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TNAM,` COUNTY 'DEPARTMENT OF' HEALTH '_
i of Envi�onmerital Healih Services Cam% N Y 105`12
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B ACT ERIA' PER. ML. Agar plate count at. 35.. C):.
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COLI .FO�sRM.GpRpO�UP,(Mostrprobable No, /100m1:).:.
ARDNESS; TOTAL -ppm
DETERGENTS -ppm
NITRATES (as. N) ppm
IRON, TOTAL ppm:
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COPIES OF FINAL PLUIS BEFOR4, CERtzvk
)MOM OR W4V: D3,` .ISSUED .:
-P
aMR'IS, RE211IRF-D TO FILE NOTME. OF DATE OF FIRST USE' OF S`isl LT
j6
V jbip-, n't f 9 ri4ijonmental Health services,
.,Disl Id Ing 'Cono true ted'By
S ection ward,
:.
f
7, i
Street
BlocEs 0 4, ,
S
e
A 2.
Sul Was..
Lot
'A'�' 7
it
or SEPA. 7T,
SMAGE. SYSTE
'�,L.Xiitprcdent that'. .I am wholly and ' completely
I loca
�renpon ible`, for:, I
`M� terl all �,'cons t rud t Ion rmd.` drainage , o f the, - zieyva rel - d i a o s a Y a t 60, i
that it hao been conatructed*aG ahowt.on the..appi6ve-*d,."�014:n,.,oze,,.,.,a
and, In accordance with- the:
and
of Health -he'
e-by" S" to G,:�ot
uarant hi 4ne
j1dii. 0;. 01r.- tq:P16ce, i� good operating condition
tion, a -part. 0 -:,ba pYqtW"toill tir
ny�
oj'verAtc %for a r two
-pe iod-of"
yearaAlniedia'eeiy: fbfto G,,l `ante
t ".: lmewa- dia-c2al n, an— *repaira mcde by*��We;�to_pm, 00.
temOr "A
o'Perate properly is c auaed by the willful,
,titl�izlng the _.qystem.
Z-
er agrees to,:accept
dersigned.4urth'
ati c' Jusive te, det6m. inat ow! 66
onc tb
tilei vivio'lon: of i,.Environ=ntal Uealth Services
of the. Wee tchedtdr i County_Departmpnt
or''not the failure of Lhe'system
to *operate waa cauoedt,' ,h q,WL
o 1166ait 6et,: og thei- occupant of -the building
utilizing the
Al% rJw OC7 9 7 6
signature
Title .2
Hada. Z S ta't�
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.%pi, copim; An uQUIRED WITH FIVE (5)
COPIES OF FINAL PLUIS BEFOR4, CERtzvk
)MOM OR W4V: D3,` .ISSUED .:
aMR'IS, RE211IRF-D TO FILE NOTME. OF DATE OF FIRST USE' OF S`isl LT
- - - - - - - - - - - -
V jbip-, n't f 9 ri4ijonmental Health services,
Putnam, County Department.pf,t,
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WELL COMPLETION REPORT
3/71
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This report is to be completed by „well driller and submitted _ to, C, ounty ,HeaLth.Department.together with laboratorX_`.epg-rt.,
const�ui$
r =„v::; ;}ysl� v�iipFE= irclicaYSrg`lniater Is�o;at�rl�BetE3�cT�l 1 i�fi3litbere cei�tifitce"�fi n comps ae Is Issued.
nc
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
N E
6L�'er_
ADDRESS
� —,4Z- i / rJ ,
LOCATION
OF WELL
g-"h04 d
(No. Street)
� a
(Town)
f•
(Lot Number)
r d�
PROPOSED
USE OF
WELL
KDOMESTIC
F1 SUPPLY
BUSINESS
F E TAB ISHMENT
INDUSTRIAL
Ij FARM
CONDITIONING
0 TEST WELL
0 OPe (Specify)
DRILLING
EQUIPMENT
[I ROTARY
OMPRESSED
AIR PERCUSSION
CABLE
D PERCUSSION
OTHER
El (Specify)
CASING
DETAILS
LENGTH (feet)
's r
DIAMETER( Inches)
��
WEIGHT PER FOOT
� THREADED ❑ WELDED
DRI SHOE 'j
EYES. CJ NO
( CASINGj UTED? "
DYES LJ NO
YIELD
TEST
�,
BAILED
PUMPED /� COMPRESSED AIR HOURS
FZ
? -
G.P.M.
