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04536
5� 5
PUTNAM COUNTY DEPARTMENT OF HEALTH t
"' ' ��
Diws�on 'of SHealth `Services Cerm% N "Y A{
Enwrorimental s X10512
AN P
a down or Villa ge
ElJG.�c
iZl1/Ei 1�� .Block
Located at: r--o
L�= -' Tax Map
Separate Sewerage ''System built by.; Address
BACTt RIA'PER ML. (Agar plate; count at 35 C).
COLIFORM. GRQUR (Most probable N6. /100ml.)
0 MFT'
HARD NESS, TOTAL - ppm
DETERGENTS-' Mg
NITRATES (as N) -, 149 /L .
IRON, TOTAL.,- IIiCJ j,
omew C..
Owneir or "Purchaser of. building
`,�Lc;vz.E Nc-cs; LSAJ Vr
Location - Street -
:ale -A inn E5
Building Type
Municipality
,> tir..uS'.i _'+ao:®i �'-,�''T"'+'t.:.�':.o �sY: ik:. ^ts .s/'i-%�(`S�Pf��'¢.. '; .1.i?'•_'mi�� i9� ".:,:eL�+ -. _��::,.oa ��`.:
Section
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 successors, 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 selvage 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 occupant of the building utilizing
The undersigned further agrees to accept as conclusive the determination
of the Director of the Division of Environmental Health Services of the Putnam Coun tv_
Department of Health as to whether or not the failure of the system to operate was
cause.d:.by; the - willful• or .negligent act of the occupant of the building utilizing the
system..
Dated this day of /'(��1`` 19,��/511'Signature
Title X�4
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COI
OF COMPLETION WILL BE ISSUED.
ve namee ana aaa.r.es
BEFORE CERTIFICATE
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.,
Division of Environmental Health Services, Putnam County Department of Health
WELL COMPLETION REPORT
3/71 u
analysis of water sample indicatin&
REPORT M
llj
of satisfactory bl
SUBMITTED W
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
. --lal quality before certificate of construction compliance is issued.
°WIN-30 DAYS OF WELL COMPLETION
OWNER
NAM
ADDRESS
LOCATION
OF WELL
(No. 8 Street)
,O� 3
(Town)
"'
(Lot Number)
27.
PROPOSED
USE OF
WELL
BUSINESS
® DOMESTIC ❑ ESTABLISHMENT
11 SUPP Y El INDUSTRIAL
'0'
❑ FARM
❑ CONDITIONING
❑ TEST WELL
(Specify)
DRILLING
EQU PMENT
11 ROTARY
COMPRESSED
DAR PERCUSSION
CABLE
❑ PERCUSSION
O(specify)
CASING
DETAILS
LENGTH (lest)
3„L
DIAMETER (inches)
�o A
WEIGHT PER FOOT
2 THREADED El WELDED
E S O 'j
[I
x YES CJ NO
CASING
E YES D NO
YIELD
TEST
❑ BAILED
HOURS
El PUMPED ® COMPRESSED AIR
G.P.M.
YIELD (O.P.M.)
WATER
LEVEL
MEASURE FROM LAND SURFACE —STATIC (Specify feet)
DURING YIELD TEST (feet)
Depth of Completed Well
in feet below Land surface: sZ %J
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
I
0402
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL CO LETS
DATE OF REPORT
WEL ILLER (Si
ture)
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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y.;10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM'- 8aa�i-
_� g _ Town Qr Village __
r. a. E6iSt0 --d i �w,"'•- °l:r %�cv�"" '^ 1T,s -ca`°u w' n 'i Jia ma+ �..• = �'.:: >a -"'w '._'` .7-p,=�3C'v�:•; .. :'1 ::.: mT+e- 810Ck ` m v _,w`e so-e •Te a
--fit MFerr° Fa -0- Ma • -,•. T_
Subdivision 8 �"� R`" r ��' '�f�-M Lot
E ' YJ orb.
Owner � °� T `JV` i 44
C> Clkv-ti Address G9fs4 � ..�� w Cr. { Nd�V1 �%Ai_1_.�✓✓�'
Building Type, Ct °4-j12 G Lot Area ' �J
Number of Bedrooms Design Flow 6 ® Total Habitable Space `�•' d�� 0 � s�Square Feet
Separate Sewerage System to consist of 6 2 50 Gal. Septic Tank and S -� I- -P• H R d l�. ^ -+1C
To be constructed by � A F t j C: n= TEM Address �i: `v`f ®c %��'�-
Water Supply: Public Supply From /q�
Private Supply to be drilled by IV 1� C} PV, �A11 V Ai�F� f
1A� Address
Other Requirements
I represent that I am wholly and completely responsible for the design and location of the
above described will be constructed as shown on the approved amendment there to and in -A
County Department of Health, and that on completion thereof a "Certificate of gpyltC
be submitted to the Department, and a written guarantee will be furnished the Or. place in good operating condition any part of said sewage disposal system d g
ance of the approval of the Certificate of Construction Compliance of Mi
will be located as shown on.the approved plan and that said well will be Inst
County Department of Health.
Date P ®+} 76 �7 Signed
Address
APPROVED FOR CONSTRUCTION: This approval expires one year from the
revocable for cause or may be amended or modified when consioWV necessary
requires a new permit. Approved for disposal of domestic i nit ry, sewage
Date // 7!L�, By
a.......
proposed system(s); 1) that the separate sewage disposal system
c¢CdAtrj yyith the standards, rules and regulations o e u nam
:tioh dlrrmbb cell satisfactory to the Commissioner of Healthwill
i%VS rs or assigns by the builder, that said builder will
:(e d�of ears immediately following the date of the issu-
Is a h ereto; 2) that the drilled well described above
�e s nd s, rules and regulations of the Putnam
P.E. y R.A.
License No. 4,zi S 3
of the building has been undertaken and is
Any change or alteration of construction
only.
r�-
Title