act of the occupant of the building utilizing the system.
Dated this day of a AJ 1-- Signature
l y 19� _;-_ v /
I
Title 6)u/„r6,
(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
0
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°YORKTOWNMEDICAL LABORATORY INC. 6227
t
as N) ppm
IRON,, TOTAL' ppm ti
{ P 0 Box 99 321:.Kear;Street
a
Yorktown Heights, N Y 10598
245 3203
y
oLLECT
a
f:^ R,E$ULT$ OF EXAMINATION OF WATER
OWNERw,,
DATE RECEIVED
EDGAR LITZRODT R.D. BOX -'i 107 A.
CITY . VILLAGE, TOWN & /OR NAMir OF; SUPPLY ;' ,'
DATE REPORTED '
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4 22_..
SAMPLING POINT s a
j q'4
.o-f17Q�•, -• ,_ t a
8ACT8RIA PER ML ;)(Agar plate count at 35° C)
COLIFORM GROUP (Mosti probable No /,1OOml )'
HARDNESS •TOTAL -ppm
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DETERGEN S, ppm . —NI
as N) ppm
IRON,, TOTAL' ppm ti
't
PUTNAJI COU�IT DEP. -.P'1t 'a T' Off' I �.LTH.
- DIVISION Or =i� '_RO ?i= ^AL L.E A L T H SERVICES
Date
Re: Property of - 7- ,0'i A
Located at Ole<_A --IA11V -6 Aliki e' 14 -Awy 0- t�o"N �eZe
A xtl-a Block Lot = a
_
Gentl e_ men
This letter is to author_ -- STANLEY Jo MDR
a duly .licensed professional °11? "?ee_' L' or :3z1SU a arc itact
(Indicate)
to apply for a Cons t""'` cti'o P rI i- _'o: a sap ' ;e s S ;IS i � �O
.Serve the :abO ,Te noted pro -o3rt' _r we '_"ds -1 _ t 1 n rasp .,- ,.-.'.l eS
_ co ce t e s �a~�da
or rezou? atio ns as _ ro_:IIlyated by e Caw__i SSi oner of the Futma-ma County
..__ Depa:`ti''TP'ity .. .s.. Hv.a�.� 1� .r -•-i�-3._.s' ,?`?' ....I. :e' S'S a.= J?'pe,rs'.o _`.q '0-f_a_� _!- _.........
connection wit',
this matter and to 3uce.^� ? se t:_e construction of Said
sys. em, or system, s i n confor:':- t 'Ti �h the prov __o= S of 2rtiCle 1L5 or
111.7, Education Lati�T, the Public. Beal th La,, , and the Putnam County Sari-
tary Code.
Very truly yours,
Si n- a d
-0 perzy
�J Fro,, �
in lo IA
'CoIMters= i Add�^ess
P . E.- -L'
' 72a,
'
•, rT
STANLEY J. L
v Telephone
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AddreRDWA LUI
AMAWALK, N. Y. 1050 ��,� � o,�
Z0.46045 OF
M_ ..,
&-46 0 108
ROOM
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FLTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES -
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
::DESIGN DATA SHEE T- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
r
Owner ,tp rli-i? L iT�j0I7 Addressc
..Located at {Street w.44M L4e4 , Q3t Block - Lot ica .e nzV s - cross st
_.Municipality Vw ,V;_W4 Water shed A,,��� «L -
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Role
Number CLOCK TIME PERCOLATION PERCOLATION
RET lapse Depth t'o'W—ater Water LeveI
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
•Inches Inches Inches
2
3
1 =�"
I °- i 3
1'3
191,E
Z2' 3
4,3
1z:4,,
j
it -3
2
��.:sj
�.: j�
%�'
�
� -3
-�
5
1
R
4
T ,
5
Notes: 1) Tests to be repeated at same depth until approximatelyy equal,
soil ,
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measureme' n' is to be made from top of hole.
1
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
.. :. DESCRIPTION_ OF SOILS .ENCOUNTERED. IN TEST
EPTH
HOLE N0. I _ HOLE NO. HOLE NO.
�s
t
!�
f�
1 t }
it
,tl
_ n
• h
r
IDICATE
LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
i�
IDICATE
LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED = `'
;STS MADE BY ,S`� L ��r Date ,S'- 2.,c ..-7 -z-,
� f.