YIELD (G.P.M.)
(.
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
I I
DURING YIELD TEST (feet)
Depth of Completed Well s s
in feet below land surface: (�
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
j
�n
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL C PLE D
DATE OF REPORT
W
Gent! er*.-D*-,-�-:
T'-LiS
Re:. ?rope-'U'Y cf-
Located at "0
Lot t
Secu:on cC& Bloc'_ -: Bloc'_ -: 0,3
,a- d 1
o r
c
0
S e --e cc-st---Dtfon of S a f d
s - Z- -1v
I �-7 " *f-, := — ' ' C, T, 7 CZ s: -r;
—117, Fduc-E:-_".2*.on La P-ablic L ., anlcl th.e Put—lam
t F N
ary Gode. 0
ij\ -11,
Very t•uly yours.,
..........
d�
0
57
0/0 t 91
C o iuri t e r s g n d- ENGIlk �
Address
5?16" -� 4 � 7
r a
elephcne
Address
A.
GOUNrY. OF ,P.IJTKIA"M 3,;; DEPARTMENT OF HEALTH' -' Division of ..Environmental Health Services
DESIGN DATA SHEET*..: SEPARATE'SEWERAGE SYSTEM. $ILE NO
Owner e.%y sror�y.�TC� Address _ .. ¢�
Located At (Street) fGo�P��re'.E i!90 . Sec. Blocky
Lot..
(Indicate nearest 'cross street),
MunicipaliCy w�iv.9�, .�GL�i �. "Watershed_.
SOIL PERCOLATION .TEST DATA, REQUIRED TO:BE'SUBMITTED.WITH APPLICATION
q.
Hole
Numbsr'' CLOCK: TI:�fE PERCOLATION
'.PERCOLATION
'Run `:.Elapse. 'Depth to 'Water Water Ledel
'
'No.' ' Time ;. 'From Ground Surface in Inches
'Soil Rate
' 'Start Stop ' Min Stop,: Drop in.
'Min /in.drop
• ` ;: 1 . 1... : ' - r : : i . A
I ches. Inches. Inches.
�
I
=.
1
�'.
�'17V
moo:
4 °9Z
J . .
.,
3.
Notes:
1) . Tests to be repeated 'at ` same: depth until ::approximately equal soil rat
es
obtained .at. each percolation test'hole.'.''.;All data to be, submitted'for.
review.
2) .Depth measurements to be, miade. from top of.hole.
,+
Soil
Rate-Approved SgoFt, /Gal,.: Checked by
-- - s-j0°z8' 50 "-W _ -- - - 150 4l'
6 9
= or
N .. N
- .. _ ''�. 200 /10 //G A[GOIYEO f�•e /'yEGGS. ' _ _
.b.,✓.: � ,oN�q'n� .vim �✓ , ?, � c'
•a.. � - _ .....- _ -- r....._ ._ _t ... -- -- -- -'_." -., _ ....... .e, '.. I1 ,:dFo soscKro.<' ,'Q a' i �°.�'" � ....._..,�... _:..�.�� .....:
et, y o ? r
4 -.8
,•q: iPHYsi'1 '
_ 7Z,' *"
_ � �.EbobttAO`7Y�cc• ' `�
'I 10'-T.HE E VNEYA ND. -1�A,
•700-p85� RADIUS
BARGERST Rc4 0 L- •43.73 N 10. 28'50" - - - -_ A06_76,,'_ y
__ -- --728
F
L0R.�ENGE - ROAD
PRC>VED
OCT 1974 - -
PUT 7 Y
lY ... ... _ _P:6
D REC , DIVISION OF
QiVfIRO- T L HEALTH SERVICWS .
LPT_NO. .18`, ' ON•SueDIVISION ;map OF DRIN6'FARM, MAP NO. 1319
LEG.E_NP
TOWN -TAX NIA'P.D'E51GNAT{ONS`:
Er