DESIGN r
"Drop:
'
lil Rate
Used Mdn/l S.D. Usable Area Provided 3
f
. of Bedrooms
Septic Tank Capacit �A s . Type A e s ri a✓�_
y
!F
1 r _�g ��Gal
-sorption Area Provided By L.F.x2�+ �` width trench.
; i
�.— - -- Other
me 08M®LLI
Box
dress
AMRVVMLhy U.
IS SPACE FOR USE BY HEALTH DE PA
it Rate Approved Sq. Ft/
7—_--`Checked by Date
0
TU 111AM COUNTY DEPaRTL 1' \T OF HEALTH
Sot Rate Approved Sq. Ft. /Gal.
s 21
eked h,:
Date
TEST
'PIT DATA 'REQUIRED -0 3 SUBMITTED i':ITH
APPLICATION
DESCRIPTION OF SOILS E" UNTERED I_: TEST HOLE
DEPTK HOSE
NO. HOLE NO . f�L
HOLE NO.
G.L.
6"
12"
2>, W.
_.
l
30"
36"
,�.
42'.
4q"
S 4`1
601,
_ .. 66_"
84'
IN'D CATE LF�TL
AT,1',TTICH GROUND WATER IS ENCOUNTERED?
IKi D;CaTE LEZrL
TO WHICH �� ATE LEVTEL RISES :AFTER BET ENCOUNTERED
TZ S *,LADE BY
11 S9
/
L =f <�gfr..o..
Date _ 2,%-
_
J
' SO 1' Rate USed
Mir /1'' Drop. S.D. L,s_= '2 e
Min/1"
Area -
PT O'
r
'No. of Bedroo"s
_—
3 Septic Tan.\ Cap ,c_ty� 9�v Gals
. Type R1
Ah s?rpti o_i A� ea
ri•ovided Eys L. F .Y2' ='' ` 36'! ;:idth
trench. Other
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BOX 267
Ness
TU 111AM COUNTY DEPaRTL 1' \T OF HEALTH
Sot Rate Approved Sq. Ft. /Gal.
s 21
eked h,:
Date
iI COl7?;TY DE ?,?T:' tT OF •i�'LTH
FUTNA
DI.V.IS.TQN OF. £ \`JIRQ \y `.TaL H:tA.L•TH.: S__'VICES.
.DESIGN DATA SHEET - SEPARATE SES:'AGE DIS_ OSAL SYSTE"%! FILE N0.
Ow er zzi� , 47'.740,01 Address 'D .� r� 14,74 � Ty � 1/z ;/y, .
Located at (Streat ayA&4 , We le-40 _ //� Blocs Lot -
(Indicate nearest cross. street)
Municipality ,''atershed �sc�►� >r��ao�,r�.
SOIL PERCQLATIO�' TEST DATA REQUIPFD TO BE- SL'E:iI' TED L' ITH APPLICATION'
Hole '
Number CLOG NE
RCOLATI0Y
PEP..CQL_E ION
Run Elaose .
Dept:- to t•at
'iater Level
No. Time
Start Stop L1,Iin.
From Ground Surface
Start Stop ..
i Inches
Drop in
Soil Rate
Min /in'. d,r oc)
Inches Inc:,es
Inches
ifs
v
4
2 G)y dy ,?. fJ'
S
1
2
5.
Notes.'
l) Tests to be repeated at same depth until approxi- =te1,, equal soi1'rates are ob-
tained at each pe cola Lion test hole. all data to be. submitted for rev iec. .
2) Depth meas�'.reT:2P.tS to be -made from toy of hole.
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NOW GIOBONS ER�Y
FORMERS -y DUSAVAOE
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NOW OR �
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1538 AC.
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5- 44-5!-30'£ 3:701
189.54 S 46'24 40 W
26 87 5-38-51-20'W �
/0 _p -µ 3'41-48'50 -W 74.13
ROAD ( 2,40
OS CA WA NA LA ,L
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SURVEY OF PROPERTY
for
�1)a1; 1 TzR0C,T-
S/ - tuate in
✓. Henry Corpenter q Co. TOWN OF PUTNAM VALLEY
Engineers 8 Land Surveyors E
Yorktown Heights, N. Y.
H.E. FR0MMHOL2, P.E. 5.12400.
Scole : / "= 40' June /5, /97/. -
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